Chapter 2
A nurse manager is discussing the scientific process with a group of nurses who will be conducting research about a clinical problem. The nurse manager likens the scientific process to the nursing process, explaining that which characteristic is common to both? Select all that apply. a) problem identification b) decision making about how to answer the problem c) analysis d) plan implementation e) development of a plan
All of them Characteristics common to the scientific process and the nurse process include: identifying what one needs to know or is curious about; deciding the approach to seeking the answer; devising a plan; implementing the plan; and assessing the evidence or analysis.
Which method of qualitative research was developed by the discipline of anthropology? a) Historical b) Ethnography c) Grounded theory d) Phenomenology
b) Ethnography Ethnographic research was developed by the discipline of anthropology and is used to examine issues of culture of interest to nursing. Historical research examines events of the past to increase understanding of the nursing profession today. The basis of grounded theory methodology is the discovery of how people describe their own reality and how their beliefs are related to their actions in a social scene. The purpose of phenomenology (both a philosophy and a research method) is to describe experiences as they are lived by the subjects being studied.
A nurse researcher must decide on the method for conducting the research. The researcher that plans to emphasize collection of numerical data and analysis would select which method of research? a) Quantitative research b) Qualitative research c) Applied research d) Basic research
a) Quantitative research
A nurse who works in a pediatric practice assesses the developmental level of children of various ages to determine their psychosocial development. These assessments are based on the work of: a) Rogers b) Watson c) Erikson d) Maslow
c) Erikson
A nursing student understands which of the following is true of concepts? a) Concepts describe objects, properties, and events and relationships among them. b) Concepts are derived through deductive and inductive reasoning. c) Concepts differentiate nursing from other disciplines. d) Concepts provide a means of testing knowledge.
a) Concepts describe objects, properties, and events and relationships among them.
The nursing instructor asks a group of students to identify a theory that describes the maturation of humans through stages. One student correctly identifies this theory as what? a) Developmental theory b) Adaptation theory c) Systems theory d) Nursing theory
a) Developmental theory Developmental theory describes maturation of humans through stages. Nursing theory describes, explains, predicts, and controls outcomes in nursing practice. Systems theory describes how parts interact together. Adaptation theory describes adjustment of living things to other living things and the environment.
Who of the following is considered to be the first nursing theorist who conceptualized nursing in terms of manipulating the environment? a) Florence Nightingale b) Dorothea Orem c) Sister Callista Roy d) Lydia Hall
a) Florence Nightingale
A charge nurse meets with staff to outline a plan to provide transcultural nursing care for patients in their health care facility. Which theorist promoted this type of caring as the central theme of nursing care, knowledge, and practice? a) Madeline Leininger b) Jean Watson c) Dorothy E. Johnson d) Betty Newman
a) Madeline Leininger Madeline Leininger's theory provides the foundations of transcultural nursing care by making caring the central theme of nursing. Jean Watson stated that nursing is concerned with promoting and restoring health, preventing illness, and caring for the sick. The central theme of Dorothy E. Johnson's theory is that problems arise due to disturbances in the system or subsystem or functioning below optimal level. Betty Newman proposed that humans are in constant relationship with stressors in the environment and the major concern for nursing is keeping the patient system stable through accurate assessment of these stressors.
A student nurse interacting with patients on a cardiac unit recognizes the four concepts in nursing theory that determine nursing practice. Of these four, which is most important? a) Person b) Environment c) Health d) Nursing
a) Person
How would a student nurse define a conceptual framework? a) A set of phenomena and related abstractions. b) A group if interrelated objects that follow a pattern. c) A foundation for nursing skills and care. d) An explanation of nursing and nursing practice.
b) A group if interrelated objects that follow a pattern. A conceptual framework is made up of a group of concepts (interrelated objects, descriptions, or events) that follows an understandable pattern.
Nurses in an ICU noticed that their clients required fewer interventions for pain when the ICU was quiet. They then asked a researcher to design a study about the effects of noise on the pain levels of hospitalized clients. How does this demonstrate the ultimate goal of expanding the nursing body of knowledge? a) Nursing research draws conclusions about the quality of client care. b) Nursing research involves clients in their care while hospitalized. c) Nursing research explains ongoing medical studies to clients, and asks for participation. d) Nursing research helps improve ways to promote and maintain health.
d) Nursing research helps improve ways to promote and maintain health.
