Intro final exam Q1

Which nursing action best represents primary prevention? a. Instructing a healthy individual to get a flu shot on a yearly basis b. Instructing a patient to take blood pressure medication every day c. Instructing a patient to live with a known disability d. Instructing a patient to undergo physical therapy following a cerebrovascular accident

A. Instructing a healthy individual to get a flu shot on a yearly basis Rationale:A healthy individual getting a flu shot is primary prevention. Primary prevention precedes disease or disability or dysfunction. Primary prevention aimed at health promotion includes health education programs, immunizations, and physical and nutritional fitness activities

A nurse is interviewing a patient being admitted to the hospital for surgery. During the interview, the nurse introduces self and explains that will be gathering some information. The nurse is in which phase of the interview? a. Orientation b. Working c. Assessment d. Termination

A. Orientation Rationale: The orientation phase begins with introducing oneself and ones position and explaining the purpose of the interview. The nurse explains to patients why the data are being collected and assures the patient that the information will remain confidential and will be used only by health care professionals who provide his or her care. During the working phase you gather information about a patients health status. When the interview comes to an end, this is called termination. Assessment is the first step in the nursing process, not the first step in an interview.

Common _____________ health behaviors include getting immunizations, maintaining proper sleep patterns, getting adequate exercise, and eating healthy foods. A: positive B: negative

A. Positive

The third component of the Basic Human Needs model (Maslow) is: A. love and belonging B. self acceptance C. basic human needs D. self-concept

A. love and belonging

A registered nurse working as a school nurse for a small poor rural school district has noticed an increase in children arriving at school without having eaten breakfast. The nurse has discussed this issue with the school principal and is working on a proposal to ask the school district to explore a school breakfast program. Which level of care did the nurse use? a. Primary care b. Continuing care c. Restorative care d. Tertiary care

A: primary care Rationale: In the settings that deliver preventative and primary care, such as schools, physicians or health care providers offices, occupational health clinics, and nursing centers, health promotion is a major theme

.A nurse who works in an inner-city health clinic is scheduling a day for student nurses to assist with a flu immunization clinic. Which of the following best describes this type of activity? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health prevention

A: primary prevention Rationale: Primary prevention decreases the vulnerability of an individual (or population) to disease

An example of a federal statute that affects health care practice is: A. Nurse Practice Act B. Americans with Disabilities Act

B. Americans with Disabilities Act

What form of insurance is a federally funded health insurance program for people greater than 65 years of age. a. Medicaid b. Medicare c. Private insurance d. A managed care organization

B: medicare

__________ health behaviors include activities that are harmful to health such as smoking, abusing drugs or alcohol, following a poor diet, and refusing to take necessary medications. A: positive B: negative

B: negative

"There is nothing that I really need to change" is an example of the _______________ stage. a. Contemplation b. Precontemplation c. Maintenance d. Engagement

B: precontemplation

_____________________ focuses on people who are experiencing health problems. a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health prevention

B: secondary prevention

____________________ is wellness education. A: restorative B: Stress management C: prevention D: Treatment

B: stress management

___________ behaviors focus on improving health, like jogging. a. Illness b. Wellness c. Social d. Antisocial

B: wellness

________ behaviors involve groups a. Illness b. Wellness c. Social d. Antisocial

C: social

When teaching a 15-year-old patient with diverticulitis about foods that should be avoided, a nurse takes the stage of growth and development into consideration. Which factor or variable did the nurse take into consideration? a. Cultural factor b. External variable c. Socioeconomic factor d. Internal variable

D. Internal variable Rationale: Internal variables include a persons stage of growth and development, intellectual background, emotional factors, and spiritual factors.

A nurse is directing the care and staffing of three cardiac units. The nurse is practicing in which nursing role? a. Advanced practice registered nurse b. Nurse researcher c. Nurse educator d. Nurse administrator

D. Nurse administrator

To determine a patients external variables for health beliefs and practices, which area should the nurse assess? a. Emotional factors b. Intellectual background c. Developmental stage d. Socioeconomic factors

D. Socioeconomic factors Rationale:External variables for health beliefs and practices include family practices, socioeconomic factors, and cultural background. Emotional factors, intellectual background, and developmental stage represent internal variables

Family would focus on families. a. National b. Community c. Individual d. Family

D. family

________________ is the use of multiple therapies such as physical, psychological, occupational, speech, and social services to help restore a person to the fullest physical, mental, social, vocational, and economic usefulness possible. a. A rehabilitation center b. A nursing center c. An adult day care center d. A hospice center

a. A rehabilitation center

A nurse in community-based practice needs a variety of skills and talents while rendering care to patients in the community. Which are competencies of the community health nurse? (Select all that apply.) a. Case manager b. Care giver c. Educator d. Advocate e. Counselor

a. Case manager b. Care giver c. Educator Rationale: Selected competencies, such as caregiver, case manager, epidemiologist, and educator, are used in the community-based setting.

