Concepts Final Exam "Chapter Questions"

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? 2, 4, 1, 3 3, 1, 4, 2 2, 4, 3, 1 3, 2, 4, 1

2, 4, 1, 3

A nurse uses the classic elements of evaluation when caring for patients: (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting your judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes) Which item below places them in their correct sequence? 1, 2, 3, 4, 5 3, 2, 1, 4, 5 5, 2, 1, 3, 4 2, 3, 1, 4, 5

5, 2, 1, 3, 4

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. A. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." B. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" C. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." D. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." E. "We need to check your health status and see what kind of nursing care you may need." F. "We need to see if you require a referral to a physician or other health care professional."

A. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." E. "We need to check your health status and see what kind of nursing care you may need." F. "We need to see if you require a referral to a physician or other health care professional."

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's BEST response to this student's diagnosis? A. "Was this diagnosis derived from a cluster of significant data or a single clue?" B. "This early diagnosis will help us manage the problem before it becomes more acute." C. "Have you determined if this is an actual or a possible diagnosis?" D. "This condition is a medical problem that should not have a nursing diagnosis."

A. "Was this diagnosis derived from a cluster of significant data or a single clue?"

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? A. "You made an inference that she is fine because she has no complaints. How did you validate this?" B. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." C. "Sometimes everyone gets lucky. Why don't you try to help another patient?" D. "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"

A. "You made an inference that she is fine because she has no complaints. How did you validate this?"

The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. A. A patient tells the nurse that she is feeling nauseous. B. A patient's ankles are swollen. C. A patient tells the nurse that she is nervous about her test results. D. A patient complains that the skin on her arms is tingling. E. A patient rates his pain as a 7 on a scale of 1 to 10. F. A patient vomits after eating supper.

A. A patient tells the nurse that she is feeling nauseous. C. A patient tells the nurse that she is nervous about her test results. D. A patient complains that the skin on her arms is tingling. E. A patient rates his pain as a 7 on a scale of 1 to 10.

A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? A. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. B. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. C. Following physical therapy, patient will begin to gradually participate in walking/running events. D. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.

A. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body.

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: A. Clinical judgment B. Clinical reasoning C. Critical thinking D. Blended competencies

A. Clinical judgment

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical changes

A. Cognitive

The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? A. Compare this reading to standards. B. Check the taxonomy of nursing diagnoses for a pertinent label. C. Check a medical text for the signs and symptoms of high blood pressure. D. Consult with colleagues.

A. Compare this reading to standards.

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? A. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. B. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. C, The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! D. It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

A. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving.

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. A. Monitoring patient status every hour B. Using intuition to troubleshoot patient problems C. Turning a patient on bed rest every 2 hours D. Becoming a nurse mentor to a student nurse E. Administering pain medication ordered by the physician F. Becoming involved in community nursing events

A. Monitoring patient status every hour C. Turning a patient on bed rest every 2 hours E. Administering pain medication ordered by the physician

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? A. Perform the focused assessment as this is an independent nurse-initiated intervention. B. Request an order from Jill's physician since this is a physician-initiated intervention. C. Request an order from Jill's physician since this is a collaborative intervention. D. Request an order from the nutritionist since this is a collaborative intervention.

A. Perform the focused assessment as this is an independent nurse-initiated intervention.

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? A. Tell the RN that he or she lacks the technical competencies to change the dressing independently. B. Assemble the equipment for the procedure and follow the steps in the procedure manual. C. Ask another student nurse to work collaboratively with him or her to change the dressing. D. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

A. Tell the RN that he or she lacks the technical competencies to change the dressing independently.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. A. The nurse carefully removes the bandages from a burn victim's arm. B. The nurse assesses a patient to check nutritional status. C. The nurse formulates a nursing diagnosis for a patient with epilepsy. D. The nurse turns a patient in bed every 2 hours to prevent pressure injuries. E. The nurse checks a patient's insurance coverage at the initial interview. F. The nurse checks for community resources for a patient with dementia.

A. The nurse carefully removes the bandages from a burn victim's arm. D. The nurse turns a patient in bed every 2 hours to prevent pressure injuries. F. The nurse checks for community resources for a patient with dementia.

