Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc.

All rights reserved
Student Learning Guide Answer Key 1
1
Student Learning Guide
Answer Key
6hAFIE8 1
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Answers will be individual.
1. An apprenticeship in nursing during the Civil
War was when a woman learned nursing by do-
ing it.
2. Nursing theory is based on relationships
among concepts and facts and not on actual
knowledge.
3. Evidence-based nursing is integrating the best
research evidence with clinical expertise and
patient values to facilitate clinical decision-
making.
4. The nursing process is a systematic way to
deliver nursing care that combines art and sci-
ence.
8hü8I AN8WE8. A68üN¥M8
1. The hospital receives a predetermined amount
of money for caring for a person with a par-
ticular DRG such as pneumonia.
2. An HMO is a type of group medical practice
where patients are enrolled for a set monthly
fee and then receive the services of a limited
network of doctors, hospitals, and other health
care providers.
3. An HMO differs from a PPO in that the PPO is
a group of physicians that have joined together
to provide services to a group of patients at dis-
counted fees in order to be the only providers
for that group of patients.
8hü8I AN8WE8
1. Any four of the following:
a. Stressed a clean environment
b. Included good nutrition in her care
c. Kept records and statistics to show validity
of her nursing practices.
d. Started nurse training schools
e. Felt holistic care was essential (meeting
psychosocial as well as physical needs)
f. Nursing directed at both illness and main-
taining health
g. Nursing should be taught by nurses
h. Continuing education is essential for nurs-
es
2. 1892—New York YWCA started the Ballard
School with a 3-month course in practical
nursing.
1918—Household Nursing School in Boston
trained nurses to care for the sick at home. This
school later became the Shepard-Gill School of
Practical Nursing.
3. Florence Nightingale’s schools of nursing in
Europe and World War II on-the-job training.
4. Any four of the following:
a. Desire and capability to teach
b. Ability to listen
c. Belief in holistic care (attention to psycho-
social as well as physical care)
d. Good therapeutic communicator
e. Able to collaborate with others
f. Ability to delegate tasks to others
g. Willing to give basic care to help another
(bathing, toileting)
h. Concern for the patient’s well-being
i. Ability to give emotional support
j. Ability to advocate for the patient
k. Ability to plan care in an organized fashion
l. Ability to effciently implement care
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 2
5.
LPN/LVN Registered Nurse
12–18 months of for-
mal training
2–5 years of formal
training
Trained to care for the
well or chronically ill
Trained to care for the
acutely ill as well as the
chronically ill; teach
preventive health care
6. Protect the public and defne the legal scope of
practice for nurses.
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1. 2
2. practical
3. 4
4. Lillian Wald
5. 2
6. 2
7. 1, 2, 4
8. 3
9. 1
10. 1, 2
11. 1, 3
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Defnition should include caring for the sick,
promoting wellness, providing health teach-
ing, giving emotional support, and attending to
psychosocial concerns. Each person’s defnition
will be different.
2. Make a list of the group’s ideas. Areas to in-
clude are assessing patients, choosing nursing
diagnoses, stating expected outcomes, planning
interventions to meet the outcomes, directly
implementing the actions, and evaluating the
outcome of the plan. Other ways could be qual-
ity assurance activities on the nursing unit;
attending continuing education presentations
or reading journals; assisting students or new
nurses on the unit; maintaining an ethical man-
ner (not divulging confdential information);
collaborating with the dietitian, physician, re-
spiratory therapist, or physical therapist on the
patient’s plan of care; considering cost-effective
ways to implement care; and applying research
fndings to care.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. delegator
2. foster
3. sought
4. controversy
5. implement
6. criteria
7. prior
8. vigilant
9. skyrocket
¥ü6AßüLA8¥ EkE86I 8E8
1. Assessment: test evaluation
2. Diagnosis: fnding, conclusion drawing
3. Outcome: removal result
4. Implementation: carrying out making
equipment
5. Evaluation: measurement analysis
6. Collegiality: education relationship with
other workers
Wü8ß AIIA6k 8kI LL8
1. a. He attributed his success to his attributes of
hard work and honesty.
b. The use of the surgical implements was
implemented with a training session.
2. c
6hAFIE8 2
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1. g
2. d
3. h
4. f
5. j
6. k
7. i
8. e
9. c
10. a
11. b
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 3
8hü8I AN8WE8
1. A relative state in which one is able to function
well physically, mentally, socially, and spiritu-
ally in order to express the full range of one’s
unique potentialities within the environment in
which one is living.
2. Any three of the following:
a. Watching dietary intake to prevent weight
gain
b. Engaging in a regular exercise program
c. Obtaining immunization against commu-
nicable disease
d. Examining the breasts or testes monthly
3. a. Monitor the body
b. Defne and interpret symptoms
c. Seek health care
d. Follow advice and self-care measures to re-
gain wellness
4. Helping people cope with adverse physiologic,
psychosocial, and spiritual responses to illness.
5. a. Perception of the stressor
b. Degree of health and ftness
c. Previous life experiences and personality
d. Social support system available
e. Personal coping mechanisms
6üMFLEII üN
1. high-level wellness; Dunn
2. an active part
3. cultural
4. unique individual
5. tends to develop slowly over a long period;
throughout life
6. a primary illness
7. physiologic, safety and security; love and be-
longing; self-esteem; self-actualization
8. the patient cope
9. changing environment
10. stress
11. sympathetic nervous system; fght or fight
12. hormones
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1. 1, 2
2. 1
3. 4
4. 3
5. 4
6. 2
7. 1 , 3
MAI6hI Nß
1. Sympathetic
2. Sympathetic
3. Parasympathetic
4. Parasympathetic
5. Sympathetic
6. Sympathetic
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Psychosocial assessment, calling in a social
worker, calling a pastor or priest or other reli-
gious leader; attentive listening; exploring con-
cerns.
2. Fatigue makes one want to rest more. Fever
may cause one to lie down and rest and it helps
eliminate invading organisms. Coughing expels
secretions and viral debris. Malaise makes one
slow down.
3. Sweaty palms, rapid pulse, muscle tenseness,
anxiety, shakiness, (others).
4. a. Obtaining information to decrease fear of
the unknown.
b. Listening to concerns and fears.
c. Enhancing healthy coping skills such as
providing quiet time for meditation.
d. Meeting needs effciently.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. adverse
2. hygiene
3. noncompliant
4. perception
5. alters
6. intervene
7. emerge
8. deviation
9. maladaptive
10. resolves
¥ü6AßüLA8¥ EkE86I 8E8
1. Biologic b, f
2. Psychosocial a, c
3. Spiritual d, e
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 4
Wü8ß AIIA6k 8kI LL8
üpposi t es
1. minimum, adverse
2. ignore
3. clear, specifc
4. dynamic, active
5. atrophy, stagnate
6. good luck, good fortune
7. overreact
8. good health, feel good
6üMMüNI 6AII üN EkE86I 8E8
Examples:
1. a. Culture Believe in preventive
health care
b. Religion Prayers for better
health can be
answered
c. Standard of living Can afford to go to the
doctor
d. Support system Family and friends
available to help
e. Genetic infuence Susceptible to heart
disease
2. Examples:
a. Sex education about STIs
b. Cancer screening
c. Importance of prenatal vitamins
3. Answers will depend on the individual.
Verbalization will increase expertise at pronun-
ciation and sentence structure.
4. Answers will depend on the individual.
6hAFIE8 3
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Examples will be individual.
1. Accepting responsibility for one’s actions.
Example: A nurse accepts accountability for the
care provided by the aide to whom a task was
assigned.
2. Communicated in confdence; secret; kept pri-
vate. Example: The patient’s history is confden-
tial.
3. Sensible and caring behavior. Example: A pru-
dent nurse follows the correct procedure for
catheterization.
4. There is failure to perform in a reasonably pru-
dent manner. Example: A nurse fails to notify
the charge nurse or doctor when a patient with
a fresh cast complains of pain and numbness.
5. Faulty or improper practice is carried out by a
professional person. Example: A licensed nurse
fails to heed signs of toxic overdose of medi-
cation and continues to administer the drug,
causing harm to the patient.
6. Making remarks about a person that are un-
true and that damage the person’s reputation.
Example: The nurse told a patient that another
nurse had been disciplined for taking patient’s
medications when this was not true.
7. Physical contact that was against the person’s
will or consent. Example: A feeding tube was
placed in a patient although no consent was
given for its placement.
8. Written defamation of character; untrue and
damaging words. Example: The newspaper
committed libel in printing untrue statements
about the doctor’s treatment of the patient.
9. Violating the right to privacy concerning one’s
body and private information without the
person’s consent. Example: Two unit secretaries
discuss the number of abortions a patient has
had.
10. Oral statements that are false or that injure
another’s reputation. Example: A nurse makes a
false statement to the effect that another nurse
forged a license card and is not entitled to be a
nurse.
11. Assault is the threat of harm to an individual.
Example: When the patient attempts to get out
of bed, the nurse pushes him down and straps
his arms to the bed rails.
8hü8I AN8WE8
1. a. S Situation
b. B Background
c. A Assessment
d. R Recommendation
2. the group; membership in the group
3. Being attentive and sincere with each patient,
listening to the patient’s needs and complaints,
keeping him or her informed of what you will
be doing, showing concern and respect.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 5
4. Being charged with practicing medicine with-
out a license. The state board of nursing may
take disciplinary action, suspending or revok-
ing the license to practice nursing.
5. Describe the specifc functions and activities of
nurses as opposed to those of other health care
professionals (and to) provide criteria for judg-
ing the quality and effectiveness of nursing care
6. Provide evidence-based and expert-based solu-
tions to areas that have been problematic in
terms of patient safety.
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1. 3
2. 1, 2, 3, 4
3. 1, 2
4. 2
5. 1
6. 1
7. 1, 2, 3
8. 1, 2, 3
9. 2
10. 2, 4
EIhI 6AL 8I IüAII üN8
These situations require synthesis and application of
knowledge.
Situation A
(Giving this information would be a breach of conf-
dentiality.)
1. c
2. lawsuit; loss of employment
Situation B
3. b (Eating the food is against hospital policy
and is unethical. It could be considered steal-
ing, even though the food cannot be served to
another person.)
Situation C
4. ethics (Taking medication prescribed for another
is illegal use of drugs, as well as stealing.)
5. legal
Situation D
6. a (Taking monetary gifts from patients is un-
ethical and is against agency policy. The ra-
tionale is that if reward is involved with one
patient, he or she may be treated better than
another patient.)
7. a (It is unethical to take money for services
you have personally rendered to a patient.
However, it is acceptable for the patient to
contribute to the hospital or to a need for the
unit on which the patient stayed.)
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. This is a direct threat of false imprisonment. It
is unethical, and if carried out is illegal. Discuss
the situation with the person who made the
statement to the patient. Suggest alternatives to
calm the patient and protect the patient’s safety.
2. Consider stating that all patients are asked to
express their preferences for care if certain
emergencies occur or health declines to the
point of inability to make one’s own decisions
any longer. Offer to explain the terms and rea-
sons for the questions on the form. Explain the
reasons why it is preferable to most people to
make their own decisions about these matters
in advance.
3. You are responsible for giving care equal to that
of the licensed nurse in all areas in which you
have already been trained. You may not legally
perform procedures that you have not been suf-
fciently trained to do yet. You are obligated to
tell the person in charge when you do not have
the appropriate training to do a procedure or
suffcient expertise to care for a group of pa-
tients.
4. You should frst consult with your clinical in-
structor and the nurse assigned to the patient.
Discuss the situation out of hearing of the child
or parents. You could explore the chart for any
other evidence of possible child abuse. If a de-
termination is made that the child could be a
victim of child abuse, you should report it to
the charge nurse and call the social worker or
report it directly to the authorities. Find out
what the correct protocol of the agency is in
this situation. It is your responsibility to see
that the authorities are notifed.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. a. jeopardize
b. escalate
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë
c. witness
d. resuscitate
2. a. prescribed
b. pertinent
c. suggestive
3. a. scope
b. proxy
c. access
d. means
e. precedent
4. a. seemingly
b. gravely
¥ü6AßüLA8¥ EkE86I 8E
Ethics: the rules or standards governing the conduct
of members of a profession. (Wording of examples
may vary.)
Wü8ß AIIA6k 8kI LL8
Examples:
1. The doctor will prescribe some medication for
the infection.
2. Take the written prescription to the pharmacy.
6üMMüNI 6AII üN EkE86I 8E8
All exercises are individual. Each requires verbaliza-
tion practice.
6hAFIE8 4
IE8MI NüLüߥ
1. b
2. e
3. c
4. d
5. a
8hü8I AN8WE8
1. a. patient input
b. collaboration with other health care team
members
c. thorough assessment
d. prioritization of needs/concerns
e. critical thinking
2. a. Defne the problem clearly.
b. Consider all possible alternatives.
c. Consider possible outcomes for each alter-
native.
d. Predict the likelihood of each outcome oc-
curring.
e. Choose the alternative with best chance of
success and fewest undesirable outcomes.
3. Rather than thinking about something at ran-
dom, critical thinking is directed and purpose-
ful and requires skills such as effective reading,
effective writing, attentive listening, and effec-
tive communicating. Critical thinking involves
keeping an open mind and looking at an is-
sue from different perspectives. It requires an
organized and systematic approach. To think
critically one must be fexible, realistic, creative,
humble, honest, curious, and insightful.
4. Speaking clearly and concisely, considering
what has been said and thinking before speak-
ing, attentively listening before responding.
5. Critical thinking skills can be improved by any
of the following:
a. Focusing on main ideas and relevant data
while reading.
b. Writing in an organized manner and ex-
pressing each thought coherently and con-
cisely, yet clearly.
c. Evaluating what has been written.
d. Consciously practicing attentive listening.
e. Thinking about what to say and how to
state it clearly and concisely in a logical way
before beginning to speak.
f. Taking time to consider a verbal response
before making one.
g. Acquiring the skills and attributes found in
the critical thinker as listed in the chapter.
h. Practicing purposeful thinking.
6. Patient problems are usually prioritized along
the lines of Maslow’s hierarchy of basic needs.
7. What will happen if the task is not done on
time.
8. fexible; reprioritize
6üN6EFI MAFFI Nß
Each person’s concept map will be different and
individual. It should depict the different areas of
your life and the responsibilities you have in each of
those areas.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 1
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1. 2, 3
2. consider all possible alternatives
3. 2, 4
4. 4
5. 1
6. 3
68I II 6AL IhI NkI Nß A6II ¥I I¥
(Requires synthesis and application of knowledge)
Priority rating What needs to be done
2 Buy books
1 Get a map and fnd
classrooms
5 Buy a parking permit
4 Call for doctor’s appointment
7 Take daughter to the doctor
8 Buy son’s school supplies
3 Go to frst class
6 Go to second class
9 Grocery shop
STEPS TOWARD BETTER
COMMUNI CATI ON
¥ü6AßüLA8¥ 8I MI LA8I II E8 EkE86I 8E
Correct opinion
6üMFLEII üN
1. unforeseen
2. implement
3. concisely
4. overlapping
5. input
6. enhance
7. coherent
8. prognosis
6üMMüNI 6AII üN EkE86I 8E8
1. Example: The man with the chest pain might
be having a heart attack (myocardial infarc-
tion). That could be life-threatening. The boy
with the cut had stopped the bleeding and
could wait for treatment of his wound.
2. Individual answers will vary.
Example: “Marta, when you are fnished with
the sphygmomanometer, I need to use it. I will
be in room 234 or 246. Would you please bring
it to me as soon as you have fnished taking the
blood pressures? I would really appreciate it as
there are no wall units in these rooms.”
6hAFIE8 5
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1. h
2. a
3. g
4. e
5. f
6. c
7. b
8. j
9. i
6üMFLEII üN
1. needs; a variety of methods
2. rapport
3. all information gathered about the patient
4. cause
5. health; problem occurring; defning character-
istics
6. subjective
7. individual
8. assessment
9. chart review
10. analyzing
11. priority
12. evaluate
13. expected outcome/goal
14. cues
15. The patient, the family/signifcant other, the
chart, diagnostic test results, the physician’s his-
tory and physical, and the admission note
16. a. interview
b. chart review
c. physical assessment
17. Safety: at risk of falling
Hygiene/grooming: needs assistance with ADLs
Elimination: urinary incontinence
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 8
Psychosocial and cultural: loss of indepen-
dence; blow to self-image from stroke
Education: instruction in walking with walker;
medication instruction; instruction in possible
cause of stroke and ways to prevent another
one.
Rest and activity: left-sided weakness; sched-
uled rest to prevent fatigue; exercises to
strengthen muscles affected on left side and to
preserve muscle function on right side
18. Many of the nursing diagnoses in Box 5-5 ft
here. Some of the most likely nursing diagnoses
are:
a. Impaired urinary elimination: incontinence
b. Impaired physical mobility
c. Disturbed thought processes
d. Risk of injury
e. Self-care defcit
19. Activity-exercise pattern
20. Present function, personal habits, lifestyle and
cultural factors, and age-related factors
6ü88ELAII üN
1. Barbara Abeyta is admitted with severe vomit-
ing. Fluid volume defcit related to excessive loss
of fuids by vomiting.
2. Leonard Henry has fallen and fractured his hip.
Impaired physical mobility related to injury as
evidenced by x-ray showing hip fracture.
3. Joel Tomaso is admitted with a very high fever
and severe infection. Hyperthermia.
4. Although recovering, Tyrone Peters suffered a
stroke that has paralyzed his right extremities.
He is right-handed. Self-care defcit, bathing,
related to neurologic impairment as evidenced by
inability to move right arm or leg.
5. Valerie Tallchief has emphysema and becomes
very short of breath whenever she tries to per-
form a task. Activity intolerance related to de-
creased lung capacity as evidenced by inability to
perform tasks without becoming short of breath.
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1. 2, 4
2. data that can be verifed by auscultation, palpa-
tion, percussion, or inspection
3. 3
4. 4
5. 2
6. 3, 4
7. 3
8. 4
9. 2
10. 1, 3
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Relief of pain; assistance with care; reduction of
fear; emotional support (in order of priority)
2. Appropriate nursing diagnoses might be:
Pain
Expected outcome: Pain will be controlled by
medication within 6 hours.
Self-care defcit, bathing
Expected outcome: Assistance with bathing will
be provided daily.
Self-care defcit, toileting
Expected outcome: Assistance with toileting
will be provided whenever needed.
Anxiety
Expected outcome: Anxiety will be decreased
within 12 hours.
Fear
Expected outcome: Fear will be relieved or re-
duced as pain is controlled and knowledge of
what is to happen is gained.
3. Objective data: Cries out when tries to move
left leg. Apprehensive facial expression and
body language. Bruise present on left forearm.
Subjective data: Sustained a fall. States is scared.
a. O
b. O
c. O
d. S
e. O
f. O
g. S
h. O
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. signifcant other
2. deviate
3. differentiate
4. over-the-counter
5. pertinent
6. alleviate
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 9
7. formulate
8. scan
9. correlate
10. concurrent condition
11. prosthesis
12. infer
Wü8ß AIIA6k 8kI LL8
1. rapport (n)—relation of harmony or accord
report (n)—account of an event or verbal sum-
mary of patient condition and care for a shift
2. elicit (v)—to get or bring out
illicit (adj)—unlawful
3. affect (v)—have an infuence; a change
effect (n)—the result of an action causing
change
6hAFIE8 ë
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1. d
2. j
3. k
4. i
5. b
6. c
7. h
8. f
9. g
10. l
11. a
12. e
8hü8I AN8WE8
A.
(Answers require analysis and synthesis of informa-
tion.)
1. Assessment
2. Planning
3. Implementation
4. Assessment
5. Assessment
6. Implementation
7. Nursing diagnosis
8. Evaluation
9. Nursing diagnosis
10. Evaluation
11. Planning
12. Planning
ß.
1. priorities of tasks
2. change-of-shift report
3. a. if visitors will be coming
b. diagnostic tests are scheduled
c. time physician may come to see the patient
d. medication administration schedules
4. introducing microorganisms during an invasive
procedure
5. multidisciplinary; managed
6. dependent
7. documentation
8. expected outcomes
9. agency policy and procedure manual
10. if interventions have been successful
11. family
12. sterile; invasive
13. spot check
8EüüEN6I Nß
(Requires synthesis and critical thinking.)
1. 5
2. 7
3. 2
4. 1
5. 3
6. 4
7. 6
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1. 3 (application of prior knowledge)
2. 1 (application of prior knowledge)
3. 4 (application of prior knowledge)
4. 1
5. 2, 4
6. 4
7. 2
8. 3
9. 1
10. 4
11. independent
12. 3
13. 4
14. 1
15. 2
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 10
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. The priority of each task; the amount of time
available; the ability of the patient to assist with
self-care; medication times; procedures to be
done; if the patient will be off the unit for diag-
nostic tests; when the physician might visit the
patient; when visitors might be expected.
2. Some positive aspects are:
• improvement of nursing care
• see if care meets current standards of care
• determine if documentation is occurring
• determine whether care given is cost-effec-
tive
3. Case Study—the nursing care plan should con-
tain the following points:
Assessment data: MVA, splenectomy incision,
bruises on right extremities, swollen right knee;
pain; cannot walk without pain.
Nursing diagnoses:
1. Impaired skin integrity related to surgical
incision
2. Risk for infection related to incision and
traumatic wounds
3. Impaired physical mobility related to inabil-
ity to walk without pain
4. Pain related to surgical incision and trau-
matic wounds
Expected outcomes:
1. Incision will heal without signs of infection
within 2 weeks.
2. Systemic infection will not occur during
next 4 weeks.
3. Will be able to walk without pain within 6
weeks.
4. Pain will be controlled by medication for 4
hours at a time.
5. Pain will resolve within 4 weeks.
Nursing interventions:
1. Dressing change daily with aseptic tech-
nique. Assess wound for signs of infection.
2. Monitor vital signs q 4 h; assess knee for
signs of infection q shift. Monitor bruises
for signs of infection.
3. Assist to BR; supervise ROM to other
extremities tid. Assist with hygiene and
grooming as needed.
4. Assess for pain q 3–4 hours. Medicate as
ordered pm. Provide distraction activities
to reduce pain. Monitor for signs of con-
stipation. Increase fuids and roughage to
prevent constipation from pain medication.
Evaluate after implementation: Gather data
related to wound status, vital signs, pain level,
and knee swelling. Determine if actions are
helping patient meet the expected outcomes.
4. Concept map. This will vary per the individual
making the map. It should include all nursing
diagnoses that would be on the patient’s nurs-
ing care plan. The appropriate interventions
would be linked to each nursing diagnosis.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. deadline
2. imminent
3. collaborative
4. strive
5. impairment
6. adept
7. blame
8. intervening
9. clue
10. sequence
11. incorporated
12. rationale
Aßß8E¥I AII üN8
1. short-term
2. long-term
3. every
4. four hours
5. range of motion
6. physical therapy
7. cerebrovascular accident
8. related to
9. urinalysis
10. outcome-based quality improvement
6hAFIE8 1
IE8MI NüLüߥ
A.
1. d
2. c
3. e
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 11
4. b
5. f
6. a
ß.
(Answers may be found in the textbook glossary or in
a dictionary.)
1. d
2. c
3. b
4. h
5. j
6. a
7. m
8. i
9. k
10. f
11. g
12. o
13. e
14. n
15. l
8hü8I AN8WE8
1. Any three of the following:
a. Provide a written record of the history,
treatment, care, and response of the patient
while under care.
b. Serve as evidence in a court of law.
c. Provide data for quality assurance studies.
d. Guide reimbursement of costs of care.
2. Any of the rules in Box 7-3 that conform to the
requirements of a legal record.
Examples:
a. Document in ink.
b. Date and time each entry.
c. Sign each entry correctly including your
title.
d. Do not leave blank lines in your nurse’s
notes.
e. Correct errors according to protocol.
f. Chart objective data after completing a
task; never chart before doing the task.
g. Note late entries correctly.
h. Identify care given by another health care
worker.
i. Document instructions given to the pa-
tient.
3. Charting is organized by nursing diag-
nosis. Assessment data are documented.
Implementation of the interventions noted
on the nursing care plan is documented along
with the patient response. Evaluation of patient
progress toward expected outcomes is placed
in the nurse’s notes. Evaluation data are docu-
mented that indicate expected outcomes have
been met.
4. a. Accuracy of what is charted.
b. Brevity using abbreviations and symbols as
accepted.
c. Completeness of assessments, actions, and
results.
6üMFLEII üN
1. guide
2. communication tool
3. expected outcomes
4. caring directly; access
5. legal record; a court of law
6. chronological
7. baseline condition
8. relevant data
9. problem; event
10. fow sheets; checklists
11. otherwise documented
12. protocols
13. abnormal data; trends
14. interventions
15. computer screen visible
16. legible
17. variance
18. behaviors
19. ordered treatments
20. safety factors; continued care
Aßß8E¥I AII üN8
(Answers may be found in the Appendix in the section
“Abbreviations.”)
1. ADL
2. ERT
3. BE
4. GU
5. DOE
6. CAD
7. CC
8. HTN
9. URI
10. WNL
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 12
11. LMP
12. TIA
13. BPH
14. BS
15. CHF
16. RLQ
17. ABD
18. CCU
19. EKG, ECG
20. SOB
21. FHR
22. CRF
23. RLL
24. MRI
25. Stat
26. NPO
27. PT
28. ROM
29. UA
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2, 3, 5
2. 3
3. 4
4. 2
5. 2
6. 24-hour intake and output
7. 1
8. 2
9. 2
10. 2, 4, 5
11. 2, 3, 5
12. 3
13. 4
14. 2
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Charting method preference is a matter of per-
sonal choice.
2. Assessment data: Female, age 22, accident
victim, alert, oriented, and able to follow com-
mands. Pupils equal and reactive; fracture of
right femur; laceration of right wrist. Pain in
leg and wrist.
Nursing diagnosis: Impaired mobility related to
fracture of right femur.
Expected outcome: Patient will regain full mo-
bility within 8 weeks.
STEPS TOWARD BETTER
COMMUNI CATI ON
¥ü6AßüLA8¥ EkE86I 8E8
1. The adage was ambiguous.
2. The audit showed a need to reimburse the
patient’s money.
3. The rule of thumb is that the duration of the
offce visit should adhere to the rules.
4. The student should jot down the acronyms that
she feels are noteworthy and compile a list.
5. The time frame required that the doctor use
brevity in talking about the offshoot in the
problem.
F8üNüN6I AII üN ANß I NIüNAII üN
8kI LL8
1. down
2. up
3. up
4. down
5. up
6. down
6hAFIE8 8
IE8MI NüLüߥ
A. Mat chi og
1. g
2. f
3. e
4. b
5. h
6. d
7. c
8. a
ß. 6oæpI et i oo
1. feedback
2. body language
3. communication
4. Therapeutic
5. active listening
6. Confdentiality
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 13
8hü8I AN8WE8
1. A person sending a message and a person who
receives the message, processes it, and indicates
that the message has been interpreted.
2. a. Culture
b. Past experience
c. Emotions and mood
d. Attitude
3. Any three of the following fve answers:
a. Medications taken today
b. Presence of pain
c. When last bowel movement occurred
d. Allergies
e. If previously hospitalized, what year
4. validated
5. a. Use of personal space
b. Norms for making eye contact
6. You might say, “That has to be hard for you” or
“I can only imagine how diffcult this is.”
7. build trust
8. Any four of the following:
a. Effective communication skills
b. Having the quality of empathy
c. Having a desire to help
d. A nonjudgmental attitude
e. Expressing honesty and genuineness
f. Displaying acceptance and respect for the
patient
9. Current vital signs, pertinent laboratory data,
intake and output, medications received,
patient allergies. Situation, Background,
Assessment, Recommendations. Phrase any rec-
ommendations very gently. Most physicians
don’t like to have the nurse suggest changes in
the care of the patient.
10. Any three of the following:
a. Update the nursing care plan
b. Charge out supplies
c. Document nursing care
d. Transmit orders
e. Communicate plans for care with another
department
f. Request a consult from another health care
professional
11. a. Have the person’s attention before begin-
ning
b. Eliminate outside distractions
c. Introduce one idea at a time
d. Do not rush the person
12. Approach the child at eye level and use a calm,
quiet, friendly voice; do not make sudden
movements or gestures.
13. Any three actions from Box 8-1.
14. a. Speak very distinctly.
b. Speak slowly with voice pitch at midrange.
c. Obtain the person’s attention before begin-
ning.
d. Face the person at eye level.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2
2. 3
3. 1, 2, 3, 4
4. 1
5. a block or barrier
6. 1
7. 3
8. 3
9. 1
10. 4
11. 3
12. 1, 2, 4
13. 3
14. 3
15. 1
MAI6hI Nß
1. i
2. h
3. d
4. a
5. b
6. e
7. g
8. j
9. c
10. f
AFFLI 6AII üN üF 6üMMüNI 6AII üN
IE6hNI üüE8
(Answers are from Tables 8-1 and 8-2.)
1. Block—defensive comment; “Tell me how that
made you feel.”
2. Therapeutic; seeking clarifcation
3. Block—changed the subject; “It is a very diff-
cult time for you.”
4. Therapeutic; encourages elaboration.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 14
5. Block—reassuring cliché. “Ummmmm....” en-
courages elaboration of feelings.
6. Therapeutic; encouraging elaboration.
7. Block—offering advice. “What are your con-
cerns?” Seeks information about feelings.
8. Therapeutic; Shows attention to what is being
said and encourages patient to continue.
9. Block—using a cliché. “You’re concerned about
the pain?” Explores feelings and opens discus-
sion of how to handle the situation of the pain.
10. Therapeutic; validates what patient is saying by
refection.
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Patient is scheduled for PT, but is experiencing
pain (physical therapist); is not eating meals
and doesn’t care for the food being served (di-
etitian); doesn’t like to take medication and
would rather use natural remedies for minor
complaints (physician); is awakening every
night about 3:00 a.m. and can’t go to sleep
(night shift nurse).
2. Information to include in report: Vicodin given
at 8:30 with pain relief; IV discontinued; dress-
ing clean and dry; wife visited; walked in hall x
3; taking clear liquid diet without nausea.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. conveyed
2. ambivalent
3. optimal
4. discount
5. judiciously
6. verify
7. lead
8. strive
6hAFIE8 9
IE8MI NüLüߥ
1. kinesthetic
2. visual
3. auditory
4. behavioral objective
5. feedback
6. return demonstration
8hü8I AN8WE8
1. a. the disease or disorder
b. diet
c. medications
d. treatment
e. self-care
2. Poor vision, poor hearing, impaired motor
function, illiteracy, or impaired cognition
3. Pain, fatigue, sense of being overwhelmed, and
multiple people coming in and out of the unit
4. a. printed material such as books and articles
b. video- or audiotapes
c. hands-on equipment
5. a. There is suffcient light for the person to
see well and that glasses are on if used.
b. The person can hear and that the hearing
aid is turned on if used.
c. That outside distractions and noise are
minimized.
d. You proceed slowly and allow time for for-
mulation of questions.
6üMFLEII üN
1. value; cultural
2. very small steps
3. Play
4. beliefs, feelings and values.
5. Defcient knowledge
6. consistency
7. printed, audio, and video materials
8. collaboratively
9. short
10. readiness; apply
11. kinesthetic
12. processing
13. dexterity
14. knowledge base
15. advantage
16. consistency
17. feedback
18. review
19. return demonstration
20. printed
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 15
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. kinesthetic
2. 4
3. 1, 3
4. 2
5. 3
6. 1, 3, 5
7. 2 , 3
8. reinforcement of the material taught
9. 3
10. 4
11. 1
12. 3
13. 3
14. 2
15. 2
16. 4
17. 1, 3, 5
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Use different modes for an assignment to deter-
mine which seems to be the best learning mode
for you.
2. Practice using different techniques within your
best mode of learning to determine what is
most effcient for you.
3. Cover the purpose of the medication, what it
should do, potential side effects and their signs
and symptoms, when and how to take the med-
ications, any precautions to be followed while
taking the medication.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. dexterity
2. literate
3. defcit
4. teaching moment
5. frame of reference
¥ü6AßüLA8¥ EkE86I 8E8
1. Patient is a noun, and means a person treated
by a doctor or nurse.
2. Patient is an adjective and means to be calm
and willing to take time.
3. Patients is the plural.
4. Patience is a noun meaning the ability to wait
calmly for something.
6hAFIE8 10
IE8MI NüLüߥ
1. b
2. c
3. a
6üMFLEII üN
1. control; direction
2. a mistake has been made or something is not
known
3. direct, concise; nonthreatening
4. defnes the problem
5. accountable
6. Competencies
7. job description
8. clear, concise; attentive listening
9. result desired; time frame
10. authority
11. feedback
12. privacy
13. feelings; empathy
14. prioritize
15. documentation of specifc problems or errors
8hü8I AN8WE8
1. a. know the capabilities and competencies of
the person
b. know whether the task delegated falls with-
in the person’s domain and can be legally
delegated
c. communicate effectively with the person
d. understand the person’s needs
2. a. coordinate personnel and make work as-
signments
b. assist with patient care
c. help resolve conficts
d. assist with writing policies and procedures
e. contribute information for evaluation of
UAPs
f. collaborate with physicians and other
health team members
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 1ë
3. a. Who is your immediate supervisor?
b. From whom do you take orders?
c. Who is over your suprvisor?
d. To whom should you report changes in
patient condition, signs of complications,
etc.?
e. To whom do you go with concerns or com-
plaints?
f. Who is in charge of scheduling your hours?
g. Whom should you call if you are ill and
cannot make it to work?
4. a. Defne the problem.
b. Look at alternative solutions.
c. Estimate possible outcomes for each alter-
native.
d. Choose the best alternative to solve the
problem.
e. Try the alternative. (If the alternative does
not work, repeat the problem-solving pro-
cess.)
5. a. Work for 1 year as a staff nurse
b. Have knowledge and experience in leader-
ship
c. Have training or experience in nursing ad-
ministration and supervision
d. Have additional training or preparation in
the specialized area to which assigned.
6. See Box 10-1 in the textbook or list others that
you feel are important.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 1, 3, 5
3. 2
4. 1, 3, 4, 5
5. 2
6. 3
7. 1, 2, 3
8. 4
9. 2
10. 1
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Considerations would be which tasks legally
cannot be delegated, the competencies of the
UAP to whom you are assigning, and facility
protocols on delegation. You might be able to
assign patient baths, bed-making, vital signs,
daily weights, and ambulation to a UAP.
2. The time organization sheet should include a
row for every hour of the shift and a column
for each patient assigned. Include all tasks to be
completed, whether they are delegated or not.
Remember to include medications, ambulation,
ROM, bathing, vital signs, weights, blood sugar
determinations, etc. Schedule in time for assess-
ment/data collection and for procedures such
as wound care. Remember to include time for
patient teaching and time for documentation.
Priority items should be entered into the time
schedule frst. For example, ordered wound care
and medications would take precedence over
bathing or ROM.
STEPS TOWARD BETTER
COMMUNI CATI ON
¥ü6AßüLA8¥ EkE86I 8E8
1. c
2. e
3. b
4. a
5. d
6üMFLEII üN
1. eye contact
2. confict resolution
3. laissez-faire
4. competent
5. cost-effective
6. reimbursement
7. chain of command
8. active listener
9. feedback
10. domain
11. constructive criticism
12. delegate
¥ü6AßüLA8¥ EkE86I 8E8
Wor d Faæi I i es
1. competent
2. compete
3. competently
FoI i t e aod EI I ect i ve 6oææuoi cat i oo
4. “LuAnn, I would like you to weigh Mr. Moore,
Ms. Garcia, and Ms. Adams before breakfast
today. Ask each patient what they were wear-
ing when they were weighed on Monday so
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 11
that our weights have a consistent basis. For
example, if Mr. Moore was wearing his slippers
and robe, weigh him with those items on; if
Ms. Garcia just had on her gown and slippers,
weigh her without her robe. Do you follow
what I mean? (LuAnn replies that she does.)
“Please be sure that the scale is balanced on
zero before weighing each patient. When you
are fnished with all three weights, please write
them down on the jot board right away so that
they will be available when the physicians make
their rounds, which usually start by 8:30 a.m. If
you have any problems, let me know. I will be
making rounds in about 10 minutes and then
I will be here at the desk. Can you relate back
to me the details of what I’ve asked you to do?”
(LuAnn replies and further dialogue occurs if she
cannot repeat the instructions correctly.)
Aßß8E¥I AII üN8
1. medication administration record
2. unlicensed assistive personnel
3. immediately
4. as soon as possible (not in the chapter, but
widely used throughout the United States in
many types of situations)
6üMFLEII üN
1. discern; mitigate
2. profcient
3. jot; grid
4. instills or fosters
I ßI üMAII 6 Fh8A8E8
1. establish eye contact
2. take precedence over
3. track down
6hAFIE8 11
IE8MI NüLüߥ
A. Mat chi og
1. o
2. j
3. a
4. b
5. k
6. c
7. h
8. l
9. m
10. i
11. d
12. f
13. n
14. g
15. e
ß. 6oæpI et i oo
1. 18 months; 6
2. libido; pleasure principle
3. Moro
4. right and wrong
5. morals
6. Intelligence
7. social
8. ideology
9. genes
10. time-out
11. folic acid; 400
12. double, triple
13. cephalocaudal; head
14. 2
8E¥I EW üF 8I8ü6Iü8E ANß FüN6II üN
Answers are in the Overview of Structure and
Function section of the chapter in the textbook.
1. amniotic sac
2. It attaches during the second week and is at-
tached by the placenta.
3. The eyes and ears begin to take shape during
the ffth week.
4. The heart begins beating at about 3 1/2 weeks.
5. The external genitalia begin to appear during
the third month.
6. By the ffth month, the fetus is 10–12 inches in
length and weighs about 1 lb.
7. Multiple births are caused by the fertilization of
more than one ovum or division of an ovum.
8. Puberty in the female occurs between ages 9–17
with 12 as the average age.
9. 14 years of age
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 18
I ßENII FI 6AII üN
1. b
2. b
3. d
4. b
5. f
6. f
7. c
8. d
9. e
10. d
11. e
12. f
13. b
14. a
15. b
8hü8I AN8WE8
1. a. levels of awareness
b. components of the personality or mind
c. psychosexual stages of development
2. a. Organization: we try to make sense of our
world
b. Adaptation: we discover new information
and adjust our thinking patterns
3. a. Obey rules to avoid punishment
b. Conform to social standards to avoid disap-
proval
c. Abide by laws and follow one’s conscience
4. a. Growth occurs in orderly and predictable
ways.
b. The rate of growth and development is in-
dividual.
c. Development is lifelong.
d. Development is multidimensional.
e. Development is continuous.
5. a. Can delay gratifcation due to trust (Table
11-2)
b. Practices new skills.
c. Formulates a plan of action and carries it
out.
d. Acquires skills of reading, mathematics,
and social skills.
e. Investigates and identifes alternatives re-
garding his or her vocational and personal
future.
6. a. Infant should not be left alone on a surface
without protection from falls.
b. Infant must be restrained in a car seat in
the back seat when the car is moving.
c. Bath water should be tested to see that it is
not too hot before putting infant into the
bath.
d. Small objects should be kept out of reach to
prevent entry into the mouth and choking.
e. Infant should be placed on its back for
sleep.
f. No infant should be left in a house or car
alone.
7. a. hormonal shifts
b. early adolescence years
8. a. A chronic disease such as diabetes or heart
disease.
b. Lack of prenatal care
c. Maternal age below 16 or over 35
d. Poor nutritional status of the mother
9. a. Increase the number of mothers who
achieve the recommended weight gain dur-
ing pregnancy.
b. Increase abstinence from alcohol, cigarettes,
and illicit drugs among pregnant women.
6üMFLEII üN
1. more than one ovum is fertilized
2. anal; 1–3 years (Table 11-1)
3. 10
4. predictable
5. physical; cognitive; psychosocial
6. 46 chromosomes
7. 40
8. nourished
9. 30
10. nutrition; oxygen
11. 18 months
12. 16–20
13. 12 to 24
14. 9–10
15. frst
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2
2. 4
3. 8
4. bonding
5. 3
6. 1
7. 2
8. 1, 3, 4
9. 1, 2, 3
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 19
10. 2
11. 3
12. 4
13. 1
14. 2
15. 1, 3, 4
IAßLE A6II ¥I I¥
(See Overview of Structure and Function section in the chapter.)
Fhysi caI 6haoges oI Fuber t y
Male
• ICSH stimulates the testes to produce testoster-
one.
• FSH stimulates the testes to begin producing
sperm.
• Enlargement of the reproductive organs occurs.
• The voice lowers in tone.
• Growth of facial, pubic, and axillary hair occurs.
• Bones thicken and skeletal muscles increase in
size.
• Nocturnal emissions occur.
Female
• FSH stimulates the ovaries to begin producing
estrogen hormones.
• Breast development occurs.
• Hips widen.
• Axillary and pubic hair appears.
• There is growth of the reproductive organs.
• FSH stimulates the development of ova and
menstruation begins.
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. a. Agencies and educational programs avail-
able in your community to help combat
teen pregnancy.
b. Employers in the area who are tuned in to
the needs of adolescents and are interested
in their school performance.
c. Drug and alcohol education programs
available in the community.
d. Assessment parameters for eating disorders.
e. Signs of depression in adolescents.
f. Assessment for high-risk behavior among
adolescents.
2. Review normal refexes, growth patterns, and
milestones of physical and mental develop-
ment. Review the importance of meeting the
infant’s needs and what those needs are in areas
of safety, nutrition, hygiene, elimination, rest,
and stimulation.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. cyanotic
2. erupt
3. resilient
4. baby fat
5. gender stereotype
6. growth spurt
¥ü6AßüLA8¥ EkE86I 8E8
1. a. vital/necessary/important
b. helping/aiding/assisting
2. linguistic: writing, speaking, learning foreign
languages, early speech, talking with others, en-
joying word play
mathematical: science, engineering, mathemat-
ics, counting, understanding number concepts
spatial: art, architecture, engineering, building
blocks, drawing
musical: singing, playing instruments, enjoy-
ing music, singing songs, playing instruments,
moving to music
bodily kinesthetic: dance, gymnastics, sports,
exercise, active play, climbing, dancing, tum-
bling
interpersonal: outgoing, friendly, leadership,
selling, working with people, outgoing, enjoys
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 20
playing with others, lead in games, enjoys visit-
ing
intrapersonal: quiet thinker, philosopher, poet,
writer, psychologist, enjoys solitary play, imagi-
nation, self-analytic
6üMMüNI 6AII üN EkE86I 8E8
Dialogues will be individual.
6hAFIE8 12
IE8MI NüLüߥ
A. Mat chi og
1. d
2. b
3. h
4. j
5. g
6. a
7. i
8. f
9. e
10. c
ß. 6oæpI et i oo
1. Middle adulthood
2. intimacy
3. 30
4. Executive substage
5. Generativity
6. Stagnation
7. Children
8. Sandwich generation
9. 45
10. 1200; 1500
11. 120/70
8hü8I AN8WE8
1. a. Responsibility for members of one’s family
b. Job responsibilities
c. Responsibility for oneself
2. a. Responsible for self
b. Responsible for family
c. Responsible for the corporation or the
country
3. Any three of the following:
a. Form close relationships with others
b. Develop an intimate relationship with a
signifcant other
c. Maintain close family ties
d. Begin taking responsibility for self
e. Continue learning and applying what has
been learned
4. Helping young people and others in the com-
munity, being productive in the workforce, vol-
unteering within the community
5. Any three of the functions listed in Box 12-1.
6. a. Families move around a lot making it hard
to maintain friends.
b. Only a small percentage of families live in
rural areas and are self-suffcient.
c. Most mothers now hold a job outside the
home. Fathers are more involved in the care
of children and care of the house than ever
before.
7. Any three of the following:
a. Feeling blame or guilt
b. Decreased self-esteem
c. Diffculty relating to other people
d. Sadness
e. Inability to trust
f. Diffculty fnding happiness
g. Relief at leaving a diffcult situation
8. a. Chemical abuse
b. Overeating
c. Inadequate sleep
d. An inactive lifestyle
e. Sexual promiscuity
9. empty nest syndrome when children have all
left home; readjusting to living with boomer-
ang children; divorce; caring for aging parents;
changing jobs or careers
10. Working crossword puzzles, playing bridge,
playing board games that require strategy,
studying a new subject, using computer pro-
grams, and any other mind-stimulating activity
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 21
IAßLE A6II ¥I I¥
Fhysi caI 6haoges
Young Adult Middle Adult
• Completion of skeletal development.
• High levels of strength, endurance and energy.
• Dental maturity with eruption of wisdom teeth.
• Physical growth of the brain continues until the
mid-20s.
• Redistribution of body weight
• Presbyopia
• Presbycusis
• Compression of the spinal column and loss of
height
• Loss of muscle tone and elasticity of body tissues
• Blood pressure increases
• Skin becomes less resilient
• Wrinkles appear
• Graying of the hair
• Thinning of scalp hair
• Decreased levels of estrogen in women and de-
cline in testosterone in men
6üMFLEII üN
1. care about and for each other
2. one or two parents and children
3. 26%
4. 40
5. a hot fash
6. garlic
7. stress
8. interests; activities
9. friendships
10. middle years
11. mobility
12. 70
13. 36%
14. poverty
15. 40
16. cervical
17. 75.7%
18. loud music
19. Relationships
20. lonely
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 4
2. 1, 3
3. 1, 2
4. 3
5. 1, 3
6. 2
7. 3
8. 1
9. 1
10. 2
11. 4
12. 1, 4
13. 3
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Answers depend on your age and developmen-
tal stage. See Table 11-2.
2. Answers depend on your age and developmen-
tal stage.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. confdante
2. down-sizing
3. juggle
4. boomerang
5. menopause
6. volunteering
7. family ties
¥ü6AßüLA8¥ EkE86I 8E8
1. Quiet—boisterous (noisy) or active
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 22
2. Blonde—dark-headed or dark
3. Athletic—nonathletic, sedentary
4. Tall—short
5. Large—small
F8üNüN6I AII üN ANß 8I8E88
tion/sion ic/ical omy ogy ity
urbanization
generation
question
maturation
tension
stagnation
pelvic
chronic
biological
skeptical
physical
cervical
economy
autonomy
biology
sociology
gerontology
maturity
infdelity
validity
fexibility
obesity
promiscuity
generativity
personality
ery edy istry
delivery
grocery
nursery
surgery
remedy
tragedy
comedy
dentistry
chemistry
6hAFIE8 13
IE8MI NüLüߥ
A. Mat chi og
1. f
2. c
3. d
4. b
5. h
6. a
7. g
8. e
ß. 6oæpI et i oo
1. conception
2. biologic
3. free radical
4. activity
5. elder abuse
6. life span
7. 77.9
8. 25.6
9. psychosocial
10. 75
11. hypertension
12. 6; 10
8hü8I AN8WE8
1. a. Biological clock theory: body cells break
down after a specifc length of time and die.
b. Free-radical theory: cells are damaged by
toxins; free radicals are unstable.
c. Wear-and-tear theory: body cells and or-
gans eventually wear out.
d. Immune system failure theory: system loses
its ability to protect the body.
e. Autoimmune theory: body no longer rec-
ognizes itself and begins to attack its own
cells.
2. a. Stops going to church, withdraws from
bridge club.
b. Takes an adult education class.
c. Copes with failing eyesight by using the bus
rather than driving; adapts to the situation.
3. a. Education (more education, longer longev-
ity)
b. Lifestyle (no smoking)
c. Personality (optimistic people live longer)
d. Gender (females live longer)
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 23
4. Any one of the changes listed in Table 13-1.
5. Re-integrative stage. Older adults carefully se-
lect how they wish to spend their time. They
do not do things just to accommodate other
people as easily anymore.
6. a. Active in the church
b. Proud of well-maintained home appear-
ance and savings for retirement
7. a. An exercise program
b. Good, balanced nutrition
c. Staying mentally active
8. Any fve of the items in Box 13-3.
9. Participation in an exercise program that pro-
motes strength and balance and is an ongoing
activity.
10. a. Increase the lifespan and quality of life by
focusing on wellness, prevention of illness
and treatment of disease.
b. Increase to at least 80% the receipt of home
food service by people age 65 and older
who have diffculty in preparing their own
meals or are otherwise in need of home-de-
livered meals.
6üMFLEII üN
1. healthier
2. diet; exercise
3. personality
4. 30
5. 2
6. frail; active
7. depressed
8. think
9. circulatory
10. physical activity
11. volunteer
12. needed
13. 35
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 4
2. 2
3. 3
4. 1, 3
5. glasses; hearing aid
6. 4
7. 2
8. 1
9. 2
10. 2
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Consider nutrition, exercise, medications, social
activities, and activities that require the active
use of the mind.
2. Safety concerns related to confusion; inability
to maintain a checkbook and attend to fnanc-
es; malnutrition from forgetting to eat; poor
hygiene; illness from forgetting medications.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. irrelevant
2. nest egg
3. myth
4. lifestyle
¥ü6AßüLA8¥ EkE86I 8E8
Myt h ver sus Iheor y ver sus Fact
1. T Theory
2. M Myth
3. F Fact
6üMMüNI 6AII üN EkE86I 8E
ANSWERS for stress markings (may vary):
Nurse: “Good morning, Mr. Hernandez. How are
you feeling?”
Mr. H.: “Pretty good for an old guy my age.”
Nurse: “Now, what medications are you taking?”
Mr. H.: “Oh, I don’t know. There are some pink
ones, and some red ones. There were some big
horse pills, too, but I stopped taking them.”
Nurse: “Why? Did the doctor tell you to stop?”
Mr. H.: “No, but they weren’t doing me any good
and they stuck in my throat.”
Nurse: “How do you know they weren’t doing you
any good?”
Mr. H.: “Well, I don’t feel any different when I take
them.”
Nurse: “Mr. H., some medications don’t make any
difference in how you feel, but they are doing their
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 24
job in your body. Your cholesterol and hyperten-
sion pills help keep the blood vessels open to your
heart and brain so you won’t have a stroke or heart
attack. You don’t want your wife to have to take care
of you if you can’t talk or feed yourself, do you?”
Mr. H.: “Oh gosh, no! Is that what will happen?”
Nurse: “Well, the medication helps prevent those
types of complications. If you have some side ef-
fects, or other problems taking those pills, talk to
the doctor and maybe he can change the prescrip-
tion. But you should continue taking them until
you talk to the doctor.”
Mr. H.: “Well, OK, but I sure don’t like those horse
pills!”
Nurse: “You know the old saying, ‘healthy as
a horse.’ Maybe that’s how they stay healthy!
Seriously, let’s see if the pills can be cut in half.”
6hAFIE8 14
IE8MI NüLüߥ
A. Mat chi og
1. e
2. d
3. g
4. l
5. b
6. k
7. j
8. c
9. o
10. h
11. i
12. f
13. a
14. m
15. n
ß. 6oæpI et i oo
1. sensitivity
2. stereotype
3. dialects
4. culture
5. world view
6. generalization
7. Pacifc Islanders
8. Ethnic
9. Chi’i
10. yin; yang
11. curandero
12. shaman
13. offering food
14. personal
15. kosher
6üMFA8I 8üN8
Answers are from Table 14-3.
Cultural Group Beliefs or Values
Hispanic-American Any of the beliefs or
values listed in
Table 14-3.
Asian-American Any of the beliefs or
values listed in
Table 14-3.
Native-American Any of the beliefs or
values listed in
Table 14-3.
African-American Any of the beliefs or
values listed in
Table 14-3.
European-American Any of the beliefs or
values listed in
Table 14-3.
8hü8I AN8WE8
1. a. Both have to do with attempting to un-
derstand one’s place in the world and life’s
meaning or purpose.
b. Spirituality concerns the spirit, or soul, and
is an element of religion.
c. Religion is a formalized system of belief
and worship.
2. a. When ill, wish to restrict diet to “hot” or
“cold” foods that are benefcial to the body
during that type of illness.
b. Do not eat any pork.
c. If Orthodox, eat only Kosher foods; do not
eat pork.
d. Prefer vegetarian meals.
3. Develop cultural awareness. Know yourself,
examine your own values, attitudes, beliefs, and
prejudices. Keep an open mind and try to look
at the world through the perspectives of cultur-
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 25
ally diverse peoples. Learn all you can about
other cultures.
4. Learning about a people’s history, appreciating
their artistic expressions, foods, and celebra-
tions.
5. a. communication
b. view of time
c. organization of the family
d. foods in the diet
e. issues related to death and dying
f. health care beliefs
6üMFLEII üN
1. values
2. rejected
3. culture
4. transition
5. equality; brotherhood
6. eighth
7. body; a previous life
8. anxiety
9. yin; yang
10. malnutrition; tuberculosis
11. human caring
12. an open mind
13. authority; older
14. 18 inches
15. European-American
16. patriarchal; matriarchal
17. temperature
18. folk or home remedy
19. Hispanic-American; African-American
20. Hispanic; Native American
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Any of the questions from p. 188 in the text-
book.
2. a. Impaired verbal communication
b. Decisional confict
c. Spiritual distress
3. Any three of the following:
a. States he or she feels at peace.
b. Expresses comfort with relationship to God
and signifcant others.
c. Identifes and employs spiritual support.
d. Develops or reestablishes spiritual practices
that nurture a relationship with God or a
higher power.
4. a. Inquire about foods normally consumed
within the patient’s culture to include in
the diet.
b. Consult with the dietitian to provide cul-
turally acceptable foods.
c. Ask the family to bring in acceptable cul-
tural dishes for the patient’s meal.
5. a. You might inquire whether a sense of peace
is being achieved.
b. Determine if prayer and spiritual readings
are being used.
c. Determine whether a religious leader is vis-
iting.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2
2. 4
3. 3
4. 1
5. 2
6. 1
7. egalitarian
8. 4
9. 1
10. 2, 3, 4
11. 2
12. 3
13. Chinese
14. African-Americans
15. 3
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Defne what your own cultural beliefs are. Ask
a peer about his or her cultural beliefs; list both
and compare.
2. Outline what you feel the spiritual needs of the
Hindu, the Buddhist, and the Muslim might
be; then plan what you would do to meet those
needs.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. refrain from
2. attire
3. prevalent
4. sustained
5. wealth of information
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 2ë
Wü8ß AIIA6k 8kI LL8
Answers will be individual. Examples are:
1. PREValent, SECond, CATegorized,
STEReotypes, CULture
2. atTIRE, reFRAIN, susTAIN, imPEDE,
HisPANic, exTENDed, nuTRItion
3. celeBRAtion, ethnoLOGical, malnuTRItion,
ecoNOMic, recogNIZE, circumCISion, curan-
DERo
4. susceptiBILity, ethnocenTRICity, evaluAtion,
interpreTAtion, egaliTARian, spirituALity
6hAFIE8 15
IE8MI NüLüߥ
A. Mat chi og
1. e
2. g
3. d
4. a
5. f
6. c
7. i
8. j
9. h
10. b
ß. 6oæpI et i oo
1. loss
2. grief
3. Anticipatory grieving
4. health care proxy
5. possible
6. validate
8hü8I AN8WE8
1. Person must be declared brain dead by absence
of brain waves that indicate life.
2. A program of care to meet the needs of the
terminally ill and their family in their home or
health care facility.
3. Any three of the following:
a. Fear of pain
b. Fear of loneliness
c. Fear of abandonment
d. Fear of the unknown
e. Fear of loss of dignity
f. Fear of loss of control
4. Euthanasia is the act of ending another person’s
life to end suffering with or without his con-
sent.
5. Passive euthanasia occurs when a patient
chooses to refuse treatment that might prolong
life. Active euthanasia is administering a drug
or treatment that ends the patient’s life.
6. Assisted suicide is making the means to end life
available to the patient when he could not oth-
erwise obtain such means, knowing that suicide
is his intent. In active euthanasia, the patient is
administered a drug or treatment that ends his
life.
7. “The nurse does not act deliberately to termi-
nate the life of any person.” and “Nurses must
not participate in assisted suicide.”
8. The right to die with dignity
9. Any of the interventions listed in the section of
the chapter on common problems.
a. Advocate for suffcient pain medication to
keep the patient comfortable.
b. Administering antiemetics.
c. Obtaining an order for morphine to ease
breathing.
d. Obtaining an order for a tranquilizer.
e. Obtain a standing laxative order.
f. Allowing decreased fuid intake when ap-
propriate.
g. Providing ice chips or hard candy to suck.
h. Removing unpleasant sights and eliminat-
ing odors before mealtime.
10. A durable power of attorney for health care is
a legal document that appoints a “health care
proxy” to carry out a person’s wishes as ex-
pressed in an advance directive.
11. a. opiate medications
b. decreased food and fuid intake
c. decreased mobility
12. a. Administer antiemetic medication.
b. Provide frequent oral care.
c. Offer small servings of home-prepared
food favorites.
13. reduce secretions, bring breathing back to more
normal, and prevent the “death rattle”
14. listen; talk
15. Any of the signs and symptoms listed in Box
15-1.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 21
6ü88ELAII üN
Answers require use of Box 15-1 plus application and
synthesis of knowledge.
1. d
2. b
3. e
4. a
5. d
6. b
7. c
8. e
9. a
10. d
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Any four of the items discussed on pp. 197-198.
a. What the physician has said about their
condition
b. Desires for advance directives and life sup-
port
c. What is hoped for from nursing care
d. What are the specifc concerns
e. Specifcs regarding religious and spiritual
needs
f. Methods of coping and emotional status
2. Any three nursing diagnoses from Box 15-4.
Examples:
a. Impaired skin integrity
b. Self-care defcit
c. Fear
3. The patient, the family, and all health care pro-
fessionals involved in the patient’s care.
4. Answers depend on nursing diagnoses listed in
question #2. Examples:
a. Patient will not experience further instanc-
es of skin breakdown before death.
b. Patient’s hygiene needs will be met daily.
c. Knowledge of what to expect as death ap-
proaches will decrease fear.
5. breakthrough pain
6. stool softener; laxative
7. small; easily digested
8. Degree of attainment of the expected out-
comes.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 1
3. 1
4. anger
5. 3
6. 4
7. a natural part of life
8. 3
9. 2
10. 2
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. You are responsible for approaching the family
about organ and tissue donation. This requires
tact. Planning an approach will make you more
comfortable with this issue.
2. Hope comes in many forms. You might help
her to hope for a more pain-free day, for the
joy of seeing something beautiful like a bird or
fower outside the window, of the joy of watch-
ing children happily playing. You could plan
ways to decrease discomforts so that there is
hope for a more comfortable day. There can be
hope for a pleasant time with a loved one.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. anticipatory
2. collaboratively
3. enhance
4. grapple
5. proactive
6. proxy
7. respite
8. validating
¥ü6AßüLA8¥ EkE86I 8E
Examples will vary.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 28
Wü8ß AIIA6k 8kI LL8
Glossary Word Root Word Meaning
an tic i pa tor y
col LAB or a tive ly
COM mon AL i ties
cul mi NA tion
in EV i ta BIL i ty
an TIC i PAT ing
anticipate
labor, collaborate
common
culminate
inevitable
anticipate
to look forward to
work, work together
shared by two or more, ordinary
to come together at the end
sure to happen
to look forward to
6üMMüNI 6AII üN EkE86I 8E8
1. Answers will be individual.
2. Example: “Ms. Rodney, I understand you are
experiencing many problems and many dis-
comforts. Now that you are in hospice care
there are several things we can do to help you.
We are going to regulate your medications so
that you achieve pain relief, but do not become
so constipated. The new medications and in-
home oxygen should help with your shortness
of breath, and that in turn should help you
relax. Our team will be just a phone call away
and we will be here at least three times a week.
We will work with your family in ways to repo-
sition you that do not cause you so much dis-
comfort. I have ordered a special air mattress to
make your bed more comfortable and to relieve
pressure on those sore spots. What is your main
concern for your care at this time?”
6hAFIE8 1ë
IE8MI NüLüߥ
A. Mat chi og
1. h
2. i
3. f
4. d
5. g
6. j
7. b
8. a
9. e
10. c
ß. 6oæpI et i oo
1. hand hygiene
2. normal fora
3. Virus
4. Protozoa
5. Rickettsia; vectors
6. fungi
7. round worms; tapeworms (also hookworm)
8. Endotoxin
9. hospital-acquired (formerly called nosocomial)
10. pathogens
11. culture
12. perform hand hygiene
13. gloving; removing gloves
14. they are dry
15. 15
16. 1/4
17. jewelry harbors microorganisms
18. sharps
19. biohazard or hazardous waste
20. Creutzfeldt-Jakob’s
8hü8I AN8WE8
1. a. adhere to mucosal surfaces or skin
b. penetrate mucous membranes
c. multiply once in the body
d. secrete harmful enzymes or toxins
e. resist phagocytosis
2. Any example from the process of infection is
acceptable.
a. Causative agent: Streptococcus bacteria
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 29
b. Reservoir: infected wound
c. Portal of exit: respiratory tract (mucous
membranes)
d. Mode of transmission: drinking from a
contaminated glass
e. Portal of entry: broken skin
f. Susceptible host: patient with a surgical in-
cision.
3. Medical asepsis is the practice of reducing the
number of organisms present or reducing the
risk of transmission of microorganisms. It is
carried out through hand hygiene, standard
precautions, and disinfection. Surgical asepsis is
a way of protecting the patient from exposure
to living microorganisms. It involves steriliza-
tion of all instruments and inanimate objects
used in surgery, use of sterile supplies and spe-
cial techniques for procedures that invade the
body.
4. a. Direct contact with body excreta or drain-
age from an infected area.
b. Indirect contact with contaminated inani-
mate objects.
c. Vectors that harbor infectious agents and
transmit infection through bites and stings.
d. Droplet contamination by the aerosol route
though sneezing and coughing.
e. Spread of infection from one part of the
body to another by personal touch, infected
fuids, or inanimate touch (gown soiled at
wound and then a different part of the pa-
tient lies on that area).
5. Exposing objects that can withstand heat and
moisture to moist heat under pressure in an
autoclave
6. a. Any point from Table 16-6, as well as:
b. poor nutrition
c. chronic illness
d. poor hygiene related to immobility
e. decreased immune function
7. a. Genitourinary tract
b. Gastrointestinal tract
c. Skin
d. Respiratory tract
8. a. fever
b. leukocytosis
c. phagocytosis
d. infammation
e. action of interferon
9. interferon
10. a. neutralize and destroy harmful agents
b. limit the spread of harmful agents to other
parts of the body
c. prepare the damaged tissues for repair
11. Naturally acquired immunity occurs when the
body produces antibodies against a microor-
ganism.
12. antitoxin; antiserum; antibodies or antitoxins
developed in another person
13. Injection of vaccines or immunizing substances
that contain dead or inactive microorganisms
or their toxins
14. when there is a possibility of being splashed by
body fuids
15. an airborne pathogen; splashed body fuid
16. being splashed in the eyes with any body fuid
17. a. Rinse the object with cold water.
b. Wash the object in hot soapy water.
c. Use a stiff-bristled brush or abrasive to
clean equipment with grooves or narrow
spaces.
d. Rinse the object well with moderately hot
water.
e. Dry the object.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 2, 3, 5, 6
3. 1
4. 2
5. 4
6. 1
7. 2
8. 1
9. 3
10. 4
11. 2
12. 3
13. fungi
14. 1, 2, 4, 5
15. 4
16. 2, 3, 5
17. 3
18. 2
19. 2
20. 1
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 30
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. MedicalAsepsis:
Handwashing to remove microorganisms.
Disinfection to prevent transfer of microorgan-
isms.
Standard precautions—use of barriers to pre-
vent transfer of microorganisms.
Containment of microorganisms—plastic bag-
ging contaminated dressings.
SurgicalAsepsis:
Autoclaving surgical instruments.
Using only sterile items for invasive procedures.
Surgical scrubbing and sterile gloving.
Using only sterile supplies and technique for
dressing changes.
2. Be sure to discuss the frst, second, and third
line of defense. Use simple examples and com-
mon terminology to discuss the defenses of the
skin, secretions, cilia, bones, blood cells, liver
cells, GI secretions and activity, urination, fever,
leukocytosis, phagocytosis, infammation, ac-
tion of interferon, immune response.
3. Discuss transmission of pathogens, particularly
HIV, hepatitis B and C, and need to prevent
such transmission. Explain why different PPEs
are used.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. virulent
