Chapter 1: Health Care Delivery and Evidence-Based Nursing Practice

Which is an important role for a nurse in the health care delivery system?

Identifying patient needs and working with patients to address them Explanation: Nurses work in various settings, requiring them to adhere to facility policies and state nurse practice acts. Among the nurse's important functions in health care delivery are identifying a patient's immediate, ongoing, and long-term needs and working in concert with the patient to address them. Balancing work with leisure activities is not the function of a nurse in the health care delivery system. A nurse does not diagnose and treat diseases and does not participate in treatment decisions regarding health restoration

A nurse, working in a health clinic, treats a variety of conditions on a daily basis. One disorder that is rapidly increasing and is the leading cause of secondary morbidity is:

Obesity Explanation: Currently about 30 % of adults and 16% of children are classified as obese (CDC, 2009). Obesity is the leading cause of secondary illnesses ranging from cancer to diabetes.

A nursing student is preparing for a class presentation addressing the collaborative practice model. Which of the following would the student expect to include?

Participation in decision making that is shared by all involved Explanation: The collaborative practice model involves all care providers, including nurses, physicians, and ancillary health personnel as well as the patient functioning within a decentralized organizational structure to collaboratively make clinical decisions. The collaborative model promotes shared participation, responsibility, and accountability in a health care environment that strives to meet the complex health care needs of the public.

According to Maslow's hierarchy of human needs, which of the following is the highest level of need?

Self-actualization Explanation: Maslow's hierarchy of need shows how a person moves from fulfilling basic needs to a higher level of priority. The ultimate goal is integrated human functioning and health. Self-actualization is the highest level need. Safety and security, physiological needs, and a sense of belonging are below the level of self-actualization.

The nurse is working at an institution that uses a collaborative practice model. Which of the following would most likely be reflected at this institution?

Shared accountability for care Explanation: A collaborative practice model involves nurses, physicians, and ancillary health personnel functioning within a decentralized organizational structure, collaboratively making clinical decisions. Collaborative practice is further enhanced with integration of the health or medical record and with joint reviews of patient care records. The collaborative model promotes shared participation, responsibility, and accountability in a health care environment.

Which is not an important reason that nurses utilize research in nursing practice?

Financial obligation Explanation: Financial obligation is not an important reason that nurses utilize research in nursing practice. The use, validation, replication, dissemination, and evaluation of research findings further the science of nursing.

A group of students are reviewing various evidence-based practice (EBP) tools used for planning client care. The students demonstrate understanding when they identify which of the following as the most detailed type?

Multidisciplinary action plan Explanation: Care maps, multidisciplinary action plans, clinical guidelines, and algorithms are evidence-based practice (EBP) tools for planning client care. Of these, multidisciplinary action plans are the most detailed.

A nurse is a member of which entity within the larger healthcare environment?

healthcare team Explanation: The healthcare team includes nurses, physicians, pharmacists, psychologists, social workers, healthcare administrators, and various other health professionals, such as physical therapists. The healthcare delivery system is the entire range of services available to clients. A health maintenance organization is a type of managed care insurance plan. A physician hospital organization is a corporate structure involving a hospital and groups of physicians.

Which statement is true regarding population demographics?

The culturally diverse population is increasing. Explanation: The population has become more culturally diverse as increasing numbers of people from different national backgrounds enter the country. The number of homeless people has significantly increased. There has been a decrease in the birth rate, and life spans are longer.

Which of the following best reflects the rationale for evidence-based practice?

A means to ensure quality care Explanation: Evidence-based practice (EBP) provides a means for ensuring quality care by identifying and evaluating current literature and research and incorporating the findings into client care. Quality assurance programs were developed and required for insurance reimbursement and for accreditation by the Joint Commission. The quality assurance programs sought to establish accountability to society on the part of the health professions for the quality, appropriateness, and cost of health services provided.