When you ask an experienced nurse why it is necessary to change the patient's bed every day, the nurse says, "I guess we have just always done it that way." This answer is an example of what type of knowledge? a) Instinctive knowledge b) Scientific knowledge c) Authoritative knowledge d) Traditional knowledge
d) Traditional knowledge Traditional knowledge is the part of nursing practice passed down from generation to generation, often without research data to support it. Scientific knowledge is that knowledge obtained through the scientific method(implying thorough research). Authoritative knowledge comes from an expert and is accepted as truth based on the person's perceived expertise. Instinct is not a source of knowledge.
A nursing student is describing building nursing theory during a fundamentals nursing class. The student describes that a theory can be built by looking at an idea as a whole and then breaking the idea down into smaller, more specific ideas. The nursing instructor knows that the student is describing which of the following? a) Theory b) Deductive reasoning c) Inductive reasoning d) Concepts
b) Deductive reasoning Deductive reasoning involves looking at an idea as a whole and then considering more specific ideas. Theory is a group of concepts and the relationships among them. Concepts are abstract ideas or objects and their relationships to one another. Inductive reasoning is derived from consideration of specific properties to conclusions about a general idea.
A nurse manager is attempting to switch the medical records in an orthopedic office to a computerized format. The nurse asks questions about the accuracy and efficiency of the current record keeping system by using the PICO format. Which statements illustrate the components of this process? Select all that apply. a) P: The nurse purchases computers from a computer store. b) I: The nurse considers interventions to make the plan work. c) C: The nurse calculates the cost of the new program. d) C: The nurse compares the written records to the computerized records. e) O: The nurse determines the occurrence of problems in the systems. f) P: The nurse chooses the population involved (orthopedic clients).
b, d, f
A nurse observes that the past five patients referred from a certain community clinic have been treated for drug and/or alcohol overdose. Based on this information, the nurse assumes that the clinic specializes in the treatment of substance abuse. This is an example of what type of reasoning? a) Nursing process b) Deductive reasoning c) General systems theory d) Inductive reasoning
d) Inductive reasoning Inductive theory describes how to break whole things into parts and then to learn how the parts work together in "systems." It emphasizes relationships between the whole and the parts and describes how parts function and behave. Reasoning is when the research builds from a specific idea or action to conclusions about general ideas. Deductive reasoning is the opposite of inductive reasoning. Deductive reasoning is research where a general idea is the starting point, then considers specific actions or ideas.
A nurse is completing a family assessment on a routine home health visit. The parents have a child with a severe peanut allergy. The mother states that she does not purchase any foods with peanut or peanut oil for her family. The other children are allowed to have foods containing peanuts while they are at school and visiting with friends and family. The nurse would conclude that which of the following theories would most like be the basis for this family's functioning? a) General Systems Theory b) Maslow's Theory c) Developmental Theory d) Adaptation Theory
d) Adaptation Theory
The American Nurses Association's Commission on Nursing Education developed guidelines for the investigative function of nurses at different educational levels. Which of the following is a guideline for a nurse with an associate degree? a) Identifies nursing problems that need to be investigated and participates in implementation of scientific studies b) Reads, interprets, and evaluates research for applicability to nursing practice c) Analyzes and reformulates nursing practice problems so that scientific knowledge and scientific method can be used to find solutions d) Assist in collection of data within an established, structured format
d) Assist in collection of data within an established, structured format The nurse with an associate degree will assist in collection of data within an established, structured format. The nurse with a bachelor's degree will read, interprets, and evaluate research for applicability to nursing practice. They will identify nursing problems that need to be investigated and participates in implementation of scientific studies. The nurse with a master's degree in nursing will analyzes and reformulates nursing practice problems so that scientific knowledge and scientific method can be used to find solutions.
For which of the following research activities is a phenomenological research method most appropriate? a) Explaining how the particular characteristics of the Vietnam War affected the roles of nurses b) Describing the health maintenance activities that are practiced by homeless, intravenous drug users c) Understanding how clients cope with a new diagnosis of Alzheimer's disease
d) Attempting to understand non-English speaking immigrants' experiences of being hospital clients Phenomenology is the type of qualitative research that attempts to understand individuals' experiences and the meanings they assign to these. Research that is undertaken within a specific culture, such as that of homeless, intravenous drug users, is characteristic of ethnography. Examining the significance of past events, such as war, is associated with historical qualitative research. Processes such as coping are the most common focuses of grounded theory.