2. scrupulously
3. impede
4. impermeable
5. render
6. prevalent
7. vector
Wü8ß AIIA6k 8kI LL8
1. b
2. c
3. a
6üMMüNI 6AII üN EkE86I 8E
Example: “Ms. Thierry, you must wash your hands
thoroughly after changing your dressing and
cleansing the wound. Bacteria from the wound area
can get onto your hands and then contaminate
anything you touch if you don’t. The bacteria could
be transferred from your hands to the telephone
or the coffee pot handle and the next person in the
house who touches the telephone or the coffee pot
would have the bacteria transferred to their hands.
The bacteria can infect them if there is a break in
the skin on the hands or if they then touch the eye
or the mouth where the bacteria can enter the body
through the mucous membranes.” (Continue with
how to handle the contaminated dressings, how to
disinfect surfaces, etc.)
6hAFIE8 11
IE8MI NüLüߥ
1. incubation period
2. irritable; fatigue; elevated temperature
3. prodromal
4. leukocytosis
5. virulence; pathogen; susceptibility
6. isolation
7. Transmission precautions
8. human immunodefciency virus
9. Contact precautions
10. direct contact
8hü8I AN8WE8
1. Any fve of the following:
a. presence of a surgical incision
b. presence of an artifcial airway
c. presence of an indwelling urinary catheter
d. insertion of an intravenous line, central
line, or arterial line
e. presence of an implanted prosthetic device
f. repeated injections or venipunctures
g. presence of immune compromise in the
patient
2. Any of the items in Health Promotion Points
17-1.
3. a. Monitor diagnostic test reports related to
infection.
b. Continually observe patients for signs of
infection.
c. Implement procedures to contain microor-
ganisms when infection is suspected.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 31
d. Properly handle, sterilize, or dispose of
contaminated items and equipment.
e. Utilize approved sanitation methods.
f. Recognize individuals at high risk for infec-
tion and implement appropriate protec-
tion.
4. With airborne precautions a room with nega-
tive air pressure is required and a respiratory
device mask is essential.
5. Any three of the following:
a. Keep the patient stimulated with appropri-
ate activities.
b. Increase sensory stimulation if signs of sen-
sory deprivation appear.
c. Listen to the patient’s feelings; give encour-
agement such as positive comments on ef-
forts at grooming or self-amusement.
d. Engage in conversation with the patient
about his or her particular interests or hob-
bies.
6. There is less exposure to heath care–acquired
infection and strict surgical asepsis is not as
necessary. Dirty supplies must be disposed of
in sealed plastic bags. Washing in a solution of
hot, soapy water with chlorine bleach will kill
most organisms. One set of linens is used by
the patient. Clean gloves may be used in place
of sterile gloves in many instances.
7. Place a special N95 particulate mask on the pa-
tient.
8. The older person’s immune system is not as
active as the younger person’s. When an older
person has one infection, there is greater risk of
contracting another because the body’s avail-
able defenses are already working to fght the
frst infection.
9. a. Puncture wounds from contaminated nee-
dles or other sharps.
b. Skin contact allowing infectious fuids to
enter through damaged or broken skin.
c. Mucous membrane contact where infec-
tious fuids enter through the mucous
membranes of the eyes, mouth, and nose.
10. a. Know what is sterile.
b. Know what is not sterile.
c. Separate sterile from unsterile.
d. Remedy contamination immediately.
11. a. Perform hand hygiene each time before
touching the patient, the catheter, the IV
site, IV line, or dressing. Wear clean gloves
when providing care. Cleanse the spout on
the catheter bag after emptying it. Inspect
the IV site continuously throughout the
shift for signs of infammation. Maintain
strict asepsis when changing the IV solu-
tion or the IV line. Perform the dressing
change using sterile technique. Do not talk
while changing the dressing. Handle the
catheter gently so that it does not cause
undue irritation of the urinary meatus or
bladder. Cleanse the catheter according to
agency policy when bathing him.
b. Perform hand hygiene before approaching
the patient. Use strict sterile technique for
insertion of the catheter. Tape the catheter
to the abdomen or leg so that there is no
pulling on the balloon which can cause ir-
ritation of the bladder when the patient
moves. Cleanse the spout of the drainage
bag after emptying it. Encourage a high
intake of fuid to keep the bladder fushed
unless contraindicated.
c. Obtain an order for a condom catheter or
other device to prevent urine contamina-
tion of the patient’s dressing. Keep his lin-
ens clean and dry. Perform hand hygiene
before giving care. Perform hand hygiene
and change gloves after cleaning up after
incontinence. Perform hand hygiene and
use gloves when turning the patient.
12. a. A sterile feld is only sterile when in con-
stant view. Even when in a sterile gown, the
back of the gown is not considered sterile
and would expose the feld to possible
pathogens.
b. Talking over a sterile feld is to be avoided
because saliva or droplets from the respira-
tory system may fall on the feld.
c. Moisture will carry microorganisms from
the outside of the package wrapper to the
items on the feld.
d. The outside of the unopened sterile pack-
ages are not sterile and will contaminate
the entire sterile feld if placed on it.
Packages should be aseptically opened and
their contents dropped into the sterile feld
from its edge.
MAI6hI Nß
All answers can be found in Box 17-1.
1. a, c
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 32
2. a, d
3. a, c
4. a, b
5. a, d
6. a, c
7. a, d
8. a, b, d
9. a, c
10. a, c
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. a. Signs of wound infection
b. Fever and malaise
c. Elevated temperature and increased white
blood cell count
d. Positive culture results
2. Risk for infection related to open wound
3. Carefully planning care and gathering all need-
ed supplies before going to the patient’s room;
anticipating patient needs.
4. About the disease process, modes of transmis-
sion, and precautions necessary to prevent
spread of the infection
5. An N-95 special particulate flter mask must be
worn when in the room.
6. a. Determining that all signs and symptoms
of the infection are gone.
b. Determining that the infection has not
been transmitted to any other patient or
a health care worker on the unit or in the
hospital.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 1, 2, 3, 4, 5
3. 1
4. hand hygiene
5. 4
6. 1, 2, 4
7. 1, 2, 4
8. 3
9. 4
10. 3
11. 1
12. 2
13. 2
14. 3
15. 3
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. The patient’s safety is at risk. Everyone in the
room is responsible for pointing out breaks in
sterility. You must point out the contamination
to the surgeon. Think about how you would do
this.
2. Determine what activities and hobbies the pa-
tient has. Work with the patient to plan activi-
ties to prevent boredom and sensory depriva-
tion.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. immunocompromised
2. integrity
3. residual
4. scalding
5. sensory deprivation
6. enhance
¥ü6AßüLA8¥ EkE86I 8E8
1. prevents spread of microorganisms/infection
2. identifcation bracelet
3. elevated temperature
4. people
5. quieter
6. initials
7. intact
8. true
9. body fuids and water
10. director of nurses
6üMMüNI 6AII üN EkE86I 8E8
Answers will be individual. This exercise will help you
to become comfortable with patient teaching.
6hAFIE8 18
IE8MI NüLüߥ
A. Mat chi og
1. f
2. d
3. b
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 33
4. e
5. c
6. a
ß. 6oæpI et i oo
1. back injury
2. pivot
3. muscles; the legs
4. necrosis
5. shoulder’s width
6. symmetry
7. ambulate
8. gait
9. logrolling
10. dangle
11. transfer (gait) belt
12. contracture
8hü8I AN8WE8
1. a. The biggest cause of injury to health care
workers is repetitive lifting.
b. Back injuries cause loss of work time and
are expensive for the employer.
2. a. an erect head centered over the body
b. buttocks in the same plane as the shoulders
with the thighs parallel to the shoulders
c. weight evenly distributed over the buttocks
and thighs
d. knees fexed at about 90 degrees with the
feet resting comfortably on the foot rests or
foor
e. arms lying comfortably in the lap or sup-
ported by the chair armrests or lap board
3. a. about shoulder-width apart
b. coordinated movements
c. close to your body
d. level or height as the object to be moved
e. pivot rather than push or twist
f. of the movement
4. Any similar example to the following: (Box 18-
1)
a. Use a wide base of support when transfer-
ring a patient. Keep feet about shoulder-
width apart.
b. Using the arms as levers placed beneath the
patient and rocking back on the heels to
move the patient to the side of the bed.
c. Lifting a box with elbows bent at sides to
keep weight of the box close to the body
and stabilize the center of gravity.
d. Raising the bed to almost waist height be-
fore attempting to reposition the patient to
reduce back strain.
e. Pulling, using weight as a counterforce,
to reduce the workload. Pivoting during a
transfer to prevent twisting the body and
possible back injury. (Synthesis of informa-
tion, pp. 261-262)
f. Face the head of the bed when moving the
patient up in the bed.
5. a. Interference with circulation which may
lead to pressure ulcers
b. Muscle cramps and possible contracture
c. Fluid collection in the lungs
6. a. Place pillows lengthwise under the arms
from the armpit to the wrist, allowing the
hand to fall slightly over the end of the pil-
low. Place a rolled pillow on the outside of
each leg to prevent external rotation. Use
a footboard or sneakers to keep the ankles
and feet in proper alignment. Place a fat,
small pillow at the curvature of the lower
spine to prevent excessive straightening of
the spine.
b. Place pillows lengthwise under each arm
to prevent undue rotation of the shoulders
and to support the joints of the arms. Place
a pillow beneath the knees, supporting
above and below the joint to help prevent
the patient from slipping down in the bed.
Place a pillow lengthwise behind the back
for comfort as indicated.
7. Lock the wheels of the wheelchair and the bed.
Place your arms under the axillae and your
hands on the scapulae. Assist to stand while
bracing the patient’s legs with your knees. Pivot
so that patient’s back is toward the bed. When
patient’s legs are against the mattress, lower the
body onto the bed. Reposition for correct align-
ment in the bed.
8. The weight of the object or person is drawn
close to the body, stabilizing your own center of
gravity.
9. Prone position is used when the patient is on
prolonged bed rest and immobilized when the
patient can tolerate the position.
10. Have patient wear sturdy slippers, allow to
stand before walking to decrease dizziness; keep
tubes and lines from tangling in legs or trip-
ping patient; use gait belt or support patient
adequately; ask to keep head up and stand as
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 34
straight as possible; do not overestimate the
distance patient can walk without extreme fa-
tigue or weakness.
11. maximally stretched; fexibility of the joint
12. 3-5
13. extremity
14. The book seems lighter when held close to the
body.
MAI6hI Nß
1. c
2. e
3. a
4. f
5. d
6. b
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. That the head is in alignment with the body,
the shoulders and hips are parallel, knees and
ankles are slightly fexed, arms hang comfort-
ably at the sides, and the feet have support.
2. Impaired physical mobility
3. The patient will master use of a wheelchair
within one month.
4. active; passive
5. logrolling
6. lock the wheels of the wheelchair
7. body mechanics
8. a. Ambulated with assistance 1/2 of the length
of the hall.
b. Ambulated length of the hall with the walk-
er.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2
2. 2, 3
3. Sims’
4. 3
5. 3
6. 4
7. 2
8. 3, 4
9. 1
10. 2, 3
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. If allowed, raise and lower the head of the bed
slightly frequently to redistribute the weight
over the sacral area. Provide a trapeze so that
the patient can reposition and lift the buttocks
off the mattress from time to time.
2. All areas against the mattress: anterior hip, lat-
eral knees, ankles, right elbow, left ear.
3. Hand and foot splints or footboard, various
size pillows or sandbags.
STEPS TOWARD BETTER
COMMUNI CATI ON
¥ü6AßüLA8¥ EkE86I 8E
The striated muscle works to move the extremities.
Inertia for long periods tends to make the muscles
atrophy. When muscles are not exercised and joints
are not moved, the joints are predisposed to con-
tractures. Exercising the joints also alleviates the
pain that can occur with inactivity. Proper position-
ing ensures that the weight of the body is dispersed
over a broad area. When performing ROM exer-
cises, it is best not to hyperfex a joint, as that may
cause injury. When transferring a patient from the
bed to a chair, a wide base of support is used so that
you do not sway while moving the patient.
F8üNüN6I AII üN üF ßI FFI 6üLI IE8M8
prognosis prog NO sis
design de SIGN
aligned a LIGNED
magnifcent mag NIF i cent
6üMMüNI 6AII üN EkE86I 8E
Dialogue will be individual. Here is an example:
Nurse: “Good morning, Mr. Brown. Are you ready
for your walk today?”
Mr. B.: “Uh-huh.”
Nurse: “First, I am going to raise the head of your
bed, to let you get oriented, and I will lower the bed
so your feet can reach the foor. Let me help you
sit up and swing your legs over the side of the bed,
that’s it! Does that feel OK?”
Mr. B.: (Waves his hand.) “Uh-uh!”
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 35
Nurse: “Are you dizzy? Just sit there for a minute,
while I get your slippers on. OK. Do you feel better
now?”
Mr. B.: (Nods.) “Uh-huh. OK.”
Nurse: “All right, if you are ready now, we will
stand up. Put your arms around my shoulders.”
Nurse: “I’m going to help you up now; one, two,
three.”
Mr. B.: “Uhhhh...”
Nurse: “Let’s just stand here until you are stable
and then we will walk around the room.”
Mr. B.: “OK.”
Nurse: “Stand straight now and walk.”
Mr. B.: “Uh-huh.”
Nurse: “You are doing fne, Mr. B.”
6hAFIE8 19
IE8MI NüLüߥ
A. Mat chi og
1. g
2. a
3. i
4. d
5. j
6. b
7. f
8. e
9. h
10. c
ß. 6oæpI et i oo
1. reactive hyperemia
2. diaphoresis
3. epidermis
4. caries
5. melanin
6. maceration
7. syncope
8E¥I EW üF 8I8ü6Iü8E ANß FüN6II üN
All answers may be found in the Overview of
Structure and Function of the Integumentary System.
1. Melanin
2. keratin
3. Sebaceous glands
4. Sebum
5. Sweat glands
6. Mucous membranes
7. dermis; corium
8. Skin
8hü8I AN8WE8
1. Any four of the following:
a. Loss of elastic fbers and adipose tissue
leads to wrinkles and sagging.
b. Loss of collagen fbers makes the skin more
fragile and slower to heal.
c. Decreased sebaceous gland activity causes
dryness and itching.
d. Temperature control is altered due to loss
of density of the skin and decreased seba-
ceous gland activity.
e. The number of hair follicles decreases,
leading to slowed growth and thinning hair.
f. Nail growth decreases and nails thicken.
2. (See Box 19-1)
a. Bed or chair confnement: continuous pres-
sure may occur at a particular area if posi-
tion is not changed.
b. Inability to move: Cannot alter pressure
over dependent areas even slightly.
c. Loss of bowel or bladder control: Moisture
contributes to maceration of skin and colo-
nization of bacteria.
d. Poor nutrition: Protein and vitamins are
needed for skin cell regeneration and to
maintain skin health.
e. Lowered mental awareness: Unaware of
how long has remained in one position
causing pressure over same areas for long
periods.
3. Dehydration, obesity, excessive diaphoresis, ex-
treme age (fragile skin), and edema
4. Any fve interventions from Safety Alert 19-1.
Examples:
a. Change the patient’s position at least q2h.
b. Use pressure-reducing devices as appropri-
ate.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 3ë
c. Minimize skin injury caused by friction
and shear forces when repositioning.
d. Keep the patient clean and dry.
e. Provide adequate nutrition and fuid in-
take.
5. See Figure 19-3; requires critical thinking.
a. Wheelchair: buttocks, sacral area, elbows,
heels
b. Semi-Fowler’s: buttocks, sacral area, backs
of thighs, heels, thoracic spine, back of
head
c. Sims’: left anterior hip, outside of left knee
and ankle, left inner elbow, left shoulder,
left ear
6. the bath
7. 1/2 to 3/4 the amount of time that pressure was
present to cause the redness.
8. Any three characteristics listed.
a. Stage I: red, deep pink, or mottled skin; no
blanching; warmth, edema, or induration.
b. Stage II: partial thickness skin loss; sur-
rounding area warm, reddening.
c. Stage III: full thickness skin loss; damaged
or necrotic subcutaneous tissue; bacterial
infection; drainage.
d. Stage IV: full thickness skin loss with exten-
sive tissue necrosis, sinus tracts, infection,
black eschar present, wet and oozing.
9. the location of the abnormality, its color and
size and reaction to the blanch test
10. a. Cleanse the skin
b. Promote comfort
c. Stimulate circulation to all areas of the
body
d. Remove waste products secreted through
the skin
11. Face, hands, axillae, and perineal area
12. a. Cleanse
b. Stimulate peripheral circulation
c. Provide comfort
13. healing
14. rectal; perineal
15. confned to bed
16. 8
17. a container with normal saline or water
18. diabetic; vascular insuffciency
19. Basin of water or a stoppered sink with some
water in the bottom
20. submerging
21. 18 or below
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. a. Cultural views regarding hygiene practices
b. Self-care abilities
2. Self-care defcit, hygiene
3. Patient will maintain normal hygiene practices
with assistance.
4. Make certain that the room is suffciently warm
with no drafts; the patient is adequately covered
with a bath blanket; skin is adequately rinsed
of soap; water is changed as it cools or becomes
too soapy; attention to perineal care is paid un-
less patient can easily reach these areas; mois-
turizing lotion is applied immediately after the
bath.
5. Skin over all bony prominences is without red-
ness or break.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 2
3. 2
4. 3
5. 3
6. 1, 4
7. 2
8. 1
9. constantly moist skin
10. 3
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Patients have a right to refuse any procedure.
Inquire why the bath is refused. See if there is a
better time for bathing.
2. See if there is an electric razor on the unit that
is sterile and that can be resterilized for the next
patient. Have a family member bring his razor
from home. Inquire if it is all right to shave him
with a disposable safety razor.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. exacerbation
2. nick
3. mottled
4. don
5. débridement
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 31
¥ü6AßüLA8¥ EkE86I 8E8
1. e
2. d
3. b
4. c
5. a
Wü8ß AIIA6k 8kI LL8
1. outer, on
2. skin
3. hard
6üMMüNI 6AII üN EkE86I 8E
Yes you should talk, but be sensitive to the patient’s
feelings. He may just want to relax, and enjoy the
pleasure of having someone take care of him, espe-
cially during the backrub.
Talk about the weather, the seasons, ask about fam-
ily, or visitors, tell something about your activities.
During the bath is a good time to gather further
assessment data, explore learning needs, and begin
patient teaching.
6hAFIE8 20
IE8MI NüLüߥ
1. environment
2. ventilation
3. humidity
4. poison
5. bioterrorism
8hü8I AN8WE8
1. a. temperature
b. ventilation
d. lighting
e. odor
f. noise
2. 68°–74° F (20°–23° C)
3. safety; comfortable
4. a. Refrain from putting odorous items in the
patient unit trash.
b. Refrain from wearing perfumes, scented
lotions, or scented cosmetics while at work.
5. Avoiding long conversations on the intercom
and limiting staff conversation in the hallway;
speak in a lowered voice.
6. glare; soft and diffuse
7. the far side rail; the bed to working height
8. a. Use good body alignment.
b. Maintain a wide base of support.
c. Face toward the direction of movement.
d. Bend at the knees rather than bending the
back.
e. Raise the bed to the proper working height.
9. Toileting the patient on a regular schedule to
prevent the need for getting up without assis-
tance.
10. Any four measures from Box 20-3. Individual
judgment dictates what is most important.
11. a. Patient with diabetes
b. Patient with impaired circulation
c. Paralyzed patient without sensory feeling
d. Patient receiving drugs that alter mental
awareness
12. any equipment that could cause a spark
13. a. Location of fre alarms
b. Location of fre extinguishers
c. Escape routes from the unit
d. Techniques for rescuing patients
14. Rescue the patient quickly.
Activate the fre alarm system.
Contain the fre by closing doors and windows.
Extinguish the fames.
15. the release of pathogenic microorganisms into
the community
16. a. gas
b. liquid
c. solid
17. 45
18. convulsions, paralysis, and death
19. time, distance, and shielding
20. nausea, vomiting, diarrhea, loss of appetite, fa-
tigue, fever, skin damage, hair loss, seizures, and
coma
21. b, a, c, d, although some would say b, c, a, d. It
takes experience to triage accurately.
22. decontamination with removal of clothing and
jewelry and scrubbing down
23. childproof latches
24. last resort
25. to bring in items from home that are familiar
such as photographs, a quilt, pillow, etc.
26. a sudden change in mental status or behavior
27. index and middle fngers
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 38
28. knots that are easy to undo
29. 2 hours; exercises
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 1
2. 1, 3
3. 2
4. 2
5. 1, 3
6. 3
7. 2
8. 3
9. cardiovascular
10. 3
11. 1, 4
12. 4
13. 1
14. 4
15. 2
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Have someone sit with him.
Use a bed alarm.
Remind him where he is and why.
Try to determine why he wants to get up.
2. A fre safety inventory is required; answer will
depend on what defciencies are found.
3. A poison safety inspection is needed; answer
will depend on what is found.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. diffuse
2. noxious
3. frayed
4. tact
5. neat and tidy
6. glare
7. compromise
8. prone
9. altercations
10. refrain from
¥ü6AßüLA8¥ EkE86I 8E8
1.
Word Physical/
Tangible
Emotional/
Intangible
frayed worn at the
edges
irritated, an-
noyed
glare a strong refected
light
to look hard at
someone with
anger or hatred
miter tall, pointed
bishop’s hat
making a corner
with two pieces
at an angle
prone lying face down likely to happen
slump to slide or bend
into a low posi-
tion
to fall or sink
down
stife preventing or
restricting from
getting air
prevent some-
one from doing
something
2. a. I hate clutter; I like to keep my work area
neat and tidy.
b. That light produces too much glare, and I
would like you to do something to diffuse
the light.
6üMMüNI 6AII üN EkE86I 8E8
1. I am putting your bed rails up for your safety so
you won’t fall out.
2. Could you please lower your voices or move
into the lounge area? Some patients are trying
to rest.
3. We do this for her own safety. We check them
regularly to be sure she is comfortable.
4. Be careful, the tea is hot.
ß8AMMA8 FüI NI8
1. in the role of
2. because
3. to the same amount
4. for example
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 39
6hAFIE8 21
IE8MI NüLüߥ
A. Mat chi og
1. f
2. b
3. h
4. a
5. i
6. e
7. d
8. j
9. c
10. g
ß. 6oæpI et i oo
1. bradypnea
2. dyspnea
3. diastolic
4. crisis
5. auscultatory gap
6. basal metabolic rate (BMR)
7. metabolism
8. hypothalamus; feedback
9. cardiac output
8E¥I EW üF 8I8ü6Iü8E ANß FüN6II üN
All answers for this section are in “Overview of the
Structures and their Functions that Regulate the Vital
Signs.”
1. cellular chemical reactions in the body
2. the thyroid, epinephrine, norepinephrine, and
testosterone hormones, and muscle movement
that produces heat
3. diaphoresis
4. into the aorta per heartbeat
5. sinoatrial node
6. stroke volume
7. 5 liters
8. the diaphragm
9. alveolar membrane
10. the nose, pharynx, larynx, trachea, bronchi,
lungs, diaphragm, and respiratory muscles
11. surfactant
12. pons; medulla
13. carotid bodies; aortic body
14. maximum pressure exerted on the arteries dur-
ing left ventricular contraction (systole)
15. the heart is at rest and pressure in the arteries is
lowest
16. stroke
17. peripheral vascular
18. decreases
19. increase
20. normal temperature
21. increased
8hü8I AN8WE8
1. If inaccurate, they will give a false picture of
the patient’s status. Comparing the current
readings with previous ones depicts trends in
temperature, blood pressure, pulse, and respira-
tions.
2. 97.5°–99.5° F; 36°–37.5° C
3. 60–100 bpm
4. Rhythm and volume
5. Over the radial artery, temporal artery, carotid
artery, femoral artery, popliteal artery, posterior
tibial artery, and dorsalis pedis artery
6. Apex of the heart [ffth intercostal space (ICS)
at mid-clavicular line]; a full minute
7. a. Bradycardia (synthesis of information)
b. Tachycardia
c. Arrhythmia
d. Unable to palpate (name the pulse site)
8. 101.3° F, or 38.5° C
9. brain; hypothalamus
10. 120/70
11. Any fve of the following factors helpful for ac-
curate BP determination:
a. Have the patient rest for at least 5 minutes
before taking the blood pressure.
b. Position the arm at heart level and support
it.
c. Attach the cuff over the bare arm.
d. Center the bladder of the cuff over the bra-
chial artery.
e. Infate the cuff while palpating the artery,
noting the level at which the pulse disap-
pears. Infate the cuff 30 mm Hg over the
level at which the pulse disappeared when
auscultating the pressure.
f. Place the diaphragm of the stethoscope
frmly but lightly over the artery with all
edges of the diaphragm in contact with the
skin.
g. Defate the cuff at about 2 mm Hg per sec-
ond and defate to zero.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 40
12. dizziness; faintness
13. orthostatic or postural
14. count the apical pulse rate at exactly the same
time as another nurse counts the radial pulse
using the same watch for both of you. Subtract
the radial pulse from the apical pulse to obtain
the pulse defcit.
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. A temporal artery or tympanic thermometer
would be best. The tympanic thermometer
should be used in the ear canal pointing toward
the tympanic membrane. Pull the ear lobe
downward gently to straighten the canal.
2. You can count the radial pulse or the brachial
pulse.
3. If the radial pulse is irregular, tell the patient
you are having trouble feeling the pulse and
take an apical pulse rate for a full minute.
4. A large adult blood pressure cuff should be
used with the sphygmomanometer and stetho-
scope. A normal adult cuff will not ft most
patients with this weight and will give a falsely
high reading.
5. You might place a hand on the chest and mea-
sure the rise of the chest on inspiration, or use a
stethoscope on the chest to listen to the breaths.
6. a. Hyperthermia related to unknown cause
b. Ineffective breathing pattern related to im-
paired respiration
c. Decreased cardiac output related to rapid
heart rate
d. Ineffective tissue perfusion related to de-
creased systemic blood fow associated with
increased vascular resistance (Other possible
nursing diagnoses might be: Risk for injury
related to consistently elevated blood pressure;
Defcient knowledge regarding disease process
and therapeutic regimen; Risk for ineffective
management of therapeutic regimen)
7. a. Temperature will return to normal with ad-
ministration of antipyretic within 8 hours.
b. Breathing will return to normal pattern
with 1 hour of use of bronchodilator medi-
cation.
c. Heart rate will return to normal within 8
hours after initiating beta blocker therapy.
d. Blood pressure will return to normal level
within 1 week after beginning antihyper-
tensive therapy.
8. a. Temperature 98.6° F (37.0° C) at 4 p.m. (6
hours later.)
b. Respirations 20 1 hour after nebulizer
treatment with albuterol.
c. Heart rate 94 bpm at 4 p.m. (8 hours after
medication)
d. BP 136/86 at clinic visit 1 week after initiat-
ing antihypertensive therapy.
9. See if there is an order for an antipyretic and
administer it if there is. Otherwise notify the
physician and obtain the order. Remove excess
bed covers and check the room temperature
to keep it no higher than 72° F. Encourage the
patient to drink a lot of fuid unless contraindi-
cated.
10. Recheck the pressure and if this happens again
assume that this is an auscultatory gap. Make a
note of the occurrence in the chart. Record the
frst sounds heard as the systolic pressure.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 2
3. 4
4. 1
5. 2, 4
6. 4
7. 2, 4
8. 1
9. 3
10. 1
11. 4
12. 124
13. higher
14. 3
15. 2
16. 1, 2, 3
17. 1
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. The respiratory rate will vary when a lower
respiratory infection is present. Causes include
secretions in the lungs interfering with oxygen
and carbon dioxide dispersion, narrowing of
bronchioles and bronchi, or obstruction of air-
ways, causing the body to increase the rate to
obtain suffcient oxygen.
2. Tries to conserve and manufacture heat to raise
the set point for core temperature. Because the
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 41
person feels cold, clothes or covers are used
to conserve heat and the person huddles with
extremities held curled close to the body, envi-
ronmental heat may be turned up. Chills may
occur that increase body metabolism thereby
increasing heat production.
3. A major examination causes some degree of
anxiety. Anxiety stimulates the sympathetic
nervous system which in turn raises the heart
rate.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. abatement
2. alter
3. contraindicated
4. propelled
5. fared
6. simultaneously
7. distract
8. clockwise
9. blunt
10. peripheral
¥ü6AßüLA8¥ EkE86I 8E8
Text Conversation
Blunt Short,
stubby, or
fat
Straightforward;
not very tactful
Superfcial Close to the
surface
Speaking in
generalities
or of nothing
important
Wü8ß AIIA6k 8kI LL8
1. he mo/dy NAM ics, blood/movement = move-
ment of the blood and pressures within the
body
2. an te/CUB ital space, above/the elbow = surface
of the arm in front of the elbow
F8üNüN6I AII üN 8kI LL8
ap ne a bra dyp ne a ta chyp ne a eup ne a
dysp ne a
hy pox i a ar rhyth mi a tach y car di a
di as tol ic a scul ta tory
feb rile py rex i a def er ves ence di a phor e sis
sphyg mo man om e ter
6üMMüNI 6AII üN EkE86I 8E8
8aæpI e ßi aI ogue ß
Nurse: “Slip this probe under your tongue. The
thermometer will beep when it is done. Turn your
arm over for me, so I can feel your pulse more eas-
ily. (Places fngers over artery.) There it is. It is regu-
lar at 76 beats per minute.”
6hAFIE8 22
IE8MI NüLüߥ
A. Mat chi og
1. k
2. i
3. b
4. f
5. c
6. e
7. l
8. m
9. h
10. j
11. g
12. d
13. a
ß. 6oæpI et i oo
1. bronchovesicular
2. turgor
3. stridor
4. adventitious
5. wheeze
6. Rinne
7. Weber
8. ascites
9. crackles
10. lordosis
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 42
I ßENII FI 6AII üN
1. c
2. d
3. d
4. b, d
5. e
6. a, b
7. e, a
8. b
9. a, b
10. b
8hü8I AN8WE8
1. a. Determining the patient’s level of health
and physiologic functioning
b. Arriving at a tentative nursing diagnosis of
a health problem
c. Confrming a diagnosis of dysfunction,
disease, or inability to carry out activities of
daily living
d. Indicating specifc body areas or systems
for addition examination or testing
e. Evaluating the effectiveness of prescribed
treatment and therapy and observing for
adverse side effects
f. Monitoring for changes in body function
2. a. Female genitalia, pelvic exam
b. Rectal exam
c. Flexible sigmoidoscopy
3. a. Mentation and level of consciousness (Skill
22-2)
b. Pupil refexes and extraocular movements;
size, equality, reaction, and accommodation
to light
c. Motor movements to command, and mus-
cle strength
d. Vital signs
4. a. Health history factors
b. Current health problems
c. Psychosocial/cultural data
5. a. Rest and activity
b. Nutritional, fuid, and electrolytes
c. Safety and security
d. Hygiene and grooming
e. Oxygenation and circulation needs
f. Psychosocial needs
g. Elimination and education needs
6. a. Need for and timing of regular physical ex-
amination
b. Recommended periodic diagnostic tests
c. Need and schedule for immunizations
d. Warning signs of cancer
e. How to perform breast self-exam
f. How to perform testicular self-exam
6üMFLEII üN
1. sweetish
2. striking the third fnger of one hand with the
index or middle fnger of the other
3. dialysis shunt; mastectomy
4. valve sounds
5. mucous membranes
6. compared bilaterally
7. tibia; ankle
8. expected outcomes
9. RNS HOPE
10. head-to-toe
11. diagnostic tests
12. unnecessary exposure
13. neurologic exam
14. 12
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. the patient, the family, the chart, other health
care workers involved in the patient’s care, and
diagnostic test results
2. an individualized plan of care can be formu-
lated
3. sight is the most helpful method (observation
and inspection)
4. data indicating problems that are defning char-
acteristics for the various nursing diagnoses are
used to support the choice of the diagnoses for
that patient
5. setting priorities of care and incorporating all
tasks and assessments needed for the shift into
the work organization plan
6. at the beginning of each shift and whenever
there appears to be a change in the patient’s
condition
7. implementing the plan’s interventions and then
evaluating whether the interventions helped the
patient reach the expected outcomes
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. palpation
3. 3
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 43
4. 2
5. 1, 3
6. 1, 4
7. 4
8. 3
9. 1
10. 1, 2, 3
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Auscultate the heart and lungs, including heart
valve sounds. Check all peripheral pulses and
compare bilaterally.
2. Blood work—laboratory tests
Mammogram, Pap smear
Stool for occult blood
Digital rectal exam; PSA test
Proctosigmoidoscopy
Urinalysis
3. See Box 22-6.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. appraising
2. opacity
3. holistic
4. ascertaining
5. subsides
6. acronym
7. patent
8. astute
¥ü6AßüLA8¥ EkE86I 8E8
1. abnormal
2. a word made from the initials of other words
3. occluded
4. sluggish
Wü8ß AIIA6k 8kI LL8
Fr oouoci at i oo oI ßi I I i cuI t Ier æs
A. Requires practice pronouncing the words.
B. 1. sphyg/mo/ma/nom/e/ter
2. oph/thal/mo/scope
Abbr evi at i oos
1. Point of maximal impulse
2. Pupils equal, round, reactive to light, and ac-
commodation
3. Breast self-exam
4. Patient-controlled analgesia
5. Activities of daily living
6. Testicular self-exam
7. Extraocular movements
8. Gastrointestinal
9. Digital rectal exam
6üMMüNI 6AII üN EkE86I 8E
A. Requires practice with a partner.
B. Who can you count on when you are having a
problem or an emergency?
Are you ever depressed or really feeling blue?
Will you be able to have someone care for you
at home while you recover, or would you like
to speak with the social worker to arrange your
convalescence?
Will you be able to obtain your medications
and dressing supplies without a problem?
What are your fears or concerns at this point in
time?
Let’s wait and see what the pathology report
and prognosis are to see if there is a further
problem.
How will you change your dressing and care for
your incision?
C. Each dialogue will be different depending on
your personality and knowledge level. Share
your dialog with a peer or your instructor for
comments.
6hAFIE8 23
IE8MI NüLüߥ
A. Mat chi og
1. f
2. e
3. c
4. a
5. d
6. b
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 44
ß. 6oæpI et i oo
1. admitting department
2. emergency admission
3. Medicare
4. TRICARE
5. routine
6. Managed care
8hü8I AN8WE8
1. stored in the closet or sent home; anything the
patient will not be using while in the hospital
should be sent home
2. a. Location of call bell and its operation.
b. Location of bathroom and its call bell.
c. How to operate the television and tele-
phone.
d. Explain visiting hours.
e. Explain NPO if necessary or tell meal
times.
f. Explain services available; i.e., chaplain, so-
cial worker, etc.
g. Answer questions.
3. a. primary and secondary diagnoses
b. current orders
c. medications including dosage, route, fre-
quency, and time of last dose given
d. physician names and phone numbers
e. brief synopsis of the hospital stay
4. a. rest and activity directions and restrictions
b. diet instructions
c. wound care
d. medications and when to take them
e. signs and symptoms of problems to report
to the physician
f. name and phone number of the physician
5. Immediately notify the physician. After the
death is pronounced, the nurse prepares the
body for viewing by the family, and then the
body is given postmortem care.
6. Sent home with the family; placed within a
valuables envelope, listed, sealed, and placed in
the hospital safe
7. accuracy of transcription
8. on the front of the chart, on the admission as-
sessment, on the MAR, and on a patient arm-
band per agency policy
9. physician; business offce and the family
10. adequate communication between caregivers
11. the physician
12. personal belongings
13. Wound care, diabetic care and teaching, IV
medication administration
14. physical therapy, occupational therapy, speech
therapy, respiratory care, personal care
15. notify the physician
16. listen to what the patient has to say, answer
questions, offer to ask the physician or super-
vising nurse to talk with the patient; ask the
patient to sign the AMA form
17. not pay for the treatment that has been received
18. a. Simply sit with the bereaved, listen, and of-
fer quiet comfort.
b. Offer to call the priest, rabbi, or religious
leader.
c. Provide privacy for grieving.
d. Tell the person you are sorry for the loss of
the loved one.
19. a. Death is from unknown causes.
b. Death is at the hands of another.
c. Patient has not been under the care of a
physician within a specifc time.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2
2. 3
3. 1, 3, 4
4. 4
5. 1
6. 4
7. 3
8. 4
9. 2
10. 1, 2, 4
11. 1
12. AMA (against medical advice)
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Answers will be individual.
2. Seek out relatives, his employer, and friends to
supply the needed information.
3. Seek the assistance of the social worker; enlist
the aid of a relative or neighbor to look in on
her if she is self-suffcient.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 45
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. signifcant other
2. protocols
3. verifed
4. synopsis
5. alleviate
6. devastating
7. lethargic
8. In general
Wü8ß AIIA6k 8kI LL8
1. drowsy
2. active
3. rectal
4. easy
5. deep
6. blind
6üMMüNI 6AII üN EkE86I 8E
Each role play will be individual.
6hAFIE8 24
IE8MI NüLüߥ
1. complete blood count (CBC); hemoglobin; he-
matocrit
2. hematocrit
3. endoscope
4. hematoma
5. jaundice
6. panel
7. polyps
8. smear
9. transducer
10. tonsilar
MAI6hI Nß
1. f
2. c
3. g
4. b
5. h
6. e
7. i
8. d
9. j
10. a
11. l
12. k
6üMFLEII üN
1. granulocytes
2. blood vessels
3. ultrasonic waves
4. hematology; components
5. leukocytosis; infection
6. prothrombin time
7. sedimentation
8. 8–12
9. standard precautions
10. glucometer
11. blood urea nitrogen (BUN); creatinine
12. deteriorates quickly
13. pathologist
14. movement
15. tissues; cells
16. kidneys, ureters, bladder
17. metal
18. electrical activity
19. heart; valves; coronary
20. pulmonary; capacity; diffusion
21. radionuclide
22. drink; water
23. GI
24. large intestine
25. endoscopic retrograde cholangiopancreatogra-
phy; stricture; cyst; stones
26. immediately
27. in a preservative solution
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 4
2. 1, 2
3. 1
4. 2
5. 1
6. 2
7. 4
8. 1
9. 1, 3
10. 4
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 4ë
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. a. Assess what the patient knows about the
test.
b. Assess what concerns the patient has about
the test.
c. Assess for safety measures that need to be
implemented before or after the test.
d. Assess for allergy to medication used for
the test or to skin preparation solutions to
be used.
2. Defcient knowledge related to unfamiliarity with
diagnostic test
3. Patient will verbalize purpose of the test and
what will be experienced during and after the
test.
4. patient teaching regarding the test
5. implementing safety measures such as frequent
vital signs, forcing fuids, or other measures to
protect the patient
6. compare the result with the previous test result
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. —what exactly is done
—purpose
—sensations patient will feel
—how long it takes
—pretest sedation
—post-test routine
2. —describe machine and sensations
—need for keeping still
—methods of dealing with claustrophobia
—amount of time it takes
3. Describe how ultrasound waves refect struc-
tures.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. diagnostic
2. titer
3. deteriorates
4. troubleshoot
Wü8ß AIIA6k 8kI LL8
1. endoscope, microscope, fuoroscope, gastro-
scope, sigmoidoscope, cystoscope, stethoscope
2. cystoscopy, gastroscopy, proctosigmoidoscopy,
sigmoidoscopy, fuoroscopy, colonoscopy
3. arteriograph
4. angiography, ultrasonography, sonography,
radiography, cineradiography, tomography,
arteriography, cholangiopancreatography, elec-
troencephalography
F8üNüN6I AII üN üF ßI FFI 6üLI IE8M8
1. AN gi OG ra phy
2. cho LAN gi o PAN cre a TOG ra phy
3. cys TOS co py
4. e LEC tro en CEPH al o gram
5. gas TROS co py
6. my o CAR di al in FARC tion
7. PAR a cen TE sis
8. PROC to sig moid OS co py
9. RA di o o PAQUE
10. RA di o IM mu no AS says
11. THO ra cen TE sis
6üMMüNI 6AII üN EkE86I 8E
Practice increases pronunciation and intonation abil-
ity.
6hAFIE8 25
IE8MI NüLüߥ
A. Mat chi og
1. d
2. c
3. g
4. f
5. h
6. a
7. j
8. k
9. i
10. e
11. l
12. b
ß. 6oæpI et i oo
1. hypovolemia
2. cardiac arrhythmia
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 41
3. hypocalcemia
4. diffusion
5. Osmosis
6. isotonic
7. hypertonic
8. edema
9. fltration
10. active transport
11. hypernatremia
12. hyperkalemia
13. hypermagnesemia
14. hyperventilation
15. diabetic
I ßENII FI 6AII üN
A.
1. High—hyperkalemia
2. Normal
3. High—hypercalcemia
4. Normal
5. Normal
6. Low—hyponatremia
ß.
1. Respiratory acidosis
2. Respiratory alkalosis
3. Metabolic acidosis
4. Metabolic alkalosis
8hü8I AN8WE8
1. a. As a vehicle for the transportation of sub-
stances to and from the cells
b. To aid heat regulation by providing perspi-
ration which evaporates
c. To assist maintenance of hydrogen ion bal-
ance in the body
d. To serve as a medium for the enzymatic ac-
tion of digestion
2. a positively charged cation for each negatively
charged anion in the fuid
3. plasma proteins and plasma colloid osmotic
pressure
4. the plasma volume of the blood; blood pressure
and circulation
5. daily weight
6. a pulse rate over 100 bpm
7. neuromuscular irritability
8. tap the facial nerve about an inch in front of
the earlobe
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Diarrhea, fatigue, nausea or anorexia, palpita-
tions, muscle weakness or paresthesia
2. Mucous membranes, urine output, and appear-
ance of eyes
3. Ineffective tissue perfusion
4. Diarrhea will stop within 24 hours; patient will
regain normal fuid balance within 8 hours;
electrolyte imbalances will be corrected within
48 hours
5. take in only clear liquids; take small sips of elec-
trolyte solution such as Gatorade every hour;
give an antidiarrheal drug; encourage intake of
water and other liquids; attempt to determine
cause of diarrhea; provide antinausea medica-
tion if needed, keep the room free from odors
6. skin turgor, weight, mucous membranes, intake
and output 24-hour totals for several days, tem-
perature, and whether excessive fuid loss has
stopped, electrolyte lab values
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 4
2. 3
3. 1
4. 1
5. 2, 3
6. 450 mL
7. 4
8. 1
9. 3
10. 4
11. 1, 2
12. 2
13. 2, 4
14. 3
15. 1
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Cover kidney’s role in potassium regulation in
the blood. Review foods containing potassium.
Meats must be decreased; see Patient Teaching
25-2.
2. Present how sodium affects blood pressure.
Refer to Patient Teaching Table 25-1 and work
with the patient’s food preferences to devise an
appropriate diet. Refer to the low-sodium diet
in Appendix 7 of the textbook.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 48
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. considerable
2. compensatory
3. tracking
4. twitch
5. lethargic
6. buffer
7. ingestion
¥ü6AßüLA8¥ EkE86I 8E8
1. Lung sounds: moist
2. Pulse: weak, full, bounding, thready, faint, slow,
rapid
3. Blood pressure: elevated
4. Mucous membranes: moist, dry, sticky
5. Urine: scanty
6. Skin: moist, dry, sticky, pale
Wü8ß AIIA6k 8kI LL8
1. shallow—deep
2. rapid—slow
3. passive—active
4. moist—dry
5. attraction—repellent
6. gain—loss
7. increase—decrease
8. defcit—excess
6üMMüNI 6AII üN EkE86I 8E
Dialogue written will vary among individuals. Here is
an example.
Nurse: “Mr. Jones, we will be monitoring all the
fuids that you take into your body and all that are
excreted. We do this any time a patient is receiving
IV fuids to make certain that he is not receiving
more fuid than the body can handle.”
Mr. J.: “So what will I have to do?”
Nurse: “You will need to write down on this sheet
all the fuids that you drink. You can just note 1/2
glass water or 1 cup of coffee and I will translate
that amount into milliliters.”
Mr. J.: “I think I can manage to do that.”
Nurse: “You will also need to be certain you use
this container when you empty your bladder. Set it
aside and turn on the call light. Someone will come
and empty the container and record the amount of
urine that was in it.”
Mr. J.: “I can’t do that myself? I hate to leave that
for someone else to do.”
Nurse: “We really need to look at the urine when
we measure it as well, so I’d prefer that you just let
us handle that task.”
Mr. J.: “OK, if you say so. I want to do what is
best.”
Nurse: “Thank you, Mr. J.”
6hAFIE8 2ë
IE8MI NüLüߥ
A. Mat chi og
1. o
2. k
3. d
4. b
5. j
6. i
7. g
8. e
9. h
10. m
11. a
12. n
13. c
14. f
15. l
ß. 6oæpI et i oo
1. carotenoids
2. incomplete protein
3. complementary proteins
4. essential
5. nonessential
6. Middle Eastern
7. kwashiorkor
8. vegan
9. unsaturated
10. saturated
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 49
11. toxicity
12. Kosher
8E¥I EW üF 8I8ü6Iü8E ANß FüN6II üN
All answers are found in the Overview of Structure
and Function section of the chapter.
1. h
2. d
3. b
4. a
5. e
6. g
7. c
8. f
8hü8I AN8WE8
1. a. fruits
b. vegetables
c. whole grains
d. fat-free or low-fat milk and milk products
2. linoleic acid, oleic acid, and linolenic acid
3. 25–30
4. Cells; tissues; play a role in maintaining fuid
balance, assist with transportation of nutrients,
and are necessary for antibody and hormone
production
5. 10–15
6. 50–60; 4
7. a. Provide a quick source of energy
b. Regulate protein and fat metabolism
c. Help fght infection
d. Promote growth of body tissues
e. Provide fber for bulk in the stool, aiding
waste elimination
8. breads, pasta, cereal, potatoes, and rice
9. metabolism; cellular
10. 500 mL
11. Examples will be of individual choice. Some
examples are:
a. Age: Older adults may receive inadequate
nutrition because of diffculty in obtaining
or preparing food.
b. Illness: Nausea may cause inadequate nutri-
ent intake.
c. Emotional status: Severe stress may cause
either anorexia or overeating and weight
gain.
d. Economic status: Inadequate funds may
lead to a diet defcient in protein.
e. Religion: Food may need to be prepared in
a certain way in order to be acceptable.
f. Culture: Appetite is usually better when
foods are familiar.
12. 6; double; triple
13. accessibility of nutrition information, nutrition
education, nutrition counseling and related ser-
vices, and healthful foods
14. sweets
15. fast foods
16. evening; obesity
17. older adults
18. 5; 3
19. 48
20. complete protein, vitamins, and minerals
21. 24.9
I ßENII FI 6AII üN
A.
All answers are in Table 26-6.
1. A
2. D
3. B
1
4. C
5. K
6. B
6
7. Folic acid
8. E
9. B
2
(ribofavin)
10. B
12
ß. Fuoct i oo oI Mi oer aI s
All answers may be found in Table 26-4. Any one an-
swer is correct.
1. Calcium: muscle action, coagulation, building
of strong bones and teeth
Defciency causes: poor bone growth, poor
blood clotting
2. Chloride: maintenance of fuid and acid-base
balance, activation of gastric enzymes
Defciency causes: acid-base imbalance
3. Magnesium: build strong teeth and bones; pro-
tein synthesis; regulation of heartbeat
Defciency causes: cardiac arrhythmia; possible
confusion or poor memory
4. Phosphorus: build strong bones and teeth;
maintain acid-base balance
Defciency causes: weakness, stiff joints, an-
orexia
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 50
5. Potassium: maintain acid-base balance; trans-
mission of nerve impulses; helps control muscle
contractions; helps regulate heartbeat
Defciency causes: cardiac arrhythmia; hyper-
tension, possible impaired growth
6. Sodium: maintain acid-base and fuid balance
Defciency causes: hyponatremia; edema of
lower extremities
7. Chromium: activates enzymes; contributes to
removal of glucose from the blood
Defciency causes: central nervous system dys-
function; weight loss; aggravation of diabetes
mellitus
8. Fluoride: contributes to formation of bones
and teeth; decreases cavities
Defciency causes: risk of dental caries
9. Iodine: helps regulate metabolism; contributes
to healthy skin, hair, and nails
Defciency causes: goiter; cretinism in children
if mother was defcient during pregnancy
10. Iron: formation of hemoglobin
Defciency causes: iron-defciency anemia
11. Zinc: immune function; protein synthesis; nor-
mal growth and sexual development; wound
healing
Defciency causes: depressed immune function;
poor growth; delayed sexual maturation
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. BMI=24.2
2. Risk for Imbalanced nutrition: less than body re-
quirements
3. a. Patient will stabilize body weight after sur-
gery within 2 months.
b. Patient will not develop diarrhea when
feeding is resumed.
4. a. Weigh patient three times per week.
b. Ask family to bring in favorite foods to
tempt appetite.
c. Start small, frequent feedings as tolerated
and slowly increase amounts.
d. Monitor closely for diarrhea or abdominal
distention.
5. a. Weight is stabilized at 128 lbs.
b. Diarrhea minimal and stopped after 3 days.
6. Refusing most of diet due to anorexia.
Weight loss of 0.5 lb. this week.
Loose stools occurred after frst 3 feedings.
Continues to experience intermittent diarrhea.
7. Revise the plan of care in attempt to fnd inter-
ventions that will assist the patient to meet the
expected outcomes.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
Answers require synthesis and application of knowl-
edge.
1. 2
2. 1, 4
3. 1, 2, 3
4. 3
5. 2
6. 3
7. 1
8. 3
9. 2
10. 1
11. 4
12. 3
13. 4
14. 3
15. 1
16. 2, 4
17. 2, 4
18. 1
19. 4
20. thyroid gland
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. See Table 26-4 for problems of defciency of the
various B vitamins.
2. Plan choices using the food pyramid and
calorie and fat charts for various fast foods.
Consider Jackie’s likes and dislikes. Suggest
take-along foods such as fresh fruit and snack
packs of carrots. Discuss nutrition bars.
3. Recommend fnger foods such as high-quality
hot dog pieces or low-fat sausage pieces, chunks
of cheese cut into fun shapes. Raw vegetable
pieces may be more appealing than cooked
vegetables. Refrain from sweet foods as much
as possible. Use 100% juice rather than juice
drinks. Try a variety of foods. Offer small re-
wards such as a story if all food is eaten. Feed
more frequently throughout the day.
4. Individual answers will indicate changes need-
ed.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 51
STEPS TOWARD BETTER
COMMUNI CATI ON
¥ü6AßüLA8¥ EkE86I 8E8
1. Child rearing is comprised of feeding, clothing,
nourishing, training, loving, and educating a
child.
2. Finicky eaters consume some foods sparingly.
3. The lack of green vegetables in his diet compro-
mised his health.
4. Many volunteers for the Meals on Wheels pro-
gram are retired and enjoy helping their peers.
6üMMüNI 6AII üN EkE86I 8E
Nurse: (1) Morning, Ms. Andrews. How’re you to-
day?
Ms. A.: I’m OK, but I wish (2) they’d gimme a bet-
ter breakfast!
Nurse: (3) Whaddaya mean? What’d you have?
Ms. A.: Just some lukewarm watery tea, (4) and cold
oatmeal and milk—with no salt. And the toast was
dry and cold.
Nurse: (5) Doesn’t sound very appetizing. I’ll speak
to dietary. Didya call the nurse and askfer hot tea?
Ms. A.: (7) Naw. ‘t wasn’t worth it. I’m goin’ home
today anyway.
Nurse: That’s good news. But (8) ya’know you’re
on a low-sodium diet. That means you’re not (9)
sposed ta have salt added to your food.
Ms. A.: Not even a little in cooking?
Nurse: Not if (10) ya want to follow doctor’s orders
and keep your blood pressure down. We don’t want
to see you back in here again.
Ms. A.: No offense, but I (11) don’ wanna BE back
here again.
(12) I’ll jus’hafta try ta get usta it, I guess.
Nurse: That’s the spirit. Now let me take your vital
signs.
1. Good Morning, Ms. Andrews. How are you to-
day?
2. they would give me
3. What do you mean? What did you have?
4. and cold oatmeal and milk. And the toast was
dry and cold.
5. That doesn’t
6. Did you call the nurse and ask for hot tea?
7. No. It wasn’t worth it. I am going home today,
anyway.
8. You know you are
9. supposed to
10. you
11. don’t want
12. I’ll just have to try to get used to it.
6hAFIE8 21
IE8MI NüLüߥ
A. 6oæpI et i oo
1. atherosclerosis
2. CHF (congestive heart failure)
3. glycosuria
4. dysphagia
5. obesity
6. bulimia
7. hypertension
8. hypertension
9. PEG (percutaneous endoscopic gastrostomy)
10. hyperosmolality
11. residue
I ßENII FI 6AII üN
Answers may be found in Table 27-1.
1. N (unless it is strained)
2. B
3. F
4. B
5. F
6. N
7. B
8. B
9. F
10. F
11. B
12. F
8hü8I AN8WE8
1. a. have paralysis or immobilization of an arm
b. are visually impaired
c. have an intravenous line in their hand or
arm
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 52
d. are severely weak or impaired
2. 6–8
3. psychological; nutritional
4. 5 lbs.; 1 lb.
5. thiamin
6. cardiovascular disease, diabetes, hypertension,
gallbladder disease, and colon and breast cancer
7. fat; sodium
8. fruits, vegetables, nuts, seeds, legumes, and low-
fat dairy products
9. secreted in normal amounts but receptor sites
won’t let it into the cells
10. a. hypertension
b. cardiovascular disease
c. kidney disease
d. stroke
e. blindness
11. 70–110
12. a. Maintaining high calorie intake
b. Increasing protein intake to maintain or
increase muscle mass
c. Offering bland, soft, or puréed foods when
the mouth is painful
d. Adding thickening agents to liquids if swal-
lowing is diffcult
e. Adding seasoning to help food taste more
appealing
f. Encouraging small frequent meals
13. a. dysphagia from a stroke
b. infammatory bowel disease
c. HIV/AIDS
d. cancer treatment
14. administering each feeding or giving a medica-
tion
15. More freedom of ambulation, easier to admin-
ister own feedings, no need for general anesthe-
sia for placement, less harmful to body image
16. Measure the tube length from skin level to the
end of the placement adapter. Compare the
measurements to the initial measurements
right after placement.
17. 8–12
18. glycosuria; diarrhea
19. Any four of the principles listed in Table 27-1.
20. speed up the rate to catch up on the amount
that should have been infused
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
Any four of the following from Table 27-5.
1. a. Measure daily weight
b. Monitor blood glucose levels every 4 hours
until stable.
c. Assess rate of fow to determine that solu-
tion is fowing no faster than rate ordered.
d. Track intake and output to prevent exces-
sive diuresis from glycosuria caused by the
TPN.
e. Monitor vital signs to detect any sign of in-
fection or complication from the TPN line
or solution.
f. Monitor albumin levels to determine nutri-
tional status.
2. Nutrition, imbalanced, less than body require-
ments related to anorexia and diffculty eating.
Defcient fuid volume, related to diarrhea. Risk
for injury related to possible aspiration related to
tube feeding.
3. Expected outcomes will depend on the nursing
diagnoses chosen. For the nursing diagnoses in
#1 above, the expected outcomes might be:
a. Caloric intake will be 2500 calories per day.
b. Fluid intake and output will be balanced
within 48 hours.
c. No injury from aspiration of tube feeding
will occur while feeding tube is in place.
4. a. Sit the patient upright at least 30 degrees
before feeding and leave up for 60 minutes
after feeding to prevent refux and aspira-
tion.
b. Check the placement of the tube to be cer-
tain it is in the stomach or intestinal tract
before initiating the feeding.
c. Check for amount of residual feeding at
least every 4 hours or before initiating an
intermittent feeding to be certain emptying
and absorption is occurring.
d. Give the solution slowly to prevent too
rapid a carbohydrate load, upsetting blood
glucose levels and causing diarrhea and
electrolyte imbalance.
5. Correct order is:
a. 3 Unclamp the tube.
b. 7 Flush the tube with water.
c. 4 Check the placement of the tube.
d. 2 Elevate the patient’s head and upper
body.
e. 1 Prepare the feeding bag.
f. 5 Check for residual feeding in the
stomach.
g. 6 Start the feeding.
h. 8 Reclamp the tube.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 53
6. Evaluation statements might be:
a. Patient demonstrates no nausea or diar-
rhea.
b. Weight has remained the same or there is
weight gain.
c. No evidence of muscle wasting or abnor-
mal serum albumin level.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 20–30
2. 2
3.
4. 3
5. 1, 2, 3
6. 2
7. 2
8. 5
9. 2
10. 3, 4
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Consider ways to decrease sodium-containing
foods; no added salt at the table or in cooking.
Should include menus for several days.
2. Frequent small meals; experiment with season-
ings to enhance taste. Add powdered milk to
solids such as meatloaf, mashed potatoes, cas-
seroles, etc. Make high-powered milk shakes
using fruits and protein powder. Add extra egg
to casseroles and dishes such as meatloaf.
3. Decrease sodium-containing foods; substitute
broiled or baked foods for deep frying. Switch
from use of lard and saturated oils to unsatu-
rated oils for cooking.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. discrepancies
2. bland
3. resection
4. binge
5. collaboration
6. trimester
7. exacerbation
8. instilled
6hAFIE8 28
IE8MI NüLüߥ
A. Mat chi og
1. m
2. h
3. e
4. g
5. i
6. j
7. c
8. d
9. k
10. f
11. b
12. l
13. n
14. o
15. a
ß. 6oæpI et i oo
1. apnea
2. tracheostomy
3. obturator
4. inspiration
5. expiration
6. hypoxemia
7. ventilation
8. Respiration
8E¥I EW üF 8I8ü6Iü8E ANß FüN6II üN
1. Central nervous system
2. Cilia
3. Alveolar macrophages
4. Chemoreceptors
5. Mucous membranes
6. Alveolar membrane
7. Trachea
8. Upper airway passages
8hü8I AN8WE8
1. See Skill 28-2. Ask if the person can speak;
stand behind the person and place arms around
the person halfway between the umbilicus and
the xiphoid process with one hand forming a
1
or 4
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 54
fst and the other over the fst. With an upward
motion forcefully thrust the hands into the ab-
domen at an upward angle.
2. a. Nasal cannula: patient can eat while receiv-
ing oxygen.
b. Simple mask: allows higher delivery of oxy-
gen than cannula.
c. Partial rebreathing mask: Can deliver 60-
80% oxygen fow.
d. Non-rebreathing mask: Can deliver 80-95%
oxygen in an emergency situation.
e. Venturi mask: Delivers consistent FiO
2
re-
gardless of breathing pattern.
f. Tracheostomy collar: Adds humidity to
oxygen fow for a tracheostomy.
g. T-bar: Adds humidity to oxygen fow for a
tracheostomy.
3. a. Preoxygenate the patient.
b. Maintain sterility of the suction catheter
and supplies.
c. Be certain suction is turned on before in-
serting the catheter.
d. Do not suction for more than 10 seconds.
4. Any fve of the following:
a. restlessness and irritability
b. increasing agitation
c. confusion
d. tachypnea
e. stridor
f. retractions
g. cardiac arrhythmia
h. cyanosis
5. Making certain that the sensor is attached and
functioning properly, the machine is properly
set, that a trend of decreasing oxygen satura-
tion is reported promptly to the physician, and
documenting readings at intervals.
6. a. To relieve an airway obstruction
b. To protect the airway
c. To facilitate suctioning
d. To provide artifcial ventilation
8EüüEN6I Nß
7 Check the carotid pulse (which is absent).
2 Call for help.
1 Shake and shout name or “Are you OK?” (No)
10 Give two breaths.
8 Position hands for chest compressions.
6 Give two breaths.
9 Give 15 chest compressions.
3 Tilt head and open airway.
5 Form seal around nose and mouth with your
mouth.
4 Check for presence of respiration (none pres-
ent).
11 Continue CPR sequence.
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Auscultate her lungs, take her vital signs, check
skin and mucous membrane color, assess short-
ness of breath with activity, check mentation.
2. Impaired gas exchange related to retained secre-
tions in right lower lobe.
3. Gas exchange will improve within 2 days.
4. Turn, cough, and deep-breathe at least every 2
hours; use incentive spirometer; ambulate fre-
quently; increase fuid intake to thin secretions;
administer oxygen as ordered; monitor lung
status and respiratory rate; provide postural
drainage if ordered.
5. Actions are effective if lungs are clear to aus-
cultation and there is no shortness of breath;
respiratory rate is within normal limits.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 4–6
2. 1
3. 1, 2, 3
4. 4
5. 2, 4
6. 3
7. 1 week
8. 1
9. 3
10. 1
11. 2–12
12. 2
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Medicate for pain; assist to splint ribs to cough;
teach forced exhalation coughing.
2. — When it will be done
— Pain medication beforehand
— How it will feel
— Need for occlusive dressing
3. — Monitor oxygen saturation of the blood in
noninvasive fashion
— Explain mechanics of light probe
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 55
— Meaning of readout on screen
— Alarms
— How readings are used
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. copious
2. brink
3. ambient
4. combustion
6hAFIE8 29
IE8MI NüLüߥ
A. Mat chi og
1. e
2. f
3. i
4. h
5. a
6. g
7. j
8. b
9. c
10. d
ß. 6oæpI et i oo
1. nocturia
2. micturition
3. residual urine
4. retention
5. incontinence
6. void
7. catheterization
8. condom catheter
8E¥I EW üF 8I8ü6Iü8E ANß FüN6II üN
1. c
2. f
3. d
4. b
5. a
6. e
I ßENII FI 6AII üN
1. __x_ Color: tea color
2. ____ Character: slightly cloudy
3. ____ Specifc Gravity: 1.025
4. ____ pH: 6.0
5. __x_ Glucose: 1+
6. __x_ Protein: 1+
7. ____ Ketones: 0
8. __x_ Leukocytes: moderate
9. ____ Erythrocytes: 0
10. __x_ Bilirubin: slight
11. __x_ Pyuria: trace
8hü8I AN8WE8
1. frequency of urination, urgency, dysuria, burn-
ing, malaise, foul-smelling urine, a slight tem-
perature elevation
2. Any four of the following:
a. When the patient cannot empty the blad-
der for more than 8 hours
b. To prepare for drainage of urine during a
surgical procedure or after an obstetrical
procedure
c. To help dilate the urethral opening
d. To splint the urethra after surgery
e. To measure residual urine
f. To monitor urine output accurately
g. To provide an avenue for bladder irrigation
h. Assist with retoning of the bladder after
bladder surgery
3. discard the catheter and use a sterile one in or-
der to avoid introducing bacteria into the blad-
der.
4. regularly experience urinary retention or in-
continence such as those who have a neuro-
muscular problem that prevents them from
emptying the bladder normally
5. Any three of the following:
a. Wash out residual urine or sediment from
the bladder.
b. Remove clots and stop oozing of blood af-
ter prostate or bladder surgery.
c. Soothe irritated bladder tissues and pro-
mote healing.
d. Ensure that the lumen of the indwelling
catheter is open and draining.
e. Instill medication into the bladder.
6. Encourage a large fuid intake unless contra-
indicated, include cranberry juice in the diet,
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 5ë
provide supplemental vitamin C, maintain ste-
rility when emptying the collection bag, clean
around the urinary meatus and rinse well at
least once a day
7. always maintain aseptic technique
8. bladder retraining program; use of a condom
catheter; teaching Kegel exercises; toileting ev-
ery 2 hours while awake; using adult briefs or
absorbent pads; surgical correction of the prob-
lem; drug therapy
9. label the specimen correctly with the patient’s
name, room number, physician’s name, date
and time; place the container in a biohazard
transport bag; transport it to the lab within
15 minutes of collection or refrigerate it until
specimen pick-up time
6üMFLEII üN
1. 1000–1800 mL
2. infection
3. 8
4. 15 minutes
5. discard
6. stone
7. dehydration
8. standing
9. Coudé
10. instillation
11. dilute
12. beneath the buttocks
13. urinary meatus; the vaginal opening
14. bladder tone
15. the drainage output
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Is there any burning? Do you have trouble ini-
tiating the stream? Is there a foul smell to the
urine? What color is the urine? How much fuid
are you drinking? Do you have get up a lot at
night? What medications are you taking?
2. Impaired urinary elimination
*Urinary retention
Risk for infection
3. a. Urine elimination will be maintained with
use of catheter or drugs.
b. Normal urinary pattern will be reestab-
lished after 2 months of drug therapy.
4. He is at risk for urinary tract infection because
of the retention. Decreasing fuid volume will
increase that risk. He should drink normal
amounts of fuid.
5. Palpate the bladder after he voids to determine
if there is still retention. Assess output and
compare it to input to see if there is a balance.
Assess if voidings are becoming less frequent
and of more volume.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 1
3. 2
4. 2, 3
5. 4
6. 2
7. 3, 4
8. 2
9. 4
10. 1
11. 2
12. 1
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Base the plan on the individual and Patient
Teaching 29-2.
2. Use Health Promotion Points “How to Prevent
Cystitis” and adjust teaching to the individual.
3. Explain dangers of urine backing up into the
kidney. Explain the functions of the kidney and
how they can be damaged.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. bulbous
2. impede
3. stasis
4. instillation
5. prone
6. pucker
7. patent
¥ü6AßüLA8¥ EkE86I 8E8
Answers will be individual. Examples are:
1. The patient with the fractured hip and a Foley
catheter was dependent on the nurse to help
him turn in bed.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 51
2. The tubing leading to the Foley catheter drain-
age bag should not be dependent; it should be
kept above the level of the bag.
3. The preoperative order is invalid because the
patient has had surgery. New orders are needed.
4. While recovering from kidney surgery, the pa-
tient is considered an invalid.
5. When stasis of urine occurs regularly, the pa-
tient is prone to urinary tract infection.
6. After placement of the urostomy tube, the pa-
tient was more comfortable on his side or in a
prone position.
6hAFIE8 30
IE8MI NüLüߥ
A. Mat chi og
1. k
2. e
3. l
4. c
5. j
6. i
7. f
8. g
9. b
10. h
11. a
12. d
ß. 6oæpI et i oo
1. fecal impaction
2. do not change
3. incontinence
4. melena; stomach; small intestine
5. vagal response
6. Valsalva maneuver
7. colostomy
8. atrophy
9. rubber baby nipple
10. periostomal
11. effuent
8E¥I EW üF 8I8ü6Iü8E ANß FüN6II üN
1. g
2. a
3. c
4. j
5. h
6. d
7. i
8. b
9. f
10. e
8hü8I AN8WE8
1. Any four of the following:
a. 1–3 tablespoons of bran mixed with apple-
sauce
b. small amounts of prune juice
c. warmed prune juice and cola
d. hot water with lemon juice
e. small serving of stewed or dried prunes
2. a. Melena: bleeding in the stomach or small
intestine