An 83-year-old female demonstrating early-stage dementia has just had surgical repair to her fractured left hip. No family member is present at the discharge planning conference to discuss the next appropriate actions. Which members of the healthcare team will be instrumental in securing the client's placement in a rehabilitation center?

All of the responses are correct Explanation: The healthcare team includes physicians, nurses, psychologists, pharmacists, dietitians, social workers, nursing assistants, technicians, and other health professionals. All members of this team collaborate on client issues (medical, social, and financial) to achieve the best possible outcomes. Physicians are not the only team members to play a role in this process. Social workers are not the only team members to play a role in this process. Nurses are not the only team members to play a role in this process.

A client comes to the clinic with the complaint that he has been ill for several weeks but does not have insurance and has delayed care. What does the nurse understand about the overall healthcare reform goals that will address issues such as this client?

The goal of healthcare reform is to provide affordable healthcare to more citizens. Explanation: The overall goal of healthcare reform is to provide affordable healthcare to more U.S. citizens. Other goals are to reduce the insurance companies' control of healthcare and to provide more assistance to senior citizens on fixed incomes. The other answers address other individual programs but not the broader terms of the healthcare initiative

Which strategy would a nurse likely discuss with a client as part of health promotion?

making positive dietary changes Explanation: Health promotion involves teaching clients strategies to enhance overall health, such as consuming a healthy diet, exercising regularly, and practicing stress-reduction techniques. Health promotion involves teaching clients strategies to enhance overall health; it is not the diagnosis or treatment of specific conditions.

A student nurse observes a nurse case manager coordinating discharge for a patient diagnosed with congestive heart failure (CHF). Which statement made by the patient indicates to the student that the patient understands the role of the case manager?

"The nurse case manager contacted my insurance company and has arranged for the home health nurse and physical therapist to visit me as soon as I get home." Explanation: A nurse case manager coordinates care between nurses, other health care personnel, and insurance companies. Nurse case managers coordinate patient care from the time of hospital admission to the time of discharge and often after discharge from an acute care setting. Care coordination provided by the nurse care manager is not episodic.

Which statement by the nurse shows an understanding of the focus of the quality assurance programs developed in the 1980s?

"The quality assurance programs focus on processes used to provide care and improving those processes." Explanation: In the 1980s, hospitals and other health care agencies implemented ongoing quality assurance programs that provided the foundation for the establishment of continuous quality improvement (CQI) programs in the 1990s. Despite these efforts to ensure the provision of quality health care, the IOM (2000) reported an alarming breakdown in quality control in the American health care system. The IOM report To Err Is Human: Building a Safer Health System (2000) noted that nearly 100,000 Americans died annually from preventable errors in hospitals, and many more suffered nonfatal injuries from errors. A subsequent IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001), envisioned a reformed health care system that is evidence based and systems oriented. Its proposed six aims for improvement included ensuring that patient care is safe, effective, patient centered, timely, efficient, and equitable (IOM, 2001).

Which of the following best describes the health-illness continuum?

A person may be considered neither completely healthy or completely ill. Explanation: The health-illness continuum views a person as being neither completely healthy nor completely ill. Use of the continuum makes it possible to view a person as simultaneously possessing degrees of both health and illness. People with chronic illness or disability may attain a high-level of wellness if they are successful in meeting their health potential withing the limits of their condition. A person's state of health is ever-changing and can fall anywhere along the continuum at any time. High-level wellness does not necessarily mean that a person is free of disease or infirmity.

Although nurse practice acts may vary state by state, all recognize several basic principles supporting the legal parameters for all registered nurses. Select the activity that falls under the scope of nursing practice.

Appraising and enhancing an individual's health-seeking perspective Explanation: The role for all registered nurses includes assessment, evaluation, and the diagnosis of an individual's response to health and illness. Only advanced practice nurses have expanded responsibilities as determined by state law and/or the practice arena.

Which is a goal of case management?