_______________ is described as a patient in assisted living and psychiatric day care. a. Continuing care b. Preventative care c. Secondary acute care d. Restorative care

a. Continuing care

_________________ defines actions as right or wrong according to principles. a. Deontology b. Feminist ethic c. Utilitarianism d. Ethics of care

a. Deontology

The nurse is providing prenatal education to a patient whose pregnancy has been confirmed. This is the patients first pregnancy and she is in her first trimester. The nurse instructs the patient that she should stop smoking, avoid alcohol, and avoid eating king mackerel because of the high mercury content in the fish. Although this advice should be followed during the entire pregnancy, the fetus is most vulnerable to adverse effects in the _____ trimester. a. first b. second c. third d. final

a. First Rationale: Exposure to potential teratogens can affect fetal development during any of the trimesters; however, vulnerability is increased during the first trimester when fetal cells are differentiating and organs are forming.

A pregnant mother of two children has been experiencing severe morning sickness and fatigue. Friends and family members have been providing her family with meals, and her husband has been taking responsibility for the housework. This is an example of which type of behavior? a. Illness b. Wellness c. Social d. Antisocial

a. Illness Rationale: Illness behavior often results in patients being released from roles, social expectations, or responsibilities

A patient has lost 10 pounds in the last 2 months from breast cancer and chemotherapy. The chemotherapy has caused the patient to not eat. Which nursing diagnosis should the nurse use to develop the plan of care? a. Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Food Intake b. Imbalanced Nutrition: Less Than Body Requirements Related to Cancer c. Imbalanced Nutrition: Less Than Body Requirements Related to Loss of Weight d. Imbalanced Nutrition: Less Than Body Requirement Related to Insufficient Prescription of Chemotherapy

a. Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Food Intake Rationale: Imbalanced Nutrition: Less Than Body Requirement is the diagnostic label, whereas decreased food intake is the state of related factor(s) or etiology. The identification of a nursing diagnosis flows from the assessment and diagnostic process. Nursing diagnoses are worded in a two-part format: the diagnostic label followed by a statement of a related factor. Identify the patients response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. Breast cancer is a medical diagnosis. Identify the problem and etiology to avoid a circular statement. Such statements are vague and give no direction to nursing care. Less than body requirements and loss of weight is circular. Avoid legally inadvisable statements that imply blame, negligence, or malpractice. The diagnosis that states insufficient prescription of chemotherapy implies that the health care provider gave an inadequate prescription.

A patient had a stroke that left the patient aphasic. A nurse is working on a plan of care. Which nursing diagnosis should the nurse use to describe the patients aphasia? a. Impaired Verbal Communication b. Anxiety c. Impaired Social Interaction d. Ineffective Coping

a. Impaired Verbal Communication Rationale: Impaired Verbal Communication is the nursing diagnostic label to describe a patient who has limited or no ability to communicate verbally

A nurse is employed by a health care agency that provides an informal training session on how to properly use a new vital sign monitor. Which type of education did the nurse receive? a. In-service education b. Advanced education c. Continuing education d. Registered nurse education

a. In-service education

When the nurse actually talks to the employee, it is called _________________ communication. a. Interpersonal b. Intrapersonal c. Public d. Private

a. Interpersonal

A nurse is admitting a 73-year-old woman with a fractured ulna and radius to the trauma unit of the hospital. The patients daughter and son-in-law are present. The nurse notices that the patient does not make eye contact when answering questions and the nurse senses that something is not right about the situation. Which technique did the nurse use? a. Intuition b. Critical thinking c. Nursing process d. Reflection

a. Intuition Rationale: The fact that the nurse senses something is not right about the situation is intuition. Intuition is the inner sensing or gut feeling that something is so. For example, a nurse walks into a patients room and, by looking at the patients appearance without the benefit of a thorough assessment, senses that he or she has worsened physically.