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. A. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. B. The nurse uses a binary decision tree for stepwise assessment and intervention. C. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. D. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. E. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. F. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

A. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. C. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes.

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. A. The nurse uses critical thinking skills to plan care for a patient. B. The nurse correctly administers IV saline to a patient who is dehydrated. C. The nurse assists a patient to fill out an informed consent form. D. The nurse learns the correct dosages for patient pain medications. E. The nurse comforts a mother whose baby was born with Down syndrome. F. The nurse uses the proper procedure to catheterize a female patient.

A. The nurse uses critical thinking skills to plan care for a patient. D. The nurse learns the correct dosages for patient pain medications.

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? A.) "New mothers need support." B.) "The lack of a father is difficult." C.) "How are you today?" D.) "It is a very sad situation."

A.) "New mothers need support."

A nurse caring for culturally diverse patients in a health care provider's office is aware that patients of certain cultures are more prone to specific disease states than the general population. Which patients would the nurse screen for diabetes mellitus based on the patient's race? Select all that apply. A.) A Native American patient B.) An African-American patient C.) An Alaska Native D.) An Asian patient E.) A White patient F.) A Hispanic patient

A.) A Native American patient C.) An Alaska Native E.) A White patient F.) A Hispanic patient

In order to provide culturally competent care, nurses must be alert to factors inhibiting sensitivity to diversity in the health care system. Which nursing actions are examples of cultural imposition? Select all that apply. A.) A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. B.) A nurse treats all patients the same whether or not they come from a different culture. C.) A nurse tells another nurse that Jewish diet restrictions are just a way for them to get a special tray of their favorite foods. D.) A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. E.) A nurse directs interview questions to an older adult's daughter even though the patient is capable of answering them. F.) A nurse refuses to care for a married gay man who is HIV positive because she is against same-sex marriage.

A.) A hospital nurse tells a nurse's aide that patients should not be given a choice whether or not to shower or bathe daily. D.) A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence.

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? A.) Cliché B.) Giving advice C.) Being judgmental D.) Changing the subject

A.) Cliché

The nurse practitioner sees patients in a community clinic that is located in a predominately White neighborhood. After performing assessments on the majority of the patients visiting the clinic, the nurse notes that many of the minority groups living within the neighborhood have lost the cultural characteristics that made them different. What is the term for this process? A.) Cultural assimilation B.) Cultural imposition C.) Culture shock D.) Ethnocentrism

A.) Cultural assimilation

A nurse is telling a new mother from Africa that she shouldn't carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies this way. The nurse believes that bassinets are safer for infants. This nurse is displaying what cultural bias? A.) Cultural imposition B.) Clustering C.) Cultural competency D.) Stereotyping

A.) Cultural imposition

A nurse is preparing to teach a patient with asthma how to use his inhaler. Which teaching method would be the BEST choice to teach the patient this skill? A.) Demonstration B.) Lecture C.) Discovery D.) Panel session

A.) Demonstration

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? A.) Determining the progress made in achieving established goals B.) Clarifying when the patient should take medications C.) Reporting the progress made in teaching to the staff D.) Including all family members in the teaching session

A.) Determining the progress made in achieving established goals

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. A.) Group decision making B.) Group leadership C.) Group power D.) Group identity E.) Group patterns of interaction F.) Group cohesiveness

A.) Group decision making D.) Group identity E.) Group patterns of interaction F.) Group cohesiveness

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? A.) Pain B.) Anxiety C.) Depression D.) Fluid volume deficit

A.) Pain

After instituting a new system for recording patient data, a nurse evaluates the "usability" of the system. Which actions by the nurse BEST reflect this goal? Select all that apply. A.) The nurse checks that the screens are formatted to allow for ease of data entry. B.) The nurse reorders the screen sequencing to maximize effective use of the system. C.) The nurse ensures that the computers can be used by specified users effectively. D.) The nurse checks that the system is intuitive, and supportive of nurses. E.) The nurse improves end-user skills and satisfaction with the new system. F.) The nurse ensures patient data is able to be shared across health care systems.