Appropriateness of services Explanation: The goals of care management are to ensure the quality, appropriateness, and timeliness of services as well as to reduce costs. Case managers do not have prescriptive authority. Fixed price reimbursement is a feature of managed care. Case managers do not utilize the nursing process.

Which of these roles would be considered an expanded nursing role?

Certified nurse practitioner (CNP) Explanation: The nurse practitioner (NP) is considered an expanded nursing role. Nurses who function in these roles provide direct care to patients through independent practice, in a practice within a health care agency, or by collaborating with a physician. CNAs, respiratory therapists, and social workers do not perform in an expanded nursing role.

Nursing students are reviewing information about expanded nursing roles. They demonstrate understanding of the information when they identify which of the following as roles of an advanced practice nurse? Select all that apply.

Certified nurse-midwife Nurse practitioner Clinical nurse specialist Certified registered nurse anesthetist Explanation: Advanced practice nurses are nurses with advanced specialized education, usually at the graduate level. They include certified nurse midwives, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. Certified critical care nurses and certified medical-surgical nurses have passed the certification examination but are not routinely considered advanced practice nurses.

Quality assurance (QA) programs were put into place in the 1980s by the Joint Commission to establish and maintain accountability to the public. These programs are responsible to the public for maintaining certain standards. Choose all of the activities that apply to QA programs.

Cost of health care services Quality delivery of services Appropriate standards of care Explanation: Quality Assurance programs have made progress in putting systems into place that have made hospitals more accountable to the public. These programs establish minimal criteria for the quality, appropriateness and cost of health services. However, regardless of nursing research studies that show that improved patient care outcomes are positively correlated with nurse-patient staffing ratios, the Joint Commission is unwilling or unable to establish guidelines.

To address the needs of a chronically ill patient and promote the concept of wellness, a nursing care plan should outline steps to:

Encourage positive health characteristics within the limits of the disease. Explanation: Those with chronic illnesses do have the potential to attain a high-level of wellness within the limits of their disability or illness. The focus of nursing care should be to emphasize a positive approach to coping with the illness. Therefore, the best approach for nursing care is to encourage appropriate health behaviors, promote a sense of hopefulness, and help the patient recognize when his or her limits have been reached. Discussing possible negative complications is not relevant. Also, promoting unnecessary restrictions or activities beyond a patient's ability is not necessary.

A nursing instructor is describing to a class the various roles that nurses assume. The instructor determines that teaching has been effective when the students identify which of the following as the focus of the nursing researcher role?

Establishment of a scientific basis for action Explanation: The primary task of nursing research is to contribute to the scientific basis of nursing practice. While achievement of patient outcomes through direct intervention can be affected by information gained through nursing research, this is not the focus of nursing research. Cost-effective, high-quality nursing care is the goal of continuous quality improvement (CQI). Health promotion through screening and early detection is a component of the practitioner role.

The nurse is providing a program at the local YMCA about stress-reduction techniques combined with a 1-mile walk around the indoor track once a week. What does this type of program address for the community?

Health promotion Explanation: Health promotion refers to engaging in strategies to enhance health such as eating a diet high in grains and complex carbohydrates, exercising regularly, balancing work with leisure activities, and practicing stress-reduction techniques. Illness prevention involves identifying risk factors such as a family history of hypertension or diabetes and reducing the effects of risk factors on one's health. Early detection uses screening diagnostic tests and procedures to identify a disease process earlier, so that treatment may be initiated earlier and be more effective. Health maintenance refers to protecting one's current level of health by preventing illness or deterioration, such as by complying with medication regimens, being screened for diseases such as breast and colon cancers, or practicing safe sex.

The National Center for Health Statistics uses data from healthcare agencies to issue quarterly and annual reports on performance related to goals for improving the health of the U.S. population. Which initiative is targeted with improving the health of all Americans?