b. Occult blood: small amount of bleeding in
the intestines
c. Pale-colored stool: blockage of bile fow
into the intestine
d. Mucus: Irritation or infammation of the
bowel
e. Foul-smelling stool that foats in water: too
much undigested fat in the stool; lack of
digestive enzymes and bile
f. Liquid stool; gastrointestinal infection or
toxicity causing diarrhea
g. Hard, dry stool: lack of fuid and fber or
lack of peristalsis
3. a. loss of body function and change in body
image
b. possibility of rejection by others
c. loss of physical or sexual attractiveness
d. death from underlying disease
4. A visit from a member of the United Ostomy
Association
5. a. Colostomy
b. Ileostomy
c. Continent diversion (pouch) (Figure 30-6)
6. a. Increase dietary fber
b. Increase fuid intake
c. Exercise regularly
d. Heed the urge to defecate
7. a. Testing the fuid temperature to be sure it
isn’t too hot.
b. Keeping the height of the enema bag no
more than 18 inches above the rectum.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 58
c. Controlling the fow of the fuid so that it
doesn’t run in too fast.
d. Stopping the fow if the patient experiences
severe cramping.
8. a. Colon cancer
b. Abdominal trauma
c. Congenital malformation of the bowel
d. Severe Crohn’s disease or ulcerative colitis
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. obtain a history of usual bowel function, diet,
and medications; characteristics of the stool;
changes in appearance of stool or pattern of
bowel movements; auscultate bowel sounds;
palpate and percuss abdomen
2. Risk for constipation related to inactivity and
narcotic pain medication
3. Patient will have normal bowel movements be-
fore discharge.
4. increase fuid intake; add fber to the diet; give a
stool softener or bulk-forming laxative; provide
privacy for defecation; assess abdominal status
and bowel pattern
5. bowel movements and appearance of stool
(intake and output; dietary intake; and toler-
ance of stool softener or bulk-forming laxative
would be assessed also)
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2–3
2. Sims’
3 1
4. 4
5. 4
6. 3
7. 1, 4
8. 2
9. 3
10. 3
11. 4
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Teach basics of how bowel works. Cover points
of bowel dietary and exercise intervention and
the importance of paying attention to the urge
to defecate. Individualize the plan to accommo-
date eating in restaurants most of the time.
2. How to collect the stool—Saran Wrap
TM
over
toilet bowl, paper plate, etc.; How much stool to
place on the test window.
3. See Steps 30-2 and individualize to the patient
as needed.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. heed
2. distention
3. triggering
4. wafer
5. oblique
6. commode
7. scanty
Wü8ß AIIA6k 8kI LL8
1. Colostomy is located along the colon.
2. Ileostomy is located along the ileum of the
small intestine.
3. Urostomy is located on the abdominal wall
where the ureter is attached to discharge urine
from the kidney.
6hAFIE8 31
IE8MI NüLüߥ
1. f
2. d
3. h
4. l
5. c
6. b
7. i
8. e
9. k
10. g
11. a
12. j
8hü8I AN8WE8
1. Biofeedback: use of a machine that measures
the degree of muscular tension to teach the pa-
tient to relax particular muscles.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 59
2. Distraction technique: patient focuses on a
word or object and the concentration blocks
out the pain sensations.
3. Epidural analgesia: catheter is placed in epidu-
ral space and opioid analgesic is administered
via a pump.
4. Guided imagery: patient is assisted to form
pleasant mental images of another place which
takes focus off of pain sensations.
5. Hypnosis: inducing a trance-like state using
focusing and relaxing techniques to alter con-
sciousness.
6. Meditation technique: patient concentrates on
a focal point such as a visual point, a sound, a
repeated phrase, or on his or her own breath-
ing, which turns attention away from pain.
7. Patient-controlled analgesia: intravenous opi-
oid medication administered from a pump by
the patient.
8. Relaxation technique: Techniques to relax mus-
cle groups that decrease muscle tension, thereby
reducing pain.
9. Transcutaneous electrical nerve stimulation:
small electrical stimulator delivers pulses of
electrical current which block the transmission
of pain sensations.
10. skin, joints, or organ viscera
11. a. Transduction: NSAIDs to block substances
that trigger the nociceptors.
b. Transmission: Opioids to interfere with the
transmission of impulses from nociceptors.
c. Perception: Distraction or guided imagery
to divert perception away from the pain.
d. Modulation: Drugs that block neurotrans-
mitter uptake.
12. unblocking the meridians, allowing for the free
fow of energy and a relief of symptoms
13. neuropathic
14 a. nonopioid medications
b. narcotics or opioids
c. adjuvant analgesics
15. cause nerve damage
16. 16; brain development
17. 9–10; want to go to bed later and to sleep later
in the morning. School hours interfere and
many teens are sleep-deprived predisposing to
driving accidents.
18. a. Fear
b. Pain
c. Stress
d. Medication side effects
19. 10–11
20. Non-rapid eye movement sleep (NREM)
21. a. Stage 1: a light sleep with relaxed muscles
lasting only a few minutes
b. Stage 2: a deeper sleep with more brain
wave activity and bursts of electrical activ-
ity lasting about 20 minutes
c. Stage 3: delta sleep with slow brain waves;
respirations and heart rate slow and the
body becomes immobile; lasts 30 minutes
to an hour
d. Stage 4: deepest stage of sleep with person
diffcult to arouse; lasts about 30 minutes
e. REM sleep: brain waves become active as
if awake; dreams occur; lasts 20 minutes or
longer
22. a. Too much caffeine
b. Nicotine from smoking
c. Alcohol consumption can cause nocturnal
awakenings
d. Regular exercise promotes sleep, but not
too close to bedtime
e. Napping during the day may disrupt night-
time sleep
23. a. Environment is too noisy.
b. Room is too hot or too cold.
c. Room is too brightly lit.
24. continuous positive airway pressure (CPAP)
machine use while sleeping
25. a. physical structural obstruction of air pas-
sages
b. obstruction due to allergy or cold
26. a. warm water compresses
b. warm blankets
c. Aquathermia pads
d. tub and whirlpool baths
e. chemical self-heating packs
f. heat-producing equipment
27. sudden-onset, recurrent, uncontrollable brief
episodes of sleep during hours of wakefulness
28. clinical evaluation, sleep logs, and sleep labora-
tory tests
29. increasing circulation to the area which can
help remove waste substances from overuse or
injury
30. a. Use a barrier between the ice pack and the
skin.
b. Limit duration of use to 15–20 minutes at a
time.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë0
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Look for changes in his vital signs; develop a
system of communication in writing or point-
ing to pictures. Use a pain scale by pointing to
the options and have him blink or move his
head for “yes” and “no” answers. Study his body
language for clues to the degree of pain.
2. Nursing diagnoses chosen will vary. Examples
are:
Anxiety related to inability to communicate nor-
mally
Risk for infection related to multiple trauma and
intubation
Impaired mobility related to trauma and ventila-
tion
Self-care defcit related to immobility
3. Expected outcomes will vary depending on
choice of nursing diagnoses. Examples: (syn-
thesis and application of knowledge)
a. Patient will learn to use alternative means
of communication by the end of the shift.
b. Patient will not develop wound or respira-
tory infection while immobilized.
c. Patient will not develop muscle atrophy
while immobilized.
d. Patient will resume self-care activities when
no longer immobilized.
4. a. Administration of analgesia via PCA pump
b. Use of distraction in the form of video-
games or TV
c. Use of guided relaxation exercises or imag-
ery
d. Use of cold packs over injured joints
5. Statements will vary depending on the expected
outcomes written. Examples: NCP 31-1
a. Indicates PCA pump is controlling pain.
b. Did not use PCA while engaged in playing
videogame.
c. Indicated guided relaxation helps decrease
pain.
d. Indicates cold packs feel good and reduce
pain.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 1
3. 2
4. frozen peas
5. 4
6. 1, 2, 3, 4
7. 2
8. 3
9. 1, 2, 4
10. 2, 4
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Consult Patient Teaching 31-1.
2. Use Table 31-2 and a drug handbook.
3. Use progressive relaxation starting at the toes or
head and going steadily down the body relaxing
the muscles in each area. Use slow, deep breaths
between each set of muscle relaxation.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
A.
1. adjuvant
2. stress
3. distraction
4. pantomime
5. divert
6. enhanced
7. perception
8. stoic
9. complementary
10. phantom
ß.
Examples are:
1. During the course of the night the patient ex-
perienced severe pain.
2. On occasion, over-the-counter pain medication
is effective for most patients.
3. During the course of an illness, over-the-
counter medication may be used before seeking
the help of a health care professional.
4. Most nurses on occasion get tired of the hours
of shift work.
5. Many nurses are likely to suffer from the effects
of shift work if they continuously have to work
the night shift.
6. Patients who are on prescription medications
and also take over-the-counter medications are
likely to suffer from some drug interactions.
7. Nurses do adjust to shift work to a fair degree
rather quickly.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë1
6üMMüNI 6AII üN EkE86I 8E8
Answers depend on individual responses.
6hAFIE8 32
IE8MI NüLüߥ
1. Accupressure
2. aromatherapy
3. chiropractic
4. Reiki
5. Folk medicine
8hü8I AN8WE8
1. a. The use of relaxation therapy along with
pain medication to increase comfort.
b. Chiropractic treatment along with muscle
relaxant and pain medication to treat a
back strain.
2. a. Relaxation techniques
b. Imagery
c. Meditation
d. Biofeedback
3. check for contraindications to the use of herbal
therapies, considering other medications the
patient is taking and the total health status of
the patient. The patient should be directed to
reliable information available about the herbals
being considered.
4. a. like cures like
b. the greater the dilution of the remedy, the
greater its potency
c. illness is specifc to the individual
6üMFLEII üN
1. Relaxation
2. National Center for Complementary and
Alternative Medicine (NCCAM)
3. Homeopathic medicine, naturopathic medi-
cine, traditional Chinese medicine, and
Ayurveda
4. philosophy
5. Acupuncture
6. redirecting mental focus; controlling breathing;
improving coordination; promoting relaxation
7. Ayurveda
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3, 4
2. 2, 3
3. 1, 3
4. 2, 4
5. 2
6. heart and respiratory rates
7. 2
8. 4
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Answers will vary according to which sites are
visited. Saw Palmetto is most frequently used to
treat benign prostatic hypertrophy. It is used to
decrease the size of the prostate. It is also a mild
diuretic. Its effectiveness is in question.
2. Chiropractic medicine is used mainly to treat
muscle and skeletal problems. It is often com-
bined with massage, electrostimulation of
muscle, and specifc exercises. Back strain and
whiplash injury are two commonly treated mal-
adies. It is based on the belief that correct spinal
alignment leads to healing of muscle strains
and impingement of nerves.
6üMFLEII üN
1. inherently
2. alignment
3. wafted
4. comprised
5. medium/conduit
¥ü6AßüLA8¥ EkE86I 8E8
1. Alternative means to do or use one thing in-
stead of another. EXAMPLE: Use relaxation
instead of giving a pain killer.
Complementary means to do or use in addition
to, to complete. EXAMPLE: Use relaxation as
well as giving a pain killer.
2. Compliment is a positive comment about
something; complimentary is a remark that
does that. EXAMPLE: That was a very good re-
port you gave in class.
Note: Complimentary can also mean free, or
without charge.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë2
3. Medium can mean a method or way of distri-
bution. EXAMPLE: Television is a medium for
advertising.
Medium can mean being in the middle.
EXAMPLE: What size do you wear? Small, me-
dium, or large?
Wü8ß AIIA6k 8kI LL8
Bioelectromagnetic-based (13)
Bio/electro/magnet/ic-base/d
bi o e lec tro mag net ic-base d
Contraindications (11)
Contra/indications
Con tra in di ca tions
Polarities (4)
Polar/ities
Po lar ities
6üMMüNI 6AII üN EkE86I 8E
Patient: I think I will skip my radiation treatments
and just eat a macrobiotic diet. My friend knows
someone who did that and is doing very well.
Nurse: You should talk to your doctor about that.
He can tell you the pros and cons of each.
Patient: What do you think about using St. John’s
wort to help my child?
Nurse: Be sure you ask the pharmacist about that
when you leave your prescription. Inform the phar-
macist of any medications your child is taking, your
child’s age, and why you wish to use St. John’s wort.
That way the pharmacist can give let you know
whether there are any contraindications to giving
your child that herb.
6hAFIE8 33
IE8MI NüLüߥ
A. Mat chi og
1. f
2. i
3. c
4. a
5. g
6. d
7. b
8. e
9. h
10. j
ß. 6oæpI et i oo
1. anaphylaxis
2. antagonist
3. drug interaction
4. pharmacodynamics
5. nursing implications
6. synergistic effect
7. therapeutic effect
8. toxic effect
8hü8I AN8WE8
1. a. The effect of the drug on a body system
b. The symptoms the drug relieves
c. The drug’s desired effect
2. safe and therapeutic effect of the drugs
3. they do not comprehend how the drug works,
why they are taking it, or that they need to take
it to maintain a steady blood level of the drug
so it can work
4. age, size, weight, and immaturity of organs
5. Any fve of the items in the textbook under
“Considerations for the Elderly”
Be certain that the patient understands what
each medication is for, when to take it, what
the potential side effects are, and what adverse
effects to report. Should be certain patient can
manage the pill containers or use a medication
planner box.
6. be certain the patient can open the medication
vials, uses a medication organizer if needed,
has written instructions as to when to take the
medications and what each medication is for,
and instruct family members about the medica-
tions
7. a. enter the body
b. reach the site of action
c. are metabolized and excreted
8. a. Purity
b. Potency
c. Bioavailability
d. Effcacy
e. Safety
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë3
9. a. Give the right drug
b. Give the right dose of the drug
c. Give the drug by the right route
d. Give the drug at the right time
e. Give the drug to the right person
10. a. What the drug is for
b. The effect the drug is supposed to have
c. When and how to take the drug
d. Precautions for taking the drug (with or
without food, etc.)
e Expected possible side effects
f. Adverse effects to report
11. every other day
12. check with the pharmacist and/or the physician
13. heparin, insulin, IV potassium, IV cardiac
drugs, and chemotherapy drugs
I ßENII FI 6AII üN
Answers are from Table 33-7.
1. b
2. e
3. a
4. c
5. h
6. d
7. f
8. g
ß8üß kNüWLEßßE
Answers can be found in any drug handbook or phar-
macology textbook.
1. Diuretic
2. 20–80 mg PO
3. PO, IV, or IM
4. Presence of anuria/hypersensitivity
5. In the morning; if second dose needed, take it
in the early afternoon
ß8üß 6AL6üLAII üN8 ANß 6üN¥E88I üN8
1. 2
2. 2.2
3. 300
4. 0.3
5. 2.76 or 3
6. 2 oz.
7. 4 capsules
8. 7.5 mL
9. 2 caps
10. 0.66 mL
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. “Mrs. Tanaka, may I see the medication vials
for those medications you are taking now? I
also need to see any other drugstore medicines
you are using even occasionally.”
For each drug, ask:
“How long have you been taking __________?”
“Have you noticed any problems with it?” (Ask
specifc questions regarding very common side
effects of the drug.)
“Do you remember to take each drug as you are
supposed to take it? How do you remember to
do that?”
2. You need to know:
a. any drug allergies she has.
b. how she plans to manage her drug regimen.
c. if any of the drugs interact.
d. nursing precautions and implications for
each drug.
e. usual and safe dosage range for each drug.
f. any side effects that she has suffered cur-
rently or in the past from the drugs she is
taking.
g. whether periodic laboratory testing is
needed for any of the drugs she is taking.
3. Noncompliance with drug regimen related to for-
getfulness.
4. Patient will use a medication planner to take all
prescribed doses of medication on time.
5. a. Assist Mrs. Tanaka to obtain a medication
planner and to set it up with the medica-
tions.
b. Make arrangements with a relative or
friend to help her refll her medication
planner each week.
c. Verify that therapeutic action of each drug
is occurring.
d. If needed, try to set up a telephone remind-
er system for Mrs. Tanaka.
e. Be certain Mrs. Tanaka understands the im-
portance and reason for taking each drug
to increase compliance.
6. Check the medication planner and pill vials at
each home visit to see that pills are indeed be-
ing taken. Question Mrs. Tanaka about when
she is taking her pills and how she is remem-
bering to use the planner. Speak with a relative
or friend who is helping Mrs. Tanaka to obtain
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë4
information about her medication compliance.
Evaluation statements might be:
Medication planner set up with prescribed
medications for one week. (Wed.) Medication
planner bins empty for Monday, Tuesday, and
Wednesday a.m. States has been remember-
ing to take medications. Sister states that Mrs.
Tanaka has been responsive to reminder calls
and has usually taken the medications already
when she calls.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2
2. 3
3. 1, 2
4. kidneys
5. 4
6. 2
7. 1
8. 1, 2, 3, 4
9. 3
10. 1
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Use a drug handbook or a pharmacology book
to locate the information needed to devise a
teaching plan. Cover action, side effects, adverse
effects to report, and nursing implications.
2. Review the laws governing the dispensing and
prescribing of scheduled drugs. Also cover
potential problems when taking a drug not pre-
scribed by physician (other drug interactions
and effects on chronic health conditions).
3. Health and health problems, allergies, why
patient is receiving the drug, other drugs and
over-the-counter medications being taken,
diagnostic tests scheduled on which the drug
might have an effect, side effects from previous
doses, what patient knows about the drug and
taking it.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. incompatible
2. compliant; tactful
3. readily
4. erroneously
5. categorize
6üMMüNI 6AII üN EkE86I 8E8
1. For this exercise, have the partner choose three
drugs that the patient might be taking. Drugs
will vary with the scenario.
2. For this exercise, use three other drugs. Atenolol
(Tenormin), alprazolam (Xanax), Vicodin (ac-
etaminophen with hydrocodone), and pravas-
tatin sodium (Pravachol) are other commonly
prescribed drugs, but any other drug may be
used.
3. Points to cover are:
a. what the drug is supposed to do.
b. how to take the drug.
c. when to take the drug and whether it must
be taken with or without food.
d. possible side effects of the drug.
e. adverse reactions to report to the physician.
f. what to do if a dose is forgotten.
g. what might happen if the medication is
stopped.
6hAFIE8 34
IE8MI NüLüߥ
A. Mat chi og
1. e
2. g
3. a
4. d
5. f
6. h
7. j
8. b
9. i
10. c
ß. Abbr evi at i oos
Vicjie Simons is being treated for asthma. Her
medications are not adequately controlling her
symptoms. The doctor orders a nebulizer treatment
for her immediately (stat) to relieve her broncho-
spasm. He tells her to discontinue the antihistamine
she has been taking as it does not seem to be help-
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë5
ing. He prescribes oral (PO) montelukast sodium
(Singulair) to be taken with water in the evening.
He puts her on another metered dose inhaler
(MDI), triamcinolone acetonide (Azmacort) and
tells her to use the new inhaler three times a day.
8hü8I AN8WE8
1. address, telephone number, date of birth, social
security number, stating name, visual recogni-
tion after one prior contact with the patient,
patient ID number on bracelet and the MAR
2. a. the correct dose (within range of normal
dose)
b. the route by which it may be given (appro-
priate route for this patient)
c. desired effects of the medication
d. potential side effects of the medication
e. interactions with other medications
f. any contraindications for giving this drug
to the patient
3. a. the full name of the patient
b. the full name of the drug
c. the dosage to be given
d. the route of administration
e. how often it is to be given
f. date the prescription was written
g. signature of the prescriber
4. a. anticoagulant
b. antihistamine
c. sedative hypnotic
d. bronchodilator
e. antibiotic
f. antidepressant
g. diuretic
h. anti-infammatory
5. spreading them on the skin, introducing them
into the rectum or vagina in a suppository, in-
stilling into eyes and ears as drops, applying to
the skin as a patch, or spreading them on mu-
cous membranes
6. a. sublingual tablets
b. enteric-coated tablets
c. sustained-release caplets
7. Any three of the following: (see Elder Care
points in chapter)
a. Whether patient is receiving another med
from another doctor for the same problem
b. Whether special caution is needed if the
patient has diffculty swallowing pills or
capsules
c. Whether the pill was swallowed after ad-
ministration or has ended up in the buccal
cavity
d. Whether there are liver or kidney problems
that require a reduced dosage of the drug
so that toxicity does not develop
8. daily: 0900
bid: 0900 and 1700
tid: 0900, 1300, and 1700
qid: 0900, 1300, 1700, and 2100
q4h: 0100, 0500, 0900, 1300, and so on
9. To take a sip of water and swallow it; place
the pill toward the back of the tongue. Have
the person take a large sip of water, place the
tongue on the roof of the mouth and with the
chin tilted slightly downward, swallow; follow
with more water.
6üMFLEII üN
1. questioned
2. without delay; immediately
3. another colleague
4. skin; mucous membranes
5. 48–72 hours
6. surgery; general anesthesia
7. smoke; lung disease
8. medication room; medicine cabinet
9. under lock and key
10. prolonged
11. patted onto
12. vaginal
13. unwrapped
14. meniscus
15. ineffective
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Assessment: Any three of the following:
a. Determine that the order is still valid
(within date).
b. Assess for patient allergies.
c. Determine why the patient is receiving the
drug.
d. Assess for therapeutic effect of previous
doses of the drug.
e. Assess for contraindications to taking the
drug.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ëë
f. Assess for side effects of previous doses of
the drug.
g. Assess for drug interactions with food or
other drugs.
h. Assess the patient’s knowledge about the
drug.
2. Risk for imbalanced nutrition, less than body re-
quirements, related to nausea
3. a. All medications will be safely administered
to each patient on time.
b. Serious side effects of medication will be
identifed quickly.
c. The medications will be effective.
d. No allergic reaction to the medication will
occur.
e. The patient will understand why the drug is
prescribed, adhere to the medication sched-
ule, and report serious side effects.
4. three times
5. Any one of the following:
a. Wound is clean and dry without infamma-
tion or tenderness.
b. Wound culture after 5 days of antibiotic
treatment is negative.
c. Temperature and WBC are within normal
limits.
d. Area of infammation and tenderness
around wound is decreased.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2
2. 3
3. 2
4. 1, 2, 4
5. 2, 3
6. 1, 2, 3
7. 3
8. 1
9. 1
10. 4
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Discard the medication and chart that it was
not given and why.
2. Verify the physician’s actual order, determine
that the pill in question is actually that medica-
tion; fgure out why the patient is to receive this
pill and why, if it is a continuing order, he has
received a different medication than this one.
3. Technically, the pill should be replaced by a new
one. However, most nurses allow the patient to
pick up the tablet and take it, as it is contami-
nated with the patient’s own microorganisms.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
This is a very potent drug. The directions for using
it are ambiguous, so we had better check with the
doctor. I don’t want to make any deviation from his
plans.
6hAFIE8 35
IE8MI NüLüߥ
A. Mat chi og
1. g
2. n
3. d
4. e
5. m
6. j
7. b
8. c
9. k
10. h
11. i
12. f
13. a
14. l
ß. 6oæpI et i oo
1. intradermal
2. anaphylactic shock
3. solute
4. Z-track
5. tuberculin
6. subcutaneous
7. compatibility
8. sterility
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë1
8hü8I AN8WE8
1. a. When the patient cannot take medication
by mouth
b. To hasten the action of the drug
c. When digestive juices would counteract the
effects of the drug if given by the oral route
2. a. Ensure that the dose is accurate.
b. Select the correct site to prevent damage to
tissues.
c. Use sterile equipment and aseptic tech-
nique to prevent infection.
3. lateral surfaces of the upper arm or the anterior
and lateral aspects of the thigh
4. abdominal
5. aspirate
6. a. Mid-deltoid muscle
b. Dorsogluteal site in buttock area*
c. Ventrogluteal site
d. Vastus lateralis site in thigh
e. Rectus femoris site in the adult thigh
7. aspirate
8. an air lock
9. emotional support
10. HIV, hepatitis B, or hepatitis C virus
11. wash the area thoroughly with soap and water,
report the incident to the charge nurse and fll
out an incident report; follow up according to
agency policy for treatment
12. 25 gauge
13. 90 degrees
14. 3 mL
15. flter
16. tenths
17. sterile water; sterile saline
18. allergies
19. aqueous; oil
20. needle sticks; blood-borne
21. the size of muscle mass and possible decreased
circulation in the area; a smaller length needle
may need to be used
6ü88ELAII üN
1. c
2. a
3. a
4. a
5. b
6. c
7. c
8. b
9. b
10. a
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Any three of the following:
a. Check for allergies.
b. Determine reason patient is to receive the
medication.
c. Assess for side effects and adverse effects to
previous doses.
d. Assess body build and circulation of area
when choosing the site for injection.
e. Determine which sites were used for recent
injections.
2. Defcient fuid volume related to vomiting
3. Vomiting will be controlled by antiemetic med-
ication within 1 hour.
4. Any three of the following:
a. Move him as little as possible.
b. Apply a cool cloth to the forehead, back of
neck, or under the chin.
c. Keep food and other odors out of the
room.
d. Decrease environmental stimuli.
e. Give nothing by mouth.
5. Statement chosen will be individual.
States nausea has eased since injection of medi-
cation.
No vomiting after injection of antiemetic.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. abdomen; 45 degree
3. 4
4. 3
5. 2
6. 2, 3, 4
7. 2, 3
8. 4
9. slowly
10. 1, 2, 3
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Discuss how to prevent a needle stick; “scoop”
up the cap; take a small biohazard sharps con-
tainer with you. Use a safety needle and syringe.
2. Waste the medication; if it is narcotic, have
someone witness the wasting and document it
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë8
on the narcotic checkout sheet. Document in
the chart that the medication was not given.
Seek an order change to a PO medication. Note
on the MAR that the medication was not taken.
3. First check—after taking the medication from
stock.
Second check—just before drawing it up.
Third check—just after drawing it up.
4. Review which type of insulin to draw up frst.
Discuss adding air to both vials frst then be-
ginning drawing of insulin.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
A.
1. aqueous
2. reconstituted
3. beveled
4. dexterity
5. compatible
6. vial
7. apprehensive
8. needle stick
ß.
1. sloughed off, with dexterity, vial
2. apprehensive, aqueous, reconstituted
3. scored, calibrated
4. hastened, induration
5. beveled, were compatible
II ME 6LAü8E8
A.
1. When I fell, I was walking up the stairs.
2. While he was in the hospital, Donald Moore
learned to give himself injections.
3. When her sister arrived, Margaret Smith was
eating.
4. After she received the injection, the patient felt
better.
5. Before the nurse gave her the injection, she was
having a lot of pain.
ß.
Answers will vary.
6hAFIE8 3ë
IE8MI NüLüߥ
A. Mat chi og
1. i
2. h
3. g
4. b
5. f
6. a
7. e
8. d
9. c
ß. 6oæpI et i oo
1. isotonic
2. hypotonic
3. hypertonic
4. infltrated
5. Macrodrop
6. microdrop
7. vascular access device
8hü8I AN8WE8
1. Any four of the following:
a. Supply hydration when fuids cannot be
taken by mouth.
b. Deliver medication directly to the blood-
stream.
c. Quickly replenish and balance electrolytes.
d. Supply nutrients when the patient cannot
absorb them from the intestinal tract or
needs supplementation.
e. Replenish blood, plasma, or particular
blood components.
2. Order of last two items will be individual.
Priority is based on potential for threat to the
patient’s life from a serious complication (Box
36-3).
a. Keep IV tubing clear of air.
b. Observe closely for transfusion reactions.
c. Keep IV fuid sterile.
d. Carefully regulate the rate of fow.
e. Protect the cannula site from contamina-
tion to avoid possible infection.
f. Assess the site frequently for signs of com-
plications.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key ë9
g. Track intake and output when a patient is
receiving IV fuids or blood.
3. a. Be certain the IV fuid to be administered is
the one actually ordered.
b. Be certain that fuid infuses at the pre-
scribed rate.
c. Maintain sterility of the system.
d. Observe for complications.
4. there is no way to retrieve the solution or medi-
cation once it is infused into a vein.
5. a. Infltration: remove IV catheter and restart
at site in other extremity.
b. Phlebitis: remove IV catheter, notify physi-
cian, apply warm soaks to the site.
c. Speed shock: stop the infusion, monitor
vital signs closely, notify the physician.
d. Circulatory overload: slow infusion, elevate
the head of the bed, keep patient warm, no-
tify the physician, assess for edema.
e. Air embolus: place on left side and lower
head of bed; inspect IV system for leak, no-
tify physician.
6. chills, back pain, itching, shortness of breath,
rash, apprehension, fever, tachycardia, nausea
and vomiting, hematuria (Skill 36-6)
7. Turn off the blood and open the saline; give
oxygen as needed; stay with the patient; notify
the physician.
8. 1500–2000
9. 50; 150
10. clarity, leaks, or particulate matter
11. snap, or click-lock
12. when it is fnished infusing, the main IV begins
infusing again at the set rate
13. normal saline
14. a. small amounts of fuid are required
b. extreme care must be used to measure the
exact amount, such as when giving IV fu-
ids to infants, children, and older adults
15. monitor the infusion closely to see if it is set
properly, running on time, and trouble-free
16. the administration tubing set
17. a. Butterfy needles
b. Over-the-needle catheters
c. Through-the-needle catheters
18. superior vena cava; atrium
19. high blood fow vessel
20. take blood pressure
21. no fuid is to be infused until placement is con-
frmed by x-ray
22. non-coring, Huber
23. 80–250
24. pack the area with hot packs to distend the vein
25. distal site
26. potassium
27. check the alarm to be certain it can be heard
outside the room or away from the patient’s
bedside if in an intensive care unit.
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. a. The correct IV solution is hanging.
b. The site is patent and the solution is infus-
ing.
c. The fow rate is that which is ordered.
d. No complications are occurring.
2. a. The patient is not allergic to the medica-
tion.
b. The medication is not incompatible with
the fuid that is infusing.
3. Risk of infection related to invasive procedure
4. Defcient fuid volume will not occur.
5. a. 25 gtt/minute
b. 83 gtt/minute
c. 31–32 gtt/minute
d. 21 gtt/minute
e. 20 gtt/minute
6. a. The level of fuid remaining in the contain-
er
b. The fow of the solution (that it is running)
c. The rate of the fow of the solution
d. The condition of the IV site
7. good skin turgor, moist mucous membranes,
and adequate urine output
8. laboratory data indicating that the blood count
has increased for the type of blood product in-
fused
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 1
3. 21
4. 3
5. 2
6. 1, 3, 4
7. 2
8. 3
9. 4
10. 4
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 10
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Pull the skin taut distal to the projected site.
Use only a 5–15 degree angle to approach the
vessel with the IV catheter. Use as small a gauge
catheter as possible.
2. First, make certain the patient is not lying on
the tubing. Next, raise the IV bag. Detach the
tubing from the cannula and attempt to aspi-
rate blood from the cannula. Reposition the
cannula by rotating it slightly. Try aspirating
again. If nothing works, discontinue the can-
nula and restart the IV at another site.
3. Attempt to aspirate blood. Untape the cannula
and rotate it slightly to move the opening away
from the vessel wall. Attempt to aspirate blood
again. See if you can gently irrigate the cannula
now. If not, discontinue the cannula and place a
new one in a different location.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
A.
1. piggyback
2. ascertain
3. discrepancy
4. rule of thumb
5. runaway
ß.
1. rule of thumb, criss-crosses and chevrons, as-
certained, discrepancies
2. mimicked, piggyback
3. runaway, taut
ß8AMMA8 FüI NI8
1. The nurse observed the patient while checking
the IV.
2. She checked the level of fuid remaining in the
bag before disconnecting it.
3. The intravenous solution was leaking out of the
bag when the patient pushed the call button.
4. Before making the subcutaneous pocket, the
surgeon entered the subclavian vessel.
6hAFIE8 31
IE8MI NüLüߥ
A. Mat chi og
1. e
2. f
3. a
4. d
5. b
6. c
7. g
8. h
ß. 6oæpI et i oo
1. Collapse of the alveoli in the lungs restricting
air fow.
2. Separation of the surgical wound.
3. Clot (thrombus) that breaks off and travels
and lodges in a blood vessel. (Solid, liquid, or
gaseous mass of undissolved matter present in a
blood or lymphatic vessel.)
4. Extrusion of the viscera through the surgical
incision resulting from wound dehiscence.
5. Loss of an extensive amount of blood which
may lead to shock; escape of blood from a rup-
tured vessel.
6. Infammation and consolidation of the lung
from retained secretions.
7. Infammation and irritation due to entry of
gastric or oropharyngeal food or fuids into
tracheobronchial passages from dysfunction or
absence of normal protective mechanisms.
8. Blood clot in a vein that restricts blood fow; it
can break off and become an embolus.
9. Infammation of a blood vessel from the irrita-
tion of a clot (thrombus) on the vessel wall.
6. 6oæbi oi og
1. colostomy
2. thoracotomy
3. cholecystectomy
4. orchiopexy
5. fbroma
6. mammoplasty
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 11
8hü8I AN8WE8
1. a. Elective—to repair a defect
b. Palliative—to reduce pain or complications
c. Curative—to correct a problem causing ill-
ness or pain
2. a. General—major surgical procedure such as
a colon resection
b. Regional—obstetrical procedures
c. Conscious sedation—short procedures
such as a dilatation and curettage or breast
biopsy
d. Local—minor surgical procedure such as
skin cyst removal
3. Any six of the types of patients listed in Table
37-1.
4. Allow time for voicing concerns and fears,
make adjustments for cultural beliefs, allow
time for questions, explain what to expect pre-
operatively and postoperatively
5. a. Lasers and fberoptics have allowed ability
to operate through much smaller
incisions.
b. Operating microscopes and robotics have
made surgical procedures more precise.
6. Check to see that the surgical consent form
is signed, lab work is on the chart, patient
has been NPO for allotted time, preoperative
checklist is complete, allergies have been noted,
patient is bathed and gowned for surgery, pre-
operative teaching is complete, and preopera-
tive medications have been given.
7. Anxiety related to the surgical experience and
outcome or anxiety related to the threat to self-
concept and threat of death.
Fear related to risk of death and loss of control
due to anesthesia.
Risk of defcient knowledge related to postopera-
tive care.
Ineffective coping related to threat to self and
multiple stressors.
8. Anxiety will be reduced by voicing concerns.
Fear will be reduced by speaking with anesthe-
siologist.
Learning related to self-care will be obtained
through postoperative teaching.
9. a. Patient is prepared physically and emotion-
ally.
b. Patient is able to demonstrate turning,
deep-breathing, coughing, and leg exer-
cises.
c. Patient is able to verbalize understanding
of the procedure and expectations for the
postoperative period.
d. Fluid and electrolyte balance will be main-
tained throughout the perioperative period.
10. Any three of the following:
a. Sets up the sterile instruments and supplies.
b. Counts sponges, needles, scalpel blades,
and instruments with the circulating nurse.
c. Gowns and gloves the surgeon.
d. Hands instruments to the operating team.
e. Anticipates needs of the operating team.
f. Monitors use of sterile technique.
11. Any three of the following:
a. Maintains the safety of the patient.
b. Supervises activities of scrub person.
c. Observes for breaks in sterile technique.
d. Counts sponges, needles, scalpel blades,
and instruments with the scrub nurse.
e. Records the events of surgery.
f. Provides further instruments and supplies.
g. Assists with gowning and gloving of surgi-
cal team.
h. Checks function of all equipment to be
used.
i. Makes certain equipment is properly
grounded.
j. Handles disposition of specimens, obtains
blood from blood bank, and fetches IV so-
lutions as needed.
12. Vital signs are stable and the patient is awake
and able to respond to stimuli.
IAßLE A6II ¥I I¥
See Table 37-5. Any one of the signs of symptoms
listed for each complication is acceptable.
8hü8I AN8WE8
1. Any fve of the following:
a. diet
b. activity and rest
c. wound care
d. use of equipment
e. signs and symptoms of complications to
report
f. when to see the doctor after discharge
2. written instructions
3. a. Maintenance of patent airway and adequate
ventilation
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 12
b. Prevention of complications
c. Promotion of comfort and rest
d. Promotion of wound healing
e. Promotion of psychological adjustment to
lifestyle or body image changes
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Take vital signs, check the chest tube to be
certain it is not kinked and that the suction
is functioning, mark the amount of drain-
age in the chamber, check the oxygen setting,
check the IV solution and fow rate, auscultate
the lungs, assess level of consciousness, assess
level of pain using a pain scale, check the Foley
catheter and make certain the tubing is not
crimped, note the amount of drainage in the
bag, check all areas of the chest dressing and
mark any drainage showing, check what pain
medication—if any—was given in the PACU
and when it was given, check what medications
the patient received preoperatively as well.
2. Impaired oxygen exchange related to partially
collapsed lung and anesthesia
Pain related to surgical procedure
Activity intolerance related to tubes, pain, and
anesthesia
Risk for injury related to decreased level of aware-
ness
3. Patient will have a normal oxygen saturation
level on room air by postoperative day three.
Pain will be controlled by oral analgesia by dis-
charge.
Patient will ambulate independently before dis-
charge.
4. Assisting the patient to the chair safely and as
painlessly as possible will require an assistant.
Assistance will be needed from the nurse for
ambulation.
The nurse will need to attend to tubes and lines
as the patient turns from side to side.
Assistance with splinting the chest will be need-
ed for effective coughing initially.
Regular assessment of pain level should be
done to keep pain under control so the pa-
tient will turn, cough, deep-breathe, and move
around.
5. Turn, cough, deep-breathe (TCDB; assessment
of chest drainage; assessment of urine fow;
checking IV fow rate and IV site; checking the
dressing; assessment for pain level; ambulation
or sitting up in the chair)
6. Turn, cough, and deep breathe q2h while
awake.
Splint chest incision while coughing.
Monitor oxygen saturation level q2h.
Auscultate lungs q shift.
Oxygen via cannula at ____L/min.
Monitor chest drainage and suction.
7. Lung sound status, oxygen saturation level,
amount of chest drainage, result of last chest
x-ray.
8. a. Oxygen saturation increased to 98%.
b. Lungs sounds present in all felds of lungs.
c. Chest drainage ceased.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 1, 4
2. 4
3. 3
4. 2
5. 2
6. 1, 3
7. 3
8. 2
9. 1
10. 92%
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. The correct order of priority would be:
1. Check the physician’s orders.
2. Check for a signed surgical consent form.
3. Check that lab work is complete and on the
chart.
4. Have the patient shower.
5. Check to see that preoperative medications
ordered are available on the unit.
6. Complete the preoperative checklist.
7. Have the patient empty the bladder.
8. Give the preoperative medications.
9. Document the patient’s readiness for the
OR.
10. Transfer the patient to the OR.
11. Prepare the unit for the postoperative re-
turn of the patient.
2. Possibilities include dehydration, loss of blood
and decreased perfusion to the kidneys, hemor-
rhagic shock, kidney toxicity from anesthesia or
drugs.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 13
3. Continue to give the patient nothing but small
ice chips that are allowed to melt in the mouth.
Encourage ambulation, auscultate bowel
sounds every 4 hours, ask patient to report the
passing of any fatus.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. allayed
2. sharps
3. groggy
4. grounded
5. prior
6üMMüNI 6AII üN EkE86I 8E8
1. Example: “What concerns you most about un-
dergoing anesthesia, Mr. Mueller?”
“The surgeon should be able to give you an
idea of what you might be facing as soon as you
wake up after surgery.”
“Tell me more about your wife, Mr. Mueller.
Have you been married a very long time?”
“We’ll help you learn to cope if you have to
have a colostomy. We have specially trained
nurses who can teach you all you need to know
to care for yourself. It might be good to wait
and see if you even need a colostomy before
you start worrying about it.”
2. Example: “Mr. Stevens, it is time to get you
ready for surgery. Here are the towels and spe-
cial soap for your shower. Soap your chest and
abdomen twice with this special soap. I’ll be
back in 15 minutes to give you the preoperative
medications.”
“Mr. Stevens, I have your preoperative medica-
tion. Would you please empty your bladder
before I give it to you?”
“OK, frst I need to check your armband to
verify you are the right patient for these medi-
cations. Good, that’s correct. if you will turn on
your side I will give you these two injections.
You stated you are not allergic to any medica-
tions, is that correct? Here is the frst injection.
Now I will put the second one right here. That’s
it, Mr. Stevens. You are all ready to go to sur-
gery. These medications may make you a little
groggy and I’m putting up the side rails as I
don’t want you to get out of bed. The orderly
will be here shortly to transport you to surgery.
I’ll be back then.”
3. “Mr. Mueller, you must stick to a soft diet for
the next few days. Once your bowel movements
are normal, you can slowly go back to your
usual diet. I want you to continue to do your
foot and leg exercises at least six times a day at
home. You should get plenty of rest and just
take it easy for the next week. Do not lift any-
thing weighing more than 5 lbs. I want you to
walk around the house twice today and then in-
crease the distance and time you walk until you
are walking around the block without any stiff-
ness or problem. Take the antibiotics in this vial
as the directions say. This vial is your pain med-
ication and you may take it every 4–6 hours
as you need for the discomfort. Remember to
drink plenty of water as this medicine can make
you constipated. Change the dressing every day.
Wash your hands thoroughly and remove the
dressing. Cleanse the area with the saline solu-
tion, pat it dry and apply new gauze pads. Tape
it crosswise as it is now. Report any redness,
new pain, fever, or other problems immediately
to your surgeon. Call tomorrow to make your
follow-up appointment with her.”
6hAFIE8 38
IE8MI NüLüߥ
A. 6oæpI et i oo
1. approximation
2. débridement
3. abscess
4. adhesion
5. exudate
6. collagen
7. infection
8. eschar
9. necrosis
10. fstula
11. phagocytosis
12. contracture
13. hematoma
14. Cellulitis
15. ecchymosis
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 14
16. sanguineous
17. serosanguineous
18. sinus
19. purulent
ß. Mat chi og
1. f
2. g
3. c
4. a
5. i
6. e
7. d
8. b
9. h
8hü8I AN8WE8
1. a. Swelling or edema
b. Erythema
c. Heat
d. Pain
e. Loss of function
2. Injury—fbrin formation—leukocytes remove
debris—granulation tissue forms—connective
tissue and capillaries become taut—scar forma-
tion.
3. Any of the examples mentioned in the section
on “Factors Affecting Wound Healing” are ac-
ceptable.
a. Age—an 80-year-old with peripheral vas-
cular disease.
b. Nutrition—the homeless person suffering
from malnutrition.
c. Lifestyle—the pack-a-day smoker.
d. Medications—the asthmatic who is on
prednisone (a steroid).
e. Infection—the cancer chemotherapy pa-
tient who is immunocompromised.
f. Chronic illness—the diabetic patient, espe-
cially with poorly controlled blood glucose.
4. a decline in immune function occurs, reduced
liver function impairs synthesis of blood fac-
tors, decreased lung function reduces available
oxygen needed for synthesis of collagen, skin
becomes fragile and easily damaged, there may
be chronic disease present.
5. fall in blood pressure; rapid, thready pulse;
increased rate of respirations; restlessness; dia-
phoresis; and cold, clammy skin
6. a piece of wide fat rubber tubing; provide an
exit for blood and fuids that accumulate from
the infammatory process so that the wound
may heal.
7. a. redness, warmth, and pain
b. purulent drainage
c. fever
d. increased WBCs
8. place the patient supine, cover the area with
large sterile dressings or towels soaked in
normal saline, reassure the patient, notify the
surgeon, and prepare the patient for a return to
surgery
9. a. relieve pain
b. reduce congestion
c. reduce infammation or swelling
d. relieve muscle spasm
e. provide comfort
f. elevate body temperature
10. a heating pad, warm moist packs, heated gel
pack, heat lamp, hot water bottle, Aquathermia
pad
11. decreasing cellular metabolism and numbing
the area
12. causing vasoconstriction and diminishing
blood fow and fuid accumulation in the area
13. attempting to create heat to bring up the tem-
perature
14. older adults may have decreased sensation in
the affected part and can’t detect something
that is too hot. The skin of older adults is much
more fragile and may sustain a burn more eas-
ily.
6üMFLEII üN
1. Infammation
2. secondary
3. tertiary
4. contracture
5. Staphylococcus aureus
6. asepsis; wound
7. absorb/contain; débride
8. compress it; close
9. shiny
10. moist
11. Montgomery straps
12. stretch gauze (Kerlix)
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 15
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Inspect the surgical wound for approximation
of the edges, whether sutures/staples are intact;
degree of redness, warmth of area, presence of
swelling, drainage, or bleeding, and degree of
pain in the area.
2. Inspect it visually, smell it, palpate the sur-
rounding area. Measure its dimensions.
3. Analyze the patient’s temperature trend and
check the blood count for WBC trend. Inquire
how the patient is feeling.
4. Impaired tissue integrity related to traumatic loss
of tissue (there is no NANDA nursing diagnosis
for actual infection).
5. Answer may vary. Example: Wound will be free
of infection within 7 days.
6. Obtain order for wound culture.
Culture wound.
Administer antibiotics as ordered.
Cleanse and inspect wound every day.
Use aseptic technique for dressing change.
Monitor temperature and WBCs.
7. Appearance of wound that indicates absence
of infection and growth of new tissue. Absence
of redness, swelling, or pain in wound area.
Absence of temperature elevation; normal
WBC.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 1
2. 2
3. 4
4. 1
5. 1, 2
6. 3
7. 4
8. 2
9. 4
10. 3
11. 1
12. 3, 4
13. 2
14. 2
15. serosanguineous
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. This could be Stage II or IV depending on the
depth of the ulcer. The eschar needs to be dé-
brided either mechanically or enzymatically
before staging and before healing will take
place. Treat with physician-prescribed débrid-
ing agent and an absorbent dressing.
2. Sterile gloves, sterile dressings—4 x 4s, ABDs,
sterile normal saline for cleansing the skin, ster-
ile forceps, discard bag, tape, disposable clean
gloves for removing the outer old dressing
3. Apply a gel hot pack after checking the tem-
perature to make certain it is not so hot it will
burn. Could use moist hot packs—again check
the temperature. For moist packs, cover with
plastic to maintain heat longer. Use for 20 min-
utes 3–6 times a day.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. hydrate
2. frayed
3. friable
4. cardinal
5. nonadherent
6. shearing forces
7. binder
8. hospital acquired
9. numbing
10. cessation
¥ü6AßüLA8¥ EkE86I 8E
Examples: frayed = worn—My nerves are so frayed
I yelled at her for nothing.
Binder = notebook—Put this paper in your binder,
please.
Radiant = glowing—Her smile was radiant.
6üMMüNI 6AII üN EkE86I 8E8
Answers will be individual.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 1ë
6hAFIE8 39
IE8MI NüLüߥ
A. Mat chi og
1. f
2. c
3. g
4. h
5. i
6. j
7. d
8. k
9. e
10. b
11. a
ß. 6oæpI et i oo
1. bivalve
2. quadriplegic
3. isometric
4. paraplegic
5. countertraction force
6. spica
7. hemiparesis
8. hemiplegia
9. moleskin
10. trapeze bar
11. hypostatic pneumonia
8hü8I AN8WE8
1. The person does not breathe as deeply, lungs
are not fully expanded, and secretions collect
in the lower airways leading to congestion and
possibly hypostatic pneumonia.
2. Inspect the skin distal to the injury; palpate
the temperature of the skin, compare to the
opposite extremity. Check movement distal to
the injury, inquire about tingling or numbness,
check sensation bilaterally; palpate pulses distal
to the injury and compare bilaterally. Check
capillary refll and inquire about the degree,
location, and nature of pain.
3. The cast should be supported by pillows with
the extremity elevated above the level of the
heart. The patient and cast should be turned
periodically to promote even drying of the cast.
Use the fat part of the palms of the hands to
handle the cast when turning or repositioning.
4. a. Air-fuidized bed: has tiny silicone beads
in an air-permeable flter sheet. Warmed
air sets the particles in motion so that they
act like a fuid causing the patient to foat.
Prevents occlusion of blood vessels and
shearing of tissues. The heat keeps the skin
dry. Used for patients at high risk for skin
breakdown.
b. Low air-loss bed: air is distributed through
multiple cushions connected in a series
to provide pressure relief for the patient.
Eliminates shear and friction.
c. Continuous lateral-rotation bed: bed moves
slowly from side to side, decreasing the re-
spiratory complications of immobility and
promoting normal urine fow. Reduces the
risk for thrombosis. Reduces pressure on
patient. Patient is wedged into the bed. May
be used with spinal traction.
d. CircOlectric bed: Allows change of position
of the patient while in bed by moving the
bed around the arc of the circle. Often used
for burn patients.
5. a. Foam and gel pads
b. Sheepskin pads
c. Pulsating air pads
d. Water mattresses
e. Heel or elbow protectors
6. (Any four of the principles/guidelines listed in
the textbook)
a. Elevate the limb and support it while ap-
plying the bandage.
b. Wrap from the distal to the proximal area.
c. Overlap turns of the bandage evenly.
d. Secure the end of the bandage.
e. Check color and sensation of the areas
distal and proximal when fnished and at
frequent intervals.
f. Remove the bandage for bathing and assess
the skin; rewrap at least twice a day.
7. Any of the following interventions:
a. Thrombus formation: encourage exercise;
increase fuids, apply elastic stockings.
b. Atelectasis: have deep-breathe or use incen-
tive spirometer.
c. Constipation: increase fuid intake and f-
ber intake; give stool softener.
d. Joint contracture: perform active or pas-
sive exercise; position joints in anatomical
alignment, splinting as needed.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 11
e. Renal stone: increase fuid intake to 3000
mL/day
f. Skin breakdown: reposition at least every 2
hours, pad bony prominences when posi-
tioning, keep clean and dry.
g. Boredom: encourage visitors at intervals;
provide diversional games and books, TV,
videogames, or use of computer.
8. Give frequent, small feedings and bedtime
nourishment. Have family and friends bring in
favorite foods. Encourage family or friends to
visit and eat with the patient.
9. correct alignment
10. shearing
11. swinging free; good alignment
12. maintained
13. move freely in the pulleys
14. countertraction
15. weight; position
16. brace
17. pressure; necrosis
18. uneven
19. palms of the hands
20. spreader bar
21. unattended
22. weak; their balance
23. 15-30; hip
24. rest the body weight on the axillary bar
25. overall length; the axillary bar; hand grip
26. freedom of movement
27. paresthesia
AFFLI 6AII üN üF IhE Nü88I Nß F8ü6E88
1. Determining if the weights are swinging free,
the ropes are moving freely, the patient is in
proper alignment and pulled up in the bed to
provide countertraction. Are the pin insertion
sites clean and dry? Does she need pain medica-
tion? Are her vital signs normal? Are there any
signs of infection? Are there any signs of com-
plications of immobility? Are the lungs clear?
Is intake and output normal? Is the urine clear?
Are bowel sounds present? Does the patient
have any complaints?
2. Impaired physical mobility related to fractured
leg in traction
3. Risk for injury related to pressure on nerves
4. Patient will not experience nerve damage while
cast is present.
5. a. Coordinate visitors so they come at inter-
vals rather than all at once.
b. Have family bring in materials for activities
she does at home such as knitting, cross-
stitch, etc.
c. Supply a jigsaw puzzle for her to work on.
6. Effectiveness of treatment is shown by x-ray
that shows proper healing of the fracture with
no evidence of infection. Normal temperature
and normal WBC would be two parameters for
evaluation.
7. a. Performing quadricep setting exercises to
prepare muscles for walking.
b. Working with PT on weight bearing in
preparation for ambulation (after traction
is discontinued).
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 1, 2
2. 3
3. 1
4. 2, 4
5. 1, 2, 3, 4
6. 3
7. 2
8. 2, 3
9. 4
10. 2
11. pad bony prominences
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Assess his interests and develop the program
around them if possible. Plan some activities
for fun and some that will make him use his
brain.
2. Allow ventilation of feelings. Explain what
you are doing each time you wrap the stump.
Explain what will happen if the stump is not
cared for properly and the pain that can occur.
3. Allow ventilation of feelings regarding loss of a
body function and the change in body image.
Explain what can happen if ambulation is at-
tempted without the walker (fractures or head
injury). Review the activities that can be per-
formed independently using the walker.
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 18
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. diversionary
2. longitudinally
3. regress
4. disintegrate
5. gait
6. debilitating
¥ü6AßüLA8¥ EkE86I 8E8
Individual answers will vary; Examples:
1. a. (Noun) Put the dirty clothes in the hamper.
b. (Verb) An arm cast can hamper ability for
self-care.
2. a. (Noun) The dictate is that no children are
allowed.
b. (Verb) She would like to dictate what I do.
3. a. (Noun) Exams cause me a lot of stress.
b. (Verb) I can’t stress the importance of
practice enough.
6üMMüNI 6AII üN EkE86I 8E
Each partner should ask the questions and then an-
swer them when the other partner asks the questions.
6hAFIE8 40
IE8MI NüLüߥ
A. Mat chi og
1. g
2. f
3. b
4. e
5. h
6. d
7. i
8. a
9. c
10. j
ß. 6oæpI et i oo
1. estrogen replacement therapy (ERT)
2. bladder retraining
3. over-the-counter
4. habit (timed) voiding
5. fecal impaction
8hü8I AN8WE8
1. a. Impaired mobility
b. Alteration in elimination
c. Alteration in nutrition
d. Sensory defcits
e. Polypharmacy
2. Physically, incontinence can lead to con-
stantly wet skin and skin breakdown. It con-
tributes to the formation of pressure ulcers.
Psychologically, it may cause embarrassment,
social withdrawal, depression, and low self-
esteem.
3. a. Transfer the person from the bed to the
chair as soon as possible.
b. Encourage active and passive range of mo-
tion exercises.
c. Teach isometric exercises to promote main-
tenance of muscle strength.
4. a. Improper footwear
b. Cluttered walkways
c. Poor lighting
d. Moving too quickly after arising
5. a. Decreased fnancial resources
b. Lack of transportation to purchase food
c. Impaired mobility making it diffcult to
prepare meals
d. Anorexia due to lack of socialization and
company for meals
6. a. Gain the person’s attention before speak-
ing.
b. Be certain the person has on glasses and/or
hearing aid and that the aid is turned on.
c. Face the person so that your lips can be
seen as you speak.
d. Speak slowly and distinctly, repeating as
necessary.
7. a. They often have multiple health problems.
b. They often see more than one physician.
c. They often use more than one pharmacy.
d. They sometimes are forgetful and repeat a
dose of medicine.
e. They do not metabolize and excrete drugs
effciently.
8. A chronic respiratory disorder may decrease
lung capacity or oxygen diffusion and thereby
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 19
reduce available oxygen in the blood. This in
turn causes fatigue with activity and decreases
mobility.
9. Decreased activity causes loss of muscle
strength, decreased joint mobility, loss of bone
mass, decreased balance and coordination, and
thereby interferes with mobility.
10. Any of the factors in Health Promotion Points
40-3 are acceptable. Individual priority will
vary.
a. Using nonslip mats underneath rugs.
b. Wiping up spills immediately.
c. Installing sturdy handrails for stairs and
steps.
d. Keeping light cords and telephone cords
out of pathways.
e. Using a night-light in bedroom, hall, and
bathroom.
11. a gait belt
12. a. gardening
b. dancing
c. home maintenance
d. swimming
13. weight bearing; calcium
14. a fall; wheelchair
15. third; half
16. medication
17. climbing on a ladder; standing on a chair
18. safety hazards
19. above head
20. reason
21. increase fuid intake
22. fecal impaction
23. sugar; fat; roughage
24. a. Sit the patient upright or in a high Fowler’s
position
b. Feed small amounts to avoid aspiration.
c. Thicken fuids to prevent aspiration
d. Have the person tuck the chin when swal-
lowing.
25. a. decreased peripheral vision
b. decreased night vision
c. decreased depth perception
26. entering; leaving
27. rearranging
28. physicians
29. impacted cerumen
30. 15%
IAßLE A6II ¥I I¥
Physical Care
Problem Contributing Factors
Impaired
mobility
Osteoporosis
Falls
Obesity
Arthritis
Cardiac or respiratory disease
that limits activity
Neurologic disorder affecting
mobility
Severe depression
Alteration in
elimination
Nervous system disorder
(stroke)
Immobility
Urinary tract infection
Insuffcient fuid and fber in
diet
Poor abdominal muscle tone
Pain medications; other
medications
Alteration in
nutrition
Neurologic defcit (stroke)
Impaired vision
Impaired mobility
Activity intolerance
Anorexia
Lack of income
Lack of transportation
Alcohol abuse
Alzheimer’s disease
Anxiety or depression
Lack of kitchen facilities
Sensory
defcit—
vision
Lack of money for eye care
Arteriosclerosis; arteritis
Diabetes
Long-term corticosteroid use
macular degeneration
Sensory
defcit—
hearing
Heredity
Meniere’s disease; labyrinthitis
Long-term exposure to loud
noise
Polypharmacy Multiple chronic disorders
Impaired vision
Multiple physicians prescribing
Use of multiple pharmacies
Forgetfulness
Impaired judgment
Borrowing drugs from others
Miscommunication
Use of OTC medications
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 80
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 3
2. 2
3. 3
4. 2, 3, 4
5. mobility
6. 1
7. 3
8. 1, 2
9. 1, 3
10. 2
11. 4
12. 3
13. 1
14. urinary incontinence
15. 1
16. 2
17. 4
18. 4
19. 2
20. 1, 3, 4
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Assess the situation completely; i.e., shopping,
food preparation, appetite, etc. Explore avail-
able meal resources; explore family’s ability to
help. Assess patient’s ability to use a microwave
oven. Assess freezer space. Enlist the help of the
social worker.
2. Assess for all safety hazards that could cause fre
or a fall.
3. Explore all aids available for a visually impaired
person.
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
A.
1. address
2. imperative
3. cueing
4. clutter
5. enhance
6. engaged
ß.
Coupled with the mud from the inclement weather
we were having, cleaning up the clutter was quite a
chore. Prudently, I addressed the problem by engag-
ing help to clean up the odoriferous mess. The situ-
ation was enhanced by cueing my helper that it was
imperative to fnish early.
6üMMüNI 6AII üN EkE86I 8E8
Answers will vary per individual. Each exercise
should be practiced with a peer, paying close attention
to each other’s pronunciation.
6hAFIE8 41
IE8MI NüLüߥ
A. Mat chi og
1. d
2. h
3. c
4. a
5. e
6. b
7. f
8. g
ß. 6oæpI et i oo
1. age-associated memory impairment
2. benign senescent forgetfulness
3. Confusion; dementia
4. selective serotonin reuptake inhibitors
5. validation
I ßENII FI 6AII üN
1. Delirium, depression
2. Delirium, dementia
3. Dementia
4. Delirium
5. Depression
6. Depression
7. Dementia
8. Dementia, delirium
9. Delirium, dementia
10. Depression, dementia
11. Dementia, depression
12. Depression
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 81
8hü8I AN8WE8
1. Any four of the items listed in Box 41-3.
2. They are interrelated in that they have similar
risk factors associated with multiple loss. Loss
contributes to feelings of despair and hopeless-
ness, leading to a distorted outlook wherein al-
cohol may seem a good solution to avoiding the
problems. Alcohol combined with depression
may lead to suicide when defenses are down
and coping mechanisms are impaired.
3. a. Elder abuse: explore conficting explana-
tion about older person’s condition.
b. Household theft: obtain and verify ID of all
workers entering the home.
c. Mail theft: use direct deposit of social secu-
rity funds.
d. White collar crime: do not give information
to strangers on the phone.
e. Vehicular theft: lock vehicle doors and
never leave the keys in the car.
4. a. Physical: using drugs to keep older person
docile.
b. Psychologic: threatening physical violence
to control behavior.
c. Material: misuse of older person’s funds.
d. Neglect: not assisting with ADLs as needed
or providing inadequate care.
5. Any two of the issues discussed in the text.
Examples:
a. Adequate health care including the cost of
prescriptions
b. Adequate public transportation to keep
older people in their own homes without
having to drive
6. First obtain a detailed and accurate medical
history and perform a thorough physical ex-
amination. Then perform a mental status exam.
7. patience; respond to questions
8. a. medication effects
b. a new environment
c. disease process
d. fuid and electrolyte imbalance
e. psychosocial stressors
9. dignity, independence, personality, and support
system and complicate diagnosis and treatment
of an illness
10. stroke, tumors, systemic infection, fuid and
electrolyte imbalance, acute infammatory
disorders, drug reactions, toxins, and sensory
overload or sensory deprivation
11. Sundowner’s syndrome or sundown syndrome
12. manage anxiety, agitation, hostility, paranoia,
and depression
13. dealing with grief over a long period of time
and physical and mental exhaustion from pro-
viding round-the-clock, 7-day a week care
14. day care and respite care
15. a. Early stage: diffculty learning new things;
mild short-term memory loss; mild depres-
sion (Box 41-4)
b. Middle stage: increased memory loss; sus-
picion, agitation, hallucinations, wander-
ing, incontinence, unable to perform ADLs
well
c. Severe memory impairment, impaired mo-
bility, deteriorating speech, weight loss, dif-
fculty swallowing, bedridden
16. art, music, and humor
17. all other types of nursing interventions have
been tried and are unsuccessful
18. trust
19. a. Observing for factors that trigger the be-
havior
b. Diverting attention (focusing attention on
one activity)
c. Maintaining a regular activity program
20. a lifelong psychological pattern, an organic
condition, or an adverse reaction to multiple
drugs
21. Any of the strategies listed in Nutritional
Therapies 41-1. Examples:
a. Serve one food at a time to decrease confu-
sion
b. Remind patient to open mouth, chew, and
swallow
c. Avoid hurrying the patient to eat
22. complaining of anorexia, sleep disturbance,
lack of energy, and loss of interest and enjoy-
ment in life
23. depression, insomnia, mental confusion, fre-
quent falls, self-neglect, uncontrollable hyper-
tension or diabetes, gastritis, or anemia
24. giving positive feedback for desired behaviors
and negative feedback for undesired behaviors
25. distraction
26. meticulous planning of personal affairs, giving
away treasured possessions, sudden euphoria,
or stated death wishes
Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved
Student Learning Guide Answer Key 82
IAßLE A6II ¥I I¥
AI thei æer ’s ßi sease
Cause Loss of function of neurons in the frontal and temporal lobes of the brain.
Signs and symptoms Increasing short-term memory loss; inability to learn new things, depression, agi-
tation, suspiciousness, hallucinations, wandering, impaired judgment and cogni-
tion, deteriorating speech.
Diagnosis Based on ruling out other causes for the symptoms; PET scan may be helpful.
Defnitive diagnosis possible only at autopsy.
Treatment Symptomatic. Drug therapy with tacrine (Cognex), rivastigmine (Exelon), galan-
tamine (Reminyl), or donepezil (Aricept) help somewhat. Use of memory aids,
antidepressant therapy for depression.
N6LEk- FN
®
EkAMI NAII üN–8I¥LE
8E¥I EW üüE8II üN8
1. 2
2. 3
3. 3
4. 4
5. infection
6. 1
7. 2
8. 4
9. 1
10. 2, 3
11. 2
12. 3
13. 1, 3, 4
14. 3
15. neglect
16. 2
17. 3
18. 3
19. 1
20. pet
68I II 6AL IhI NkI Nß A6II ¥I II E8
1. Intervention should include increasing social
contact, activities that will increase her self-
esteem (volunteering, etc.), increase physical
activity, obtain social atmosphere for meals,
possible attendance in a grief support group,
antidepressant medication.
2. List the signs and symptoms of elder abuse.
Approach will be individual but should begin
with establishing a trusting, confdential rela-
tionship. The social worker should be consult-
ed.
3. Individual answers; consider means for older
people to obtain transportation for food and
physician appointments as well as social activ-
ity. How could an inexpensive chore service be
provided for seniors?
STEPS TOWARD BETTER
COMMUNI CATI ON
6üMFLEII üN
1. unkempt
2. Advocacy
3. pose
4. condescending
5. implication
6üMMüNI 6AII üN EkE86I 8E
Dialogue will be individual.