A nursing student understands which of the following is true of concepts? a) Concepts provide a means of testing knowledge. b) Concepts differentiate nursing from other disciplines. c) Concepts are derived through deductive and inductive reasoning. d) Concepts describe objects, properties, and events and relationships among them.
d) Concepts describe objects, properties, and events and relationships among them.
When looking at a model for evidence-based practice, what is the final step of the process? a) Formulating a clinical question b) Searching the literature c) Appraising evidence d) Evaluating practice change
d) Evaluating practice change
The nursing student studying research exhibits an understanding when informing the instructor that which of the following is the bridge between theory and practice? a) Case management b) Theory development c) Client-focused care d) Evidence-based research
d) Evidence-based research
A nurse is formulating a clinical question in PICO format. What does the letter P represent? a) Comparison to another similar treatment b) Clearly defined, focused literature review c) Specific identification of the desired outcome d) Explicit descriptions of the population of interest
d) Explicit descriptions of the population of interest The P in the PICO format represents an explicit description of the patient population of interest.I represents the intervention,C represents the comparison, and O stands for the outcome.
Who is considered to be the first nursing researcher? a) Florence Nightingale b) Clara Barton c) Lillian Wald d) Dorothea Dix
a) Florence Nightingale
A nurse has received a doctoral degree from a research oriented educational program. Which activities would this nurse be able to perform? Select all that apply. a) develops methods for scientific inquiry of phenomena related to nursing b) provides leadership for integrating scientific knowledge with other sources for nursing advancement c) uses analytic and empirical methods to modify existing scientific knowledge so that the knowledge is relevant to nursing d) conducts investigations to monitor the quality of clinical nursing practice e) conducts investigations to evaluate the contribution of nursing activities to clients' well-being.
a, c A nurse prepared at the doctoral level from a research-oriented program would be able to use analytic and empirical methods to discover ways to modify or extend existing scientific knowledge so it is relevant to nursing, and would also be able to develop methods for scientific inquiry of phenomena relevant to nursing. A nurse prepared at the doctoral level from a practice-oriented program would be able to provide leadership for the integration of scientific knowledge with other sources of knowledge for the advancement of practice, and also would be able to conduct investigations to evaluate the contribution of nursing activities to the well-being of clients. A nurse prepared at the master's level would conduct investigations for the purpose of monitoring the quality of the practice of nursing in a clinical setting.
How would a student nurse define a conceptual framework? a) A set of phenomena and related abstractions. b) A group if interrelated objects that follow a pattern. c) An explanation of nursing and nursing practice. d) A foundation for nursing skills and care.
b) A group if interrelated objects that follow a pattern. A conceptual framework is made up of a group of concepts (interrelated objects, descriptions, or events) that follows an understandable pattern.
A nurse manager schedules a clinic for the staff to address common nursing interventions used in the facility and to explore how they can be performed more efficiently and effectively. What is the term for this type of theory affecting change in clinical nursing practice? a) Prescriptive theory b) Descriptive theory c) Developmental theory d) General systems theory
a) Prescriptive theory Prescriptive theories address nursing interventions and are designed to control, promote, and change clinical nursing practice. Descriptive theories describe a phenomenon, an event, a situation, or a relationship. Developmental theory outlines the process of growth and development of humans as orderly and predictable, beginning with conception and ending with death. General systems theory describes how to break whole things into parts and then to learn how the parts work together in "systems."
The nurse researcher would like to gather data about the attitudes of young adults on spirituality and health care. What is the most effective form of research on this topic? a) Qualitative research b) Quantitative research c) Delphi study d) Methodologic survey
a) Qualitative research Attitudes on spirituality and health care require the nurse to interview clients or informants to obtain qualitative research. Qualitative research involves the systematic collection and analysis of more subjective, narrative materials using procedures in which there tends to be minimal researcher-imposed control.
When a researcher begins to form plans for a research project, the researcher must decide on the method for conducting the research. The nurse researcher that plans to emphasize collection of narrative data and the analyses would select which of the following methods of research? a) Qualitative research b) Quantitative research c) Applied research d) Basic research
a) Qualitative research Qualitative research utilizes words or narrative for data, rather than numbers. Quantitative research utilizes numerical values and statistical analysis of data. Basic research is utilized to generate or refine theory. Applied research is utilized for its application in clinical practice. The stem of the question did not provide information as to the application of the study.