_____________ is reflecting on your own judgments and realizing multiple solutions are acceptable a. Maturity b. Analyticity c. Systematicity d. Inquisitiveness

a. Maturity

A patient states that he or she cannot afford health care insurance for the family because of a low income. What is the best form of insurance available for this patient? a. Medicaid b. Medicare c. Private insurance d. A managed care organization

a. Medicaid Rationale: Medicaid is a form of insurance for low-income families.

A nurse is teaching the staff about the phases of the interview process. Which information should the nurse include in the teaching session? a. Orientation, working, termination b. Orientation, assessment, evaluation c. Planning, assessment, termination d. Planning, assessment, evaluation

a. Orientation, working, termination Rationale: The three phases of the interview process are orientation, working, and termination. Assessment, evaluation, and planning are phases in the nursing process.

A nurse is practicing as a community health nurse. What is the primary focus of care for this nurse? a. Providing care to subpopulations b. Practicing care in existing services c. Being a specialist in public health science d. Having a case management certification

a. Providing care to subpopulations

A nurse is preparing a discharge summary. Which item should the nurse include? a. Provision for follow-up care b. Patient status at admission c. Standardized nursing care plan d. Detailed description of nursing procedures

a. Provision for follow-up care Rationale: A nursing discharge note needs to cover the reason for hospitalization, procedures performed, care, treatment, and services provided, patient status at discharge, information provided to the patient and family, and provisions for follow-up care. Patient status at discharge, not admission, is included. Standardized nursing care plans are based on the institutions standards of nursing practice and are preprinted established guidelines of care for patients with similar health problems. Detailed descriptions of nursing procedures are located in policy and procedure manuals, but not in a discharge summary.

A nurse should emphasize health promotion, wellness strategies, and illness prevention activities as important forms of health care. Which is considered a health promotion strategy? a. Routine exercise b. Stress management class c. Influenza immunization d. Tetanus booster

a. Routine exercise Rationale: Routine exercise is done to promote health and is a health promotion strategy.

Health disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic groups that are often exacerbated by which of the following? (Select all that apply.) a. Social status b. Economics c. Environment d. Improved access to health care

a. Social status b. Economics c. Environment Rationale: Healthy People 2020 defines a health disparity as a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Poor access to health care is one social determinant of health that contributes to health disparities.

The ________________ regulates nursing programs and nursing practice. a. The Board of Nursing b. The American Medical Association c. The National League for Nursing d. The American Nurses Association

a. The Board of Nursing

___________________ requires health care organizations to determine how well an organization meets patient needs and expectations and accredits health care organizations. a. The Joint Commission b. National Priorities Partnership c. Accountable Care Organization d. Managed Care

a. The Joint Commission

Which of the following would indicate that the nurse has established a level of mutual problem solving? a. The nurse helps the patient develop questions to ask the health care provider. b. The nurse tells the patient what needs to be done to resolve health problems. c. The nurse is seen as the authority when it comes to health care issues. d. The nurse excludes the family from health discussions to protect privacy.

a. The nurse helps the patient develop questions to ask the health care provider. Rationale: caring nurse helps hospitalized patients understand how to think about their health and illness and to figure out questions to ask of their health care providers. In addition, a caring nurse helps patients explore options for resolving health problems and provides information and instruction. Using evidence in practice is an aspect of mutual problem solving, with a nurse continuously learning and engaging patients and families in discussions about their health issues. Basic to nursing practice is the inclusion of family members in a patients care.

A nurse is using SBAR. Which information will the nurse report for the B? a. The patient had a broken right leg with a cast applied 2 days ago. b. The toes are cool and pale. c. The patient is reporting severe pain10 out of 10even after pain medication was given. d. The nurse requests that the primary health care provider examine the patient.

a. The patient had a broken right leg with a cast applied 2 days ago. Rationale: B stands for background. The information for the patients background is the following: the patient had a broken right leg with a cast applied 2 days ago.

What should the nurse caring for a dying patient understand about the patient? (Select all that apply.) a. The patient has the right to be in control. b. The patient must be compliant with his medical regimen. c. The patient should expect to be free from pain. d. The patient should be lied to so as to maintain his sense of hope. e. The patient has the right to die in peace and dignity.

a. The patient has the right to be in control. c. The patient should expect to be free from pain. e. The patient has the right to die in peace and dignity. Rationale: The Dying Persons Bill of Rights states that the patient has the right to be treated as a living human being until he dies, be in control, express his feelings and emotions about his approaching death in his own way, be free from pain, have his questions answered honestly and not be deceived, and die in peace and dignity.