Healthy People 2020 Explanation: The Healthy People 2020 campaign provides an overall action plan to improve the health and quality of life of people living in the United States. The initiative includes 26 leading health indicators for measuring the overall health of the U.S. population. The Joint Commission is an independent agency that accredits and certifies healthcare organizations and programs in the United States. The AHRQ is the organization that developed standardized quality indicators used to measure healthcare quality at the federal, state, and local levels. Quality indicators are not an initiative; they are standards for measuring healthcare quality.

The Healthy People 2020 initiative targets the improvement of health for all. In addition to eliminating health disparities, what are the broad goals of this plan?

Increasing the quality and length of a healthy life Explanation: Two broad goals of the Healthy People 2020 initiative are to increase quality and years of healthy life and eliminate health disparities. Healthy People 2020 initiatives will help with treatable problems but will not prevent problems. The initiative does not apply a systematic approach to health improvement or increase technological innovations.

The nurse educator is planning a teaching session for nursing students related to the treatment and management of gestational diabetes. The nurse educator arranges for a dietitian, pharmacist, and physician assistant to participate in the lesson plan. Which professional nurse competency is the nurse educator demonstrating?

Interdisciplinary teamwork Explanation: By integrating interdisciplinary core competencies into the curriculum, the nurse educator is demonstrating interdisciplinary teamwork. A case-study approach planning care around individual patient preferences is an example of patient-centered care. Conducting a review of the evidence-based literature related to gestational diabetes reflects evidence-based practice. Providing education related to measures/indicators or tools used to assess the level of care provided within a system of care to populations of patients with gestational diabetes exemplifies a quality improvement measure.

Students are reviewing information about community health nursing. The students demonstrate understanding of the term "community-oriented nursing practice" by describing it as which of the following?

Nursing interventions that can promote wellness, reduce illness spread, and improve the health status of groups Explanation: Community-oriented nursing practice focuses on nursing interventions that can promote wellness, reduce the spread of illness, and improve the health status of groups of citizens or the community at large. Community-based nursing and home health care is directed toward specific client groups with identified needs, which usually relate to illness, injury, or disability, resutling most often from advanced age or chronic illness. Community nursing centers are nurse managed and provide primary care, often to underserved populations. Home care nursing is a specialty area that provides care in the home and community to meet the needs of clients who are discharged from acute care institutions to their homes and communities early in the recovery process and with complex needs.

A nurse is preparing a presentation for a local community group addressing the influences on health care delivery. Which of the following would the nurse include in presentation when describing disease patterns?

Obesity along with conditions associated with it has become a major health concern. Explanation: In recent years, obesity has become a major health concern and the multiple comorbidities that accompany it add significantly to its associated mortality. Although many infectious diseases have been controlled or eradicated, some such as tuberculosis, acquired immunodeficiency syndrome and sexually transmitted infections are on the rise. The prevalence of chronic illnesses and disability is increasing because of the lengthened lifespan in the United States and the advances in care and treatment. People with chronic illnesses constitute the largest group of health care consumers in the United States.

A 54-year-old client on a fixed income has had an electrocardiogram (ECG) as part of an annual physical examination. The physician notes an abnormal Q wave on an otherwise unremarkable ECG. What legislation supports the focus on chronic disease prevention, health promotion, and quality, affordable health care for everyone?

Patient Protection and Affordable Care Act Explanation: The Patient Protection and Affordable Care Act, also known as the ACA, supports access to quality, affordable health care, improved access to innovative and preventive health care programs and therapies, and expanded insurance coverage. "To Err Is Human: Building a Safer Health System" and "Crossing the Quality Chasm: A New Health System for the 21st Century" are IOM reports. Centers for Medicare and Medicaid Services (CMS) partnered with the Agency for Healthcare Research and Quality (AHRQ) to launch the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

A nurse is preparing a presentation for a local community group about health, wellness, and illness. When describing the concept of wellness, which of the following features would the nurse include? Select all that apply.