The second step in implementation of evidence-based practice includes systematic review. In order to complete a systematic review of the literature the nurse must do which of the following? a) Summarize findings from multiple studies that are related to a particular nursing practice. b) Ask a question about a clinical practice. c) Recommend best practices for client care. d) Provide a statical analysis for studies.
a) Summarize findings from multiple studies that are related to a particular nursing practice.
Nurses on a busy hospital ward plan nursing care for patients. Which nursing action best exemplifies the primary focus of nursing? a) The nurse comforts a patient who received bad results from a test. b) The nurse focuses on the procedures being performed for patients that day. c) The nurse adjusts the environment of the patient to facilitate provision of care. d) The nurse concentrates on the health status of a patient.
a) The nurse comforts a patient who received bad results from a test. The focus of nursing is promoting health and wellness in partnership with individuals, families, communities, and populations. With this in mind, the nurse would not concentrate on the health status of the client. The nurse would not focus on the procedures to be performed for clients that day. The nurse would not adjust the environment of the patient to facilitate provision of care. The nurse would comfort the client who received bad results from a test. By focusing on this intervention of the four listed, the nurse is providing physical, emotional, and spiritual support for the client.
A nurse researcher is working on developing a problem statement for a research study. When writing the problem statement, which characteristic would the nurse need to keep in mind? Select all that apply. a) The population to be studied is stated. b) The issue being studied should be clearly identified. c) Empiric testing is encouraged. d) The relationship between variables is left open to interpretation. e) The study's direction will flow from the statement.
a, b, c The problem statement should be clear and unambiguous, express a relationship between two or more variables, identify the population to be studied, and encourage empiric testing. The problem statement, a key step in the research process, identifies the direction that a research project will take.
Research is included as an essential component of nursing by which of the following organizations? (Select all that apply.) a) International Council of Nurses b) Nursing specialty organizations c) IOM d) ANA e) AMA
a, b, d The IOM and AMA are predominantly based in medicine. The nursing organizations such as the ANA, International Council of Nurses, and specialty organizations are calling for more research in nursing.
A group of nursing students are in a study group preparing for their fundamentals class. They are reviewing historical influences on the development of nursing research in the 1970s and 1980s. They correctly identify which of the following as historical events in this time period? Select all that apply. a) Research focused on clinical research, including clinical interventions. b) The National Institute of Nursing Research came into existence to be in equal status with other institutes of health. c) Primary client care led to research investigating outcomes and quality of care. d) Concerns of nursing education involved student-learning experiences and clinical evaluation. e) The nursing process was studied.
a, c, d, e The National Institute of Nursing Research came was established in 1993 rather than in the 1970s and 1980s. All of the other choices are correct regarding nursing research developments in this time frame.
A nurse researcher is examining the cause-and-effect relationship between the consumption of tap water containing minimal amounts of bleach, and the incidence of cancer in rats. The research is taking place in a laboratory setting. What type of quantitative research is being used based upon this description? a) Descriptive research b) Experimental research c) Correlational research d) Quasi-experimental research
b) Experimental research Experimental research examines the cause-and-effect relationships between variables under highly controlled conditions. Experimental research studies often occur in a laboratory setting. Descriptive research explores and describes events in a real-life situation to identify relationships between, and among, events. Correlational research examines the type and degree of relationships between two or more variables. Quasi-experimental research examines the cause-and-effect relationships between selected variables and is typically situated outside of a laboratory setting.
Which skill is foundational for a nursing student's participation in the evidence-based practice process? a) Become involved in evidence-based practice research. b) Read and understand a research article. c) Critically analyze research articles and the findings. d) Publish an article on evidence-based practice findings.
b) Read and understand a research article.
Which statement best explains the importance of theoretic frameworks? a) Theoretic frameworks advance the ethical aspects of practice. b) Theoretic frameworks advance nursing knowledge and practice. c) Theoretic frameworks guide physiologic nursing care. d) Theoretic frameworks guide psychosocial nursing care.
b) Theoretic frameworks advance nursing knowledge and practice.