A patient has been admitted to the hospital with advanced colon cancer and is receiving palliative care at this time. The nurse feels anxious in caring for this patient, but realizes which of the following? a. The patient needs the nurses presence and personal connection. b. Remaining silent would signify a noncaring attitude. c. All people react to loss in the same way. d. Reminiscing only makes a difficult situation worse.

a. The patient needs the nurses presence and personal connection. Rationale: Many nurses become anxious when caring for dying patients or people coping with grief and loss. Confidence helps you to understand that even if there is nothing you can do or say to change the situation, the patient needs your compassionate presence and a personal connection. Confidence helps you accept the responsibility to remain present even in difficult situations. By silently sharing a moment of sadness with a patient or family member, you communicate caring and send the message that you respect and accept their feelings in the moment. Do not assume that other people react to loss or grief as you do or that a particular behavior necessarily indicates grief. Encouraging patients to tell stories about their loved one gives them an opportunity to provide information in a natural, unstructured, and meaningful way.

The patients home has been demolished by a tornado. The patients spouse and child were killed and the spouse is in need of a leg amputation. The nurse realizes that which of the following is true? a. The patient will deal with his losses using usual coping strategies. b. A patients normal coping strategies are always adequate. c. Patients usually seek new strategies to deal with loss. d. At the end of life, people still rely on the usual coping strategies.

a. The patient will deal with his losses using usual coping strategies. Rationale: Individuals respond to loss by using their usual coping strategies. Sometimes when people experience multiple losses or lose something of great significance, their usual coping strategies are inadequate. At the end of life, people often find new coping mechanisms and new resources to maintain control and stability.

The patient has severe injuries. The nurse knows that the general adaptation syndrome (GAS) was viewed as a reaction to stress consisting of: (Select all that apply.) a. a pattern of alarm. b. deleterious consequences. c.a stage of resistance. d. developmental impairment. e. a state of exhaustion.

a. a pattern of alarm. c.a stage of resistance. e. a state of exhaustion. Rationale: The GAS was viewed as a reaction to stress consisting of three distinct stages; a pattern of alarm, followed by a stage of resistance as a person attempts to compensate for changes induced by the alarm stage. A state of exhaustion follows if the person cannot successfully adapt during the stage of resistance or if stress remains unrelieved. When stress reaches chronic, harmful levels, deleterious consequences follow, from compromised immune function to weight gain to developmental impairment. Deleterious consequences and developmental consequences, then, are a product of unsuccessful GAS, not a part of the syndrome.

The _________________ is a probability level that tells you whether the difference between two groups was likely related to the intervention or if it was simply a difference by chance. a. p value b. Abstract c. Analysis d. Literature review

a. p value (usually set at 0.05)

Preconception counseling is a growing trend in health care with the goal being to secure the best outcome for mother, fetus, and significant others through good prenatal care and teaching that: a. teratogens can affect fetal development during any trimester. b. the placenta prevents teratogens from passing to the fetus. c. teratogens are all man-made, preventable, and do not include viruses or bacteria. d. smoking has been shown to have no effect on fetal development.

a. teratogens can affect fetal development during any trimester. Rationale: Teratogens are chemical or physiological agents capable of having adverse effects on the fetus. Exposure to potential teratogens can affect fetal development during any of the trimesters; however, vulnerability is increased during the first trimester when fetal cells are differentiating and organs are forming. Because the placenta is extremely porous, teratogens pass easily from mother to fetus. Some examples of teratogens are viruses, drugs (prescribed, over-the-counter, and street drugs), alcohol, and environmental pollutants, such as lead. The fetal effect of these harmful agents depends on the developmental stage in which exposure takes place. In addition, there is evidence that mothers who smoke deliver infants with lower birth weights than nonsmoking mothers.