Student Learning Guide Answer Key 

5. LPN/LVN 12–18 months of formal training Trained to care for the well or chronically ill

Registered Nurse 2–5 years of formal training Trained to care for the acutely ill as well as the chronically ill; teach preventive health care

S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. 2. 3. 4. 5. 6. 7. 8. 9. delegator foster sought controversy implement criteria prior vigilant skyrocket

6. Protect the public and define the legal scope of practice for nurses. nC le X- pn ® eXamination–Styl e r eview Que Stion S 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 2 practical 4 Lillian Wald 2 2 1, 2, 4 3 1 1, 2 1, 3

v oC a b u l a ry e X e rC i S eS 1. 2. 3. 4. Assessment: test evaluation Diagnosis: finding, conclusion Outcome: removal result Implementation: carrying out drawing

making equipment 5. Evaluation: measurement analysis 6. Collegiality: education relationship with other workers w o r d at taC k S k i l lS 1. a. He attributed his success to his attributes of hard work and honesty. b. The use of the surgical implements was implemented with a training session. 2. c

Criti C a l thinking aCtivitie S 1. Definition should include caring for the sick, promoting wellness, providing health teaching, giving emotional support, and attending to psychosocial concerns. Each person’s definition will be different. 2. Make a list of the group’s ideas. Areas to include are assessing patients, choosing nursing diagnoses, stating expected outcomes, planning interventions to meet the outcomes, directly implementing the actions, and evaluating the outcome of the plan. Other ways could be quality assurance activities on the nursing unit; attending continuing education presentations or reading journals; assisting students or new nurses on the unit; maintaining an ethical manner (not divulging confidential information); collaborating with the dietitian, physician, respiratory therapist, or physical therapist on the patient’s plan of care; considering cost-effective ways to implement care; and applying research findings to care.

