Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

b.Rinne: Activate tuning fork. Hold base of fork

against patient’s mastoid process and ask

him/her to tell you when the sound can no

longer be heard. Immediately place the still-

vibrating fork close to the external ear canal

and ask the patient if he/she can hear the

sound. A normal ear will hear the sound.

Repeat procedure with other ear.

10.Equipment: Vials of aromatic substances, visual

acuity chart, penlight, sharp object, cotton balls,

vials of solution to test taste, tuning fork, tongue

depressor, reflex hammer, and familiar objects.

Position: sitting.

11.Sample answers:

a.Orientation: What is today’s date?

b.Immediate memory: What did you eat for

lunch today?

c. Past memory: When is your wedding

anniversary?

d.Abstract reasoning: Explain the proverb “a

stitch in time, saves nine.”

e.Language: Would you read this passage from

this book?

12. a.lub; b.mitral; c.tricuspid; d.ventricular; e.S1;
    f.apical; g.S2; h.systole; i.aortic; j.pulmonic;
    k.dub; l.one
    REFLECTIVE PRACTICE USING CRITICAL
    THINKING SKILLS
    Sample Answers
    1.What type of health assessments would the nurse
    caring for Billy conduct?
    In the emergency room, the nurse should perform
    an emergency assessment to determine the effects
    of the bee sting and the allergic reaction that
    occurred. Once Billy is stabilized, the nurse should
    perform a focused assessment of Billy’s allergies and
    answer the parent’s questions at this time.
    2.What would be a successful outcome for Billy and
    his family?
    Billy demonstrates the proper method for self-
    injecting epinephrine
    Billy and his family state methods to avoid bee
    stings in the future and emergency interventions in
    the event a bee sting occurs
    3.What intellectual, technical, interpersonal, and/or
    ethical/legal competencies are most likely to bring
    about the desired outcome?
    Intellectual: knowledge of the typical assessment
    findings associated with an allergic reaction
    Interpersonal: ability to communicate and interact
    effectively with patients and their families during
    times of stress
    Ethical/Legal: knowledge of special regulations and
    legislation detailing nursing responsibilities when
    providing first aid in camp situations
    4.What resources might be helpful for this family?
    Printed or AV materials on allergic reactions to
    insect bites and how to treat them.

CHAPTER 26

PRACTICING FOR NCLEX

MULTIPLE CHOICE QUESTIONS

1.a 2.c 3.d 4.b 5.a

6.b 7.a

ALTERNATE-FORMAT QUESTIONS

Multiple Response Questions

1.b, d, e

2.a, b, e

3.a, c, d

4.b, c, d

5.a, b, c, e

6.c, d, f

7.a, c, f

Prioritization Questions

1.

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:

368 ANSWER KEY

bha f dcge

DEVELOPING YOUR KNOWLEDGE BASE

MATCHING EXERCISES

1. d.Contact poison control center. In ED, stomach
   lavage (may remove unabsorbed pills); possible
   use of cathartic. If dose is toxic, use of chelating
   agent


2. b.Never induce vomiting; dilute poison with milk
   or water, take to ED immediately.


3. a.In ED, activated charcoal or acetylcysteine either
   orally or via NG tube.


4. e.Chelating therapy and monitor lead levels


5. c.Never induce vomiting; contact physician or poi-
   son control center.
   6.d 7.g 8.e 9.a 10.f
   11.c 12.b
   CORRECT THE FALSE STATEMENTS
   1.True
   2.True
   3.True
   4.False—home
   5.False—children
   6.True
   7.True
   8.False—preschooler
   9.False—falls
   10.False—unjustified
   11.False—children under 5
   12.True
   SHORT ANSWER
   
   
   1. a.Neonates and infants: mother who smokes;
      mother who drinks alcohol
      b.Toddler and preschooler: child abuse; expanded
      environment
      c. School-aged child: accidents, fire
   
   
   
   

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