A nurse is discussing dietary issues with a Latino client in the clinic. The client states, "My grandmother always told me that I needed to include beans in my diet so that my muscles would grow." The information that the client is expressing is known as what? a) Authoritative knowledge b) Traditional knowledge c) Philosophical knowledge d) Scientific knowledge
b) Traditional knowledge
A nurse develops the following foreground question using the PICO format in preparation for a research study: "In overweight clients, how do chromium supplements compared to no supplements help with weight loss?" Which part of the question reflects the intervention? a) weight loss b) chromium supplements c) no supplements d) overweight clients
b) chromium supplements In this question, the intervention (I) would be the use of chromium supplements. The population (P) would be overweight clients. The comparison (C) would be no supplements. The outcome (O) would be weight loss.
One of the primary focuses of nursing research is to: a) determine outcomes for clients. b) generate knowledge to guide practice. c) quantify outcomes related to clients. d) prevent further disease and death.
b) generate knowledge to guide practice.
The nursing instructor is discussing nursing theories and concepts with a group of nursing students in a fundamentals course. In guiding the thoughts and understanding of concepts, the instructor discusses nursing concepts specifically. The purpose of concepts in nursing practice include which of the following? (Select all that apply.) a) Provide a constant for all nursing care. b) Guide the steps of the nursing process. c) Suggest appropriate nursing interventions. d) Serve in the determination of what information is relevant related to a specific client issue. e) Suggest appropriate nursing outcomes for a client.
b, c, d, e The focus of nursing changes as does the care of the client through the wellness-illness continuum. Therefore, the concepts will change with regard to their applicability within a theory or in a specific clients care. The other statements are all correct with regard the nursing concepts.
A nurse has graduated with a baccalaureate degree in nursing. Which research activities would be appropriate for this nurse? Select all that apply. a) assisting others in applying scientific knowledge in nursing practice b) sharing research findings with colleagues c) interpreting research for applicability to nursing practice d) facilitating investigation of problems in the clinical setting e) applying research findings to nursing practice
b, c, e A baccalaureate prepared nurse would be able to interpret research for applicability to nursing practice, apply established findings of nursing and other health-related research to nursing practice, and share research finding with colleagues. A master's prepared nurse facilitates investigation of problems in the clinical setting and assists others in applying scientific knowledge in nursing practice.
A nurse is using general systems theory to describe the role of nursing to provide health promotion and patient teaching. Which statements reflect key points of this theory? Select all that apply. a) A system is a set of individual elements that rarely interact with each other. b) The whole system is always greater than its parts. c) Boundaries separate systems from each other and their environments. d) A change in one subsystem will not affect other subsystems. e) To survive, open systems maintain balance through feedback. f) A closed system allows input from and to the environment.
b, c, e According to general systems theory, a system is a set of interacting elements contributing to the overall goal of the system. The whole system is always greater than its parts. Boundaries separate systems from each other and their environments. Systems are hierarchical in nature and are composed of interrelated subsystems that work together in such a way that a change in one element could affect other subsystems, as well as the whole. To survive, open systems maintain balance through feedback. An open system allows energy, matter, and information to move freely between systems and boundaries, whereas a closed system does not allow input from or output to the environment.
Which group of nurses would be least likely involved in direct research? Select all that apply. a) Nurse Practitioners b) Student nurses c) Clinical Nurse Specialists d) Novice nurses e) Nurses at the PhD level
b, d Direct research, except in the role of data collection or administration of medications and treatments as a protocol in a research project, usually does not involve student nurses and novice nurses. Master's prepared nurses such as clinical nurse specialists and nurse practitioners, as well as nurses at the PhD level, can be involved in direct research.
Which nursing actions reflect the use of philosophy as a knowledge base when delivering evidence-based care to patients? Select all that apply. a) A nurse interviews and examines a new patient diagnosed with prehypertension to formulate a care plan. b) A nurse draws from personal experiences of being a patient to establish a therapeutic relationship with a patient. c) A nurse searches the Internet to find the latest treatments for type 2 diabetes. d) A nurse uses spiritual training to draw strength when counseling a patient who is in hospice for an inoperable brain tumor. e) A nurse follows the protocol for assessing postoperative patients in the ICU. f) A nursing student studies anatomy and physiology of the body systems to understand the disease states of assigned patients.
b, d. Philosophy is the study of wisdom, fundamental knowledge, and the processes used to develop and construct one's perceptions of life. A philosophy is developed from personal experiences (such as the experience of being the patient), through formal and informal educational experiences, through religion and culture (such as using spiritual training as a source of strength), and from the environment. Interviewing and examining patients to formulate a care plan and using protocol for assessing patients in the ICU involve knowledge of processes. Researching the Internet and studying anatomy and physiology use scientific knowledge to deliver evidence-based care.