Chapter  terminology 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. g d h f j k i e c a b

Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved

Student Learning Guide Answer Key 

Short a nSwer 1. A relative state in which one is able to function well physically, mentally, socially, and spiritually in order to express the full range of one’s unique potentialities within the environment in which one is living. 2. Any three of the following: a. Watching dietary intake to prevent weight gain b. Engaging in a regular exercise program c. Obtaining immunization against communicable disease d. Examining the breasts or testes monthly 3. a. Monitor the body b. Define and interpret symptoms c. Seek health care d. Follow advice and self-care measures to regain wellness 4. Helping people cope with adverse physiologic, psychosocial, and spiritual responses to illness. 5. a. Perception of the stressor b. Degree of health and fitness c. Previous life experiences and personality d. Social support system available e. Personal coping mechanisms Completion 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. high-level wellness; Dunn an active part cultural unique individual tends to develop slowly over a long period; throughout life a primary illness physiologic, safety and security; love and belonging; self-esteem; self-actualization the patient cope changing environment stress sympathetic nervous system; fight or flight hormones

mat C h i n g 1. 2. 3. 4. 5. 6. Sympathetic Sympathetic Parasympathetic Parasympathetic Sympathetic Sympathetic

C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. Psychosocial assessment, calling in a social worker, calling a pastor or priest or other religious leader; attentive listening; exploring concerns. 2. Fatigue makes one want to rest more. Fever may cause one to lie down and rest and it helps eliminate invading organisms. Coughing expels secretions and viral debris. Malaise makes one slow down. 3. Sweaty palms, rapid pulse, muscle tenseness, anxiety, shakiness, (others). 4. a. Obtaining information to decrease fear of the unknown. b. Listening to concerns and fears. c. Enhancing healthy coping skills such as providing quiet time for meditation. d. Meeting needs efficiently. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. adverse hygiene noncompliant perception alters intervene emerge deviation maladaptive resolves

nC le X- pn ® eXam review 1. 2. 3. 4. 5. 6. 7. 1, 2 1 4 3 4 2 1,3

v oC a b u l a ry e X e rC i S eS 1. Biologic b, f 2. Psychosocial a, c 3. Spiritual d, e

Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved

Student Learning Guide Answer Key 

w ord attaCk SkillS opposites 1. minimum, adverse 2. ignore 3. clear, specific 4. dynamic, active 5. atrophy, stagnate 6. good luck, good fortune 7. overreact 8. good health, feel good Communi Cation eXerCiSe S Examples: 1. a. Culture b. Religion c. Standard of living d. Support system e. Genetic influence Believe in preventive health care Prayers for better health can be answered Can afford to go to the doctor Family and friends available to help Susceptible to heart disease

2. Examples: a. Sex education about STIs b. Cancer screening c. Importance of prenatal vitamins 3. Answers will depend on the individual. Verbalization will increase expertise at pronunciation and sentence structure. 4. Answers will depend on the individual.

Chapter  terminology Examples will be individual. 1. Accepting responsibility for one’s actions. Example: A nurse accepts accountability for the care provided by the aide to whom a task was assigned. 2. Communicated in confidence; secret; kept private. Example: The patient’s history is confidential.

3. Sensible and caring behavior. Example: A prudent nurse follows the correct procedure for catheterization. 4. There is failure to perform in a reasonably prudent manner. Example: A nurse fails to notify the charge nurse or doctor when a patient with a fresh cast complains of pain and numbness. 5. Faulty or improper practice is carried out by a professional person. Example: A licensed nurse fails to heed signs of toxic overdose of medication and continues to administer the drug, causing harm to the patient. 6. Making remarks about a person that are untrue and that damage the person’s reputation. Example: The nurse told a patient that another nurse had been disciplined for taking patient’s medications when this was not true. 7. Physical contact that was against the person’s will or consent. Example: A feeding tube was placed in a patient although no consent was given for its placement. 8. Written defamation of character; untrue and damaging words. Example: The newspaper committed libel in printing untrue statements about the doctor’s treatment of the patient. 9. Violating the right to privacy concerning one’s body and private information without the person’s consent. Example: Two unit secretaries discuss the number of abortions a patient has had. 10. Oral statements that are false or that injure another’s reputation. Example: A nurse makes a false statement to the effect that another nurse forged a license card and is not entitled to be a nurse. 11. Assault is the threat of harm to an individual. Example: When the patient attempts to get out of bed, the nurse pushes him down and straps his arms to the bed rails. S h o r t an S w e r 1. a. S Situation b. B Background c. A Assessment d. R Recommendation 2. the group; membership in the group 3. Being attentive and sincere with each patient, listening to the patient’s needs and complaints, keeping him or her informed of what you will be doing, showing concern and respect.

Copyright © 2009, 2005, 2001 by Saunders, an imprint of Elsevier, Inc. All rights reserved

3. 2. a (Taking monetary gifts from patients is unethical and is against agency policy. Find out what the correct protocol of the agency is in this situation. 2.pn ® eXamination–Styl e r eview Que Stion S 1. Suggest alternatives to calm the patient and protect the patient’s safety. lawsuit. Provide evidence-based and expert-based solutions to areas that have been problematic in terms of patient safety. You should first consult with your clinical instructor and the nurse assigned to the patient. It is your responsibility to see that the authorities are notified. 3. Consider stating that all patients are asked to express their preferences for care if certain emergencies occur or health declines to the point of inability to make one’s own decisions any longer. You are obligated to tell the person in charge when you do not have the appropriate training to do a procedure or sufficient expertise to care for a group of patients. All rights reserved . 3 1. b (Eating the food is against hospital policy and is unethical. Inc. 4 7. as well as stealing. a. ethics (Taking medication prescribed for another is illegal use of drugs. 2 2 1 1 1. jeopardize b. Discuss the situation out of hearing of the child or parents. he or she may be treated better than another patient. 2. You may not legally perform procedures that you have not been sufficiently trained to do yet. 4. 8. The rationale is that if reward is involved with one patient. If a determination is made that the child could be a victim of child abuse.Student Learning Guide Answer Key  4. However. even though the food cannot be served to another person. escalate ethi C al Situation S These situations require synthesis and application of knowledge.) Copyright © 2009. 2.) 5. You are responsible for giving care equal to that of the licensed nurse in all areas in which you have already been trained. 10. Discuss the situation with the person who made the statement to the patient. a (It is unethical to take money for services you have personally rendered to a patient. you should report it to the charge nurse and call the social worker or report it directly to the authorities. Situation A (Giving this information would be a breach of confidentiality. It could be considered stealing. 3 1. c 2. 3 2 2. loss of employment Situation B 3. Offer to explain the terms and reasons for the questions on the form. Describe the specific functions and activities of nurses as opposed to those of other health care professionals (and to) provide criteria for judging the quality and effectiveness of nursing care 6.) Situation C 4. 9. it is acceptable for the patient to contribute to the hospital or to a need for the unit on which the patient stayed. suspending or revoking the license to practice nursing. 7. You could explore the chart for any other evidence of possible child abuse.) 1. legal Situation D 6. It is unethical. 5. 5. 4. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. Being charged with practicing medicine without a license. 4 1. 6. The state board of nursing may take disciplinary action. 3. 2001 by Saunders. an imprint of Elsevier. 2005. This is a direct threat of false imprisonment.) C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. nC le X. and if carried out is illegal. Explain the reasons why it is preferable to most people to make their own decisions about these matters in advance. 2.

2. patient input b. 2001 by Saunders. considering what has been said and thinking before speaking. a. Taking time to consider a verbal response before making one. It requires an organized and systematic approach. witness resuscitate prescribed pertinent suggestive scope proxy access means precedent seemingly gravely v oCabulary eXerCi Se Ethics: the rules or standards governing the conduct of members of a profession. Inc. 5. To think critically one must be flexible. c. 8. c. 2. 2005. g. Thinking about what to say and how to state it clearly and concisely in a logical way before beginning to speak. e. 4. Patient problems are usually prioritized along the lines of Maslow’s hierarchy of basic needs. d. Critical thinking involves keeping an open mind and looking at an issue from different perspectives. Choose the alternative with best chance of success and fewest undesirable outcomes. 7. h. The doctor will prescribe some medication for the infection. Speaking clearly and concisely. a. d. a. 3. 5. creative. critical thinking is directed and purposeful and requires skills such as effective reading. humble. b. Writing in an organized manner and expressing each thought coherently and concisely. Define the problem clearly. Each requires verbalization practice. and insightful. 3. Critical thinking skills can be improved by any of the following: a. d. Consider possible outcomes for each alternative. a. b. 6.) w ord attaCk SkillS Examples: 1. realistic. prioritization of needs/concerns e. Acquiring the skills and attributes found in the critical thinker as listed in the chapter. It should depict the different areas of your life and the responsibilities you have in each of those areas. Short a nSwer 1. Rather than thinking about something at random. flexible. Evaluating what has been written.Student Learning Guide Answer Key  c. an imprint of Elsevier. 3. f. All rights reserved . Take the written prescription to the pharmacy. Practicing purposeful thinking. critical thinking Copyright © 2009. b e c d a 2. Communi Cation eXerCiSe S All exercises are individual. a. e. Consider all possible alternatives. b. thorough assessment d. What will happen if the task is not done on time. honest. reprioritize C o nC e p t ma p p i n g Each person’s concept map will be different and individual. effective writing. attentive listening. 4. yet clearly. Chapter  terminology 1. Focusing on main ideas and relevant data while reading. b. e. Consciously practicing attentive listening. d. curious. (Wording of examples may vary. and effective communicating. Predict the likelihood of each outcome occurring. collaboration with other health care team members c. b. 2. 4. c. c. attentively listening before responding.

The boy with the cut had stopped the bleeding and could wait for treatment of his wound. 9. Example: “Marta. 13. 14. diagnostic test results. 6. chart review c. needs. 2. h a g e f c b j i Chapter  Completion 1. I need to use it. 7. interview b. the chart. when you are finished with the sphygmomanometer. problem occurring. 6. 2001 by Saunders. All rights reserved . 3.” Criti C a l thinking aCtivity (Requires synthesis and application of knowledge) Priority rating 2 1 5 4 7 8 3 6 9 What needs to be done Buy books Get a map and find classrooms Buy a parking permit Call for doctor’s appointment Take daughter to the doctor Buy son’s school supplies Go to first class Go to second class Grocery shop terminology 1.Student Learning Guide Answer Key  nC le X. 11. 17. the physician’s history and physical. unforeseen implement concisely overlapping input enhance coherent prognosis Communi Cation eXerCiSe S 1. 2. 7. Copyright © 2009. 5. 2. 2. 5. 10. Inc. 2.pn ® eXamination–Styl e r eview Que Stion S 1. Example: The man with the chest pain might be having a heart attack (myocardial infarction). 8. 6. That could be life-threatening. a variety of methods rapport all information gathered about the patient cause health. 15. physical assessment Safety: at risk of falling Hygiene/grooming: needs assistance with ADLs Elimination: urinary incontinence STEPS TOWARD BETTER COMMUNICATION v oCabulary Similaritie S eXe r C i Se Correct opinion Completion 1. 3. the family/significant other. 3. 4. 8. 8. 3 consider all possible alternatives 2. 4. I will be in room 234 or 246. 9. Would you please bring it to me as soon as you have finished taking the blood pressures? I would really appreciate it as there are no wall units in these rooms. 4 4 1 3 2. 12. 4. an imprint of Elsevier. 5. 4. and the admission note a. Individual answers will vary. defining characteristics subjective individual assessment chart review analyzing priority evaluate expected outcome/goal cues The patient. 5. 6. 16. 3. 7. 2005.

Student Learning Guide Answer Key 

Psychosocial and cultural: loss of independence; blow to self-image from stroke Education: instruction in walking with walker; medication instruction; instruction in possible cause of stroke and ways to prevent another one. Rest and activity: left-sided weakness; scheduled rest to prevent fatigue; exercises to strengthen muscles affected on left side and to preserve muscle function on right side 18. Many of the nursing diagnoses in Box 5-5 fit here. Some of the most likely nursing diagnoses are: a. Impaired urinary elimination: incontinence b. Impaired physical mobility c. Disturbed thought processes d. Risk of injury e. Self-care deficit 19. Activity-exercise pattern 20. Present function, personal habits, lifestyle and cultural factors, and age-related factors Correlation 1. Barbara Abeyta is admitted with severe vomiting. Fluid volume deficit related to excessive loss of fluids by vomiting. 2. Leonard Henry has fallen and fractured his hip. Impaired physical mobility related to injury as evidenced by x-ray showing hip fracture. 3. Joel Tomaso is admitted with a very high fever and severe infection. Hyperthermia. 4. Although recovering, Tyrone Peters suffered a stroke that has paralyzed his right extremities. He is right-handed. Self-care deficit, bathing, related to neurologic impairment as evidenced by inability to move right arm or leg. 5. Valerie Tallchief has emphysema and becomes very short of breath whenever she tries to perform a task. Activity intolerance related to decreased lung capacity as evidenced by inability to perform tasks without becoming short of breath. nC le X- pn ® eXamination–Styl e r eview Que Stion S 1. 2, 4 2. data that can be verified by auscultation, palpation, percussion, or inspection 3. 3 4. 4 5. 2

6. 7. 8. 9. 10.

3, 4 3 4 2 1, 3

C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. Relief of pain; assistance with care; reduction of fear; emotional support (in order of priority) 2. Appropriate nursing diagnoses might be: Pain Expected outcome: Pain will be controlled by medication within 6 hours. Self-care deficit, bathing Expected outcome: Assistance with bathing will be provided daily. Self-care deficit, toileting Expected outcome: Assistance with toileting will be provided whenever needed. Anxiety Expected outcome: Anxiety will be decreased within 12 hours. Fear Expected outcome: Fear will be relieved or reduced as pain is controlled and knowledge of what is to happen is gained. 3. Objective data: Cries out when tries to move left leg. Apprehensive facial expression and body language. Bruise present on left forearm. Subjective data: Sustained a fall. States is scared. a. O b. O c. O d. S e. O f. O g. S h. O S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. 2. 3. 4. 5. 6. significant other deviate differentiate over-the-counter pertinent alleviate

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Student Learning Guide Answer Key 

7. 8. 9. 10. 11. 12.

formulate scan correlate concurrent condition prosthesis infer

11. Planning 12. Planning b. 1. priorities of tasks 2. change-of-shift report 3. a. if visitors will be coming b. diagnostic tests are scheduled c. time physician may come to see the patient d. medication administration schedules 4. introducing microorganisms during an invasive procedure 5. multidisciplinary; managed 6. dependent 7. documentation 8. expected outcomes 9. agency policy and procedure manual 10. if interventions have been successful 11. family 12. sterile; invasive 13. spot check S eQ u e nC i n g (Requires synthesis and critical thinking.) 1. 5 2. 7 3. 2 4. 1 5. 3 6. 4 7. 6 n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 3 (application of prior knowledge) 1 (application of prior knowledge) 4 (application of prior knowledge) 1 2, 4 4 2 3 1 4 independent 3 4 1 2

w ord attaCk SkillS 1. rapport (n)—relation of harmony or accord report (n)—account of an event or verbal summary of patient condition and care for a shift 2. elicit (v)—to get or bring out illicit (adj)—unlawful 3. affect (v)—have an influence; a change effect (n)—the result of an action causing change

Chapter  terminology 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. d j k i b c h f g l a e

Short a nSwer a. (Answers require analysis and synthesis of information.) 1. Assessment 2. Planning 3. Implementation 4. Assessment 5. Assessment 6. Implementation 7. Nursing diagnosis 8. Evaluation 9. Nursing diagnosis 10. Evaluation

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Student Learning Guide Answer Key 

0

Criti C a l thinking aCtivitie S 1. The priority of each task; the amount of time available; the ability of the patient to assist with self-care; medication times; procedures to be done; if the patient will be off the unit for diagnostic tests; when the physician might visit the patient; when visitors might be expected. 2. Some positive aspects are: • improvement of nursing care • see if care meets current standards of care • determine if documentation is occurring • determine whether care given is cost-effective 3. Case Study—the nursing care plan should contain the following points: Assessment data: MVA, splenectomy incision, bruises on right extremities, swollen right knee; pain; cannot walk without pain. Nursing diagnoses: 1. Impaired skin integrity related to surgical incision 2. Risk for infection related to incision and traumatic wounds 3. Impaired physical mobility related to inability to walk without pain 4. Pain related to surgical incision and traumatic wounds Expected outcomes: 1. Incision will heal without signs of infection within 2 weeks. 2. Systemic infection will not occur during next 4 weeks. 3. Will be able to walk without pain within 6 weeks. 4. Pain will be controlled by medication for 4 hours at a time. 5. Pain will resolve within 4 weeks. Nursing interventions: 1. Dressing change daily with aseptic technique. Assess wound for signs of infection. 2. Monitor vital signs q 4 h; assess knee for signs of infection q shift. Monitor bruises for signs of infection. 3. Assist to BR; supervise ROM to other extremities tid. Assist with hygiene and grooming as needed. 4. Assess for pain q 3–4 hours. Medicate as ordered pm. Provide distraction activities to reduce pain. Monitor for signs of constipation. Increase fluids and roughage to prevent constipation from pain medication.

Evaluate after implementation: Gather data related to wound status, vital signs, pain level, and knee swelling. Determine if actions are helping patient meet the expected outcomes. 4. Concept map. This will vary per the individual making the map. It should include all nursing diagnoses that would be on the patient’s nursing care plan. The appropriate interventions would be linked to each nursing diagnosis. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. deadline imminent collaborative strive impairment adept blame intervening clue sequence incorporated rationale

a b b r e v i at i o nS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. short-term long-term every four hours range of motion physical therapy cerebrovascular accident related to urinalysis outcome-based quality improvement

Chapter  terminology a. 1. d 2. c 3. e

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Student Learning Guide Answer Key 

4. b 5. f 6. a b. (Answers may be found in the textbook glossary or in a dictionary.) 1. d 2. c 3. b 4. h 5. j 6. a 7. m 8. i 9. k 10. f 11. g 12. o 13. e 14. n 15. l Short a nSwer 1. Any three of the following: a. Provide a written record of the history, treatment, care, and response of the patient while under care. b. Serve as evidence in a court of law. c. Provide data for quality assurance studies. d. Guide reimbursement of costs of care. 2. Any of the rules in Box 7-3 that conform to the requirements of a legal record. Examples: a. Document in ink. b. Date and time each entry. c. Sign each entry correctly including your title. d. Do not leave blank lines in your nurse’s notes. e. Correct errors according to protocol. f. Chart objective data after completing a task; never chart before doing the task. g. Note late entries correctly. h. Identify care given by another health care worker. i. Document instructions given to the patient. 3. Charting is organized by nursing diagnosis. Assessment data are documented.

Implementation of the interventions noted on the nursing care plan is documented along with the patient response. Evaluation of patient progress toward expected outcomes is placed in the nurse’s notes. Evaluation data are documented that indicate expected outcomes have been met. 4. a. Accuracy of what is charted. b. Brevity using abbreviations and symbols as accepted. c. Completeness of assessments, actions, and results. Completion 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. guide communication tool expected outcomes caring directly; access legal record; a court of law chronological baseline condition relevant data problem; event flow sheets; checklists otherwise documented protocols abnormal data; trends interventions computer screen visible legible variance behaviors ordered treatments safety factors; continued care

a b b r e v i at i o nS (Answers may be found in the Appendix in the section “Abbreviations.”) 1. ADL 2. ERT 3. BE 4. GU 5. DOE 6. CAD 7. CC 8. HTN 9. URI 10. WNL

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17. 6. 1. 29. 19. 26. 21. Pupils equal and reactive. 5 3 4 2 2 24-hour intake and output 1 2 2 2. 4. Charting method preference is a matter of personal choice. 4. 5. 11. The student should jot down the acronyms that she feels are noteworthy and compile a list. 2001 by Saunders. 5 2. p r o n u nC i at i o n a n d i n t o n at i o n S k i l lS 1. The audit showed a need to reimburse the patient’s money. 12. 20. 3. 2. The adage was ambiguous. 4. 4. 4. 13. 6. The rule of thumb is that the duration of the office visit should adhere to the rules. oriented. 5. 7. Copyright © 2009. LMP TIA BPH BS CHF RLQ ABD CCU EKG. 1. 12. age 22. an imprint of Elsevier.Student Learning Guide Answer Key  11. 2. 8. ECG SOB FHR CRF RLL MRI Stat NPO PT ROM UA S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N v oC a b u l a ry e X e rC i S eS 1. 22. 3. 3. 3. Expected outcome: Patient will regain full mobility within 8 weeks. down up up down up down nC le X. Pain in leg and wrist. fracture of right femur. 24. Assessment data: Female. matching g f e b h d c a Completion feedback body language communication Therapeutic active listening Confidentiality Criti C a l thinking aCtivitie S 1. The time frame required that the doctor use brevity in talking about the offshoot in the problem. 5. 7. 2. 10. 2. 4. 28. All rights reserved . 8. 18. 13. 3. Nursing diagnosis: Impaired mobility related to fracture of right femur.pn ® eXamination–Styl e r eview Que Stion S 1. 14. 9. and able to follow commands. 6. 2. 6. 5. Inc. 5. alert. b. 2. 5 3 4 2 Chapter  terminology a. 14. 15. 25. 2. 3. 23. 16. laceration of right wrist. 3. accident victim. 2005. 27.

Past experience c. When last bowel movement occurred d.” 7.” 4. friendly voice. Approach the child at eye level and use a calm. 10. Displaying acceptance and respect for the patient 9. Do not rush the person 12. Any four of the following: a. Attitude 3. 12. Transmit orders e. Most physicians don’t like to have the nurse suggest changes in the care of the patient. processes it. 11. validated 5. 6. 13. Face the person at eye level.” 2. All rights reserved . a. Introduce one idea at a time d. Therapeutic. and indicates that the message has been interpreted. Presence of pain c. 13. 14. Speak slowly with voice pitch at midrange. 14. intake and output. Update the nursing care plan b. Document nursing care d. Norms for making eye contact 6. Having the quality of empathy c. 3. patient allergies. 6. 2. 4 1 a block or barrier 1 3 3 1 4 3 1. 9. medications received. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. Assessment. 9. Any three of the following five answers: a.Student Learning Guide Answer Key  Short a nSwer 1. Block—changed the subject. 7. 4. encourages elaboration. do not make sudden movements or gestures. A nonjudgmental attitude e. c. 8. Situation. 5. “Tell me how that made you feel. 10. 2 3 1. 2001 by Saunders. Communicate plans for care with another department f. a. a. Effective communication skills b. Culture b. 4. Having a desire to help d. 2. Eliminate outside distractions c. “It is a very difficult time for you. 5. 2005. Any three actions from Box 8-1. Have the person’s attention before beginning b. 8. quiet. Charge out supplies c. an imprint of Elsevier. 3. what year 4. Current vital signs. 2. Any three of the following: a. 15. 10. Request a consult from another health care professional 11. If previously hospitalized. Recommendations. 4 3 3 1 mat C h i n g 1. You might say. A person sending a message and a person who receives the message. b. 7. Therapeutic. seeking clarification 3. “That has to be hard for you” or “I can only imagine how difficult this is. Allergies e. a. Speak very distinctly. Inc. build trust 8. Obtain the person’s attention before beginning. Phrase any recommendations very gently. 3. Copyright © 2009. Emotions and mood d. 2. Medications taken today b.) 1. Block—defensive comment. Background. Expressing honesty and genuineness f. i h d a b e g j c f a p p l iC at i o n o f C o m m u n iC at i o n t eC h n iQ u eS (Answers are from Tables 8-1 and 8-2. d. Use of personal space b. 2. pertinent laboratory data.

Student Learning Guide Answer Key  5. 6. “Ummmmm. 8. 6. 20. That outside distractions and noise are minimized. wife visited. walked in hall x 3. 9. IV discontinued. 17. There is sufficient light for the person to see well and that glasses are on if used.. Information to include in report: Vicodin given at 8:30 with pain relief. Poor vision. 18. You proceed slowly and allow time for formulation of questions. dressing clean and dry. Shows attention to what is being said and encourages patient to continue. an imprint of Elsevier. “What are your concerns?” Seeks information about feelings. 10. taking clear liquid diet without nausea. 2. poor hearing. Patient is scheduled for PT. 7. 3. 7. hands-on equipment 5. 3.. 13. 2001 by Saunders. 19. All rights reserved . 2. return demonstration S h o r t an S w e r 1. sense of being overwhelmed. medications d. behavioral objective 5. diet c. Therapeutic. Inc. Criti C a l thinking aCtivitie S 1. a. cultural very small steps Play beliefs. 9. printed material such as books and articles b. fatigue. value. Pain. feedback 6. encouraging elaboration. kinesthetic 2. Completion 1. d. validates what patient is saying by reflection. 4.. 16. 4.” encourages elaboration of feelings. Therapeutic. 7. 5. 10. self-care 2. is not eating meals and doesn’t care for the food being served (dietitian). a. 2. apply kinesthetic processing dexterity knowledge base advantage consistency feedback review return demonstration printed Chapter  terminology 1. but is experiencing pain (physical therapist). b. 12. Block—reassuring cliché. auditory Copyright © 2009. 5. treatment e. audio. 8. Block—offering advice. 2005. illiteracy. “You’re concerned about the pain?” Explores feelings and opens discussion of how to handle the situation of the pain. 8. 6. 11. The person can hear and that the hearing aid is turned on if used. conveyed ambivalent optimal discount judiciously verify lead strive 4. Deficient knowledge consistency printed. STEPS TOWARD BETTER COMMUNICATION Completion 1. and can’t go to sleep (night shift nurse). doesn’t like to take medication and would rather use natural remedies for minor complaints (physician). 14. the disease or disorder b. or impaired cognition 3. Block—using a cliché. a. is awakening every night about 3:00 a. and video materials collaboratively short readiness. Therapeutic.or audiotapes c. 15. feelings and values.m. c. and multiple people coming in and out of the unit 4. visual 3. impaired motor function. video.

Competencies 7. documentation of specific problems or errors S h o r t an S w e r 1. feedback 12. result desired. 2005. concise. Copyright © 2009. 3 2 3 1. job description 8. nonthreatening 4. dexterity literate deficit teaching moment frame of reference v oCabulary eXerCi SeS 1. c 3. STEPS TOWARD BETTER COMMUNICATION Completion 1. know the capabilities and competencies of the person b. any precautions to be followed while taking the medication. 4. 3. direct. 16. 2. clear. 3. 5. All rights reserved . 2.3 reinforcement of the material taught 3 4 1 3 3 2 2 4 1. privacy 13. 2. Patients is the plural. 3. concise. a Completion 1. potential side effects and their signs and symptoms. collaborate with physicians and other health team members Criti C a l thinking aCtivitie S 1. 11. direction 2. 5 3. defines the problem 5.Student Learning Guide Answer Key  nC le X. assist with patient care c. prioritize 15. 5 2. 17.pn ® eXamination–Styl e r eview Que Stion S 1. Patient is an adjective and means to be calm and willing to take time. accountable 6. 8. a. 13. a mistake has been made or something is not known 3. 10. time frame 10. an imprint of Elsevier. help resolve conflicts d. 5. 2001 by Saunders. Practice using different techniques within your best mode of learning to determine what is most efficient for you. 6. communicate effectively with the person d. 14. 15. kinesthetic 4 1. attentive listening 9. 12. authority 11. a. know whether the task delegated falls within the person’s domain and can be legally delegated c. and means a person treated by a doctor or nurse. what it should do. Chapter 0 terminology 1. assist with writing policies and procedures e. 4. control. Patience is a noun meaning the ability to wait calmly for something. contribute information for evaluation of UAPs f. Patient is a noun. Use different modes for an assignment to determine which seems to be the best learning mode for you. 3. when and how to take the medications. 9. 7. understand the person’s needs 2. 3. 4. empathy 14. 2. coordinate personnel and make work assignments b. Cover the purpose of the medication. Inc. b 2. feelings.

a. vital signs. 5 2 3 1. a. 4. Try the alternative. I would like you to weigh Mr. S T E P S TO WA R D BE T T E R C O M M U N I C AT I O N v oC a b u l a ry e X e rC i S e S 1. 2. a. bed-making. the competencies of the UAP to whom you are assigning. Copyright © 2009. 5. Priority items should be entered into the time schedule first. and ambulation to a UAP. and Ms. 9. Ask each patient what they were wearing when they were weighed on Monday so Criti C a l thinking aCtivitie S 1. 6. c. 2. Choose the best alternative to solve the problem. 3. 6. vital signs. The time organization sheet should include a row for every hour of the shift and a column for each patient assigned. 7. Who is in charge of scheduling your hours? g. Remember to include time for patient teaching and time for documentation. 5. Remember to include medications. 2001 by Saunders. Have additional training or preparation in the specialized area to which assigned. Moore. Considerations would be which tasks legally cannot be delegated. 2005.) 5. etc. 7. e. 3. See Box 10-1 in the textbook or list others that you feel are important. Have knowledge and experience in leadership c. whether they are delegated or not. ROM.? e. weights. ordered wound care and medications would take precedence over bathing or ROM. 2. 4. ambulation. 3. c e b a d Completion 1. d. signs of complications. 6. Adams before breakfast today. 5 2 1. 3 1. 5. To whom do you go with concerns or complaints? f. d. daily weights. blood sugar determinations. 10. (If the alternative does not work. Estimate possible outcomes for each alternative. and facility protocols on delegation. competent 2. 9.Student Learning Guide Answer Key  3. Who is your immediate supervisor? From whom do you take orders? Who is over your suprvisor? To whom should you report changes in patient condition. Have training or experience in nursing administration and supervision d. 4.pn ® eXamination–Styl e r eview Que Stion S 1. Look at alternative solutions. 3. 4. competently polite and effective Communication 4. “LuAnn. 12. For example. Ms. b. repeat the problem-solving process. Inc. compete 3. nC le X. eye contact conflict resolution laissez-faire competent cost-effective reimbursement chain of command active listener feedback domain constructive criticism delegate v oC a b u l a ry e X e rC i S eS wo r d f a m i l i e s 1. b. an imprint of Elsevier. 10. Work for 1 year as a staff nurse b. All rights reserved . 11. 3 4 2 1 2. You might be able to assign patient baths. Include all tasks to be completed. Schedule in time for assessment/data collection and for procedures such as wound care. 8. Garcia. 2. c. bathing. etc. Define the problem. 3. Whom should you call if you are ill and cannot make it to work? 4. 8.

take precedence over 3.) “Please be sure that the scale is balanced on zero before weighing each patient. amniotic sac 2. 2005. 3. 7. triple cephalocaudal. Puberty in the female occurs between ages 9–17 with 12 as the average age. All rights reserved . 1. mitigate proficient jot. the fetus is 10–12 inches in length and weighs about 1 lb. 4. Garcia just had on her gown and slippers. 14. 14 years of age idiomati C phraSe S 1. which usually start by 8:30 a. 6. 8. 13. 14. 11.Student Learning Guide Answer Key  that our weights have a consistent basis. pleasure principle Moro right and wrong morals Intelligence social ideology genes time-out folic acid. 4. 2001 by Saunders. 7. head 2 C omple tion 1. b k c h l m i d f n g e Completion 18 months. 400 double. 6.) abbreviation S 1. Multiple births are caused by the fertilization of more than one ovum or division of an ovum. If you have any problems. 10. 1. 12. medication administration record unlicensed assistive personnel immediately as soon as possible (not in the chapter. b. establish eye contact 2. 4. 15. please write them down on the jot board right away so that they will be available when the physicians make their rounds. 10. It attaches during the second week and is attached by the placenta. matching o j a Copyright © 2009. 1. The external genitalia begin to appear during the third month. an imprint of Elsevier. if Mr. 13. discern. but widely used throughout the United States in many types of situations) 4. track down Chapter  terminology a. For example. 8. 2. By the fifth month. if Ms. 5. 3. 9. 8. let me know. 6. 6 libido. 9. 4. 7. 12. 3. 2.m. 5. 11. 5. The heart begins beating at about 3 1/2 weeks. 3. weigh him with those items on. Inc. Can you relate back to me the details of what I’ve asked you to do?” (LuAnn replies and further dialogue occurs if she cannot repeat the instructions correctly. When you are finished with all three weights. grid instills or fosters r e v i e w o f S t r uC t u r e a n d f u nC t i o n Answers are in the Overview of Structure and Function section of the chapter in the textbook. 2. The eyes and ears begin to take shape during the fifth week. 3. 9. I will be making rounds in about 10 minutes and then I will be here at the desk. weigh her without her robe. Do you follow what I mean? (LuAnn replies that she does. 2. Moore was wearing his slippers and robe.

a. A chronic disease such as diabetes or heart disease. Infant should be placed on its back for sleep. 12. b b d b f f c d e d e f b a b Short a nSwer 1. 4. a. oxygen 18 months 16–20 12 to 24 9–10 first n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. 10. e. 6. 8. 12. Investigates and identifies alternatives regarding his or her vocational and personal future. an imprint of Elsevier.Student Learning Guide Answer Key  identifi Cation 1. mathematics. Completion 1. 3. early adolescence years 8. 9. 9. Increase abstinence from alcohol. 15. Maternal age below 16 or over 35 d. 2. e. 6. b. 7. 2 4 8 bonding 3 1 2 1. 7. 6. levels of awareness components of the personality or mind psychosexual stages of development Organization: we try to make sense of our world Adaptation: we discover new information and adjust our thinking patterns Obey rules to avoid punishment Conform to social standards to avoid disapproval Abide by laws and follow one’s conscience Growth occurs in orderly and predictable ways. d. 13. Can delay gratification due to trust (Table 11-2) Practices new skills. 4. a. 3. 7. Bath water should be tested to see that it is not too hot before putting infant into the bath. 4 1. a. 1–3 years (Table 11-1) 10 predictable physical. and social skills. c. b. c. No infant should be left in a house or car alone. hormonal shifts b. Acquires skills of reading. Poor nutritional status of the mother 9. 3. e. more than one ovum is fertilized anal. Lack of prenatal care c. d. Inc. 14. Formulates a plan of action and carries it out. a. b. 10. Small objects should be kept out of reach to prevent entry into the mouth and choking. The rate of growth and development is individual. 3 Copyright © 2009. 13. a. 15. 2005. and illicit drugs among pregnant women. a. 4. 5. 8. Development is continuous. b. psychosocial 46 chromosomes 40 nourished 30 nutrition. b. Infant should not be left alone on a surface without protection from falls. 11. 5. f. 3. 2001 by Saunders. 7. Development is multidimensional. 9. a. c. 2. c. 5. 6. 5. Infant must be restrained in a car seat in the back seat when the car is moving. 2. 11. b. 8. 2. 4. All rights reserved . 14. a. b. c. Increase the number of mothers who achieve the recommended weight gain during pregnancy. 2. cognitive. cigarettes. b. Development is lifelong. d. 3.

Assessment parameters for eating disorders. • FSH stimulates the development of ova and menstruation begins. 5. Drug and alcohol education programs available in the community. pubic. building blocks. enjoying music. 2001 by Saunders. gymnastics. 2. architecture. e. • The voice lowers in tone. selling. understanding number concepts spatial: art. growth patterns. 3. an imprint of Elsevier. Criti C a l thinking aCtivitie S 1. leadership. learning foreign languages. c. • Nocturnal emissions occur. tumbling interpersonal: outgoing. playing instruments. engineering. cyanotic Female • FSH stimulates the ovaries to begin producing estrogen hormones. • Axillary and pubic hair appears. mathematics. 2. 14.) ph y s i c a l C h a n g e s o f p u b e r t y Male • ICSH stimulates the testes to produce testosterone. dancing. f. • There is growth of the reproductive organs. 3. • Enlargement of the reproductive organs occurs. 4. and milestones of physical and mental development. drawing musical: singing. outgoing. vital/necessary/important b. 12. enjoys Copyright © 2009. and axillary hair occurs. nutrition. Agencies and educational programs available in your community to help combat teen pregnancy. and stimulation. d. a. helping/aiding/assisting 2. playing instruments. All rights reserved . • FSH stimulates the testes to begin producing sperm. Review normal reflexes. Review the importance of meeting the infant’s needs and what those needs are in areas of safety. moving to music bodily kinesthetic: dance. sports. 13. early speech. 4 table aCtivity (See Overview of Structure and Function section in the chapter. engineering. • Bones thicken and skeletal muscles increase in size. active play. Assessment for high-risk behavior among adolescents. • Growth of facial. singing songs. talking with others. working with people. 2005. elimination. linguistic: writing. friendly. a. 6. Inc. rest. b.Student Learning Guide Answer Key  10. Signs of depression in adolescents. hygiene. Employers in the area who are tuned in to the needs of adolescents and are interested in their school performance. 15. speaking. exercise. STEPS TOWARD BETTER COMMUNICATION Completion 1. erupt resilient baby fat gender stereotype growth spurt v oC a b u l a ry e X e rC i S eS 1. 2 3 4 1 2 1. climbing. 11. • Breast development occurs. enjoying word play mathematical: science. • Hips widen. counting.

8. 3. lead in games. Sadness e. c. an imprint of Elsevier. Inadequate sleep d. 7. a. Fathers are more involved in the care of children and care of the house than ever before.Student Learning Guide Answer Key 0 playing with others. Chemical abuse b. imagination. 2. Decreased self-esteem c. using computer programs. Any three of the functions listed in Box 12-1. changing jobs or careers 10. Helping young people and others in the community. 9. readjusting to living with boomerang children. Develop an intimate relationship with a significant other c. Any three of the following: a. and any other mind-stimulating activity Short a nSwer 1. Responsibility for members of one’s family Job responsibilities Responsibility for oneself Responsible for self Responsible for family Responsible for the corporation or the country Copyright © 2009. divorce. philosopher. 5. Difficulty finding happiness g. psychologist. 2005. a. b. writer. Working crossword puzzles. Overeating c. self-analytic Communi Cation eXerCiSe S Dialogues will be individual. 3. Inc. Only a small percentage of families live in rural areas and are self-sufficient. Form close relationships with others b. Chapter  terminology a. 7. c. Families move around a lot making it hard to maintain friends. Begin taking responsibility for self e. 10. 1. 6. 5. poet. 6. 9. Most mothers now hold a job outside the home. Continue learning and applying what has been learned 4. 4. Relief at leaving a difficult situation 8. playing bridge. 4. playing board games that require strategy. enjoys solitary play. a. Feeling blame or guilt b. empty nest syndrome when children have all left home. Any three of the following: a. 2. matching d b h j g a i f e c Completion Middle adulthood intimacy 30 Executive substage Generativity Stagnation Children Sandwich generation 45 1200. 7. 1500 120/70 3. a. Difficulty relating to other people d. Maintain close family ties d. 11. studying a new subject. caring for aging parents. 6. Inability to trust f. 2001 by Saunders. 8. Sexual promiscuity 9. volunteering within the community 5. b. 2. 10. An inactive lifestyle e. being productive in the workforce. 1. All rights reserved . c. b. enjoys visiting intrapersonal: quiet thinker. b.

8. 2 3 1. confidante down-sizing juggle boomerang menopause volunteering family ties nC le X. 3. 4. Quiet—boisterous (noisy) or active Copyright © 2009. 18. Dental maturity with eruption of wisdom teeth. 10. activities friendships middle years mobility 70 36% poverty 40 cervical 75. Middle Adult • • • • • • • • • • • Redistribution of body weight Presbyopia Presbycusis Compression of the spinal column and loss of height Loss of muscle tone and elasticity of body tissues Blood pressure increases Skin becomes less resilient Wrinkles appear Graying of the hair Thinning of scalp hair Decreased levels of estrogen in women and decline in testosterone in men 7. 2. 13. 2. 4. 4 1.7% loud music Relationships lonely C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. 13. 11. 4. 12. 20. 6. Physical growth of the brain continues until the mid-20s. 3. All rights reserved . 3 2 v oC a b u l a ry e X e rC i S eS 1.pn ® eXamination–Styl e r eview Que Stion S 1. 2005. 4 3 Completion 1. 2. an imprint of Elsevier. Inc. 11. High levels of strength. 10. 6. 14.Student Learning Guide Answer Key  table aCtivity physical Changes Young Adult • • • • Completion of skeletal development. 12. 17. 3. 7. 3 1. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. 3 1 1 2 4 1. 6. 5. See Table 11-2. care about and for each other one or two parents and children 26% 40 a hot flash garlic stress interests. 2. 9. Answers depend on your age and developmental stage. 5. 16. 9. 7. 15. endurance and energy. 5. 19. 8. Answers depend on your age and developmental stage. 2001 by Saunders.

b. Copes with failing eyesight by using the bus rather than driving. Personality (optimistic people live longer) d. adapts to the situation. 3.9 25. Wear-and-tear theory: body cells and organs eventually wear out. Biological clock theory: body cells break down after a specific length of time and die. All rights reserved . longer longevity) b. 2005. 2. Stops going to church. 2. Lifestyle (no smoking) c.6 psychosocial 75 11. a. 4. 4. 10 S h o r t an S w e r 1. 3. a. 5. an imprint of Elsevier. 8. Autoimmune theory: body no longer recognizes itself and begins to attack its own cells. e. a. d. sedentary Tall—short Large—small p ronun Ciation and Stre SS tion/sion urbanization generation question maturation tension stagnation ic/ical pelvic chronic biological skeptical physical cervical omy economy autonomy ogy biology sociology gerontology ity maturity infidelity validity flexibility obesity promiscuity generativity personality ery delivery grocery nursery surgery edy remedy tragedy comedy istry dentistry chemistry Chapter  terminology a. 2001 by Saunders. b. 7. 6. 3. matching f c d b h a g e Completion conception biologic free radical activity elder abuse life span 77. 6. 10. 8. c. 3. 1. 5. Education (more education. 6. free radicals are unstable. withdraws from bridge club. 7. 1. 9. Blonde—dark-headed or dark Athletic—nonathletic. Inc. 2. Gender (females live longer) Copyright © 2009. c. Free-radical theory: cells are damaged by toxins. 4. Immune system failure theory: system loses its ability to protect the body. hypertension 12. b. 5. Takes an adult education class.Student Learning Guide Answer Key  2.

Proud of well-maintained home appearance and savings for retirement 7. 8. Staying mentally active 8. 2. They do not do things just to accommodate other people as easily anymore. Mr. I don’t feel any different when I take them. T Theory 2. Increase to at least 80% the receipt of home food service by people age 65 and older who have difficulty in preparing their own meals or are otherwise in need of home-delivered meals. 2. 10.” Nurse: “How do you know they weren’t doing you any good?” Mr. but I stopped taking them. 10. 5. a.” Nurse: “Now.: “Oh. Re-integrative stage. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. too. How are you feeling?” Mr. 3. All rights reserved . M Myth 3. hearing aid 4 2 1 2 2 Copyright © 2009. 4. H.: “No. prevention of illness and treatment of disease. but they weren’t doing me any good and they stuck in my throat.: “Well. 7. what medications are you taking?” Mr. exercise. 6. an imprint of Elsevier. medications. There were some big horse pills. b. 10. a. 2005. 2. Hernandez. 3. Any one of the changes listed in Table 13-1. 4. 9. 9. poor hygiene.. 6. but they are doing their nC le X. and some red ones. active depressed think circulatory physical activity volunteer needed 35 C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. Inc. 6. social activities.” Nurse: “Mr. Safety concerns related to confusion. Completion 1. 2.” Nurse: “Why? Did the doctor tell you to stop?” Mr. 3. I don’t know. Consider nutrition. 13. 8. H. 4. Increase the lifespan and quality of life by focusing on wellness. 5. 2001 by Saunders. An exercise program b. exercise personality 30 2 frail. H. 9. irrelevant nest egg myth lifestyle v oC a b u l a ry e X e rC i S eS my t h v e r s u s th e o r y v e r s u s f a c t 1. H. H. 12. Good. illness from forgetting medications. 11. Active in the church b. Any five of the items in Box 13-3. 4 2 3 1.: “Pretty good for an old guy my age.Student Learning Guide Answer Key  4. malnutrition from forgetting to eat.pn ® eXamination–Styl e r eview Que Stion S 1. and activities that require the active use of the mind. healthier diet. some medications don’t make any difference in how you feel. F Fact C o m m u n iC at i o n e X e rC i S e ANSWERS for stress markings (may vary): Nurse: “Good morning. There are some pink ones. Participation in an exercise program that promotes strength and balance and is an ongoing activity. inability to maintain a checkbook and attend to finances. a. 3 glasses. Older adults carefully select how they wish to spend their time. 7. balanced nutrition c. 5.