Performing to one's best ability Feeling that everything is together Being able to adjust and adapt Experiencing a feeling of well-being Explanation: Wellness has been defined as being equivalent to health and is characterized by four components: (1) the capacity to perform to the best of one's ability; (2) the ability to adjust and adapt to varying situations; (3) a reported feeling of well-being; and (4) a sense that "everything is together" and harmonious. Wellness is subjective and does not necessarily mean that a person is completely free of illness. Rather, the health-illness continuum makes it possible to regard a person as simultaneously possessing degrees of both health and illness.

An occupational nurse is working with patients at a construction site. According to Maslow's Hierarchy of Needs, what dimension of care should the nurse make the highest priority in working with these clients?

Physiologic Explanation: Maslow ranked human needs as follows: physiologic needs; safety and security; sense of belonging and affection; esteem and self-respect; and self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs. Such a hierarchy is a useful framework that can be applied to the various nursing models for assessment of a client's strengths, limitations, and need for nursing interventions. The other answers are incorrect because they are not of primary importance when caring for clients at a worksite.

According to Maslow, which category of needs represents the most basic on the hierarchy?

Physiologic needs Explanation: Physiologic needs must be met before an individual is able to move toward psychological health and well-being. Self-actualization is the highest level of need. Safety and security, while a lower level of need, are not essential to physiologic survival. A sense of belonging and affection needs are not essential to physiologic survival.

A client is experiencing anorexia related to the adverse effects of cancer treatment. Using Maslow's hierarchy, the nurse identifies this need as reflecting which of the following?

Physiology Explanation: Difficulties involving a loss of appetite would most likely indicate a nutritional problem, reflecting Maslow's physiologic needs. Esteem and self-respect needs would reflect a person's need to feel good about himself or herself and to feel a sense of pride and accomplishment. Safety and security needs would reflect protection from actual or potential physical and emotional harm. Belongingness and affection needs would reflect a feeling of belonging to families, peers, friends, and community.

According to the ANA's Code of Ethics, a nurse is responsible for promoting community health. Toward this end, registered nurses should focus on:

Placing emphasis on wellness and health promotion to prevent acute illness and decrease the rise in chronic diseases seen with increased longevity. Explanation: From the perspective of promoting community health, the nurse should focus on health, wellness, and the promotion of self-care. The majority of Americans today suffer from chronic debilitative illnesses that can be managed successfully with clearly articulated and coordinated plans of care overseen by nurses. A health care provider would always plan and manage treatment approaches to care. The RN is responsible for discharge planning.

According to the American Nurses Association (1995), the advanced practice registered nurse is distinguished from other registered nurses according to scope of practice. Select the activity that would distinguish the advanced practice nurse from other RNs.

Prescribes medications Explanation: All registered nurses are responsible for interpreting health care provider orders, developing nursing care plans and reporting abnormal diagnostic test results. Only RNs with a master's or doctoral degree and credentialed by the American Nurses Credentialing Center or a Specialties National Certification Body can function as advanced practice nurses and prescribe medications.

Which of the following delineates actions that are legally permitted for a particular profession based on specific educational qualifications

Scope of practice Explanation: Scope of practice is used to delineate actions that are legally permitted for a particular profession, based on specific educational qualifications. The job description represents qualifications and duty of employment. The Code of Ethics represents ethical standards. The code is an ideal framework for nurses to use in ethical decision-making. Under the Occupational Safety and Health Act of 1970, employers are responsible for providing a safe and healthy workplace for their employees.

Which tool is often used by case managers?

Standards of care Explanation: Case managers usually make use of tools such as critical pathways, practice guidelines, and standards of care to help them plan and coordinate care. Insurance companies measure the costs of services provided to a case manager's patients as a means of assessing the case manger's effectiveness. One of the complaints about case management is that the "bottom line" will become more important than quality. For this reason, and because they are in the best position to collect outcome data, case managers usually are integral members of hospital-based and insurance-based quality improvement programs.