A.) The nurse checks that the screens are formatted to allow for ease of data entry. C.) The nurse ensures that the computers can be used by specified users effectively. D.) The nurse checks that the system is intuitive, and supportive of nurses.

A nurse is using the steps in informatics evaluation to evaluate the use of a portal as a patient resource. What are examples of activities that might occur in the "determining the question" step? Select all that apply. A.) The nurse develops a clear, focused question to determine the data to be collected. B.) The nurse determines what to evaluate. C.) The nurse determines how the data ultimately should be reported. D.) The nurse decides what specific data elements need to be collected. E.) The nurse clarifies exactly how the data will be collected. F.) The nurse performs comprehensive documentation of the data collected.

A.) The nurse develops a clear, focused question to determine the data to be collected. C.) The nurse determines how the data ultimately should be reported.

A registered nurse assumes the role of nurse coach to provide teaching to patients who are recovering from a stroke. Which nursing intervention directly relates to this role? A.) The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change. B.) The nurse is the expert in providing teaching and education strategies to provide dietary and activity modifications. C.) The nurse becomes a mentor to the patients and encourages them to create their own fitness programs. D.) The nurse assumes an authoritative role to design the structure of the coaching session and support the achievement of patient goals.

A.) The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change.

Population health addresses the health status and health issues of aggregate populations and addresses ways in which resources may be allocated to address these concerns. What is the driving force behind the use by health corporations of analytics and big data to support population health? A.) The transition from fee-for-service models to value-based payment models B.) A growing older population with more complicated health needs C.) The overcrowding and understaffing of hospitals D.) The shortage of health care professionals, particularly nurses

A.) The transition from fee-for-service models to value-based payment models

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? A. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" B. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." C. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." D. "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

B. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care."

A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three-part nursing diagnoses? 1. Disabled Family Coping related to lack of knowledge about home care of child on ventilator 2. Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-lb weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height-weight charts 3. Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" 4. Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?" "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" 5. Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression A. (1) and (3) B. (2) and (4) C. (1), (2), and (3) D. (1), (2), (3), (4), and (5)

B. (2) and (4)

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A. A nurse sits down with a patient and prioritizes existing diagnoses. B. A nurse assesses a woman for postpartum depression during routine care. C. A nurse plans interventions for a patient who is diagnosed with epilepsy. D. A busy nurse takes time to speak to a patient who received bad news. E. A nurse reassesses a patient whose PRN pain medication is not working. F. A nurse coordinates the home care of a patient being discharged.

B. A nurse assesses a woman for postpartum depression during routine care. D. A busy nurse takes time to speak to a patient who received bad news. E. A nurse reassesses a patient whose PRN pain medication is not working.

A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? A. Offer the patient 60-mL fluid every 2 hours while awake. B. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. C. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. D. At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.

B. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL.

A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? A. Maslow's human needs B. Gordon's functional health patterns C. Human response patterns D. Body system model

B. Gordon's functional health patterns

A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. A. Bronchial pneumonia B. Impaired gas exchange C. Ineffective airway clearance D. Potential complication: sepsis E. Infection related to pneumonia F. Risk for septic shock

B. Impaired gas exchange C. Ineffective airway clearance F. Risk for septic shock

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? A. Systematic B. Interpersonal C. Dynamic D. Universally applicable in nursing situations

B. Interpersonal

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. A. It functions independently of nursing standards, ethics, and state practice acts. B. It is based on the principles of the nursing process, problem solving, and the scientific method. C. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. D. It is not designed to compensate for problems created by human nature, such as medication errors. E. It is constantly re-evaluating, self-correcting, and striving for improvement. F. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

B. It is based on the principles of the nursing process, problem solving, and the scientific method. C. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. E. It is constantly re-evaluating, self-correcting, and striving for improvement.