3. no! Is that what will happen?” Nurse: “Well. 1. 14. Pacific Islanders Ethnic Chi’i yin. 9. Do not eat any pork. and prejudices. Inc. 14. ‘healthy as a horse. 6. If Orthodox. let’s see if the pills can be cut in half. 2. 8. a. b. 2005. 1. 8. 12. Develop cultural awareness. 4. 5. OK. 13. the medication helps prevent those types of complications. 11. Prefer vegetarian meals.: “Well. wish to restrict diet to “hot” or “cold” foods that are beneficial to the body during that type of illness. Both have to do with attempting to understand one’s place in the world and life’s meaning or purpose. Any of the beliefs or values listed in Table 14-3. Any of the beliefs or values listed in Table 14-3. 2. Any of the beliefs or values listed in Table 14-3. Your cholesterol and hypertension pills help keep the blood vessels open to your heart and brain so you won’t have a stroke or heart attack. attitudes. 15. 15. eat only Kosher foods. When ill. Cultural Group Beliefs or Values Hispanic-American Any of the beliefs or values listed in Table 14-3. If you have some side effects. do not eat pork. 4. Asian-American Chapter  terminology a.: “Oh gosh. 2001 by Saunders. 11. beliefs. 13. b. 9. You don’t want your wife to have to take care of you if you can’t talk or feed yourself. c. H. yang curandero shaman offering food personal kosher C o m pa r iS o nS Answers are from Table 14-3. 10. b.’ Maybe that’s how they stay healthy! Seriously. 5. H. 7. All rights reserved . examine your own values. a. 3.” Mr. Any of the beliefs or values listed in Table 14-3. an imprint of Elsevier. c. but I sure don’t like those horse pills!” Nurse: “You know the old saying.” 7. talk to the doctor and maybe he can change the prescription. 12.Student Learning Guide Answer Key  job in your body. and is an element of religion. Know yourself. 2. 3. But you should continue taking them until you talk to the doctor. Religion is a formalized system of belief and worship. matching e d g l b k j c o h i f a m n Completion sensitivity stereotype dialects culture world view generalization Native-American African-American European-American S h o r t an S w e r 1. Spirituality concerns the spirit. or soul. do you?” Mr. 6. or other problems taking those pills. d. Keep an open mind and try to look at the world through the perspectives of culturCopyright © 2009. 10.

9. organization of the family d. 12. foods in the diet e. communication b. 16. 15. 5. 5. 5. 2. 13. b. Outline what you feel the spiritual needs of the Hindu. a. Identifies and employs spiritual support. a. yang malnutrition. 2. 20. 11. refrain from attire prevalent sustained wealth of information appli C ation of the n urSing pr oC e S S 1. 7. Inquire about foods normally consumed within the patient’s culture to include in the diet. 3. 2 4 3 1 2 1 egalitarian 4 1 2. Any three of the following: a. and the Muslim might be. Ask the family to bring in acceptable cultural dishes for the patient’s meal. 4. 2. 10. Impaired verbal communication b. foods. Determine whether a religious leader is visiting. 5. 8. Learning about a people’s history. Determine if prayer and spiritual readings are being used. 3. Expresses comfort with relationship to God and significant others. health care beliefs Completion 1. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. Inc. c. 13. 19. 14. States he or she feels at peace. values rejected culture transition equality. Consult with the dietitian to provide culturally acceptable foods. c. 17. African-American Hispanic. 12. d. 10. 2005. appreciating their artistic expressions. 3. list both and compare. 18. Spiritual distress 3. c. You might inquire whether a sense of peace is being achieved. a. Define what your own cultural beliefs are. Learn all you can about other cultures. the Buddhist. issues related to death and dying f. 8. 11. Ask a peer about his or her cultural beliefs. 14. 3. b. b. Develops or reestablishes spiritual practices that nurture a relationship with God or a higher power. 6. 2001 by Saunders. 188 in the textbook. tuberculosis human caring an open mind authority. matriarchal temperature folk or home remedy Hispanic-American. 5.Student Learning Guide Answer Key  ally diverse peoples. Copyright © 2009. then plan what you would do to meet those needs. 4. 4. Any of the questions from p. view of time c. 2. 7. a previous life anxiety yin. and celebrations. 6. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. brotherhood eighth body. 9. 4. Native American 4. older 18 inches European-American patriarchal. an imprint of Elsevier. Decisional conflict c. 15. a. All rights reserved . 2. 4 2 3 Chinese African-Americans 3 C r i t iC a l t h i n k i n g a Ct i v i t i eS 1.

circumCISion. b. 10. exTENDed. A durable power of attorney for health care is a legal document that appoints a “health care proxy” to carry out a person’s wishes as expressed in an advance directive. 12. Allowing decreased fluid intake when appropriate. Active euthanasia is administering a drug or treatment that ends the patient’s life. ethnocenTRICity. 8. Advocate for sufficient pain medication to keep the patient comfortable. Fear of loneliness c. c. 4. Administer antiemetic medication. b. 14. 5. e. a. 3. 8. decreased mobility a. malnuTRItion. Obtain a standing laxative order. CULture 2. 6. reduce secretions. Fear of abandonment d. 2. Short a nSwer 1. b. Examples are: 1. celeBRAtion. 5. Person must be declared brain dead by absence of brain waves that indicate life. “The nurse does not act deliberately to terminate the life of any person. 11. h. interpreTAtion. reFRAIN. STEReotypes. 2001 by Saunders. Fear of the unknown 13. atTIRE. HisPANic. Inc. c. Obtaining an order for morphine to ease breathing. 1. 1. ethnoLOGical. In active euthanasia.” The right to die with dignity Any of the interventions listed in the section of the chapter on common problems. 9. Passive euthanasia occurs when a patient chooses to refuse treatment that might prolong life. 7. Obtaining an order for a tranquilizer. Administering antiemetics. susceptiBILity. Removing unpleasant sights and eliminating odors before mealtime. g. 15. f. matching e g d a f c i j h b Completion loss grief Anticipatory grieving health care proxy possible validate 7. opiate medications b. and prevent the “death rattle” listen. 3. 5. nuTRItion 3. Any three of the following: a. Fear of loss of dignity f. spirituALity 4. CATegorized.Student Learning Guide Answer Key  w ord attaCk SkillS Answers will be individual. evaluAtion. Offer small servings of home-prepared food favorites. Assisted suicide is making the means to end life available to the patient when he could not otherwise obtain such means. 2. recogNIZE. PREValent. Providing ice chips or hard candy to suck. imPEDE. Fear of pain b. e. 4. egaliTARian. All rights reserved . SECond. bring breathing back to more normal. susTAIN. 2. talk Any of the signs and symptoms listed in Box 15-1. Provide frequent oral care. Fear of loss of control Euthanasia is the act of ending another person’s life to end suffering with or without his consent. Chapter  terminology a. a. d. 10. the patient is administered a drug or treatment that ends his life. 6. 6. A program of care to meet the needs of the terminally ill and their family in their home or health care facility. Copyright © 2009. curanDERo 4. decreased food and fluid intake c. 9. ecoNOMic. an imprint of Elsevier.” and “Nurses must not participate in assisted suicide. knowing that suicide is his intent. 2005. 3.

Examples: a. 9. Patient will not experience further instances of skin breakdown before death. Methods of coping and emotional status 2. Specifics regarding religious and spiritual needs f. 8. 6. 2001 by Saunders. d appli C ation of the n urSing pr oC e S S 1. d 6. breakthrough pain 6. This requires tact. the family. nC le X. b 3. There can be hope for a pleasant time with a loved one. 1 3. Answers depend on nursing diagnoses listed in question #2. Self-care deficit c. b. easily digested 8. 1. All rights reserved . of the joy of watching children happily playing. Any four of the items discussed on pp. a. 5. Inc. Examples: a. anticipatory collaboratively enhance grapple proactive proxy respite validating v oC a b u l a ry e X e rC i S e Examples will vary. What the physician has said about their condition b. 6. a 5. small. Impaired skin integrity b. 4. b 7. The patient. Knowledge of what to expect as death approaches will decrease fear. laxative 7. and all health care professionals involved in the patient’s care. 3. What are the specific concerns e. 1 anger 3 4 a natural part of life 3 2 2 C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. You are responsible for approaching the family about organ and tissue donation. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. 7. Fear 3. Desires for advance directives and life support c. 10. 7. Planning an approach will make you more comfortable with this issue. Patient’s hygiene needs will be met daily. Hope comes in many forms.Student Learning Guide Answer Key  Correlation Answers require use of Box 15-1 plus application and synthesis of knowledge. 4. You might help her to hope for a more pain-free day. What is hoped for from nursing care d. e 4. for the joy of seeing something beautiful like a bird or flower outside the window. 2. 197-198. 3 2. Copyright © 2009. 5. 4. Any three nursing diagnoses from Box 15-4. c. 2005. an imprint of Elsevier. 2. 8. d 2. e 9. stool softener. a 10. You could plan ways to decrease discomforts so that there is hope for a more comfortable day.pn ® eXamination–Styl e r eview Que Stion S 1. c 8. 5. Degree of attainment of the expected outcomes.

penetrate mucous membranes c.Student Learning Guide Answer Key  w ord attaCk SkillS Glossary Word an tic i pa tor y col LAB or a tive ly COM mon AL i ties cul mi NA tion in EV i ta BIL i ty an TIC i PAT ing Root Word anticipate labor. work together shared by two or more. 20. Inc. 9. Example: “Ms. I understand you are experiencing many problems and many discomforts. 5. 15. 4. tapeworms (also hookworm) Endotoxin hospital-acquired (formerly called nosocomial) pathogens culture perform hand hygiene gloving. 8. 1. 11. 13. 7. 2001 by Saunders. We are going to regulate your medications so that you achieve pain relief. Completion hand hygiene normal flora Virus Protozoa Rickettsia. collaborate common culminate inevitable anticipate Meaning to look forward to work. 3. matching h i f d g j b 1. 2. Answers will be individual. 2. 6. Rodney. 3. We will work with your family in ways to reposition you that do not cause you so much discomfort. The new medications and inhome oxygen should help with your shortness of breath. an imprint of Elsevier. multiply once in the body d. 17. All rights reserved . 10. 7. 2. 1. Any example from the process of infection is acceptable. and that in turn should help you relax. 19. a 9. e 10. resist phagocytosis 2. 4. 18. adhere to mucosal surfaces or skin b. Causative agent: Streptococcus bacteria Copyright © 2009. ordinary to come together at the end sure to happen to look forward to Communi Cation eXerCiSe S 1. What is your main concern for your care at this time?” 8. secrete harmful enzymes or toxins e. c b. Now that you are in hospice care there are several things we can do to help you. Our team will be just a phone call away and we will be here at least three times a week. but do not become so constipated. 6. 5. I have ordered a special air mattress to make your bed more comfortable and to relieve pressure on those sore spots. 2005. removing gloves they are dry 15 1/4 jewelry harbors microorganisms sharps biohazard or hazardous waste Creutzfeldt-Jakob’s Chapter  terminology S h o r t an S w e r a. 12. a. vectors fungi round worms. 14. 16. a.

a. 6 1 2 4 1 2 1 3 4 2 3 fungi 1. Mode of transmission: drinking from a contaminated glass e. 8. 2001 by Saunders. use of sterile supplies and special techniques for procedures that invade the body. Skin d. 19. 10. chronic illness d. Indirect contact with contaminated inanimate objects. Susceptible host: patient with a surgical incision. c. Use a stiff-bristled brush or abrasive to clean equipment with grooves or narrow spaces. a. 3. 9. Any point from Table 16-6. inflammation e. neutralize and destroy harmful agents b. antiserum. e. antitoxin. Genitourinary tract b. 4. Portal of entry: broken skin f. 16. phagocytosis d. when there is a possibility of being splashed by body fluids 15. Gastrointestinal tract c. or inanimate touch (gown soiled at wound and then a different part of the patient lies on that area). 18. 17. b. 11. 14. d. c. 5. Rinse the object with cold water. leukocytosis c. an airborne pathogen. 9. infected fluids. a. Portal of exit: respiratory tract (mucous membranes) d. fever b. 6. poor hygiene related to immobility e. 7. 2005. All rights reserved . 5 3 2 2 1 Copyright © 2009. Dry the object. 5. an imprint of Elsevier. limit the spread of harmful agents to other parts of the body c. 12. prepare the damaged tissues for repair 11. standard precautions. being splashed in the eyes with any body fluid 17. Respiratory tract a. as well as: b. 20. splashed body fluid 16. poor nutrition c. and disinfection. 15. b. Rinse the object well with moderately hot water. It involves sterilization of all instruments and inanimate objects used in surgery. Vectors that harbor infectious agents and transmit infection through bites and stings. It is carried out through hand hygiene. decreased immune function a. d. e. 12. Surgical asepsis is a way of protecting the patient from exposure to living microorganisms. 5. Wash the object in hot soapy water. antibodies or antitoxins developed in another person 13. Droplet contamination by the aerosol route though sneezing and coughing. 3. 3. 2. Reservoir: infected wound c. Medical asepsis is the practice of reducing the number of organisms present or reducing the risk of transmission of microorganisms.Student Learning Guide Answer Key  3. 4. 6. 7. 3 2. 4. Naturally acquired immunity occurs when the body produces antibodies against a microorganism. 5 4 2. action of interferon interferon 10. Injection of vaccines or immunizing substances that contain dead or inactive microorganisms or their toxins 14. b. Exposing objects that can withstand heat and moisture to moist heat under pressure in an autoclave a. Direct contact with body excreta or drainage from an infected area. Inc. 2. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. Spread of infection from one part of the body to another by personal touch. 13. 8.

6. 9. Surgical Asepsis: Autoclaving surgical instruments. etc. Implement procedures to contain microorganisms when infection is suspected. leukocytosis. b 2. Any five of the following: a. secretions. 6. presence of an indwelling urinary catheter d. and third line of defense. action of interferon. how to disinfect surfaces. Be sure to discuss the first. 2. 2. particularly HIV. Disinfection to prevent transfer of microorganisms. 3. 10. 7. Using only sterile items for invasive procedures. 4. and need to prevent such transmission. Explain why different PPEs are used. hepatitis B and C. Any of the items in Health Promotion Points 17-1. 3. 2. 4. Thierry. 5. blood cells. elevated temperature prodromal leukocytosis virulence. c. Medical Asepsis: Handwashing to remove microorganisms. Use simple examples and common terminology to discuss the defenses of the skin. Monitor diagnostic test reports related to infection. incubation period irritable.” (Continue with how to handle the contaminated dressings. Standard precautions—use of barriers to prevent transfer of microorganisms. immune response. virulent scrupulously impede impermeable render prevalent vector cleansing the wound. insertion of an intravenous line. presence of an artificial airway c. All rights reserved . Inc. 5. second. or arterial line e.) Chapter  terminology 1. a. fatigue. b. w ord attaCk SkillS 1. 2005.Student Learning Guide Answer Key 0 Criti C a l thinking aCtivitie S 1. Discuss transmission of pathogens. bones. 3. presence of an implanted prosthetic device f. Continually observe patients for signs of infection. pathogen. The bacteria could be transferred from your hands to the telephone or the coffee pot handle and the next person in the house who touches the telephone or the coffee pot would have the bacteria transferred to their hands. 8. repeated injections or venipunctures g. presence of immune compromise in the patient 2. urination. The bacteria can infect them if there is a break in the skin on the hands or if they then touch the eye or the mouth where the bacteria can enter the body through the mucous membranes. a Communi Cation eXerCiSe Example: “Ms. central line. 2001 by Saunders. susceptibility isolation Transmission precautions human immunodeficiency virus Contact precautions direct contact S h o r t an S w e r 1. fever. you must wash your hands thoroughly after changing your dressing and Copyright © 2009. c 3. STEPS TOWARD BETTER COMMUNICATION Completion 1. 7. liver cells. Bacteria from the wound area can get onto your hands and then contaminate anything you touch if you don’t. Surgical scrubbing and sterile gloving. inflammation. presence of a surgical incision b. GI secretions and activity. Using only sterile supplies and technique for dressing changes. an imprint of Elsevier. Containment of microorganisms—plastic bagging contaminated dressings. phagocytosis. cilia. 3.

b. 5. Puncture wounds from contaminated needles or other sharps. Listen to the patient’s feelings. d. mat C h i n g All answers can be found in Box 17-1. Cleanse the spout on b. Keep the patient stimulated with appropriate activities. Any three of the following: a. sterilize. mouth. 8. Skin contact allowing infectious fluids to enter through damaged or broken skin. b. Increase sensory stimulation if signs of sensory deprivation appear. Do not talk while changing the dressing. f. Perform hand hygiene and use gloves when turning the patient. Recognize individuals at high risk for infection and implement appropriate protection. Wear clean gloves when providing care. Mucous membrane contact where infectious fluids enter through the mucous membranes of the eyes. Packages should be aseptically opened and their contents dropped into the sterile field from its edge. a. A sterile field is only sterile when in constant view. the catheter. or dispose of contaminated items and equipment. When an older person has one infection. Keep his linens clean and dry. give encouragement such as positive comments on efforts at grooming or self-amusement. Properly handle. Perform hand hygiene each time before touching the patient. a. a. Inc. 2005. Remedy contamination immediately. there is greater risk of contracting another because the body’s available defenses are already working to fight the first infection. Cleanse the spout of the drainage bag after emptying it. c. 10. 12. d. c Copyright © 2009. Clean gloves may be used in place of sterile gloves in many instances. 1. c. Handle the catheter gently so that it does not cause undue irritation of the urinary meatus or bladder. b. Perform hand hygiene before giving care. 2001 by Saunders. Use strict sterile technique for insertion of the catheter. Moisture will carry microorganisms from the outside of the package wrapper to the items on the field. e. Know what is sterile. Tape the catheter to the abdomen or leg so that there is no pulling on the balloon which can cause irritation of the bladder when the patient moves. The outside of the unopened sterile packages are not sterile and will contaminate the entire sterile field if placed on it. c.Student Learning Guide Answer Key  4. b. Know what is not sterile. d. or dressing. The older person’s immune system is not as active as the younger person’s. a. IV line. With airborne precautions a room with negative air pressure is required and a respiratory device mask is essential. a. All rights reserved . Engage in conversation with the patient about his or her particular interests or hobbies. Place a special N95 particulate mask on the patient. Inspect the IV site continuously throughout the shift for signs of inflammation. d. Perform hand hygiene and change gloves after cleaning up after incontinence. and nose. Perform hand hygiene before approaching the patient. c. the back of the gown is not considered sterile and would expose the field to possible pathogens. Obtain an order for a condom catheter or other device to prevent urine contamination of the patient’s dressing. Utilize approved sanitation methods. 6. Cleanse the catheter according to agency policy when bathing him. Talking over a sterile field is to be avoided because saliva or droplets from the respiratory system may fall on the field. One set of linens is used by the patient. soapy water with chlorine bleach will kill most organisms. the IV site. Separate sterile from unsterile. Washing in a solution of hot. Perform the dressing change using sterile technique. Encourage a high intake of fluid to keep the bladder flushed unless contraindicated. an imprint of Elsevier. Maintain strict asepsis when changing the IV solution or the IV line. the catheter bag after emptying it. c. Dirty supplies must be disposed of in sealed plastic bags. 7. Even when in a sterile gown. 9. There is less exposure to heath care–acquired infection and strict surgical asepsis is not as necessary. 11.

Carefully planning care and gathering all needed supplies before going to the patient’s room. About the disease process. 6. Positive culture results 2. 2. 5 1 hand hygiene 4 1. 6. 13. Work with the patient to plan activities to prevent boredom and sensory deprivation. 5. 2. 3. This exercise will help you to become comfortable with patient teaching. 5. c C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. 8. 7. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. 5. 15. Elevated temperature and increased white blood cell count d. modes of transmission. 9. prevents spread of microorganisms/infection identification bracelet elevated temperature people quieter initials intact true body fluids and water director of nurses C o m m u n iC at i o n e X e rC i S e S Answers will be individual. a. Everyone in the room is responsible for pointing out breaks in sterility. 4. 4 3 4 3 1 2 2 3 3 v oC a b u l a ry e X e rC i S eS 1. An N-95 special particulate filter mask must be worn when in the room.Student Learning Guide Answer Key  2. 3. 8. immunocompromised integrity residual scalding sensory deprivation enhance appli C ation of the n urSing pr oC e S S 1. d a. Chapter  terminology a. 2. 9. Think about how you would do this. 11. 4 1. 4. an imprint of Elsevier. c a. 8. 7. b. anticipating patient needs. 10. 4. 3. b a. 12. 2.pn ® eXamination–Styl e r eview Que Stion S 1. 2. 10. Inc. Determine what activities and hobbies the patient has. 4. You must point out the contamination to the surgeon. and precautions necessary to prevent spread of the infection 5. 3. Fever and malaise c. a. c a. b. 6. matching f d b Copyright © 2009. nC le X. d a. 2. 2. 2001 by Saunders. 9. 14. a. Risk for infection related to open wound 3. 3. d a. c a. 6. The patient’s safety is at risk. Determining that the infection has not been transmitted to any other patient or a health care worker on the unit or in the hospital. 2. 4. 3. 1. 5. 10. 3 1. Signs of wound infection b. 2005. 6. 7. d a. 4. All rights reserved . Determining that all signs and symptoms of the infection are gone.

Lock the wheels of the wheelchair and the bed. close to your body d. Keep feet about shoulderwidth apart. 1. b. e 5. Muscle cramps and possible contracture c. 3. pivot rather than push or twist f. level or height as the object to be moved e. of the movement 4. 10. 12. Pulling. Reposition for correct alignment in the bed. 10.Student Learning Guide Answer Key  4. the legs necrosis shoulder’s width symmetry ambulate gait logrolling dangle transfer (gait) belt contracture 5. Lifting a box with elbows bent at sides to keep weight of the box close to the body and stabilize the center of gravity. Face the head of the bed when moving the patient up in the bed. Use a wide base of support when transferring a patient. an imprint of Elsevier. Place a flat. about shoulder-width apart b. 8. Inc. Short a nSwer 1. ask to keep head up and stand as Copyright © 2009. Back injuries cause loss of work time and are expensive for the employer. b. Interference with circulation which may lead to pressure ulcers b. use gait belt or support patient adequately. The biggest cause of injury to health care workers is repetitive lifting. Raising the bed to almost waist height before attempting to reposition the patient to reduce back strain. knees flexed at about 90 degrees with the feet resting comfortably on the foot rests or floor e. Place a rolled pillow on the outside of each leg to prevent external rotation. 9. allow to stand before walking to decrease dizziness. Using the arms as levers placed beneath the patient and rocking back on the heels to move the patient to the side of the bed. an erect head centered over the body b. arms lying comfortably in the lap or supported by the chair armrests or lap board 3. a. c. 4. Any similar example to the following: (Box 181) a. d. Assist to stand while bracing the patient’s legs with your knees. (Synthesis of information. 7. Pivot so that patient’s back is toward the bed. allowing the hand to fall slightly over the end of the pillow. a. Place a pillow lengthwise behind the back for comfort as indicated. Have patient wear sturdy slippers. Fluid collection in the lungs a. buttocks in the same plane as the shoulders with the thighs parallel to the shoulders c. 2001 by Saunders. supporting above and below the joint to help prevent the patient from slipping down in the bed. 11. Prone position is used when the patient is on prolonged bed rest and immobilized when the patient can tolerate the position. 6. c 6. Place pillows lengthwise under the arms from the armpit to the wrist. stabilizing your own center of gravity. Use a footboard or sneakers to keep the ankles and feet in proper alignment. 6. 2. e. coordinated movements c. small pillow at the curvature of the lower spine to prevent excessive straightening of the spine. The weight of the object or person is drawn close to the body. Place a pillow beneath the knees. weight evenly distributed over the buttocks and thighs d. lower the body onto the bed. Place your arms under the axillae and your hands on the scapulae. 8. to reduce the workload. a b. 5. a. All rights reserved . a. Place pillows lengthwise under each arm to prevent undue rotation of the shoulders and to support the joints of the arms. using weight as a counterforce. 261-262) f. 7. pp. Completion back injury pivot muscles. When patient’s legs are against the mattress. b. 9. 2. keep tubes and lines from tangling in legs or tripping patient. Pivoting during a transfer to prevent twisting the body and possible back injury. 2005.

various size pillows or sandbags. Ambulated length of the hall with the walker. Provide a trapeze so that the patient can reposition and lift the buttocks off the mattress from time to time. Proper positioning ensures that the weight of the body is dispersed over a broad area. maximally stretched. the shoulders and hips are parallel. left ear. Inertia for long periods tends to make the muscles atrophy. it is best not to hyperflex a joint. Hand and foot splints or footboard. do not overestimate the distance patient can walk without extreme fatigue or weakness. 2. and I will lower the bed so your feet can reach the floor. Here is an example: Nurse: “Good morning. 3. a. that’s it! Does that feel OK?” Mr.) “Uh-uh!” Copyright © 2009. nC le X. If allowed. 8. I am going to raise the head of your bed. the joints are predisposed to contractures. 2.Student Learning Guide Answer Key  11. 12. raise and lower the head of the bed slightly frequently to redistribute the weight over the sacral area. c e a f d b appli C ation of the n urSing pr oC e S S 1. 14. straight as possible. knees and ankles are slightly flexed. Ambulated with assistance 1/2 of the length of the hall. Inc. 10. 5. Let me help you sit up and swing your legs over the side of the bed. 6. b. 3. as that may cause injury. 5. All areas against the mattress: anterior hip. B. arms hang comfortably at the sides. 3. right elbow. 4. lateral knees. 4. a wide base of support is used so that you do not sway while moving the patient. 4 1 2. Brown. 6.” Nurse: “First. 3 Sims’ 3 3 4 2 3. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N v oC a b u l a ry e X e rC i S e The striated muscle works to move the extremities. logrolling 6. Mr. 7. ankles. 9. an imprint of Elsevier. 2 2.pn ® eXamination–Styl e r eview Que Stion S 1. 13. The patient will master use of a wheelchair within one month. 2. That the head is in alignment with the body.: “Uh-huh. All rights reserved . p r o n u nC i at i o n o f d i f f iC u lt t e r mS prognosis design aligned magnificent prog NO sis de SIGN a LIGNED mag NIF i cent m atC hing 1. lock the wheels of the wheelchair 7. flexibility of the joint 3-5 extremity The book seems lighter when held close to the body. When muscles are not exercised and joints are not moved. and the feet have support. B. 3 C o m m u n iC at i o n e X e rC i S e Dialogue will be individual. 4. active. Are you ready for your walk today?” Mr. When transferring a patient from the bed to a chair. 2005. to let you get oriented. Impaired physical mobility 3. C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. passive 5.: (Waves his hand. When performing ROM exercises. 2001 by Saunders. Exercising the joints also alleviates the pain that can occur with inactivity. 2. body mechanics 8.

10. 1. if you are ready now..” Mr. Temperature control is altered due to loss of density of the skin and decreased sebaceous gland activity. corium 8. B. The number of hair follicles decreases. b. 3. 7. 3. B. e. 2. Any four of the following: a. Melanin 2. 5. Mr. Examples: a. 3.: “OK. All rights reserved . Change the patient’s position at least q2h. 2005. Bed or chair confinement: continuous pressure may occur at a particular area if position is not changed. Any five interventions from Safety Alert 19-1. and edema 4. 6. 2001 by Saunders. 9. 5. one. matching g a i d j b f e h c Completion reactive hyperemia diaphoresis epidermis caries melanin maceration syncope Copyright © 2009.” Mr.” Nurse: “You are doing fine. Put your arms around my shoulders. 6. Loss of bowel or bladder control: Moisture contributes to maceration of skin and colonization of bacteria. dermis. Skin S h o r t an S w e r 1. c. d. leading to slowed growth and thinning hair. B.: “Uh-huh.” Nurse: “All right. 1. Mucous membranes 7. we will stand up.” Nurse: “I’m going to help you up now.” Nurse: “Stand straight now and walk. 2. 4. keratin 3. Decreased sebaceous gland activity causes dryness and itching. Loss of elastic fibers and adipose tissue leads to wrinkles and sagging. excessive diaphoresis. Sebaceous glands 4. Sweat glands 6. Inc. 8. f. B. B. Loss of collagen fibers makes the skin more fragile and slower to heal. two. Lowered mental awareness: Unaware of how long has remained in one position causing pressure over same areas for long periods. OK. c. 1.Student Learning Guide Answer Key  Nurse: “Are you dizzy? Just sit there for a minute. obesity.” Mr.” Nurse: “Let’s just stand here until you are stable and then we will walk around the room. an imprint of Elsevier. Inability to move: Cannot alter pressure over dependent areas even slightly. b. Nail growth decreases and nails thicken.. Dehydration. 2. d.” r e v i e w o f S t r uC t u r e a n d f u nC t i o n All answers may be found in the Overview of Structure and Function of the Integumentary System. OK.: (Nods. Do you feel better now?” Mr. b. 4. e. three.) “Uh-huh. while I get your slippers on. b. Use pressure-reducing devices as appropriate. (See Box 19-1) a. Poor nutrition: Protein and vitamins are needed for skin cell regeneration and to maintain skin health. 7.: “Uhhhh. extreme age (fragile skin). Chapter  terminology a. Sebum 5.

15. 3. 7. requires critical thinking. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. Remove waste products secreted through the skin Face. See if there is an electric razor on the unit that is sterile and that can be resterilized for the next patient. perineal confined to bed 8 a container with normal saline or water diabetic. 2. the patient is adequately covered with a bath blanket. a. 19. b. Provide comfort healing rectal. See Figure 19-3. 20. 10. an imprint of Elsevier. moisturizing lotion is applied immediately after the bath. 9. wet and oozing. surrounding area warm. 16. drainage. Stage I: red. its color and size and reaction to the blanch test a. backs of thighs. Cleanse b. heels b. 2005. Semi-Fowler’s: buttocks. c. 13. Promote comfort c. 18. vascular insufficiency Basin of water or a stoppered sink with some water in the bottom submerging 18 or below a p p l iC at i o n o f t h e n u rS i n g p r oC e S S 1. 5. and perineal area a. skin is adequately rinsed of soap. 6. Stimulate circulation to all areas of the body d. left inner elbow. Have a family member bring his razor from home. Provide adequate nutrition and fluid intake. hands. Any three characteristics listed. thoracic spine. Inc. 2001 by Saunders. sacral area. d. Stage II: partial thickness skin loss. Patient will maintain normal hygiene practices with assistance. Keep the patient clean and dry. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. All rights reserved . 10. Skin over all bony prominences is without redness or break. Stage III: full thickness skin loss. 8. 12. Self-care abilities 2. 2. 3 2 2 3 3 1. left ear the bath 1/2 to 3/4 the amount of time that pressure was present to cause the redness. Cultural views regarding hygiene practices b. Stimulate peripheral circulation c. 4 2 1 constantly moist skin 3 C r i t iC a l t h i n k i n g a Ct i v i t i eS Patients have a right to refuse any procedure. or mottled skin. bacterial infection. no blanching. deep pink. warmth. damaged or necrotic subcutaneous tissue. 9. e. sinus tracts. sacral area. outside of left knee and ankle. a. 7. reddening. 14. See if there is a better time for bathing. 11. d. 3. 4. 21. 6. black eschar present. elbows. edema. back of head c. 4. 1. 8. attention to perineal care is paid unless patient can easily reach these areas. Stage IV: full thickness skin loss with extensive tissue necrosis. Inquire why the bath is refused. 4. hygiene 3. axillae. Minimize skin injury caused by friction and shear forces when repositioning. water is changed as it cools or becomes too soapy. Cleanse the skin b. or induration. Self-care deficit. Sims’: left anterior hip.Student Learning Guide Answer Key  5. 17. Inquire if it is all right to shave him with a disposable safety razor. the location of the abnormality. 5. 5. Wheelchair: buttocks. heels. c. Make certain that the room is sufficiently warm with no drafts. a. infection. 2. exacerbation nick mottled don débridement Copyright © 2009. left shoulder.

convulsions. hard Communi Cation eXerCiSe Yes you should talk. on 2. explore learning needs. and shielding 20. to bring in items from home that are familiar such as photographs. or scented cosmetics while at work. Contain the fire by closing doors and windows. soft and diffuse 7. b. pillow. skin 3. b. 3. 15. 4. 2005. Rescue the patient quickly. Individual judgment dictates what is most important. ventilation d. glare. diarrhea. c. Use good body alignment. a. and coma 21. tell something about your activities. odor f. Chapter 0 terminology 1. hair loss. 5. Any four measures from Box 20-3. c. Patient with diabetes b. scented lotions. last resort 25. distance. safety. vomiting. 4. etc. Refrain from putting odorous items in the patient unit trash. Inc. the seasons. seizures. 2. 10. a. Bend at the knees rather than bending the back. a. Location of fire alarms b. 3. a. or visitors. a. nausea. loss of appetite. Toileting the patient on a regular schedule to prevent the need for getting up without assistance. Patient with impaired circulation c. 2. Patient receiving drugs that alter mental awareness 12. decontamination with removal of clothing and jewelry and scrubbing down 23. Maintain a wide base of support. time. e. e d b c a w ord attaCk SkillS 1. noise 2. environment ventilation humidity poison bioterrorism Short a nSwer 1. 26. an imprint of Elsevier. a quilt. 5. and begin patient teaching. a. ask about family. Extinguish the flames. outer.Student Learning Guide Answer Key  v oCabulary eXerCi SeS 1. 5. Refrain from wearing perfumes. 11. and enjoy the pleasure of having someone take care of him. Location of fire extinguishers c. and death 19. d. b. a sudden change in mental status or behavior 27. temperature b. comfortable 4. 68°–74° F (20°–23° C) 3. although some would say b. the bed to working height 8. Face toward the direction of movement. solid 17. the far side rail. but be sensitive to the patient’s feelings. paralysis. fever. skin damage. gas b. d. 6. 9. Escape routes from the unit d. fatigue. d. All rights reserved . Techniques for rescuing patients 14. It takes experience to triage accurately. liquid c. Avoiding long conversations on the intercom and limiting staff conversation in the hallway. any equipment that could cause a spark 13. Raise the bed to the proper working height. Talk about the weather. 45 18. speak in a lowered voice. c. lighting e. a. Paralyzed patient without sensory feeling d. childproof latches 24. 2001 by Saunders. During the bath is a good time to gather further assessment data. especially during the backrub. the release of pathogenic microorganisms into the community 16. index and middle fingers Copyright © 2009. a. He may just want to relax. 22. Activate the fire alarm system.

11. 3 3 2 3 cardiovascular 3 1. 5. 9. I am putting your bed rails up for your safety so you won’t fall out. A poison safety inspection is needed. in the role of because to the same amount for example Copyright © 2009. answer will depend on what deficiencies are found. 6. That light produces too much glare. Word frayed glare Physical/ Tangible worn at the edges a strong reflected light tall. 15. an imprint of Elsevier. b. 5. 2005.pn ® eXamination–Styl e r eview Que Stion S 1. diffuse noxious frayed tact neat and tidy glare compromise prone altercations refrain from 2. Have someone sit with him. C o m m u n iC at i o n e X e rC i S e S 1. 2. 2. We do this for her own safety. 1 1. 9. STEPS TOWARD BETTER COMMUNICATION Completion 1. 3. 4. 3 2 2 1. 2001 by Saunders. A fire safety inventory is required. answer will depend on what is found. exercises nC le X. I like to keep my work area neat and tidy. 6. annoyed to look hard at someone with anger or hatred making a corner with two pieces at an angle likely to happen to fall or sink down prevent someone from doing something miter prone slump stifle Criti C a l thinking aCtivitie S 1. 4. 14. 3. 8. 2 hours.Student Learning Guide Answer Key  28. g r a m m a r po i n tS 1. 7. 3. 4 4 1 4 2 v oC a b u l a ry e X e rC i S eS 1. 10. knots that are easy to undo 29. the tea is hot. 2. a. 8. 13. Be careful. We check them regularly to be sure she is comfortable. 7. 10. I hate clutter. 4. Inc. Could you please lower your voices or move into the lounge area? Some patients are trying to rest. and I would like you to do something to diffuse the light. 4. Use a bed alarm. 12. 3. 2. 2. 3. All rights reserved . pointed bishop’s hat lying face down to slide or bend into a low position preventing or restricting from getting air Emotional/ Intangible irritated. Try to determine why he wants to get up. Remind him where he is and why.

Unable to palpate (name the pulse site) 8. or 38. increased S h o r t an S w e r 1. popliteal artery. 120/70 11. 10. 6. trachea. 9. a full minute 7. b. stroke volume 7. 7. norepinephrine. and muscle movement that produces heat 3. they will give a false picture of the patient’s status.5° F.Student Learning Guide Answer Key  Chapter  terminology a. Over the radial artery. 4.” 1. Bradycardia (synthesis of information) b. and respiratory muscles 11. c. diaphoresis 4. 1. 9. noting the level at which the pulse disappears. Tachycardia c. the diaphragm 9. the nose. matching f b h a i e d j c g Completion bradypnea dyspnea diastolic crisis auscultatory gap basal metabolic rate (BMR) metabolism hypothalamus. Deflate the cuff at about 2 mm Hg per second and deflate to zero. blood pressure. d. decreases 19. 7. aortic body 14. 5. maximum pressure exerted on the arteries during left ventricular contraction (systole) Copyright © 2009. Center the bladder of the cuff over the brachial artery. femoral artery. peripheral vascular 18. medulla 13. Inflate the cuff 30 mm Hg over the level at which the pulse disappeared when auscultating the pressure. e. Any five of the following factors helpful for accurate BP determination: a. alveolar membrane 10. normal temperature 21. sinoatrial node 6. and respirations. g. brain. and dorsalis pedis artery 6. diaphragm. stroke 17. into the aorta per heartbeat 5.5° C 3. epinephrine. posterior tibial artery. Have the patient rest for at least 5 minutes before taking the blood pressure. 1. 2001 by Saunders.5° C 9. 6. 4. r eview of StruCture and fun C t i o n All answers for this section are in “Overview of the Structures and their Functions that Regulate the Vital Signs. feedback cardiac output 15. carotid bodies. 2. 2. cellular chemical reactions in the body 2. 8. 101. Inflate the cuff while palpating the artery. Attach the cuff over the bare arm. 5 liters 8. 8.5°–99. If inaccurate. 36°–37. 2. Place the diaphragm of the stethoscope firmly but lightly over the artery with all edges of the diaphragm in contact with the skin. the thyroid. lungs. pulse. 2005. Comparing the current readings with previous ones depicts trends in temperature. bronchi. 3. an imprint of Elsevier. Rhythm and volume 5. b. hypothalamus 10. surfactant 12. 5. 3. and testosterone hormones. Inc. temporal artery. the heart is at rest and pressure in the arteries is lowest 16. 60–100 bpm 4. pharynx.3° F. All rights reserved . f. Apex of the heart [fifth intercostal space (ICS) at mid-clavicular line]. increase 20. a. Position the arm at heart level and support it. Arrhythmia d. 97. larynx. pons. carotid artery.

Heart rate 94 bpm at 4 p. Heart rate will return to normal within 8 hours after initiating beta blocker therapy. You can count the radial pulse or the brachial pulse. dizziness. Inc. 2. 6. 2005. A normal adult cuff will not fit most patients with this weight and will give a falsely high reading. 12. orthostatic or postural 14. Causes include secretions in the lungs interfering with oxygen and carbon dioxide dispersion. Subtract the radial pulse from the apical pulse to obtain the pulse deficit. a. 7. a. a. Recheck the pressure and if this happens again assume that this is an auscultatory gap. A large adult blood pressure cuff should be used with the sphygmomanometer and stethoscope. (8 hours after medication) d. 2. Breathing will return to normal pattern with 1 hour of use of bronchodilator medication. 14. 3. 9. 2001 by Saunders. The respiratory rate will vary when a lower respiratory infection is present. c.) b. Temperature will return to normal with administration of antipyretic within 8 hours. BP 136/86 at clinic visit 1 week after initiating antihypertensive therapy. or use a stethoscope on the chest to listen to the breaths. All rights reserved . 2. 9. 11. 2. 3. 4. 16. 15. tell the patient you are having trouble feeling the pulse and take an apical pulse rate for a full minute. Otherwise notify the physician and obtain the order.m. 17. Blood pressure will return to normal level within 1 week after beginning antihypertensive therapy. count the apical pulse rate at exactly the same time as another nurse counts the radial pulse using the same watch for both of you. Make a note of the occurrence in the chart. If the radial pulse is irregular. 4. Hyperthermia related to unknown cause b. Risk for ineffective management of therapeutic regimen) 7.0° C) at 4 p. 3 1 C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. Because the Copyright © 2009. Temperature 98. b. Tries to conserve and manufacture heat to raise the set point for core temperature. 5.6° F (37.Student Learning Guide Answer Key 0 12. or obstruction of airways. Respirations 20 1 hour after nebulizer treatment with albuterol. 10. c. narrowing of bronchioles and bronchi. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. Record the first sounds heard as the systolic pressure. 5. Deficient knowledge regarding disease process and therapeutic regimen.m. (6 hours later. See if there is an order for an antipyretic and administer it if there is. d. 10. 4 4 2. 8. appli C ation of the n urSing pr oC e S S 1. 8. The tympanic thermometer should be used in the ear canal pointing toward the tympanic membrane. 4 1 3 1 4 124 higher 3 2 1. Remove excess bed covers and check the room temperature to keep it no higher than 72° F. causing the body to increase the rate to obtain sufficient oxygen. Ineffective tissue perfusion related to decreased systemic blood flow associated with increased vascular resistance (Other possible nursing diagnoses might be: Risk for injury related to consistently elevated blood pressure. Ineffective breathing pattern related to impaired respiration c. 13. Pull the ear lobe downward gently to straighten the canal. faintness 13. A temporal artery or tympanic thermometer would be best. Encourage the patient to drink a lot of fluid unless contraindicated. 3 2 4 1 2. You might place a hand on the chest and measure the rise of the chest on inspiration. an imprint of Elsevier. 6. Decreased cardiac output related to rapid heart rate d.

1. 4. 4. blood/movement = movement of the blood and pressures within the body 2. he mo/dy NAM ics. 10. 3. 4. Anxiety stimulates the sympathetic nervous system which in turn raises the heart rate. 9.Student Learning Guide Answer Key  person feels cold. an imprint of Elsevier. 9. STEPS TOWARD BETTER COMMUNICATION Completion 1. abatement alter contraindicated propelled flared simultaneously distract clockwise blunt peripheral hy pox i a ar rhyth mi a tach y car di a di as tol ic a scul ta tory feb rile py rex i a def er ves ence di a phor e sis sphyg mo man om e ter C o m m u n iC at i o n e X e rC i S e S Sample dialogue b Nurse: “Slip this probe under your tongue. It is regular at 76 beats per minute. 2001 by Saunders. 12. (Places fingers over artery. All rights reserved . 6. 3. 5. not very tactful Speaking in generalities or of nothing important w ord attaCk SkillS 1. 8. 5. A major examination causes some degree of anxiety. Turn your arm over for me. stubby. b. 9. 10. 7. 2. 5. 11. 6. clothes or covers are used to conserve heat and the person huddles with extremities held curled close to the body. Inc. above/the elbow = surface of the arm in front of the elbow p ronun Ciation Skill S ap ne a bra dyp ne a dysp ne a ta chyp ne a eup ne a Copyright © 2009. 3. The thermometer will beep when it is done. 3. 1. 10. so I can feel your pulse more easily. Chills may occur that increase body metabolism thereby increasing heat production. 2005. 8. or flat Close to the surface Conversation Straightforward. environmental heat may be turned up. 13. 7.” Chapter  terminology a. 2. 8. 2. 6. 7. an te/CUB ital space. matching k i b f c e l m h j g d a Completion bronchovesicular turgor stridor adventitious wheeze Rinne Weber ascites crackles lordosis v oCabulary eXerCi SeS Blunt Superficial Text Short.) There it is.

3. and accommodation to light c. 3 2. Evaluating the effectiveness of prescribed treatment and therapy and observing for adverse side effects f. the patient. Rectal exam c. and muscle strength d. 2001 by Saunders. reaction.Student Learning Guide Answer Key  identifi Cation 1. Health history factors b. 2. 10. a. 2005. a. disease. a. c d d b. valve sounds 5. d e a. Psychosocial/cultural data 5. e. Need for and timing of regular physical examination b. implementing the plan’s interventions and then evaluating whether the interventions helped the patient reach the expected outcomes n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. Mentation and level of consciousness (Skill 22-2) b. Female genitalia. Pupil reflexes and extraocular movements. sweetish 2. sight is the most helpful method (observation and inspection) 4. Need and schedule for immunizations Warning signs of cancer How to perform breast self-exam How to perform testicular self-exam Completion 1. b b c. Current health problems c. 9. Recommended periodic diagnostic tests Copyright © 2009. All rights reserved . a. Safety and security d. d. f. fluid. Rest and activity b. at the beginning of each shift and whenever there appears to be a change in the patient’s condition 7. Determining the patient’s level of health and physiologic functioning b. Flexible sigmoidoscopy 3. b e. other health care workers involved in the patient’s care. tibia. diagnostic tests 12. Psychosocial needs g. 12 a p p l iC at i o n o f t h e n u rS i n g p r oC e S S 1. expected outcomes 9. and diagnostic test results 2. 5. data indicating problems that are defining characteristics for the various nursing diagnoses are used to support the choice of the diagnoses for that patient 5. an imprint of Elsevier. 8. palpation 3. RNS HOPE 10. the chart. size. Hygiene and grooming e. Elimination and education needs 6. the family. 3 Short a nSwer 1. mastectomy 4. 4. or inability to carry out activities of daily living d. an individualized plan of care can be formulated 3. Motor movements to command. Indicating specific body areas or systems for addition examination or testing e. 6. pelvic exam b. head-to-toe 11. unnecessary exposure 13. Oxygenation and circulation needs f. neurologic exam 14. Inc. Arriving at a tentative nursing diagnosis of a health problem c. a b a. Monitoring for changes in body function 2. compared bilaterally 7. 7. and electrolytes c. mucous membranes 6. ankle 8. equality. striking the third finger of one hand with the index or middle finger of the other 3. Vital signs 4. Confirming a diagnosis of dysfunction. setting priorities of care and incorporating all tasks and assessments needed for the shift into the work organization plan 6. dialysis shunt. a. a. Nutritional.

