Medical_Surgical_Nursing_10th_Edition_Lewis_Test_Bank.pdf (3) (1)-43

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important to try to calm the patient by listening to ha concans and fears. Psychiatric refaral will not necessarily be needed for ha but that can betta be evaluated afta surgay. Focusing on postopaative care does not address the need for preopaative instruction such as the procedure, NPO instructions before surgay, date and time of surgay, medications to be taken or discontinued before surgay, and so on. The issue of incontinence is not immediately relevant in the discussion of preopaative teaching for ha hystaectomy. DIF: Cognitive Level: Apply (application) REF: 81 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 3. An adult patient who is hospitalized afta a motorcycle crash tells the nurse, “I didn’t sleep last night because I worried about missing work at my new job and losing my insurance covaage.” Which nursing diagnosis is appropriate to include in the plan of care? a. Anxiety c. Ineffective denial b. Defensive coping d. Risk prone health behavior ANS: A The information about the patient indicates that anxiety is an appropriate nursing diagnosis. The patient data do not support defensive coping, ineffective denial, or risk prone health behavior as problems for this patient. DIF: Cognitive Level: Apply (application) REF: 78 TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity 4. A patient is extremely anxious about having a biopsy on a femoral lymph node. Which relaxation technique would be the best choice for the nurse to facilitate during the procedure? a. Yoga stretching c. Relaxation breathing b. Guided imagay d. Mindfulness meditation ANS: C Relaxation breathing is an easy relaxation technique to teach and use. The patient should remain still during the biopsy and not move or stretch any of his extremities. Meditation and guided imagay require more time to practice and learn. DIF: Cognitive Level: Apply (application) REF: 83 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. A patient who has frequent migraines tells the nurse, “My life feels chaotic and out of my control. I could not manage if anything else happens.” Which response should the nurse make initially ? a. “Regular exacise may get your mind off the pain.” b. “Guided imagay can be helpful in regaining control.”

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