An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. A. Performing the initial patient assessments B. Making patient beds C. Giving patients bed baths D. Administering patient medications E. Ambulating patients F. Assisting patients with meals

B. Making patient beds C. Giving patients bed baths E. Ambulating patients F. Assisting patients with meals

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure? A. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions B. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings C. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention D. A complete list of reimbursable charges for each nursing intervention

B. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings

A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? A. Actual B. Possible C. Risk D. Collaborative

B. Possible

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? A. No problem B. Possible problem C. Actual nursing diagnosis D. Clinical problem other than nursing diagnosis

B. Possible problem

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? A. Administer pain medication. B. Reassess the patient. C. Prepare the equipment. D. Explain the procedure to the patient.

B. Reassess the patient.

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? A. Risk for Impaired Skin Integrity B. Related to prescribed bed rest C. As evidenced by D. As evidenced by reddened areas of skin on the heels and back

B. Related to prescribed bed rest

A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a White man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis? A. Actual B. Risk C. Possible D. Wellness

B. Risk

A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. A. The nurse uses the nursing interview to collect patient data. B. The nurse analyzes data collected in the nursing assessment. C. The nurse develops a care plan for the patient. D. The nurse points out the patient's strengths. E. The nurse assesses the patient's mental status. F. The nurse identifies community resources to help his family cope.

B. The nurse analyzes data collected in the nursing assessment. D. The nurse points out the patient's strengths. F. The nurse identifies community resources to help his family cope.

A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. A. The nurse formulates nursing diagnoses. B. The nurse identifies expected patient outcomes. C. The nurse selects evidence-based nursing interventions. D. The nurse explains the nursing care plan to the patient. E. The nurse assesses the patient's mental status. F. The nurse evaluates the patient's outcome achievement.

B. The nurse identifies expected patient outcomes. C. The nurse selects evidence-based nursing interventions. D. The nurse explains the nursing care plan to the patient.

A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? A.) "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." B.) "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" C.) "I will need to call in on the 8th of August because I have a doctor's appointment." D.) "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

B.) "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?"

A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? A.) "Would you prefer a bath or a shower?" B.) "May I help you with a bed bath now or later this morning?" C.) "I will be giving you your bath. Do you use soap or shower gel?" D.) "I prefer a shower in the evening. When would you like your bath?"

B.) "May I help you with a bed bath now or later this morning?"

A nurse forms a contractual agreement with a morbidly obese patient to achieve optimal weight goals. Which statement best describes the nature of this agreement? A.) "This agreement forms a legal bond between the two of us to achieve your weight goals." B.) "This agreement will motivate the two of us to do what is necessary to meet your weight goals." C.) "This agreement will help us determine what learning outcomes are necessary to achieve your weight goals." D.) "This agreement will limit the scope of the teaching session and make stated weight goals more attainable."

B.) "This agreement will motivate the two of us to do what is necessary to meet your weight goals."

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish and the nurse speaks only English. What is the appropriate nursing intervention? A.) Use short words and talk more loudly. B.) Ask an interpreter for help. C.) Explain why care can't be provided. D.) Provide instructions in writing.

B.) Ask an interpreter for help.

A nurse has taught a patient with diabetes how to administer his daily insulin. How should the nurse evaluate the teaching-learning process? A.) By determining the patient's motivation to learn B.) By deciding if the learning outcomes have been achieved C.) By allowing the patient to practice the skill he has just learned D.) By documenting the teaching session in the patient's medical record

B.) By deciding if the learning outcomes have been achieved

A home health care nurse is using the steps of the SDLC, to design a new system for home health care documentation. The nurse analyzes the old system and develops plans for the new system. What is the next step of the nurse in this process? A.) Test B.) Design C.) Implement D.)Evaluate

B.) Design

Nurses incorporate telecare in patient care plans. Which services are MOST representative of this technologic advance? Select all that apply. A.) Diagnostic testing B.) Easy access to specialists C.) Health and fitness apps D.) Early warning and detection technologies E.) Digital medication reminder systems F.) Monitoring of progress following treatment

B.) Easy access to specialists C.) Health and fitness apps D.) Early warning and detection technologies

A nurse is using the ESFT model to understand a patient's conception of a diagnosis of chronic obstructive pulmonary disease (COPD). Which interview question would be MOST appropriate to assess the E aspect of this model—Explanatory model of health and illness? A.) How do you get your medications? B.) How does having COPD affect your lifestyle? C.) Are you concerned about the side effects of your medications? D.) Can you describe how you will take your medications?