3 Criti C a l thinking aCtivitie S 1.Student Learning Guide Answer Key  4. Blood work—laboratory tests Mammogram. abnormal a word made from the initials of other words occluded sluggish Chapter  terminology a. 5. reactive to light. STEPS TOWARD BETTER COMMUNICATION Completion 1. 4. 2. 7. 6. Patient-controlled analgesia 5. Breast self-exam 4. Pupils equal. 4 4 3 1 1. PSA test Proctosigmoidoscopy Urinalysis 3. 3. 8. 2. matching f e c a d b w ord attaCk SkillS p ronunc iation of d ifficult terms A. appraising opacity holistic ascertaining subsides acronym patent astute abbreviations 1. Requires practice pronouncing the words. Check all peripheral pulses and compare bilaterally. Share your dialog with a peer or your instructor for comments. v oCabulary eXerCi SeS 1. Extraocular movements 8. 10. B. 3 1. Requires practice with a partner. All rights reserved . and accommodation 3. or would you like to speak with the social worker to arrange your convalescence? Will you be able to obtain your medications and dressing supplies without a problem? What are your fears or concerns at this point in time? Let’s wait and see what the pathology report and prognosis are to see if there is a further problem. How will you change your dressing and care for your incision? C. Pap smear Stool for occult blood Digital rectal exam. 4. Point of maximal impulse 2. Testicular self-exam 7. B. Auscultate the heart and lungs. 2. Each dialogue will be different depending on your personality and knowledge level. 1. Who can you count on when you are having a problem or an emergency? Are you ever depressed or really feeling blue? Will you be able to have someone care for you at home while you recover. round. 1. 2. sphyg/mo/ma/nom/e/ter 2. 2001 by Saunders. oph/thal/mo/scope Copyright © 2009. 6. including heart valve sounds. See Box 22-6. 5. 6. Activities of daily living 6. 3. 8. 2. an imprint of Elsevier. 2005. 2 1. 4. Inc. 9. Digital rectal exam C o m m u n iC at i o n e X e rC i S e A. 5. 7. Gastrointestinal 9. 3.

chaplain. and friends to supply the needed information. rest and activity directions and restrictions b. Provide privacy for grieving. Sent home with the family. 3. and then the body is given postmortem care.Student Learning Guide Answer Key  b. route. Immediately notify the physician. and time of last dose given d. 6. speech therapy. 12. on the MAR. not pay for the treatment that has been received 18. 3. 3. All rights reserved . Location of call bell and its operation. etc. c. personal care 15. answer questions. 6. i. Seek out relatives. Wound care. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. the nurse prepares the body for viewing by the family. a. the physician 12. 19. diet instructions c. 3. notify the physician 16. a. 2 3 1. his employer. and on a patient armband per agency policy 9. occupational therapy. medications and when to take them e.e. listen. Explain services available. b. 2. 7. 9. listed. signs and symptoms of problems to report to the physician f. Patient has not been under the care of a physician within a specific time. stored in the closet or sent home. a. an imprint of Elsevier. d. enlist the aid of a relative or neighbor to look in on her if she is self-sufficient. medications including dosage.. physician. business office and the family 10. 4. After the death is pronounced. Answers will be individual. 6. 10. rabbi. 4 4 1 4 3 4 2 1. diabetic care and teaching. and offer quiet comfort. IV medication administration 14. a. How to operate the television and telephone. 5. physician names and phone numbers e. primary and secondary diagnoses b. Answer questions. c. Simply sit with the bereaved. f. 2005. Completion admitting department emergency admission Medicare TRICARE routine Managed care Short a nSwer 1. placed within a valuables envelope. e. 11. 5. social worker. c. b. name and phone number of the physician 5. Death is at the hands of another. accuracy of transcription 8. Location of bathroom and its call bell. frequency. physical therapy. offer to ask the physician or supervising nurse to talk with the patient. g. Seek the assistance of the social worker. on the front of the chart. brief synopsis of the hospital stay 4. Death is from unknown causes. anything the patient will not be using while in the hospital should be sent home 2. a. 2001 by Saunders. 3. Offer to call the priest. wound care d. 8. 2. 2. 4 1 AMA (against medical advice) C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. listen to what the patient has to say. current orders c. sealed. Tell the person you are sorry for the loss of the loved one. 2. Explain visiting hours. 4. Inc. or religious leader. b. ask the patient to sign the AMA form 17. and placed in the hospital safe 7. on the admission assessment. respiratory care. d. adequate communication between caregivers 11. Explain NPO if necessary or tell meal times. Copyright © 2009. personal belongings 13. 1.

2. 12. an imprint of Elsevier. diffusion radionuclide drink. drowsy active rectal easy deep blind Communi Cation eXerCiSe Each role play will be individual. 25. valves. hematocrit 3. 8. components leukocytosis. 11. 10. 18. 11. 6. e i d j a l k Completion 1. 4 1. 12. tonsilar m atC hing 1. stones 26. transducer 10. 4. 14. 5. endoscope 4. water GI large intestine endoscopic retrograde cholangiopancreatography. Chapter  terminology 1. 8. 8. hemoglobin. ureters. 2001 by Saunders. 3. 15. 3 4 w ord attaCk SkillS 1. 3. coronary pulmonary. jaundice 6. polyps 8. infection prothrombin time sedimentation 8–12 standard precautions glucometer blood urea nitrogen (BUN). 2. immediately 27. 20. smear 9. complete blood count (CBC). All rights reserved . in a preservative solution n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. 4. 5. 23. 5. 7. 7. 10. Inc. 13. 16. 2. 6. panel 7. 24.Student Learning Guide Answer Key  STEPS TOWARD BETTER COMMUNICATION Completion 1. granulocytes blood vessels ultrasonic waves hematology. 9. 2. 2005. 5. stricture. 4. 7. 6. 5. 3. capacity. 2 1 2 1 2 4 1 1. 4. cyst. hematoma 5. 22. f c g b h Copyright © 2009. 9. 17. creatinine deteriorates quickly pathologist movement tissues. 2. 21. 19. 3. 4. cells kidneys. 9. 8. hematocrit 2. 7. bladder metal electrical activity heart. 3. 10. significant other protocols verified synopsis alleviate devastating lethargic In general 6. 6.

fluoroscope. 6. Assess for safety measures that need to be implemented before or after the test. 3. patient teaching regarding the test 5. All rights reserved . ultrasonography. diagnostic titer deteriorates troubleshoot 2. arteriograph 4. 2. fluoroscopy. 8. microscope. cystoscopy. 2. cholangiopancreatography. gastroscope. or other measures to protect the patient 6. electroencephalography p r o n u nC i at i o n o f d i f f iC u lt t e r mS 1. cineradiography. 7. Inc. 6. 3. AN gi OG ra phy cho LAN gi o PAN cre a TOG ra phy cys TOS co py e LEC tro en CEPH al o gram gas TROS co py my o CAR di al in FARC tion PAR a cen TE sis PROC to sig moid OS co py RA di o o PAQUE RA di o IM mu no AS says THO ra cen TE sis C o m m u n iC at i o n e X e rC i S e Practice increases pronunciation and intonation ability. 3. STEPS TOWARD BETTER COMMUNICATION Completion 1. sigmoidoscope. cardiac arrhythmia Copyright © 2009. 9. arteriography. Assess for allergy to medication used for the test or to skin preparation solutions to be used. 11. 2. sonography. 9. endoscope. Deficient knowledge related to unfamiliarity with diagnostic test 3. Assess what the patient knows about the test. 5. Completion 1.Student Learning Guide Answer Key  appli C ation of the n urSing pr oC e S S 1. 4. 1. matching d c g f h a j k i e l b w ord attaCk SkillS 1. 8. radiography. Chapter  terminology a. colonoscopy 3. tomography. proctosigmoidoscopy. 2. angiography. b. Assess what concerns the patient has about the test. 4. stethoscope b. 2005. 7. 12. Describe how ultrasound waves reflect structures. 4. 4. —what exactly is done —purpose —sensations patient will feel —how long it takes —pretest sedation —post-test routine 2. d. forcing fluids. 2001 by Saunders. 11. 10. cystoscope. —describe machine and sensations —need for keeping still —methods of dealing with claustrophobia —amount of time it takes 3. sigmoidoscopy. c. Patient will verbalize purpose of the test and what will be experienced during and after the test. 5. a. 10. implementing safety measures such as frequent vital signs. an imprint of Elsevier. gastroscopy. compare the result with the previous test result Criti C a l thinking aCtivitie S 1. hypovolemia 2.

4 3 1 1 2. Present how sodium affects blood pressure. 9. tap the facial nerve about an inch in front of the earlobe C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. and whether excessive fluid loss has stopped. Cover kidney’s role in potassium regulation in the blood. Ineffective tissue perfusion 4. the plasma volume of the blood. 2. 15. 14. blood pressure and circulation 5. 10. electrolyte imbalances will be corrected within 48 hours 5. 2001 by Saunders. electrolyte lab values n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. Inc. 4 3 1 identifi Cation a. 4. take small sips of electrolyte solution such as Gatorade every hour. Diarrhea will stop within 24 hours. 3 450 mL 4 1 3 4 1. fatigue. keep the room free from odors 6. 12. take in only clear liquids. muscle weakness or paresthesia 2. 7. To serve as a medium for the enzymatic action of digestion 2. urine output. 2. 4. 2. 3. High—hyperkalemia Normal High—hypercalcemia Normal Normal Low—hyponatremia Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis Short a nSwer 1. patient will regain normal fluid balance within 8 hours. plasma proteins and plasma colloid osmotic pressure 4. see Patient Teaching 25-2. neuromuscular irritability 8. 4. b. 2005. skin turgor. temperature. 6. Review foods containing potassium. 6. a. 7. daily weight 6. 13. 2. 5. 8. provide antinausea medication if needed. Copyright © 2009. 12. 3. an imprint of Elsevier. Mucous membranes. 11. 15. mucous membranes. 3. give an antidiarrheal drug. 8. and appearance of eyes 3. Diarrhea. All rights reserved . 10. 14. a positively charged cation for each negatively charged anion in the fluid 3. 5. encourage intake of water and other liquids. intake and output 24-hour totals for several days. 2 2 2. attempt to determine cause of diarrhea.Student Learning Guide Answer Key  3. 11. To assist maintenance of hydrogen ion balance in the body d. palpitations. Refer to Patient Teaching Table 25-1 and work with the patient’s food preferences to devise an appropriate diet. nausea or anorexia. 1. Refer to the low-sodium diet in Appendix 7 of the textbook. As a vehicle for the transportation of substances to and from the cells b. weight. 5. Meats must be decreased. 4. hypocalcemia diffusion Osmosis isotonic hypertonic edema filtration active transport hypernatremia hyperkalemia hypermagnesemia hyperventilation diabetic a p p l iC at i o n o f t h e n u rS i n g p r oC e S S 1. 6. 9. To aid heat regulation by providing perspiration which evaporates c. 1. a pulse rate over 100 bpm 7. 13.

” Mr. 9. we will be monitoring all the fluids that you take into your body and all that are excreted. 5. 6. Blood pressure: elevated 4. Pulse: weak. shallow—deep rapid—slow passive—active moist—dry attraction—repellent gain—loss increase—decrease deficit—excess Chapter  terminology a.: “So what will I have to do?” Nurse: “You will need to write down on this sheet all the fluids that you drink. 14. 10. faint. 10. Skin: moist. 6. bounding. Mucous membranes: moist. 5.” v oCabulary eXerCi SeS 1. 3.” Mr. J. 7. 4. b. 11.” Copyright © 2009. J. 2005.” Nurse: “Thank you. thready.” Mr. J. slow.” Nurse: “We really need to look at the urine when we measure it as well.: “I can’t do that myself? I hate to leave that for someone else to do. 7. 2. Inc. 8. 8. J. 8. Jones. 4. sticky 5. I want to do what is best. 6. Someone will come and empty the container and record the amount of urine that was in it. 2. You can just note 1/2 glass water or 1 cup of coffee and I will translate that amount into milliliters. 2. so I’d prefer that you just let us handle that task. 4. We do this any time a patient is receiving IV fluids to make certain that he is not receiving more fluid than the body can handle. 4. Lung sounds: moist 2. an imprint of Elsevier. considerable compensatory tracking twitch lethargic buffer ingestion Nurse: “You will also need to be certain you use this container when you empty your bladder. Set it aside and turn on the call light. 3. 2001 by Saunders. matching o k d b j i g e h m a n c f l Completion carotenoids incomplete protein complementary proteins essential nonessential Middle Eastern kwashiorkor vegan unsaturated saturated Communi Cation eXerCiSe Dialogue written will vary among individuals. 9. pale w ord attaCk SkillS 1. Mr.Student Learning Guide Answer Key  STEPS TOWARD BETTER COMMUNICATION Completion 1. J. full.” Mr. 6. 13. Nurse: “Mr. 3. 5. 1. 2. 12. 7. Here is an example. All rights reserved . 15. dry. 5. 1. rapid 3.: “OK.: “I think I can manage to do that. dry. sticky. 7. Urine: scanty 6. 3. if you say so.

anorexia Copyright © 2009. oleic acid. linoleic acid. D 3. h 2. Some examples are: a. E 9. B1 4. play a role in maintaining fluid balance. breads. an imprint of Elsevier. b. Religion: Food may need to be prepared in a certain way in order to be acceptable. 2005. a. regulation of heartbeat Deficiency causes: cardiac arrhythmia. maintain acid-base balance Deficiency causes: weakness. assist with transportation of nutrients. 4 7. Emotional status: Severe stress may cause either anorexia or overeating and weight gain. potatoes. f. and are necessary for antibody and hormone production 5. stiff joints.Student Learning Guide Answer Key  11. coagulation. f Short a nSwer 1. 17. 13. fruits b. b 4. 3 48 complete protein. 1. double. and linolenic acid 3. function of minerals All answers may be found in Table 26-4. 1. fat-free or low-fat milk and milk products 2. Provide fiber for bulk in the stool. Phosphorus: build strong bones and teeth. nutrition counseling and related services. e. 12. K 6. cereal. Promote growth of body tissues e. 18. 15. 21. 50–60. a 5. vegetables c. 10–15 6.9 i d e n t i f iC at i o n a. 500 mL 11. Inc. Economic status: Inadequate funds may lead to a diet deficient in protein. B12 b. Kosher r eview of StruCture and fun C t i o n All answers are found in the Overview of Structure and Function section of the chapter. All answers are in Table 26-6. Culture: Appetite is usually better when foods are familiar. Calcium: muscle action. nutrition education. Chloride: maintenance of fluid and acid-base balance. All rights reserved . Provide a quick source of energy b. 19. triple accessibility of nutrition information. a. Any one answer is correct. 6. Regulate protein and fat metabolism c. 14. e 6. Magnesium: build strong teeth and bones. A 2. building of strong bones and teeth Deficiency causes: poor bone growth. Cells. 2001 by Saunders. protein synthesis. vitamins. Age: Older adults may receive inadequate nutrition because of difficulty in obtaining or preparing food. d 3. tissues. Examples will be of individual choice. activation of gastric enzymes Deficiency causes: acid-base imbalance 3. C 5. d. c. metabolism. whole grains d. 16. poor blood clotting 2. aiding waste elimination 8. cellular 10. Help fight infection d. and minerals 24. c 8. 1. B6 7. and rice 9. Illness: Nausea may cause inadequate nutrient intake. B2 (riboflavin) 10. and healthful foods sweets fast foods evening. 25–30 4. pasta. obesity older adults 5. 20. g 7. toxicity 12. Folic acid 8. possible confusion or poor memory 4.

Monitor closely for diarrhea or abdominal distention. Sodium: maintain acid-base and fluid balance Deficiency causes: hyponatremia. Raw vegetable pieces may be more appealing than cooked vegetables. Revise the plan of care in attempt to find interventions that will assist the patient to meet the expected outcomes. hypertension. b. an imprint of Elsevier. edema of lower extremities 7. contributes to healthy skin. Weigh patient three times per week. helps control muscle contractions. Iron: formation of hemoglobin Deficiency causes: iron-deficiency anemia 11. 4 3.5 lb. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS Answers require synthesis and application of knowledge. 4 12. 3 5. a. Continues to experience intermittent diarrhea. 1. Start small. Recommend finger foods such as high-quality hot dog pieces or low-fat sausage pieces. 1 19. All rights reserved . a. contributes to removal of glucose from the blood Deficiency causes: central nervous system dysfunction. aggravation of diabetes mellitus 8. Potassium: maintain acid-base balance. 1 11. 3 13. 2001 by Saunders. protein synthesis. 5. cretinism in children if mother was deficient during pregnancy 10. Refrain from sweet foods as much as possible. c. 4 17. Copyright © 2009. Try a variety of foods. Iodine: helps regulate metabolism. thyroid gland C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. delayed sexual maturation appli C ation of the n urSing pr oC e S S 1. See Table 26-4 for problems of deficiency of the various B vitamins.2 2. b. Weight loss of 0. Refusing most of diet due to anorexia. Use 100% juice rather than juice drinks. 4. Chromium: activates enzymes. and nails Deficiency causes: goiter. wound healing Deficiency causes: depressed immune function. Individual answers will indicate changes needed. Diarrhea minimal and stopped after 3 days. Suggest take-along foods such as fresh fruit and snack packs of carrots. transmission of nerve impulses. poor growth. Loose stools occurred after first 3 feedings. 3 4. 4 14. Risk for Imbalanced nutrition: less than body requirements 3. 2005. 4. frequent feedings as tolerated and slowly increase amounts. Inc. normal growth and sexual development. chunks of cheese cut into fun shapes. Consider Jackie’s likes and dislikes. 3 7. 2 6. Offer small rewards such as a story if all food is eaten.Student Learning Guide Answer Key 0 5. this week. b. 3. Fluoride: contributes to formation of bones and teeth. Weight is stabilized at 128 lbs. Zinc: immune function. 1. Patient will not develop diarrhea when feeding is resumed. Ask family to bring in favorite foods to tempt appetite. d. 7. Patient will stabilize body weight after surgery within 2 months. 3 15. 2. 1. 2. 1 8. 3 9. 2 2. 1 16. decreases cavities Deficiency causes: risk of dental caries 9. Discuss nutrition bars. 2. Feed more frequently throughout the day. Plan choices using the food pyramid and calorie and fat charts for various fast foods. a. possible impaired growth 6. hair. helps regulate heartbeat Deficiency causes: cardiac arrhythmia. 2. 2 10. BMI=24. 4 20. 6. weight loss. 4 18.

A. training. you 11. don’t want 12. 5. That doesn’t 6. B 9. That means you’re not (9) sposed ta have salt added to your food. 5. supposed to 10. A. Ms. I guess. Nurse: That’s good news. I am going home today. they would give me 3. Ms. 4. F 4. 1. And the toast was dry and cold. F S h o r t an S w e r 1. but I wish (2) they’d gimme a better breakfast! Nurse: (3) Whaddaya mean? What’d you have? Ms. How are you today? 2. N (unless it is strained) 2.: No offense. Did you call the nurse and ask for hot tea? 7. Andrews. You know you are 9. We don’t want to see you back in here again. 8. A. 8. Communi Cation eXerCiSe Nurse: (1) Morning. Nurse: (5) Doesn’t sound very appetizing. 3. 2005. Didya call the nurse and askfer hot tea? Ms. 2. 3. an imprint of Elsevier. Completion atherosclerosis CHF (congestive heart failure) glycosuria dysphagia obesity bulimia hypertension hypertension PEG (percutaneous endoscopic gastrostomy) hyperosmolality residue i d e n t i f iC at i o n Answers may be found in Table 27-1. What do you mean? What did you have? 4. I’ll just have to try to get used to it. B 5. 4. and cold oatmeal and milk. N 7. anyway. Good Morning. Ms.: Not even a little in cooking? Nurse: Not if (10) ya want to follow doctor’s orders and keep your blood pressure down. It wasn’t worth it. a. I’m goin’ home today anyway. (12) I’ll jus’hafta try ta get usta it. 2. Andrews. and educating a child. 10. 7. How’re you today? Ms. are visually impaired c. B 8. F 10. Inc.: I’m OK. 11. Now let me take your vital signs. Nurse: That’s the spirit. but I (11) don’ wanna BE back here again. clothing. have paralysis or immobilization of an arm b. 2001 by Saunders. nourishing. And the toast was dry and cold. Chapter  terminology a. The lack of green vegetables in his diet compromised his health. F 6. B 12. 6. A. But (8) ya’know you’re on a low-sodium diet. A. Ms. All rights reserved . Child rearing is comprised of feeding. 1. 9. have an intravenous line in their hand or arm Copyright © 2009.Student Learning Guide Answer Key  STEPS TOWARD BETTER COMMUNICATION v oCabulary eXerCi SeS 1. Many volunteers for the Meals on Wheels program are retired and enjoy helping their peers. 1.: (7) Naw.: Just some lukewarm watery tea. I’ll speak to dietary. loving. B 3. Finicky eaters consume some foods sparingly. (4) and cold oatmeal and milk—with no salt. No. ‘t wasn’t worth it. F 11.

Deficient fluid volume. 6 Start the feeding. cancer treatment administering each feeding or giving a medication More freedom of ambulation. Check for amount of residual feeding at least every 4 hours or before initiating an intermittent feeding to be certain emptying and absorption is occurring.Student Learning Guide Answer Key  2. 11. imbalanced. sodium fruits. f. legumes. Increasing protein intake to maintain or increase muscle mass c. c. Compare the measurements to the initial measurements right after placement. no need for general anesthesia for placement. nutritional 5 lbs. Measure daily weight b. g. 9. d. dysphagia from a stroke b. Copyright © 2009. Correct order is: a. 12. d. 3. 8 Reclamp the tube. Adding seasoning to help food taste more appealing f. f. diarrhea Any four of the principles listed in Table 27-1. 3. 8–12 glycosuria. h. 5 Check for residual feeding in the stomach. soft. are severely weak or impaired 6–8 psychological. Monitor vital signs to detect any sign of infection or complication from the TPN line or solution. seeds. HIV/AIDS d. 8. 1. Fluid intake and output will be balanced within 48 hours. nuts. Expected outcomes will depend on the nursing diagnoses chosen. 1 Prepare the feeding bag. gallbladder disease. 4 Check the placement of the tube. hypertension. 19. 5. vegetables. 14. b. stroke e. 2 Elevate the patient’s head and upper body. a. Inc. 4. c. related to diarrhea. b. thiamin cardiovascular disease. Assess rate of flow to determine that solution is flowing no faster than rate ordered. 1 lb. less than body requirements related to anorexia and difficulty eating. the expected outcomes might be: a. and lowfat dairy products secreted in normal amounts but receptor sites won’t let it into the cells a. blindness 70–110 a. Caloric intake will be 2500 calories per day. 18. appli C ation of the n urSing pr oC e S S Any four of the following from Table 27-5.. All rights reserved . 2005. 7. speed up the rate to catch up on the amount that should have been infused 2. Track intake and output to prevent excessive diuresis from glycosuria caused by the TPN. less harmful to body image Measure the tube length from skin level to the end of the placement adapter. Give the solution slowly to prevent too rapid a carbohydrate load. 3 Unclamp the tube. hypertension b. e. Risk for injury related to possible aspiration related to tube feeding. 17. c. 10. easier to administer own feedings. Encouraging small frequent meals a. Sit the patient upright at least 30 degrees before feeding and leave up for 60 minutes after feeding to prevent reflux and aspiration. No injury from aspiration of tube feeding will occur while feeding tube is in place. or puréed foods when the mouth is painful d. c. Monitor blood glucose levels every 4 hours until stable. 15. 6. e. upsetting blood glucose levels and causing diarrhea and electrolyte imbalance. Monitor albumin levels to determine nutritional status. diabetes. cardiovascular disease c. Adding thickening agents to liquids if swallowing is difficult e. inflammatory bowel disease c. 20. 16. For the nursing diagnoses in #1 above. and colon and breast cancer fat. kidney disease d. 7 Flush the tube with water. a. b. Maintaining high calorie intake b. Check the placement of the tube to be certain it is in the stomach or intestinal tract before initiating the feeding. 2001 by Saunders. d. 13. 5. an imprint of Elsevier. d. Nutrition. 4. Offering bland.

an imprint of Elsevier. 11. 1. 5. Add extra egg to casseroles and dishes such as meatloaf. Evaluation statements might be: a. 6. 6. 1. 3. b. stand behind the person and place arms around the person halfway between the umbilicus and the xiphoid process with one hand forming a Copyright © 2009. nCle X. 2. 3. Weight has remained the same or there is weight gain. 5. 4. experiment with seasonings to enhance taste. 4 Chapter  terminology a. 3. 3. See Skill 28-2. S TEPS T OWARD B ETTER C OMMUNICATION Completion 1. 4. Switch from use of lard and saturated oils to unsaturated oils for cooking. 6. 2005. 9. 2001 by Saunders. 2. 14. 8. Make high-powered milk shakes using fruits and protein powder. 10. 6. substitute broiled or baked foods for deep frying. 3. 8. c. 7. casseroles.pn ® eXamination–Styl e r eview Que Stion S 1. 7. etc. 3. Add powdered milk to solids such as meatloaf. 5. 13. 5. 7. matching m h e g i j c d k f b l n o a Completion apnea tracheostomy obturator inspiration expiration hypoxemia ventilation Respiration Criti C al t hinking aCtivitie S 1. Consider ways to decrease sodium-containing foods. 4. Should include menus for several days. 4. 10.Student Learning Guide Answer Key  6. 15. 2. Ask if the person can speak. 5. 2. discrepancies bland resection binge collaboration trimester exacerbation instilled r e v i e w o f S t r uC t u r e a n d f u nC t i o n 1. 6. 12. 8. Inc. mashed potatoes. 8. 4. Decrease sodium-containing foods. No evidence of muscle wasting or abnormal serum albumin level. Patient demonstrates no nausea or diarrhea. All rights reserved . 7. Frequent small meals. 8. 2. 20–30 2 1 3 1. b. 2. 3 2 2 5 or 4 2 3. 2. Central nervous system Cilia Alveolar macrophages Chemoreceptors Mucous membranes Alveolar membrane Trachea Upper airway passages S h o r t an S w e r 1. 9. 7. no added salt at the table or in cooking.

e. administer oxygen as ordered. 4 3 1 week 1 3 1 2–12 2 C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. Maintain sterility of the suction catheter and supplies. 3 4 2. b. c. f. provide postural drainage if ordered. cyanosis Making certain that the sensor is attached and functioning properly. 5. g. and documenting readings at intervals. retractions g. a p p l iC at i o n o f t h e n u rS i n g p r oC e S S 1. 5. Any five of the following: a. d. a. Impaired gas exchange related to retained secretions in right lower lobe. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. Venturi mask: Delivers consistent FiO2 regardless of breathing pattern. Tracheostomy collar: Adds humidity to oxygen flow for a tracheostomy. stridor f. 8. check mentation. Give 15 chest compressions. 4. confusion d. T-bar: Adds humidity to oxygen flow for a tracheostomy. Auscultate her lungs. 7. monitor lung status and respiratory rate. Inc. Actions are effective if lungs are clear to auscultation and there is no shortness of breath. Be certain suction is turned on before inserting the catheter. fist and the other over the fist. Copyright © 2009. 4–6 1 1. cardiac arrhythmia h. 3. assist to splint ribs to cough. d. 10. respiratory rate is within normal limits. All rights reserved . c. and deep-breathe at least every 2 hours. cough. — When it will be done — Pain medication beforehand — How it will feel — Need for occlusive dressing 3. a. Form seal around nose and mouth with your mouth. take her vital signs. 3. With an upward motion forcefully thrust the hands into the abdomen at an upward angle. 6. assess shortness of breath with activity. 9. Preoxygenate the patient. Nasal cannula: patient can eat while receiving oxygen. an imprint of Elsevier. 4. the machine is properly set. Do not suction for more than 10 seconds. Call for help. Turn. restlessness and irritability b. teach forced exhalation coughing. check skin and mucous membrane color. 5. b. Position hands for chest compressions. — Monitor oxygen saturation of the blood in noninvasive fashion — Explain mechanics of light probe Se Quen Cing 7 2 1 10 8 6 9 Check the carotid pulse (which is absent). Gas exchange will improve within 2 days. 2005. 2. increase fluid intake to thin secretions. 2. 2001 by Saunders. To facilitate suctioning d. 11. 4. Shake and shout name or “Are you OK?” (No) Give two breaths. 4 Check for presence of respiration (none present). tachypnea e. 12. Give two breaths. To relieve an airway obstruction b. ambulate frequently. Non-rebreathing mask: Can deliver 80-95% oxygen in an emergency situation. 3. use incentive spirometer. a. Medicate for pain. To provide artificial ventilation 3 5 Tilt head and open airway. that a trend of decreasing oxygen saturation is reported promptly to the physician. 11 Continue CPR sequence. To protect the airway c. 6. Simple mask: allows higher delivery of oxygen than cannula.Student Learning Guide Answer Key  2. increasing agitation c. 2. Partial rebreathing mask: Can deliver 6080% oxygen flow. 2.

10. 5. 6. 8. 4. Soothe irritated bladder tissues and promote healing. c. 2. 7. 5. frequency of urination. 6. 7. To provide an avenue for bladder irrigation h. 3. 6. Assist with retoning of the bladder after bladder surgery 3. Instill medication into the bladder. 8. 3. 3. 5. copious brink ambient combustion i d e n t i f iC at i o n 1. 4. To splint the urethra after surgery e. 11. b. 4. To monitor urine output accurately g. 5. 2. 2005. 6. 2. c f d b a e Copyright © 2009. d. 4. Ensure that the lumen of the indwelling catheter is open and draining. Wash out residual urine or sediment from the bladder. foul-smelling urine. 2. 4. urgency.025 ____ pH: 6. discard the catheter and use a sterile one in order to avoid introducing bacteria into the bladder. 8. 3. Remove clots and stop oozing of blood after prostate or bladder surgery. When the patient cannot empty the bladder for more than 8 hours b. 1. 2001 by Saunders. 4. regularly experience urinary retention or incontinence such as those who have a neuromuscular problem that prevents them from emptying the bladder normally 5. dysuria. e. 1. malaise. include cranberry juice in the diet. burning. 9. __x_ Color: tea color ____ Character: slightly cloudy ____ Specific Gravity: 1.0 __x_ Glucose: 1+ __x_ Protein: 1+ ____ Ketones: 0 __x_ Leukocytes: moderate ____ Erythrocytes: 0 __x_ Bilirubin: slight __x_ Pyuria: trace S h o r t an S w e r Chapter  terminology a. an imprint of Elsevier. To prepare for drainage of urine during a surgical procedure or after an obstetrical procedure c. a slight temperature elevation 2. matching e f i h a g j b c d Completion nocturia micturition residual urine retention incontinence void catheterization condom catheter 1. To help dilate the urethral opening d. 9. To measure residual urine f. b. 10.Student Learning Guide Answer Key  — Meaning of readout on screen — Alarms — How readings are used STEPS TO WARD BETTER COMMUNICATION Completion 1. Encourage a large fluid intake unless contraindicated. 3. 2. Inc. Any three of the following: a. 6. All rights reserved . 7. r eview of StruCture and fun C t i o n 1. Any four of the following: a.

7. 4. 8. Inc. 15. 4. Examples are: 1. 4. 7. He is at risk for urinary tract infection because of the retention. All rights reserved . 2005. 13. 1000–1800 mL infection 8 15 minutes discard stone dehydration standing Coudé instillation dilute beneath the buttocks urinary meatus. date and time. room number. Impaired urinary elimination *Urinary retention Risk for infection 3. Urine elimination will be maintained with use of catheter or drugs. surgical correction of the problem. 5. S T E P S T OWA R D B E T T E R C O M M U N I C AT I O N Completion 1. Assess output and compare it to input to see if there is a balance. use of a condom catheter. an imprint of Elsevier. clean around the urinary meatus and rinse well at least once a day 7. using adult briefs or absorbent pads. Decreasing fluid volume will v oC a b u l a ry e X e rC i S eS Answers will be individual. 10. 11. Use Health Promotion Points “How to Prevent Cystitis” and adjust teaching to the individual. Normal urinary pattern will be reestablished after 2 months of drug therapy. Base the plan on the individual and Patient Teaching 29-2. 2001 by Saunders. 8. Assess if voidings are becoming less frequent and of more volume. 3. teaching Kegel exercises. 11. always maintain aseptic technique 8. 3. 6. 5. 7. b. toileting every 2 hours while awake. 2. 5. 6. 3. physician’s name. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. 5. bulbous impede stasis instillation prone pucker patent appli C ation of the n urSing pr oC e S S 1. the vaginal opening bladder tone the drainage output increase that risk. Explain dangers of urine backing up into the kidney. 12. Explain the functions of the kidney and how they can be damaged. 14. He should drink normal amounts of fluid.Student Learning Guide Answer Key  provide supplemental vitamin C. transport it to the lab within 15 minutes of collection or refrigerate it until specimen pick-up time Completion 1. a. label the specimen correctly with the patient’s name. drug therapy 9. maintain sterility when emptying the collection bag. place the container in a biohazard transport bag. 2. 6. Copyright © 2009. 4 2 4 1 2 1 C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. 3 1 2 2. 2. 4. 12. 3. 9. 3 4 2 3. bladder retraining program. The patient with the fractured hip and a Foley catheter was dependent on the nurse to help him turn in bed. Palpate the bladder after he voids to determine if there is still retention. 10. 2. 9. Is there any burning? Do you have trouble initiating the stream? Is there a foul smell to the urine? What color is the urine? How much fluid are you drinking? Do you have get up a lot at night? What medications are you taking? 2.

Ileostomy c. 1. 7. loss of body function and change in body image b. The tubing leading to the Foley catheter drainage bag should not be dependent. When stasis of urine occurs regularly. lack of digestive enzymes and bile f. 5. 6. 9. 5. Colostomy b. 7. hot water with lemon juice e. 4. After placement of the urostomy tube. 10. a. Any four of the following: a. 1. Continent diversion (pouch) (Figure 30-6) 6. 3. Hard. small amounts of prune juice c. g 2. loss of physical or sexual attractiveness d. 3. All rights reserved . 2. 11. 7. 4. a. a Copyright © 2009. Keeping the height of the enema bag no more than 18 inches above the rectum. New orders are needed. Testing the fluid temperature to be sure it isn’t too hot. 6. Mucus: Irritation or inflammation of the bowel e. 12. stomach. Increase dietary fiber b. dry stool: lack of fluid and fiber or lack of peristalsis 3. b. Increase fluid intake c. c j h d i b f e S h o r t an S w e r 1.Student Learning Guide Answer Key  2. the patient is prone to urinary tract infection. Inc. the patient was more comfortable on his side or in a prone position. warmed prune juice and cola d. 8. While recovering from kidney surgery. 6. a. Occult blood: small amount of bleeding in the intestines c. Liquid stool. Melena: bleeding in the stomach or small intestine b. 2. 5. 8. possibility of rejection by others c. 11. Exercise regularly d. it should be kept above the level of the bag. 9. the patient is considered an invalid. Foul-smelling stool that floats in water: too much undigested fat in the stool. matching k e l c j i f g b h a d Completion fecal impaction do not change incontinence melena. an imprint of Elsevier. death from underlying disease 4. 9. 4. 4. 10. 1–3 tablespoons of bran mixed with applesauce b. gastrointestinal infection or toxicity causing diarrhea g. small intestine vagal response Valsalva maneuver colostomy atrophy rubber baby nipple periostomal effluent r eview of StruCture and fun C t i o n 1. 2001 by Saunders. 6. 2005. 10. 8. 3. 3. b. Heed the urge to defecate 7. The preoperative order is invalid because the patient has had surgery. Chapter 0 terminology a. small serving of stewed or dried prunes 2. A visit from a member of the United Ostomy Association 5. a. a. 5. Pale-colored stool: blockage of bile flow into the intestine d.

dietary intake. changes in appearance of stool or pattern of bowel movements. 8. 4. Urostomy is located on the abdominal wall where the ureter is attached to discharge urine from the kidney. Biofeedback: use of a machine that measures the degree of muscular tension to teach the patient to relax particular muscles. 8. 10. 2. heed distention triggering wafer oblique commode scanty w o r d at taC k S k i l lS 1. 3. increase fluid intake. Inc. 3 4. palpate and percuss abdomen 2. 2–3 Sims’ 1 4 4 3 1. 12. Individualize the plan to accommodate eating in restaurants most of the time. 4..Student Learning Guide Answer Key  c. Cover points of bowel dietary and exercise intervention and the importance of paying attention to the urge to defecate. Teach basics of how bowel works. assess abdominal status and bowel pattern 5. 9. S h o r t an S w e r 1. d. 2. 7. Congenital malformation of the bowel d. 3. 8. characteristics of the stool. See Steps 30-2 and individualize to the patient as needed. 3. 2005. 5. and medications. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. provide privacy for defecation. 9. auscultate bowel sounds. an imprint of Elsevier. 11. diet. 11. 2001 by Saunders. 2. Colon cancer b. Patient will have normal bowel movements before discharge. f d h l c b i e k g a j Criti C a l thinking aCtivitie S 1. etc. paper plate. 6. Controlling the flow of the fluid so that it doesn’t run in too fast. 2. 10. 6. give a stool softener or bulk-forming laxative. Severe Crohn’s disease or ulcerative colitis appli C ation of the n urSing pr oC e S S 1. bowel movements and appearance of stool (intake and output. a. Colostomy is located along the colon. and tolerance of stool softener or bulk-forming laxative would be assessed also) nC le X. Stopping the flow if the patient experiences severe cramping. Abdominal trauma c. 7. add fiber to the diet. 4. 5. 4 2 3 3 4 2. 5. 3. 6. How to collect the stool—Saran WrapTM over toilet bowl. Ileostomy is located along the ileum of the small intestine. Copyright © 2009. Chapter  terminology 1. obtain a history of usual bowel function. 7. All rights reserved .pn ® eXamination–Styl e r eview Que Stion S 1. Risk for constipation related to inactivity and narcotic pain medication 3. How much stool to place on the test window.

sudden-onset. Nicotine from smoking c. 6. a. respirations and heart rate slow and the body becomes immobile. 10–11 20. but not too close to bedtime e. Perception: Distraction or guided imagery to divert perception away from the pain. Fear b. b. a. adjuvant analgesics 15. Use a barrier between the ice pack and the skin. want to go to bed later and to sleep later in the morning. Napping during the day may disrupt nighttime sleep 23. Meditation technique: patient concentrates on a focal point such as a visual point. increasing circulation to the area which can help remove waste substances from overuse or injury 30. Limit duration of use to 15–20 minutes at a time. Room is too brightly lit. a sound. a. dreams occur. lasts 20 minutes or longer 22. 3. 4. Distraction technique: patient focuses on a word or object and the concentration blocks out the pain sensations. an imprint of Elsevier. REM sleep: brain waves become active as if awake. Guided imagery: patient is assisted to form pleasant mental images of another place which takes focus off of pain sensations. Transduction: NSAIDs to block substances that trigger the nociceptors. Regular exercise promotes sleep. a. b. c. a. Aquathermia pads d. Copyright © 2009. heat-producing equipment 27. Transmission: Opioids to interfere with the transmission of impulses from nociceptors. d. 9–10. a. Too much caffeine b. sleep logs. Stage 3: delta sleep with slow brain waves. recurrent. allowing for the free flow of energy and a relief of symptoms 13. Stage 4: deepest stage of sleep with person difficult to arouse. Non-rapid eye movement sleep (NREM) 21. and sleep laboratory tests 29. 24. warm water compresses b.Student Learning Guide Answer Key  2. 10. clinical evaluation. c. 5. Relaxation technique: Techniques to relax muscle groups that decrease muscle tension. or organ viscera 11. Medication side effects 19. joints. obstruction due to allergy or cold 26. Inc. 16. 2001 by Saunders. continuous positive airway pressure (CPAP) machine use while sleeping 25. Alcohol consumption can cause nocturnal awakenings d. Stage 2: a deeper sleep with more brain wave activity and bursts of electrical activity lasting about 20 minutes c. Stress d. 7. which turns attention away from pain. cause nerve damage 16. Environment is too noisy. 12. 8. a. thereby reducing pain. chemical self-heating packs f. a repeated phrase. lasts about 30 minutes e. Hypnosis: inducing a trance-like state using focusing and relaxing techniques to alter consciousness. Room is too hot or too cold. Patient-controlled analgesia: intravenous opioid medication administered from a pump by the patient. narcotics or opioids c. uncontrollable brief episodes of sleep during hours of wakefulness 28. neuropathic 14 a. Modulation: Drugs that block neurotransmitter uptake. Transcutaneous electrical nerve stimulation: small electrical stimulator delivers pulses of electrical current which block the transmission of pain sensations. 9. 2005. nonopioid medications b. Epidural analgesia: catheter is placed in epidural space and opioid analgesic is administered via a pump. tub and whirlpool baths e. All rights reserved . unblocking the meridians. School hours interfere and many teens are sleep-deprived predisposing to driving accidents. warm blankets c. or on his or her own breathing. b. 18. physical structural obstruction of air passages b. Pain c. a. lasts 30 minutes to an hour d. brain development 17. Stage 1: a light sleep with relaxed muscles lasting only a few minutes b. skin.

develop a system of communication in writing or pointing to pictures. 10. c. Indicates cold packs feel good and reduce pain. adjuvant stress distraction pantomime divert enhanced perception stoic complementary phantom b. 2. 9. 5. All rights reserved . Many nurses are likely to suffer from the effects of shift work if they continuously have to work the night shift. Use of cold packs over injured joints 5. Patients who are on prescription medications and also take over-the-counter medications are likely to suffer from some drug interactions. 5. 3. nC le X. over-the-counter pain medication is effective for most patients. Patient will not develop wound or respiratory infection while immobilized. 8. 3. d. Examples: NCP 31-1 a. 7.Student Learning Guide Answer Key 0 appli C ation of the n urSing pr oC e S S 1. Indicated guided relaxation helps decrease pain. 4. Inc. Administration of analgesia via PCA pump b. Use slow. 3. 2. 2005. Examples are: Anxiety related to inability to communicate normally Risk for infection related to multiple trauma and intubation Impaired mobility related to trauma and ventilation Self-care deficit related to immobility 3. Did not use PCA while engaged in playing videogame. 2. 2001 by Saunders. Use of distraction in the form of videogames or TV c. Indicates PCA pump is controlling pain. 4 2. an imprint of Elsevier. 3. 2. 1. d. 7. Examples: (synthesis and application of knowledge) a. 4. b.pn ® eXamination–Styl e r eview Que Stion S 1. 10. 3 1 2 frozen peas 4 6. over-thecounter medication may be used before seeking the help of a health care professional. Patient will resume self-care activities when no longer immobilized. Use of guided relaxation exercises or imagery d. b. Use progressive relaxation starting at the toes or head and going steadily down the body relaxing the muscles in each area. Most nurses on occasion get tired of the hours of shift work. During the course of an illness. 4 C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. c. Consult Patient Teaching 31-1. 3. a. 8. Expected outcomes will vary depending on choice of nursing diagnoses. Statements will vary depending on the expected outcomes written. Copyright © 2009. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion a. Study his body language for clues to the degree of pain. Nurses do adjust to shift work to a fair degree rather quickly. 6. 1. Use Table 31-2 and a drug handbook. Look for changes in his vital signs. On occasion. Patient will not develop muscle atrophy while immobilized. 7. deep breaths between each set of muscle relaxation. Nursing diagnoses chosen will vary. 6. 2. Use a pain scale by pointing to the options and have him blink or move his head for “yes” and “no” answers. 2. 4. 9. During the course of the night the patient experienced severe pain. 2. 5. Examples are: 1. 4 2 3 1. 4. Patient will learn to use alternative means of communication by the end of the shift.

Completion 1. 3. 2. 2. check for contraindications to the use of herbal therapies. 4 2 heart and respiratory rates 2 4 Chapter  terminology 1. inherently alignment wafted comprised medium/conduit S hort anSwer 1. It is often combined with massage. traditional Chinese medicine. b. Relaxation 2. 2. 2.Student Learning Guide Answer Key  Communi Cation eXerCiSe S Answers depend on individual responses. like cures like b. EXAMPLE: Use relaxation instead of giving a pain killer. 2. 7. 8. naturopathic medicine. EXAMPLE: Use relaxation as well as giving a pain killer. 5. Relaxation techniques b. promoting relaxation 7. the greater the dilution of the remedy. Saw Palmetto is most frequently used to treat benign prostatic hypertrophy. 2005. a. 4. National Center for Complementary and Alternative Medicine (NCCAM) 3. a. 4 2. 4. It is used to decrease the size of the prostate. It is based on the belief that correct spinal alignment leads to healing of muscle strains and impingement of nerves. or without charge. electrostimulation of muscle. the greater its potency c. Acupuncture 6. controlling breathing. Accupressure aromatherapy chiropractic Reiki Folk medicine C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. Compliment is a positive comment about something. 2. an imprint of Elsevier. It is also a mild diuretic. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. Back strain and whiplash injury are two commonly treated maladies. Chiropractic medicine is used mainly to treat muscle and skeletal problems. 4. Biofeedback 3. 4. Inc. Ayurveda v oC a b u l a ry eX e rC i S eS 1. 5. Meditation d. 3. The use of relaxation therapy along with pain medication to increase comfort. and specific exercises. improving coordination. Copyright © 2009. philosophy 5. Chiropractic treatment along with muscle relaxant and pain medication to treat a back strain. The patient should be directed to reliable information available about the herbals being considered. 5. 3 1. considering other medications the patient is taking and the total health status of the patient. and Ayurveda 4. All rights reserved . Note: Complimentary can also mean free. complimentary is a remark that does that. to complete. 2001 by Saunders. Imagery c. a. Alternative means to do or use one thing instead of another. 3. illness is specific to the individual C omple tion 1. Its effectiveness is in question. Answers will vary according to which sites are visited. 3 2. redirecting mental focus. Homeopathic medicine. 3. 6. Complementary means to do or use in addition to. EXAMPLE: That was a very good report you gave in class.

That way the pharmacist can give let you know whether there are any contraindications to giving your child that herb. what the potential side effects are. and immaturity of organs 5. The symptoms the drug relieves c. My friend knows someone who did that and is doing very well. All rights reserved . Bioavailability d. 4. He can tell you the pros and cons of each. your child’s age. 6. 9. size. 5. Purity b. g d b e h j Completion anaphylaxis antagonist drug interaction pharmacodynamics nursing implications synergistic effect therapeutic effect toxic effect S h o r t an S w e r 1. 5. EXAMPLE: Television is a medium for advertising. 3. b. Potency c. 1. or that they need to take it to maintain a steady blood level of the drug so it can work 4. or large? w ord attaCk SkillS Bioelectromagnetic-based (13) Bio/electro/magnet/ic-base/d bi o e lec tro mag net ic-base d Contraindications (11) Contra/indications Con tra in di ca tions Polarities (4) Polar/ities Po lar ities Communi Cation e XerCiSe Patient: I think I will skip my radiation treatments and just eat a macrobiotic diet. 2. Nurse: You should talk to your doctor about that. matching f i c a Copyright © 2009. reach the site of action c. 10. when to take it. they do not comprehend how the drug works. EXAMPLE: What size do you wear? Small. a. and what adverse effects to report. 7. 7. 6. a. enter the body b. 8. Any five of the items in the textbook under “Considerations for the Elderly” Be certain that the patient understands what each medication is for. are metabolized and excreted 8. Medium can mean a method or way of distribution. 1. Inform the pharmacist of any medications your child is taking. weight. a. 2005. 2. and instruct family members about the medications 7. Should be certain patient can manage the pill containers or use a medication planner box. 2001 by Saunders. an imprint of Elsevier.Student Learning Guide Answer Key  3. why they are taking it. The drug’s desired effect 2. and why you wish to use St. has written instructions as to when to take the medications and what each medication is for. John’s wort. age. Patient: What do you think about using St. be certain the patient can open the medication vials. Inc. Medium can mean being in the middle. 8. safe and therapeutic effect of the drugs 3. John’s wort to help my child? Nurse: Be sure you ask the pharmacist about that when you leave your prescription. 3. medium. uses a medication organizer if needed. 4. The effect of the drug on a body system b. 6. Efficacy e. Safety Chapter  terminology a.

4. 6. g.” For each drug. If needed. a. c. ask: “How long have you been taking __________?” “Have you noticed any problems with it?” (Ask specific questions regarding very common side effects of the drug. b. Diuretic 2. nursing precautions and implications for each drug.3 2. a. take it in the early afternoon drug Cal Culation S and Con v e rS i o nS 1. how she plans to manage her drug regimen. Tanaka. etc. e. any drug allergies she has. In the morning. Noncompliance with drug regimen related to forgetfulness. 0. c. every other day 12. if second dose needed. Verify that therapeutic action of each drug is occurring. Adverse effects to report 11. 20–80 mg PO 3. and chemotherapy drugs identifi Cation Answers are from Table 33-7. try to set up a telephone reminder system for Mrs.) e Expected possible side effects f. 7. IV cardiac drugs. Presence of anuria/hypersensitivity 5.Student Learning Guide Answer Key  9. Tanaka about when she is taking her pills and how she is remembering to use the planner. PO. Question Mrs. 10. Tanaka understands the importance and reason for taking each drug to increase compliance. Check the medication planner and pill vials at each home visit to see that pills are indeed being taken. Assist Mrs. b. insulin. 5. 3. Patient will use a medication planner to take all prescribed doses of medication on time. 1. c 5. 2.2 300 0. You need to know: a. 9. a 4. “Mrs. Tanaka. h 6. Give the right drug Give the right dose of the drug Give the drug by the right route Give the drug at the right time Give the drug to the right person What the drug is for The effect the drug is supposed to have When and how to take the drug Precautions for taking the drug (with or without food. heparin.) “Do you remember to take each drug as you are supposed to take it? How do you remember to do that?” 2. a. d. IV. Tanaka to obtain a medication planner and to set it up with the medications. usual and safe dosage range for each drug. if any of the drugs interact. 1. f. All rights reserved . d. check with the pharmacist and/or the physician 13. d. d 7. Make arrangements with a relative or friend to help her refill her medication planner each week. e. e. d. 4 capsules 7. an imprint of Elsevier. f 8. IV potassium.76 or 3 2 oz. 2 2. 8. 6. b. b 2. Tanaka to obtain Copyright © 2009. g drug knowledge Answers can be found in any drug handbook or pharmacology textbook. 5. 2001 by Saunders. Speak with a relative or friend who is helping Mrs. may I see the medication vials for those medications you are taking now? I also need to see any other drugstore medicines you are using even occasionally. 4. 3. b. c. c.66 mL a p p l iC at i o n o f t h e n u rS i n g p r oC e S S 1. whether periodic laboratory testing is needed for any of the drugs she is taking. e 3. Be certain Mrs.5 mL 2 caps 10. or IM 4. 2005. any side effects that she has suffered currently or in the past from the drugs she is taking. Inc.