Which is not an example of a problem statement? a) "Is there a relationship between diet soda intake and obesity in adolescent boys?" b) "What is it like for teens with cystic fibrosis to experience a lung transplant that fails?" c) "Is it better to tell clients that a medical error has occurred with their care and do an internal investigation, or tell them about the error and do an internal investigation?" d) "In clients with stage II pressure ulcers, does screening for and treating diagnosed depression decrease healing time?"
c) "Is it better to tell clients that a medical error has occurred with their care and do an internal investigation, or tell them about the error and do an internal investigation?" A problem statement identifies the direction that a research project will take. It should be introduced at the beginning of a research project and include a population to be studied, as well as express a relationship between two or more variables. A problem statement that contains a judgment or that is asking about ethics, morals, or values is not amenable to the research process.
A nursing student is describing abstract ideas with a group of student peers. The student suggests that these ideas can be a group of objects and the relationships among them. The nursing instructor knows that the student is describing which of the following? a) Deductive reasoning b) Inductive reasoning c) Concepts d) Theory
c) Concepts Concepts are abstract ideas or objects and their relationships to one another. Theory is a group of concepts and the relationships among them. Deductive reasoning provides a basis for theory development as one studies a general idea to more specific properties. Inductive reasoning is derived from consideration of specific properties to make conclusions about a general idea.
When conducting quantitative research, the researcher collects information to support a hypothesis. This information would be identified as: a) The subject b) Variables c) Data d) The instrument
c) Data Data refers to information that the researcher collects from subjects in the study (expressed in numbers). A variable is something that varies and has different values that can be measured. Instruments are devices used to collect and record the data, such as rating scales, pencil-and-paper tests, and biologic measurements.
A nurse is completing a family assessment on a routine home health visit. There is a mother, father, and three children ages 2, 4, and 6 years of age. She watches the children individually as they play and interact with one another. She compares each child with the norms established for the age groups and determines and they are all within normal limits for their ages. The nurse would be utilizing which of the following theories as the basis for this part of the family assessment? a) Adaptation Theory b) General Systems Theory c) Developmental Theory d) Maslow's Theory
c) Developmental Theory
A nursing theorist examines a hospital environment by studying each ward and how it works individually, then relates this information to the hospital as a whole working entity. This is an example of the use of which theory? a) Adaptation theory b) Developmental theory c) General systems theory d) Psychosocial theory
c) General systems theory
Which type of quantitative research is often conducted to examine the effects of nursing interventions on patient outcomes? a) Descriptive research b) Correlational research c) Quasi-experimental research d) Experimental research
c) Quasi-experimental research Quasi-experimental research is often conducted in clinical settings to examine the effects of nursing interventions on patient outcomes. Descriptive research is often used to generate new knowledge about topics with little or no prior research. Correlational research examines the type and degree of relationships between two or more variables. Experimental research examines cause-and-effect relationships between variables under highly controlled conditions.
Marion is a nurse in a nursing home. She strongly believes that the care she provides be evidence based and tailored to her population. She is constantly looking for ways in which to improve client outcomes. Recently, she has noticed that more and more of the residents she works with have a diagnosis of depression. Marion wants to decrease depression rates. Place the following actions in the order that they should occur following the scientific process of nursing practice. a. Marion assesses the problem of an increased number of residents with depression. b. Marion makes a nursing diagnosis. c. Marion starts a group therapy session once a week for residents to talk about shared experiences. d. Marion uses anonymous surveys of residents to evaluate depression levels. a) a, c, b, d b) b, c, d, a c) c, b, d, a d) a, b, c, d
d) a, b, c, d The first step is the nurse assesses the problem; the second step is to determine the appropriate nursing diagnosis; the third step involves the nurse planning an intervention. In this case, Marion starts a group therapy session for the residents so they can discuss their experiences with depression. Finally, the nurse evaluates the outcome.