B.) How does having COPD affect your lifestyle?

A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? A.) A closed-ended answer B.) Information clarification C.) The nurse to give advice D.) Assertive behavior

B.) Information clarification

A nurse is using informatics technology to decide which patients may be at risk for readmission. What is the term for this type of analytic? A.) Data visualization B.) Predictive analytics C.) Big data D.) Data recall

B.) Predictive analytics

A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? A.) Promoting health B.) Preventing illness C.) Restoring health D.) Facilitating coping

B.) Preventing illness

A nurse is caring for a patient who is admitted to the hospital with injuries sustained in a motor vehicle accident. While he is in the hospital, his wife tells him that the bottom level of their house flooded, damaging their belongings. When the nurse enters his room, she notes that the patient is visibly upset. The nurse is aware that the patient will most likely be in need of which type of counseling? A.) Long-term developmental B.) Short-term situational C.) Short-term motivational D.) Long-term motivational

B.) Short-term situational

A nurse is planning teaching strategies based on the affective domain of learning for patients addicted to alcohol. What are examples of teaching methods and learning activities promoting behaviors in this domain? Select all that apply. A.) The nurse prepares a lecture on the harmful long-term effects of alcohol on the body. B.) The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. C.) The nurse asks patients for a return demonstration for using relaxation exercises to relieve stress. D.) The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. E.) The nurse uses a pamphlet to discuss the tenants of the Alcoholics Anonymous program to patients. F.) The nurse reinforces the mental benefits of gaining self-control over an addiction.

B.) The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. D.) The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. F.) The nurse reinforces the mental benefits of gaining self-control over an addiction.

A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? A. "You know your personal situation better than I do, so I will respect your wishes." B. "If you don't accept these services, your baby's health will suffer." C. "Let's take a look at the plan again and see if we can adjust it to fit your needs." D. "I'm going to assign your case to a social worker who can explain the services better."

C. "Let's take a look at the plan again and see if we can adjust it to fit your needs."

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. A. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. B. A nurse consults with a psychiatrist for a patient who abuses pain killers. C. A nurse checks the skin of bedridden patients for skin breakdown. D. A nurse orders a kosher meal for an orthodox Jewish patient. E. A nurse records the I&O of a patient as prescribed by his health care provider. F. A nurse prepares a patient for minor surgery according to facility protocol.

C. A nurse checks the skin of bedridden patients for skin breakdown. D. A nurse orders a kosher meal for an orthodox Jewish patient. F. A nurse prepares a patient for minor surgery according to facility protocol.

A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical changes

C. Affective

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: A. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice B. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice C. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice D. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

C. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice

The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? A. Initial planning B. Standardized planning C. Ongoing planning D. Discharge planning

C. Ongoing planning

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? A. Patient-centered care B. Evidence-based practice C. Quality improvement D. Informatics

C. Quality improvement

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? A. Allow the UAPs to do the admission assessment and report the findings to the RN. B. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. C. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. D. Contact his or her labor representative to report this practice to the state board of nursing.

C. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration.

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? A. The nurse judges whether the patient database is adequate to address the problem. B. The nurse considers whether or not to suggest a counseling session for the patient. C. The nurse reassesses the patient and decides how best to intervene in her care. D. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

C. The nurse reassesses the patient and decides how best to intervene in her care.

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? A. Protocols for treating the patient problem B. Standardized treatment guidelines C. The nurse's ideas about the patient problem and treatment D. Clinical pathways for the treatment of sickle cell anemia

C. The nurse's ideas about the patient problem and treatment

The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? A. Inform the charge nurse. B. Inform the surgeon. C. Validate the finding. D. Document the finding.

C. Validate the finding.

A nurse is interviewing a newly admitted patient. Which question is considered culturally sensitive? A.) "Do you think you will be able to eat the food we have here?" B.) "Do you understand that we can't prepare special meals?" C.) "What types of food do you eat for meals?" D.) "Why can't you just eat our food while you are here?"