2 kidneys 4 2 1 1. Sister states that Mrs. 8. 9. (Wed. have the partner choose three drugs that the patient might be taking. and pravastatin sodium (Pravachol) are other commonly prescribed drugs. All rights reserved . erroneously 5. compliant. 8. and nursing implications. when to take the drug and whether it must be taken with or without food. For this exercise. f. STEPS TOWARD BETTER COMMUNICATION Completion 1. 3. Also cover potential problems when taking a drug not prescribed by physician (other drug interactions and effects on chronic health conditions). 5. 3. 2 3 1. other drugs and over-the-counter medications being taken. c. b. 4. how to take the drug. incompatible 2. 5. d.) Medication planner bins empty for Monday. Atenolol (Tenormin). matching e g a d f h j b i c b.m. Tanaka has been responsive to reminder calls and has usually taken the medications already when she calls. an imprint of Elsevier. readily Chapter  terminology a. The doctor orders a nebulizer treatment for her immediately (stat) to relieve her bronchospasm. and Wednesday a. adverse effects to report. tactful 3. For this exercise. 2001 by Saunders. categorize C o m m u n iC at i o n e X e rC i S e S 1. alprazolam (Xanax). 3. but any other drug may be used. allergies. e. Points to cover are: a. what patient knows about the drug and taking it. 6. what to do if a dose is forgotten. 2. Vicodin (acetaminophen with hydrocodone). Use a drug handbook or a pharmacology book to locate the information needed to devise a teaching plan. adverse reactions to report to the physician. 9. He tells her to discontinue the antihistamine she has been taking as it does not seem to be help- Copyright © 2009. Review the laws governing the dispensing and prescribing of scheduled drugs. 10. 4 3 1 4. 2. Health and health problems. Evaluation statements might be: Medication planner set up with prescribed medications for one week. abbreviations Vicjie Simons is being treated for asthma. use three other drugs. 6. 7. Drugs will vary with the scenario. why patient is receiving the drug. 2. Inc. States has been remembering to take medications. what the drug is supposed to do. 7. side effects from previous doses. Cover action. diagnostic tests scheduled on which the drug might have an effect. g. possible side effects of the drug. side effects. Criti C a l thinking aCtivitie S 1. 2. what might happen if the medication is stopped. 3. Her medications are not adequately controlling her symptoms. 10. 3. 2005.Student Learning Guide Answer Key  information about her medication compliance. 1. nC le X.pn ® eXamination–Styl e r eview Que Stion S 1. 2. Tuesday. 4.

d. 11. a. Determine that the order is still valid (within date). the route by which it may be given (appropriate route for this patient) c. diuretic h. triamcinolone acetonide (Azmacort) and tells her to use the new inhaler three times a day. anticoagulant b. signature of the prescriber 4. place the tongue on the roof of the mouth and with the chin tilted slightly downward. 2005. antihistamine c. the full name of the drug c. 10. He prescribes oral (PO) montelukast sodium (Singulair) to be taken with water in the evening. the correct dose (within range of normal dose) b. Whether there are liver or kidney problems that require a reduced dosage of the drug so that toxicity does not develop 8. telephone number. b. daily: 0900 bid: 0900 and 1700 tid: 0900. All rights reserved . 12. Inc. 5. To take a sip of water and swallow it. Determine why the patient is receiving the drug. Assess for therapeutic effect of previous doses of the drug. applying to the skin as a patch. interactions with other medications f. desired effects of the medication d. lung disease medication room. 0900. or spreading them on mucous membranes 6. the dosage to be given d. 1300. anti-inflammatory 5. patient ID number on bracelet and the MAR 2. social security number. Whether the pill was swallowed after administration or has ended up in the buccal cavity d. 2001 by Saunders. antibiotic f. and 1700 qid: 0900. a. Assess for patient allergies. 14. 8. He puts her on another metered dose inhaler (MDI). immediately another colleague skin. visual recognition after one prior contact with the patient. a. stating name. and 2100 q4h: 0100. a. mucous membranes 48–72 hours surgery. 6. how often it is to be given f. general anesthesia smoke. questioned without delay. 3. Have the person take a large sip of water. c. Assess for contraindications to taking the drug. bronchodilator e. Assessment: Any three of the following: a. an imprint of Elsevier. 13. address. Whether special caution is needed if the patient has difficulty swallowing pills or capsules c. 0500. instilling into eyes and ears as drops. 1300. place the pill toward the back of the tongue. any contraindications for giving this drug to the patient 3. antidepressant g. enteric-coated tablets c. 7. Short a nSwer 1. the full name of the patient b. spreading them on the skin. Whether patient is receiving another med from another doctor for the same problem b. medicine cabinet under lock and key prolonged patted onto vaginal unwrapped meniscus ineffective a p p l iC at i o n o f t h e n u rS i n g p r oC e S S 1. 2. 4. the route of administration e. date the prescription was written g. date of birth. sustained-release caplets 7. Any three of the following: (see Elder Care points in chapter) a. swallow. sedative hypnotic d.Student Learning Guide Answer Key  ing. 15. Copyright © 2009. and so on 9. introducing them into the rectum or vagina in a suppository. sublingual tablets b. potential side effects of the medication e. 9. e. 1700. Completion 1. follow with more water. 1300.

he has received a different medication than this one. The directions for using it are ambiguous. 5. 4. 6.Student Learning Guide Answer Key  2. 8. d. adhere to the medication schedule. 3 1. f. 2. Technically. The medications will be effective. 7.pn ® eXamination–Styl e r eview Que Stion S 1. Serious side effects of medication will be identified quickly. Temperature and WBC are within normal limits. I don’t want to make any deviation from his plans. g n d e m j b c k h i f a l intradermal anaphylactic shock solute Z-track tuberculin subcutaneous compatibility sterility b. figure out why the patient is to receive this pill and why. 10. Assess for drug interactions with food or other drugs. Area of inflammation and tenderness around wound is decreased. h. 7. 2. 3 3 1 1 4 1. 4. an imprint of Elsevier. c. the pill should be replaced by a new one. However. No allergic reaction to the medication will occur. All rights reserved . most nurses allow the patient to pick up the tablet and take it. 11. 5. b. 2. less than body requirements. determine that the pill in question is actually that medication. Wound is clean and dry without inflammation or tenderness. 1. Chapter  terminology a . three times Any one of the following: a. 2. The patient will understand why the drug is prescribed. 6. 3. 7. so we had better check with the doctor. related to nausea a. 12. 6. 14. d. 2005. 4. 13. 3. Assess the patient’s knowledge about the drug. Completion Criti C a l thinking aCtivitie S 1. Verify the physician’s actual order. 8. 8. 9. e. 4. 9. 3. 3. 4 2. 2. g. All medications will be safely administered to each patient on time. Wound culture after 5 days of antibiotic treatment is negative. as it is contaminated with the patient’s own microorganisms. Assess for side effects of previous doses of the drug. 2. 3. 5. b. Copyright © 2009. and report serious side effects. Risk for imbalanced nutrition. ma t c h i n g nC le X. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion This is a very potent drug. 2001 by Saunders. if it is a continuing order. Inc. c. 5. Discard the medication and chart that it was not given and why. 2 3 2 1. 10.

Dorsogluteal site in buttock area* c. 3 4 slowly 1. Any three of the following: a. 2005. needle sticks. e. follow up according to agency policy for treatment 12. 2. Ventrogluteal site d. Vastus lateralis site in thigh e. sterile saline 18. 3. Use a safety needle and syringe. c a a a b c c b 9. allergies 19. back of neck. b. Assess body build and circulation of area when choosing the site for injection. a smaller length needle may need to be used Correlation 1. 5. blood-borne 21. Vomiting will be controlled by antiemetic medication within 1 hour. or hepatitis C virus 11. the size of muscle mass and possible decreased circulation in the area. Inc. 4. 8. 3. Keep food and other odors out of the room. Any three of the following: a.Student Learning Guide Answer Key  Short a nSwer 1. Apply a cool cloth to the forehead. Give nothing by mouth. 2. 2. Assess for side effects and adverse effects to previous doses. 9. 3 abdomen. filter 16. or under the chin. 4 2. e. 45 degree 4 3 2 2. 25 gauge 13. Discuss how to prevent a needle stick. 2. 5. aspirate 8. Deficient fluid volume related to vomiting 3. lateral surfaces of the upper arm or the anterior and lateral aspects of the thigh 4. 7. an air lock 9. 3. aspirate 6. To hasten the action of the drug c. States nausea has eased since injection of medication. report the incident to the charge nurse and fill out an incident report. 4. aqueous. 10. a. take a small biohazard sharps container with you. 3. if it is narcotic. 90 degrees 14. 2. b 10. 4. Rectus femoris site in the adult thigh 7. 5. Use sterile equipment and aseptic technique to prevent infection. tenths 17. No vomiting after injection of antiemetic. b. Move him as little as possible. Determine reason patient is to receive the medication. “scoop” up the cap. Waste the medication. a. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. HIV. 6. a. All rights reserved . c. b. 7. an imprint of Elsevier. When the patient cannot take medication by mouth b. When digestive juices would counteract the effects of the drug if given by the oral route 2. Select the correct site to prevent damage to tissues. Statement chosen will be individual. Mid-deltoid muscle b. sterile water. Check for allergies. 6. hepatitis B. a a p p l iC at i o n o f t h e n u rS i n g p r oC e S S 1. c. d. have someone witness the wasting and document it Copyright © 2009. Ensure that the dose is accurate. 3 mL 15. 2001 by Saunders. wash the area thoroughly with soap and water. Determine which sites were used for recent injections. Decrease environmental stimuli. emotional support 10. oil 20. 3 C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. abdominal 5. d. 8. c.

6. Supply hydration when fluids cannot be taken by mouth. Second check—just before drawing it up. Donald Moore learned to give himself injections. vial apprehensive. 5. 2005. 4. I was walking up the stairs. 6. b. 1. Deliver medication directly to the bloodstream. plasma. b. an imprint of Elsevier. calibrated hastened. f. a. 1. Carefully regulate the rate of flow.Student Learning Guide Answer Key  on the narcotic checkout sheet. induration beveled. Replenish blood. When I fell. STEPS TOWARD BETTER COMMUNICATION Completion a. reconstituted scored. 4. 7. Supply nutrients when the patient cannot absorb them from the intestinal tract or needs supplementation. 4. 3. were compatible S h o r t an S w e r 1. 4. 7. 2. 1. 2. 1. First check—after taking the medication from stock. 5. d. Answers will vary. Note on the MAR that the medication was not taken. time Clau SeS a. All rights reserved . Document in the chart that the medication was not given. 8. she was having a lot of pain. 2. Observe closely for transfusion reactions. with dexterity. 9. Seek an order change to a PO medication. After she received the injection. Inc. 5. 2. 5. c. 2. Before the nurse gave her the injection. e. 1. Review which type of insulin to draw up first. Quickly replenish and balance electrolytes. Third check—just after drawing it up. 4. Copyright © 2009. 3. Any four of the following: a. 7. Assess the site frequently for signs of complications. b. c. Margaret Smith was eating. 2. 3. 3. Keep IV tubing clear of air. 2001 by Saunders. aqueous. Chapter  terminology a. While he was in the hospital. d. b. 3. Discuss adding air to both vials first then beginning drawing of insulin. Keep IV fluid sterile. When her sister arrived. matching i h g b f a e d c Completion isotonic hypotonic hypertonic infiltrated Macrodrop microdrop vascular access device aqueous reconstituted beveled dexterity compatible vial apprehensive needle stick sloughed off. Order of last two items will be individual. Protect the cannula site from contamination to avoid possible infection. 6. 3. the patient felt better. Priority is based on potential for threat to the patient’s life from a serious complication (Box 36-3). or particular blood components. 8. 5. b. 4. e.

good skin turgor. The correct IV solution is hanging. 9. 80–250 pack the area with hot packs to distend the vein distal site potassium check the alarm to be certain it can be heard outside the room or away from the patient’s bedside if in an intensive care unit. 6. Maintain sterility of the system. 150 clarity. b. e. inspect IV system for leak. Over-the-needle catheters c. laboratory data indicating that the blood count has increased for the type of blood product infused n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. monitor vital signs closely. 21 gtt/minute e. Phlebitis: remove IV catheter. 26. 10. The site is patent and the solution is infusing. d. there is no way to retrieve the solution or medication once it is infused into a vein. Deficient fluid volume will not occur. The flow of the solution (that it is running) c. notify the physician. nausea and vomiting. 6. notify the physician. c. tachycardia. The flow rate is that which is ordered. 5. The medication is not incompatible with the fluid that is infusing. All rights reserved . back pain. 20. 25 gtt/minute b. a. 3. 24. an imprint of Elsevier. hematuria (Skill 36-6) Turn off the blood and open the saline. b. a. 17. d. 25. 27. itching. No complications are occurring. 4. Circulatory overload: slow infusion. The patient is not allergic to the medication. 4. and adequate urine output 8. b. 18. The condition of the IV site 7. Butterfly needles b. g. Observe for complications. 7. extreme care must be used to measure the exact amount. moist mucous membranes. 19. keep patient warm. 2. notify physician. 22. 83 gtt/minute c. and older adults monitor the infusion closely to see if it is set properly. 2. The level of fluid remaining in the container b. or particulate matter snap. or click-lock when it is finished infusing. a. a. stay with the patient. running on time. shortness of breath. The rate of the flow of the solution d. 15.Student Learning Guide Answer Key  3. a. 21. d. apply warm soaks to the site. 8. c. 3. 12. 10. c. rash. Air embolus: place on left side and lower head of bed. small amounts of fluid are required b. Be certain the IV fluid to be administered is the one actually ordered. fever. Inc. the main IV begins infusing again at the set rate normal saline a. Risk of infection related to invasive procedure 4. such as when giving IV fluids to infants. give oxygen as needed. 11. 20 gtt/minute 6. 5. Track intake and output when a patient is receiving IV fluids or blood. 14. Huber 23. leaks. chills. Through-the-needle catheters superior vena cava. 5. a. children. Infiltration: remove IV catheter and restart at site in other extremity. Be certain that fluid infuses at the prescribed rate. 9. 3. notify physician. apprehension. and trouble-free the administration tubing set a. 7. notify the physician. assess for edema. a p p l iC at i o n o f t h e n u rS i n g p r oC e S S 1. 3 1 21 3 2 1. elevate the head of the bed. 2001 by Saunders. atrium high blood flow vessel take blood pressure no fluid is to be infused until placement is confirmed by x-ray non-coring. 13. 4 2 3 4 4 Copyright © 2009. 8. 31–32 gtt/minute d. 2005. b. Speed shock: stop the infusion. 16. 1500–2000 50.

criss-crosses and chevrons. 2.Student Learning Guide Answer Key 0 Criti C a l thinking aCtivitie S 1. Extrusion of the viscera through the surgical incision resulting from wound dehiscence. Untape the cannula and rotate it slightly to move the opening away from the vessel wall. Chapter  terminology a. mimicked. 8. 6. The intravenous solution was leaking out of the bag when the patient pushed the call button. 6. 5. 3. Blood clot in a vein that restricts blood flow. 3. (Solid. discontinue the cannula and restart the IV at another site. runaway. an imprint of Elsevier. 6. See if you can gently irrigate the cannula now. or gaseous mass of undissolved matter present in a blood or lymphatic vessel. Attempt to aspirate blood. 3. 4. Attempt to aspirate blood again. 9. 3. Combining colostomy thoracotomy cholecystectomy orchiopexy fibroma mammoplasty Copyright © 2009. Loss of an extensive amount of blood which may lead to shock. Try aspirating again. 5. 4. 8. All rights reserved . 2. 2. matching e f a d b c g h piggyback ascertain discrepancy rule of thumb runaway b. 5. 7. discrepancies 2. the surgeon entered the subclavian vessel. b. 7. She checked the level of fluid remaining in the bag before disconnecting it. make certain the patient is not lying on the tubing. liquid. Inflammation of a blood vessel from the irritation of a clot (thrombus) on the vessel wall. Before making the subcutaneous pocket. taut grammar point S 1. Use as small a gauge catheter as possible. 4.) 4. 2. First. C. Next. 2. 1. piggyback 3. 5. rule of thumb. Collapse of the alveoli in the lungs restricting air flow. 2. Inc. Inflammation and irritation due to entry of gastric or oropharyngeal food or fluids into tracheobronchial passages from dysfunction or absence of normal protective mechanisms. Reposition the cannula by rotating it slightly. 1. Pull the skin taut distal to the projected site. If nothing works. 4. escape of blood from a ruptured vessel. it can break off and become an embolus. Separation of the surgical wound. Completion 1. 1. 1. STEPS TOWARD BETTER COMMUNICATION Completion a. raise the IV bag. If not. Inflammation and consolidation of the lung from retained secretions. Detach the tubing from the cannula and attempt to aspirate blood from the cannula. Clot (thrombus) that breaks off and travels and lodges in a blood vessel. 3. 2005. ascertained. Use only a 5–15 degree angle to approach the vessel with the IV catheter. discontinue the cannula and place a new one in a different location. 2001 by Saunders. The nurse observed the patient while checking the IV. 3.

needles. a. patient has been NPO for allotted time. Any three of the following: a. b. Hands instruments to the operating team. Assists with gowning and gloving of surgical team. 12. Counts sponges. Risk of deficient knowledge related to postoperative care. Check to see that the surgical consent form is signed. d. diet b. a. Local—minor surgical procedure such as skin cyst removal 3. wound care d. Curative—to correct a problem causing illness or pain 2. Allow time for voicing concerns and fears. 2001 by Saunders. Handles disposition of specimens. obtains blood from blood bank. 7. use of equipment e. 6. Fear related to risk of death and loss of control due to anesthesia. lab work is on the chart. preoperative teaching is complete. c. Conscious sedation—short procedures such as a dilatation and curettage or breast biopsy d. an imprint of Elsevier. c. Provides further instruments and supplies. Vital signs are stable and the patient is awake and able to respond to stimuli. and leg exercises. and instruments with the circulating nurse. Ineffective coping related to threat to self and multiple stressors. activity and rest c. Palliative—to reduce pain or complications c. deep-breathing. Inc. Operating microscopes and robotics have made surgical procedures more precise. Maintains the safety of the patient. allow time for questions. All rights reserved . Gowns and gloves the surgeon. and preoperative medications have been given. and instruments with the scrub nurse. Fear will be reduced by speaking with anesthesiologist. Any three of the following: a. scalpel blades. a. j. g. needles. b. Any five of the following: a. coughing. Observes for breaks in sterile technique. Patient is able to verbalize understanding of the procedure and expectations for the postoperative period. f. a. Any one of the signs of symptoms listed for each complication is acceptable. ta b l e a Ct i v i t y See Table 37-5. Fluid and electrolyte balance will be maintained throughout the perioperative period. f. i. written instructions 3. b. Supervises activities of scrub person. Sets up the sterile instruments and supplies. 2005. explain what to expect preoperatively and postoperatively 5.Student Learning Guide Answer Key  Short a nSwer 1. Maintenance of patent airway and adequate ventilation Copyright © 2009. d. Anticipates needs of the operating team. General—major surgical procedure such as a colon resection b. 9. Any six of the types of patients listed in Table 37-1. e. h. preoperative checklist is complete. Patient is able to demonstrate turning. scalpel blades. e. Learning related to self-care will be obtained through postoperative teaching. Monitors use of sterile technique. Lasers and fiberoptics have allowed ability to operate through much smaller incisions. S h o r t an S w e r 1. Records the events of surgery. allergies have been noted. and fetches IV solutions as needed. Patient is prepared physically and emotionally. 11. 10. Regional—obstetrical procedures c. 8. a. d. Anxiety will be reduced by voicing concerns. when to see the doctor after discharge 2. c. Checks function of all equipment to be used. make adjustments for cultural beliefs. signs and symptoms of complications to report f. Makes certain equipment is properly grounded. Anxiety related to the surgical experience and outcome or anxiety related to the threat to selfconcept and threat of death. Elective—to repair a defect b. Counts sponges. patient is bathed and gowned for surgery. b. 4.

check the Foley catheter and make certain the tubing is not crimped. Assisting the patient to the chair safely and as painlessly as possible will require an assistant. Assistance with splinting the chest will be needed for effective coughing initially. deep-breathe (TCDB. Chest drainage ceased. assess level of pain using a pain scale. a. 5. 9. cough. and anesthesia Risk for injury related to decreased level of awareness 3. Check that lab work is complete and on the chart. pain. e. kidney toxicity from anesthesia or drugs. 10. 2005. check what medications the patient received preoperatively as well. loss of blood and decreased perfusion to the kidneys. check what pain medication—if any—was given in the PACU and when it was given. 4 4 3 2 2 1. c. Inc. assessment of chest drainage. Monitor oxygen saturation level q2h. b. and move around. 2. 1. 7. Copyright © 2009. 4. 3. Patient will ambulate independently before discharge. cough. checking IV flow rate and IV site. d. Check for a signed surgical consent form. 2. Have the patient empty the bladder. oxygen saturation level. 6. c. an imprint of Elsevier.Student Learning Guide Answer Key  b. ambulation or sitting up in the chair) 6. result of last chest x-ray. hemorrhagic shock. Prepare the unit for the postoperative return of the patient. Auscultate lungs q shift. 7. auscultate the lungs. Monitor chest drainage and suction. 2. 2. assess level of consciousness. 10. check the oxygen setting. All rights reserved . Impaired oxygen exchange related to partially collapsed lung and anesthesia Pain related to surgical procedure Activity intolerance related to tubes. check the chest tube to be certain it is not kinked and that the suction is functioning. 3 3 2 1 92% C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. 3. deep-breathe. The nurse will need to attend to tubes and lines as the patient turns from side to side. Check to see that preoperative medications ordered are available on the unit. Lungs sounds present in all fields of lungs. Give the preoperative medications. 4. 8. Check the physician’s orders. mark the amount of drainage in the chamber. Patient will have a normal oxygen saturation level on room air by postoperative day three. 11. Possibilities include dehydration. 8. 2001 by Saunders. 8. Regular assessment of pain level should be done to keep pain under control so the patient will turn. Document the patient’s readiness for the OR. Oxygen via cannula at ____L/min. Assistance will be needed from the nurse for ambulation. Splint chest incision while coughing. amount of chest drainage. note the amount of drainage in the bag. check the IV solution and flow rate. Transfer the patient to the OR. checking the dressing. 9. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. The correct order of priority would be: 1. 5. assessment of urine flow. Complete the preoperative checklist. 7. Turn. cough. Oxygen saturation increased to 98%. Take vital signs. Pain will be controlled by oral analgesia by discharge. assessment for pain level. Turn. Lung sound status. check all areas of the chest dressing and mark any drainage showing. 5. 4. Prevention of complications Promotion of comfort and rest Promotion of wound healing Promotion of psychological adjustment to lifestyle or body image changes appli C ation of the n urSing pr oC e S S 1. 6. Have the patient shower. and deep breathe q2h while awake.

It might be good to wait and see if you even need a colostomy before you start worrying about it. I want you to walk around the house twice today and then increase the distance and time you walk until you are walking around the block without any stiffness or problem. These medications may make you a little groggy and I’m putting up the side rails as I don’t want you to get out of bed. 5. Mueller?” “The surgeon should be able to give you an idea of what you might be facing as soon as you wake up after surgery. I have your preoperative medication. that’s correct. Here are the towels and special soap for your shower. 9. You are all ready to go to surgery. Take the antibiotics in this vial as the directions say. Encourage ambulation. The orderly will be here shortly to transport you to surgery. Do not lift anything weighing more than 5 lbs.Student Learning Guide Answer Key  3. 2001 by Saunders. 4. new pain. Remember to drink plenty of water as this medicine can make you constipated. STEPS TOWARD BETTER COMMUNICATION Completion 1. All rights reserved . I’ll be back in 15 minutes to give you the preoperative medications. Now I will put the second one right here. 8. Once your bowel movements are normal. 15. Stevens. an imprint of Elsevier. 14. Call tomorrow to make your follow-up appointment with her. fever. Example: “What concerns you most about undergoing anesthesia. Would you please empty your bladder before I give it to you?” “OK. Mr.” 2. Tape it crosswise as it is now. 3. 7. 2. Continue to give the patient nothing but small ice chips that are allowed to melt in the mouth. Completion approximation débridement abscess adhesion exudate collagen infection eschar necrosis fistula phagocytosis contracture hematoma Cellulitis ecchymosis Copyright © 2009.” 3. is that correct? Here is the first injection. Inc. I want you to continue to do your foot and leg exercises at least six times a day at home. You stated you are not allergic to any medications. 2005. Mueller. 13. 1. you must stick to a soft diet for the next few days. it is time to get you ready for surgery. Have you been married a very long time?” “We’ll help you learn to cope if you have to have a colostomy. 6. 11. That’s it. You should get plenty of rest and just take it easy for the next week. first I need to check your armband to verify you are the right patient for these medications. or other problems immediately to your surgeon. 10. Wash your hands thoroughly and remove the dressing. 4.” “Tell me more about your wife. 3. allayed sharps groggy grounded prior Communi Cation eXerCiSe S 1. This vial is your pain medication and you may take it every 4–6 hours as you need for the discomfort. Soap your chest and abdomen twice with this special soap. you can slowly go back to your usual diet. auscultate bowel sounds every 4 hours. if you will turn on your side I will give you these two injections. Cleanse the area with the saline solution. 2. Report any redness. 5. Stevens. We have specially trained nurses who can teach you all you need to know to care for yourself. I’ll be back then. ask patient to report the passing of any flatus. Mr. Stevens. Mueller. “Mr. 12. pat it dry and apply new gauze pads. Good.” “Mr. Change the dressing every day. Example: “Mr. Mr.” Chapter  terminology a.

reduce inflammation or swelling d. and cold. provide comfort f. provide an exit for blood and fluids that accumulate from the inflammatory process so that the wound may heal. close shiny moist Montgomery straps stretch gauze (Kerlix) Copyright © 2009. heat lamp. 5. fever d. 5. Injury—fibrin formation—leukocytes remove debris—granulation tissue forms—connective tissue and capillaries become taut—scar formation. heated gel pack. relieve muscle spasm e. 18. Medications—the asthmatic who is on prednisone (a steroid). Aquathermia pad 11. Nutrition—the homeless person suffering from malnutrition. a decline in immune function occurs. warm moist packs. b. relieve pain b.Student Learning Guide Answer Key  16. increased WBCs 8. Chronic illness—the diabetic patient. reduced liver function impairs synthesis of blood factors. increased rate of respirations. 17. c. clammy skin 6. a piece of wide flat rubber tubing. a. especially with poorly controlled blood glucose. reassure the patient. 4. warmth. 3. 12. Infection—the cancer chemotherapy patient who is immunocompromised. cover the area with large sterile dressings or towels soaked in normal saline. hot water bottle. 4. rapid. 2. 9. 19. 7. 2001 by Saunders. Age—an 80-year-old with peripheral vascular disease. Swelling or edema b. attempting to create heat to bring up the temperature 14. Lifestyle—the pack-a-day smoker. decreasing cellular metabolism and numbing the area 12. 6. Any of the examples mentioned in the section on “Factors Affecting Wound Healing” are acceptable. d. a. sanguineous serosanguineous sinus purulent matching f g c a i e d b h Short a nSwer 1. Heat d. causing vasoconstriction and diminishing blood flow and fluid accumulation in the area 13. 7. notify the surgeon. e. Completion 1. The skin of older adults is much more fragile and may sustain a burn more easily. place the patient supine. redness. 11. purulent drainage c. skin becomes fragile and easily damaged. b. a heating pad. thready pulse. 7. débride compress it. an imprint of Elsevier. reduce congestion c. Inflammation secondary tertiary contracture Staphylococcus aureus asepsis. older adults may have decreased sensation in the affected part and can’t detect something that is too hot. 6. wound absorb/contain. and pain b. 10. Loss of function 2. there may be chronic disease present. elevate body temperature 10. 8. f. fall in blood pressure. decreased lung function reduces available oxygen needed for synthesis of collagen. 2005. 3. Pain e. a. 3. and prepare the patient for a return to surgery 9. 4. 2. a. diaphoresis. 5. 8. 9. All rights reserved . 1. Erythema c. Inc. restlessness.

3. All rights reserved . Apply a gel hot pack after checking the temperature to make certain it is not so hot it will burn. 7. and degree of pain in the area. 1 2 4 1 1. 6. Absence of temperature elevation. 2. Administer antibiotics as ordered. Use for 20 minutes 3–6 times a day. tape. Obtain order for wound culture. Cleanse and inspect wound every day. sterile forceps. Answer may vary. disposable clean gloves for removing the outer old dressing 3. 10. 5. For moist packs. This could be Stage II or IV depending on the depth of the ulcer. 15. 6. 6. 5. 2. 2005. swelling. palpate the surrounding area. 2. 7. Appearance of wound that indicates absence of infection and growth of new tissue. Culture wound. 4 2 2 serosanguineous brided either mechanically or enzymatically before staging and before healing will take place. Sterile gloves. discard bag. 11. 3. hydrate frayed friable cardinal nonadherent shearing forces binder hospital acquired numbing cessation v oC a b u l a ry e X e rC i S e Examples: frayed = worn—My nerves are so frayed I yelled at her for nothing. please. 13. 8. cover with plastic to maintain heat longer. 12. Use aseptic technique for dressing change. 9. 4. or pain in wound area. Criti C a l thinking aCtivitie S 1. Impaired tissue integrity related to traumatic loss of tissue (there is no NANDA nursing diagnosis for actual infection). 2. sterile dressings—4 x 4s. 2 3 4 2 4 3 1 3. 7. degree of redness. 5. Radiant = glowing—Her smile was radiant. Example: Wound will be free of infection within 7 days. Could use moist hot packs—again check the temperature. ABDs. Treat with physician-prescribed débriding agent and an absorbent dressing. S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. or bleeding. 10.Student Learning Guide Answer Key  appli C ation of the n urSing pr oC e S S 1. The eschar needs to be déCopyright © 2009. normal WBC. 14. Inquire how the patient is feeling. an imprint of Elsevier. drainage. 8. C o m m u n iC at i o n e X e rC i S e S Answers will be individual. 2001 by Saunders. Inc. Inspect the surgical wound for approximation of the edges. warmth of area. 3. sterile normal saline for cleansing the skin. nC le X. Analyze the patient’s temperature trend and check the blood count for WBC trend. presence of swelling. whether sutures/staples are intact. Inspect it visually. 9. Monitor temperature and WBCs. smell it. 4. Binder = notebook—Put this paper in your binder. Measure its dimensions.pn ® eXamination–Styl e r eview Que Stion S 1. Absence of redness. 4.

5. c. 4. 10. Low air-loss bed: air is distributed through multiple cushions connected in a series to provide pressure relief for the patient. 8. 4. increase fluids. 5. 2. 9. Copyright © 2009. Elevate the limb and support it while applying the bandage. Reduces the risk for thrombosis. Check capillary refill and inquire about the degree. 7. a. c. The cast should be supported by pillows with the extremity elevated above the level of the heart. 3. (Any four of the principles/guidelines listed in the textbook) a. Pulsating air pads d. 2005. Atelectasis: have deep-breathe or use incentive spirometer. Use the flat part of the palms of the hands to handle the cast when turning or repositioning. 10. Reduces pressure on patient. Constipation: increase fluid intake and fiber intake. Heel or elbow protectors 6. an imprint of Elsevier. palpate the temperature of the skin. 7. Remove the bandage for bathing and assess the skin. position joints in anatomical alignment. f. 2. 2. b. The heat keeps the skin dry. and secretions collect in the lower airways leading to congestion and possibly hypostatic pneumonia. Overlap turns of the bandage evenly. lungs are not fully expanded. Often used for burn patients. Eliminates shear and friction. compare to the opposite extremity. 11. Continuous lateral-rotation bed: bed moves slowly from side to side. Water mattresses e. 6. 9. CircOlectric bed: Allows change of position of the patient while in bed by moving the bed around the arc of the circle. 8. check sensation bilaterally. matching f c g h i j d k e b a Completion bivalve quadriplegic isometric paraplegic countertraction force spica hemiparesis hemiplegia moleskin trapeze bar hypostatic pneumonia Short a nSwer 1. The patient and cast should be turned periodically to promote even drying of the cast. Any of the following interventions: a. 4. Secure the end of the bandage. inquire about tingling or numbness. e. b. decreasing the respiratory complications of immobility and promoting normal urine flow. Foam and gel pads b. Thrombus formation: encourage exercise. The person does not breathe as deeply. Sheepskin pads c. Check movement distal to the injury. b. a. d. rewrap at least twice a day. 11. 6. Used for patients at high risk for skin breakdown. Inc. 1. d. Air-fluidized bed: has tiny silicone beads in an air-permeable filter sheet. palpate pulses distal to the injury and compare bilaterally. Prevents occlusion of blood vessels and shearing of tissues. d. 7. location. Check color and sensation of the areas distal and proximal when finished and at frequent intervals. May be used with spinal traction. 3. and nature of pain. 5. Joint contracture: perform active or passive exercise. Warmed air sets the particles in motion so that they act like a fluid causing the patient to float. b. 3. Inspect the skin distal to the injury. give stool softener. 1. 2001 by Saunders. Patient is wedged into the bed. apply elastic stockings. splinting as needed. All rights reserved . Wrap from the distal to the proximal area.Student Learning Guide Answer Key  Chapter  terminology a. c.

Are the pin insertion sites clean and dry? Does she need pain medication? Are her vital signs normal? Are there any signs of infection? Are there any signs of complications of immobility? Are the lungs clear? Is intake and output normal? Is the urine clear? Are bowel sounds present? Does the patient have any complaints? 2. 21. position brace pressure. 13. 3 4 2 pad bony prominences appli C ation of the n urSing pr oC e S S 1. 6. Skin breakdown: reposition at least every 2 hours. Supply a jigsaw puzzle for her to work on. 3. 16. Allow ventilation of feelings regarding loss of a body function and the change in body image. pad bony prominences when positioning. 23. All rights reserved . etc. c. 9. 25. a. 18. 20. their balance 15-30. Have family and friends bring in favorite foods. 3. TV. Assess his interests and develop the program around them if possible. 2005. 2. 2 3 1 2. 26. provide diversional games and books. good alignment maintained move freely in the pulleys countertraction weight. Explain what you are doing each time you wrap the stump. Effectiveness of treatment is shown by x-ray that shows proper healing of the fracture with no evidence of infection. Have family bring in materials for activities she does at home such as knitting. Normal temperature and normal WBC would be two parameters for evaluation. Explain what can happen if ambulation is attempted without the walker (fractures or head injury). 2001 by Saunders. 4 1. 3. 6. 17. Encourage family or friends to visit and eat with the patient. b. an imprint of Elsevier. correct alignment shearing swinging free. 22. small feedings and bedtime nourishment. Risk for injury related to pressure on nerves 4. 8. Impaired physical mobility related to fractured leg in traction 3. e. 4. a. the axillary bar. Boredom: encourage visitors at intervals. g. Patient will not experience nerve damage while cast is present. the patient is in proper alignment and pulled up in the bed to provide countertraction. 10. 11. videogames. crossstitch. keep clean and dry. 14. 11. Working with PT on weight bearing in preparation for ambulation (after traction is discontinued). Performing quadricep setting exercises to prepare muscles for walking. 10. 7. hand grip freedom of movement paresthesia 5. n C l eX -p n ® e X a m i n at i o n – S t y l e r e v i e w Q u eS t i o nS 1. 12. 1. Coordinate visitors so they come at intervals rather than all at once. Give frequent. 9. Renal stone: increase fluid intake to 3000 mL/day f. C r i t iC a l t h i n k i n g a Ct i v i t i eS 1. Allow ventilation of feelings. 5. 2. 15. 24. 4 3 2 2. necrosis uneven palms of the hands spreader bar unattended weak. 27. or use of computer. Plan some activities for fun and some that will make him use his brain. b. Determining if the weights are swinging free. Explain what will happen if the stump is not cared for properly and the pain that can occur. 19. 7.Student Learning Guide Answer Key  8. 2. hip rest the body weight on the axillary bar overall length. Inc. the ropes are moving freely. Review the activities that can be performed independently using the walker. Copyright © 2009.

a. 8. Psychologically. A chronic respiratory disorder may decrease lung capacity or oxygen diffusion and thereby v oCabulary eXerCi SeS Individual answers will vary. 9. b. Be certain the person has on glasses and/or hearing aid and that the aid is turned on. 2. a. Examples: 1. 4. a. 7. matching g f b e h d i a c j b. Moving too quickly after arising 5. a. Communi Cation eXerCiSe Each partner should ask the questions and then answer them when the other partner asks the questions. 6. depression. b. 5. social withdrawal. Sensory deficits e. 6. Decreased financial resources b. b.Student Learning Guide Answer Key  STEPS TOWARD BETTER COMMUNICATION Completion 1. a. a. e. Alteration in nutrition d. 4. 2. d. Polypharmacy 2. Gain the person’s attention before speaking. (Noun) Put the dirty clothes in the hamper. 2. 4. 3. a. 5. (Noun) Exams cause me a lot of stress. 3. Speak slowly and distinctly. They do not metabolize and excrete drugs efficiently. (Verb) An arm cast can hamper ability for self-care. Cluttered walkways c. Poor lighting d. They often see more than one physician. c. 3. Inc. Improper footwear b. 3. a. 4. it may cause embarrassment. 2001 by Saunders. an imprint of Elsevier. c. 5. Teach isometric exercises to promote maintenance of muscle strength. Anorexia due to lack of socialization and company for meals 6. b. 8. d. a. (Verb) She would like to dictate what I do. Alteration in elimination c. Face the person so that your lips can be seen as you speak. Transfer the person from the bed to the chair as soon as possible. Lack of transportation to purchase food c. and low selfesteem. It contributes to the formation of pressure ulcers. incontinence can lead to constantly wet skin and skin breakdown. 7. bladder retraining over-the-counter habit (timed) voiding fecal impaction S h o r t an S w e r 1. 10. (Noun) The dictate is that no children are allowed. They often use more than one pharmacy. (Verb) I can’t stress the importance of practice enough. 2005. Impaired mobility making it difficult to prepare meals d. estrogen replacement therapy (ERT) Copyright © 2009. Impaired mobility b. Chapter 0 terminology a. c. 3. diversionary longitudinally regress disintegrate gait debilitating 2. 1. Completion 1. They often have multiple health problems. repeating as necessary. They sometimes are forgetful and repeat a dose of medicine. Encourage active and passive range of motion exercises. Physically. b. b. All rights reserved .

and bathroom. Any of the factors in Health Promotion Points 40-3 are acceptable. arteritis Diabetes Long-term corticosteroid use macular degeneration Heredity Meniere’s disease. 16. Using a night-light in bedroom. decreased depth perception entering. Decreased activity causes loss of muscle strength. 22. 25. hall. decreased night vision c. Individual priority will vary. labyrinthitis Long-term exposure to loud noise Multiple chronic disorders Impaired vision Multiple physicians prescribing Use of multiple pharmacies Forgetfulness Impaired judgment Borrowing drugs from others Miscommunication Use of OTC medications Alteration in elimination Alteration in nutrition Sensory deficit— vision Sensory deficit— hearing Polypharmacy Copyright © 2009. All rights reserved . e. wheelchair third. 19. Sit the patient upright or in a high Fowler’s position b. half medication climbing on a ladder. swimming weight bearing. decreased joint mobility. standing on a chair safety hazards above head reason increase fluid intake fecal impaction sugar. 15. loss of bone mass. 30. Thicken fluids to prevent aspiration d. other medications Neurologic deficit (stroke) Impaired vision Impaired mobility Activity intolerance Anorexia Lack of income Lack of transportation Alcohol abuse Alzheimer’s disease Anxiety or depression Lack of kitchen facilities Lack of money for eye care Arteriosclerosis. This in turn causes fatigue with activity and decreases mobility. roughage a. reduce available oxygen in the blood. fat. 13. Inc. Using nonslip mats underneath rugs. a. calcium a fall. 27. Feed small amounts to avoid aspiration. decreased balance and coordination. a gait belt a. 2005. 23. Wiping up spills immediately. 29. home maintenance d. an imprint of Elsevier. 17. 18. 21. a. c. Keeping light cords and telephone cords out of pathways. 14. leaving rearranging physicians impacted cerumen 15% ta b l e a Ct i v i t y Physical Care Problem Impaired mobility Contributing Factors Osteoporosis Falls Obesity Arthritis Cardiac or respiratory disease that limits activity Neurologic disorder affecting mobility Severe depression Nervous system disorder (stroke) Immobility Urinary tract infection Insufficient fluid and fiber in diet Poor abdominal muscle tone Pain medications. 26. decreased peripheral vision b. 12. 10. c. 20. Have the person tuck the chin when swallowing. b. gardening b. and thereby interferes with mobility. Installing sturdy handrails for stairs and steps.Student Learning Guide Answer Key  9. 24. 28. dancing c. 11. 2001 by Saunders. d.

2 1. 9. C o m m u n iC at i o n e X e rC i S e S Answers will vary per individual. 19. 2. 3 2 3 2. 3. Assess freezer space. Explore available meal resources. 2. 3. 17. 12. 10.e. 11. 5. dementia selective serotonin reuptake inhibitors validation Criti C a l thinking aCtivitie S 1. 1. All rights reserved . 8. 2. 3. 5. 5.. 4. 8. STEPS TOWARD BETTER COMMUNICATION Completion a. Delirium. Coupled with the mud from the inclement weather we were having. 3. explore family’s ability to help. 5. 4 b. 2. dementia Dementia. 7. 3. Enlist the help of the social worker. 15. 2. 3. 4. 8. 18. 3 2 4 3 1 urinary incontinence 1 2 4 4 2 1. 12. 1. shopping. dementia Depression. 3. 10. Chapter  terminology a. 4. 6.Student Learning Guide Answer Key 0 nC le X. Prudently. Assess for all safety hazards that could cause fire or a fall. paying close attention to each other’s pronunciation. appetite. Each exercise should be practiced with a peer. 6. cleaning up the clutter was quite a chore. delirium Delirium. i d e n t i f iC at i o n 1. 13. depression Depression address imperative cueing clutter enhance engaged Copyright © 2009. 6. 5. etc. 2001 by Saunders. 1. 2. 9. 20. Assess the situation completely. i. 16. 2005. an imprint of Elsevier. 7. 4. Assess patient’s ability to use a microwave oven. 14. food preparation. Inc. 6. 11. 4. The situation was enhanced by cueing my helper that it was imperative to finish early. 4 mobility 1 3 1.pn ® eXamination–Styl e r eview Que Stion S 1. Explore all aids available for a visually impaired person. b. dementia Dementia Delirium Depression Depression Dementia Dementia. 3. 7. depression Delirium. I addressed the problem by engaging help to clean up the odoriferous mess. matching d h c a e b f g Completion age-associated memory impairment benign senescent forgetfulness Confusion.

Material: misuse of older person’s funds. respond to questions 8. a. or stated death wishes Copyright © 2009. Diverting attention (focusing attention on one activity) c. Avoid hurrying the patient to eat 22. stroke. Sundowner’s syndrome or sundown syndrome 12. Inc. Severe memory impairment. hallucinations. mild short-term memory loss. sudden euphoria. White collar crime: do not give information to strangers on the phone. Alcohol combined with depression may lead to suicide when defenses are down and coping mechanisms are impaired. hostility. trust 19. Examples: a. giving positive feedback for desired behaviors and negative feedback for undesired behaviors 25. drug reactions. frequent falls. independence. chew. an organic condition. impaired mobility. They are interrelated in that they have similar risk factors associated with multiple loss. suspicion. complaining of anorexia. depression. toxins. music. 7-day a week care 14. Observing for factors that trigger the behavior b. 4. a. c. b. meticulous planning of personal affairs. Serve one food at a time to decrease confusion b.Student Learning Guide Answer Key  Short a nSwer 1. 5. tumors. and sensory overload or sensory deprivation 11. e. or anemia 24. and humor 17. and loss of interest and enjoyment in life 23. Elder abuse: explore conflicting explanation about older person’s condition. day care and respite care 15. Mail theft: use direct deposit of social security funds. self-neglect. agitation. systemic infection. fluid and electrolyte imbalance. giving away treasured possessions. mild depression (Box 41-4) b. patience. incontinence. sleep disturbance. Adequate health care including the cost of prescriptions b. Household theft: obtain and verify ID of all workers entering the home. uncontrollable hypertension or diabetes. and depression 13. Physical: using drugs to keep older person docile. a. distraction 26. disease process d. Middle stage: increased memory loss. medication effects b. wandering. difficulty swallowing. Loss contributes to feelings of despair and hopelessness. unable to perform ADLs well c. 2. Then perform a mental status exam. lack of energy. gastritis. weight loss. c. d. an imprint of Elsevier. deteriorating speech. All rights reserved . art. 7. agitation. Neglect: not assisting with ADLs as needed or providing inadequate care. b. dealing with grief over a long period of time and physical and mental exhaustion from providing round-the-clock. acute inflammatory disorders. mental confusion. First obtain a detailed and accurate medical history and perform a thorough physical examination. a. or an adverse reaction to multiple drugs 21. Any two of the issues discussed in the text. all other types of nursing interventions have been tried and are unsuccessful 18. a lifelong psychological pattern. a new environment c. dignity. Adequate public transportation to keep older people in their own homes without having to drive 6. Psychologic: threatening physical violence to control behavior. Any of the strategies listed in Nutritional Therapies 41-1. Early stage: difficulty learning new things. d. a. insomnia. psychosocial stressors 9. Vehicular theft: lock vehicle doors and never leave the keys in the car. 3. 2001 by Saunders. Any four of the items listed in Box 41-3. Maintaining a regular activity program 20. 2005. Examples: a. and swallow c. paranoia. manage anxiety. Remind patient to open mouth. leading to a distorted outlook wherein alcohol may seem a good solution to avoiding the problems. fluid and electrolyte imbalance e. and support system and complicate diagnosis and treatment of an illness 10. bedridden 16. personality.

The social worker should be consulted. List the signs and symptoms of elder abuse. Approach will be individual but should begin with establishing a trusting. Cause Signs and symptoms Diagnosis Treatment nC le X. impaired judgment and cognition. 14. Inc. 10. increase physical activity. 4 3 neglect 2 3 3 1 pet 2. rivastigmine (Exelon). 19. or donepezil (Aricept) help somewhat. 7. unkempt Advocacy pose condescending implication C o m m u n iC at i o n e X e rC i S e Criti C a l thinking aCtivitie S 1.Student Learning Guide Answer Key  table aCtivity a l z h e i m e r ’s d i s e a s e Loss of function of neurons in the frontal and temporal lobes of the brain. 3. 2. 6.pn ® eXamination–Styl e r eview Que Stion S 1.). Increasing short-term memory loss. deteriorating speech. Intervention should include increasing social contact. suspiciousness. an imprint of Elsevier. All rights reserved . How could an inexpensive chore service be provided for seniors? S T E P S T O WA R D B E T T E R C O M M U N I C AT I O N Completion 1. inability to learn new things. Based on ruling out other causes for the symptoms. possible attendance in a grief support group. etc. activities that will increase her selfesteem (volunteering. 5. agitation. antidepressant therapy for depression. Use of memory aids. depression. 15. 5. 3. 16. 11. 12. 9. 2. galantamine (Reminyl). obtain social atmosphere for meals. confidential relationship. Dialogue will be individual. 2001 by Saunders. 8. hallucinations. 2 3 3 4 infection 1 2 4 1 2. 20. Drug therapy with tacrine (Cognex). 2005. 4. Copyright © 2009. 13. Definitive diagnosis possible only at autopsy. 18. 4. Symptomatic. 3. 3 2 3 1. 17. consider means for older people to obtain transportation for food and physician appointments as well as social activity. antidepressant medication. PET scan may be helpful. Individual answers. wandering. 3.

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