C.) "What types of food do you eat for meals?"

A nurse designing a new EHR system for a pediatric office follows usability concepts in system design. Which concepts are recommended in system design? Select all that apply. A.) Users should not explore with forgiveness for unintended consequences. B.) Shortcuts for frequent users should not be incorporated into the system. C.) Content emphasis should be on information needed for decision making. D..) The less times users need to apply prior experience to a new system the better. E.) All the information needed should be presented to reduce cognitive load. F.) The number of steps it takes to complete tasks should be minimized.

C.) Content emphasis should be on information needed for decision making. E.) All the information needed should be presented to reduce cognitive load. F.) The number of steps it takes to complete tasks should be minimized.

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. A.) Fill the silence with lighter conversation directed at the patient. B.) Use the time to perform the care that is needed uninterrupted. C.) Discuss the silence with the patient to ascertain its meaning. D.) Allow the patient time to think and explore inner thoughts. E.) Determine if the patient's culture requires pauses between conversation. F.) Arrange for a counselor to help the patient cope with emotional issues.

C.) Discuss the silence with the patient to ascertain its meaning. D.) Allow the patient time to think and explore inner thoughts. E.) Determine if the patient's culture requires pauses between conversation.

A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? A.) Determining the established goals of the institution B.) Ensuring that verbal and nonverbal communication is congruent C.) Engaging in self-talk to plan the day and decrease fear D.) Speaking with fellow colleagues about how they feel

C.) Engaging in self-talk to plan the day and decrease fear

A nurse is using information from informatics technology that is synthesized so that relationships between lung cancer diagnoses and smoking are identified. What part of "DIKW" does this represent? A.) Data B.) Information C.) Knowledge D.) Wisdom

C.) Knowledge

A nurse is teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information? A.) Ask Me 3 B.) Newest Vital Sign (NVS) C.) Teach-back method D.) TEACH acronym

C.) Teach-back method

A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. A.) The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. B.) The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. C.) The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. D.) The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. E.) The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. F.) The nurse continues a teaching session on STIs for a sexually active male adolescent despite his protest that "I've heard enough already!"

C.) The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. D.) The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. E.) The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching.

A nurse is teaching a novice nurse how to provide care for patients in a culturally diverse community health clinic. Although all these actions are recommended, which one is MOST basic to providing culturally competent care? A.) Learning the predominant language of the community B.) Obtaining significant information about the community C.) Treating each patient at the clinic as an individual D.) Recognizing the importance of the patient's family

C.) Treating each patient at the clinic as an individual

Nurses test new technology in phases. In which phase would the nurse "test drive" the new system? A.) Unit B.) Function C.) User acceptance D.) Integration

C.) User acceptance

A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly? A. "Outcome not met." B. "1/21/20—Patient reports no change in diet." C. "Outcome not met. Patient reports no change in diet or activity level." D. "1/21/20—Outcome not met. Patient reports no change in diet or activity level."

D. "1/21/20—Outcome not met. Patient reports no change in diet or activity level."

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? 1. Ineffective Coping related to inability to maintain marriage 2. Defensive Coping related to loss of job and economic security 3. Altered Thought Processes related to panic state 4. Decisional Conflict related to placement of parent in a long-term care facility A. (1) and (2) B. (3) and (4) C. (1), (2), and (3)(1) D. (2), (3), and (4)

D. (2), (3), and (4) 2. Defensive Coping related to loss of job and economic security 3. Altered Thought Processes related to panic state 4. Decisional Conflict related to placement of parent in a long-term care facility

A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? A. Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. B. Schedule the testing and meal planning first and complete hygiene as time permits. C. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. D. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

D. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? A. Thank the wife for being present. B. Ask the wife if she wants to remain. C. Ask the wife to leave. D. Ask the patient if he would like the wife to stay.

D. Ask the patient if he would like the wife to stay.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? A. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. B. y 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. C. By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). D. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

D. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

A student health nurse is counseling a college student who wants to lose 20 lb. The nurse develops a plan to increase the student's activity level and decrease her consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 lb, the student has lost only 1 lb. Which is the BEST nursing response? A. Congratulate the student and continue the care plan. B. Terminate the care plan since it is not working. C. Try giving the student more time to reach the targeted outcome. D. Modify the care plan after discussing possible reasons for the student's partial success.

D. Modify the care plan after discussing possible reasons for the student's partial success.

A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? A. Collaborative problem B. Interdisciplinary problem C. Medical problem D. Nursing problem

D. Nursing problem

A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? A. Correct the initial assessment form. B. Redo the initial assessment and document current findings. C. Conduct and document an emergency assessment. D. Perform and document a focused assessment of skin integrity.

D. Perform and document a focused assessment of skin integrity.

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? A. Comprehensive B. Initial C. Time-lapsed D. Quick priority

D. Quick priority

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? A. Travelbee's B. Watson's C. Benner's D. Swanson's

D. Swanson's

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? A. The nurse collects data to identify health problems. B. The nurse collects data to identify patient strengths. C. The nurse collects data to justify terminating the care plan. D. The nurse collects data to measure outcome achievement.

D. The nurse collects data to measure outcome achievement.

A nurse is counseling a 19-year-old athlete who had his right leg amputated below the knee following a motorcycle accident. During the rehabilitation process, the patient refuses to eat or get up to ambulate on his own. He says to the nurse, "What's the point. My life is over now and I'll never be the football player I dreamed of becoming." What is the nurse counselor's best response to this patient? A.) "You're young and have your whole life ahead of you. You should focus on your rehabilitation and make something of your life." B.) "I understand how you must feel. I wanted to be a famous singer, but I wasn't born with the talent to be successful at it." C.) "You should concentrate on other sports that you could play even with prosthesis." D.) "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?"

D.) "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?"

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? A,) "I'm just the IV therapist checking your IV." B.) "I've been transferred to this division and will be caring for you." C.) "I'm sorry, my name is John Smith and I am your nurse." D.) "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

D.) "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? A.) "Do you take two injections of insulin to decrease the complications?" B.) "Most health care providers recommend diet and exercise to regulate blood sugar." C.) "Most complications of diabetes are related to neuropathy." D.) "What specific complications have you experienced?"

D.) "What specific complications have you experienced?"

During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? A.) "You need to speak to the patient quietly so you don't disturb the other patients." B.) "Let me help you with your transfer technique." C.) "When you are finished, be sure to apologize for your rough demeanor." D.) "When your patient is safe and comfortable, meet me at the desk."

D.) "When your patient is safe and comfortable, meet me at the desk."

A nurse is caring for patients of diverse cultures in a community health care facility. Which characteristics of cultural diversity that exist in the United States should the nurse consider when planning culturally competent care? Select all that apply. A.) The United States has become less inclusive of same-sex couples. B.) Cultural diversity is limited to people of varying cultures and races. C.) Cultural diversity is separate and distinct from health and illness. D.) People may be members of multiple cultural groups at one time. E.) Culture guides what is acceptable behavior for people in a specific group. F.) Cultural practices may evolve over time but mainly remain constant.

D.) People may be members of multiple cultural groups at one time. E.) Culture guides what is acceptable behavior for people in a specific group. F.) Cultural practices may evolve over time but mainly remain constant.

A nurse is testing a new computer program designed to store patient data. In what phase of testing would the nurse determine if the system can handle high volumes of end-users or care providers using the system at the same time? A.) Unit B.) Function C.) Integration D.) Performance

D.) Performance

A nurse states, "That patient is 78 years old—too old to learn how to change a dressing." What is the nurse demonstrating? A.) Cultural imposition B.) Clustering C.) Cultural competency D.) Stereotyping

D.) Stereotyping

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? A.) The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." B.) The nurse places a hand on the patient's arm and states, "You feel so alone." C.) The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." D.) The nurse holds the patient's hand and asks, "What makes you feel so alone?"

D.) The nurse holds the patient's hand and asks, "What makes you feel so alone?"

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? A.) The use of reflective questions B.) The use of closed questions C.) The use of assertive questions D.) The use of clarifying questions

D.) The use of clarifying questions