A patient states, Im burning up, and I have a fever. The nurse takes the patients temperature, observes the skin for flushing, and feels the skin temperature. This is an example of __________ subjective data. a. validating b. clustering c. reviewing d. documenting

a. validating Rationale: Validation of assessment data is the comparison of data with another source to confirm accuracy. The nurse reviews data to validate that measurable, objective physical findings support subjective data

While a nurse is assessing a patients chest pain, the patient states, The pain hurts in the middle of my chest. The nurse asks, Can you tell me where the pain is exactly and describe what it feels like? Which attitude for critical thinking is the nurse using? a. Integrity b. Discipline c. Planning d. Nursing diagnosis

b. Discipline Rationale: The nurse is being thorough, which is using the critical thinking attitude of discipline. A disciplined thinker misses few details and follows an orderly or systematic approach when collecting information, making decisions, or taking action

A patient has met the goals and outcomes mutually agreed upon for improvement of ventilatory status. What should the nurse do next? a. Modify the care plan. b. Discontinue the care plan. c. Create a nursing diagnosis that states goals have been met. d. Reassess the patients response to care and evaluate interventions.

b. Discontinue the care plan. Rationale: After a nurse determines that expected outcomes and goals have been met and evaluation confirms it, the nurse discontinues that portion of the care plan. The nurse modifies a care plan when goals are not met. Create a nursing diagnosis occurs after assessment, not during evaluation. Reassessing the patient occurs if the goals are not met.

The student nurse was late for clinical rounds because she had to change the tire on her car. She is in the process of preparing pain medication for her patient when her nursing instructor asks her to identify the drug classification of the medication that she is preparing. The student nurse is very frustrated, becomes tearful, and states, I cant seem to crush this tablet correctly. This reaction to the instructor is most likely a result of what ego-defense mechanism? a. Compensation b. Displacement c. Denial d. Dissociation

b. Displacement Rationale: Displacement is transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Dissociation is experiencing a subjective sense of numbing and a reduced awareness of ones surroundings.

Which action by the nurse is the final step in a complete assessment? a. Forming diagnostic conclusions b. Documentation of findings c. Auscultation d. Palpation

b. Documentation of findings Rationale: Communication of assessment findings, either verbally or through documentation, is the last step of a complete assessment. The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. The techniques of a physical examination include inspection, palpation, percussion, auscultation, and smell. After reviewing and validating a patients assessment, the next step of the nursing process is to form diagnostic conclusions.

A nurse is working in a health care clinic. She loves her work because of all the different people she meets. She professes to care for all of them and states that she understands them because she realizes which of the following is true? a. Basically all patients are the same. b. Each person has a unique background. c. Caring for people requires very little experience. d. There are standard solutions to most health care problems

b. Each person has a unique background.

___________ refers to the ability to form an opinion or draw sound conclusions. a. Competency b. Judgment c. Advocacy d. Utilitarianism

b. Judgment

The nurse manager of a 30-bed medical surgical unit has noticed that the fall rate of postoperative patients has increased in the past 2 months. The nurse manager wants to address this situation using evidence-based practice. Which type of trigger did the nurse manager use? a. Literature-focused trigger b. Problem-focused trigger c. Knowledge-focused trigger d. Expectations-focused trigger

b. Problem-focused trigger Rationale: A problem-focused trigger is one you face while caring for patients or a trend you see on a nursing unit.

A patient who needs nursing and rehabilitation after a stroke would benefit most by receiving care at which center? a. Primary care center b. Restorative care center c. Assisted living center d. Respite center

b. Restorative care center Rationale: Restorative care centers provide rehabilitation and nursing care. In primary care centers, health promotion is the major theme.

Upon checking a medication order, the nurse notices that the dosage is more than three times the normal range for this medication. The nurse calls the primary health care provider to question the order. Which critical thinking attitude did the nurse use? a. Confidence b. Risk taking c. Fairness d. Curiosity

b. Risk taking Rationale: If your knowledge causes you to question a health care providers order, do so. This illustrates risk taking.

A pregnant teenager asks the clinic nurse why she cannot smoke during the first trimester. Remembering growth and development, what is the nurses best response? a. Smoking is a bad habit, but it probably wont affect the baby. b. Smoking may affect organ systems that are beginning to develop. c. Smoking will only affect the baby in the third trimester. d. Smoking mothers usually produce overweight babies

b. Smoking may affect organ systems that are beginning to develop. Rationale: Teratogens are chemical or physiological agents capable of having adverse effects on the fetus. Exposure to potential teratogens can affect fetal development during any of the trimesters; however, vulnerability is increased during the first trimester when fetal cells are differentiating and organs are forming. In addition, there is evidence that mothers who smoke deliver infants with lower birth weights than nonsmoking mothers.

A patient is aphasic from a recent stroke. The nurse is taking a multidisciplinary approach to this patients care. Who would be most appropriate for the nurse to collaborate with regarding the patients aphasia? a. Interpreter b. Speech therapist c. Physical therapist d. Mental health nurse specialist

b. Speech therapist Rationale:Speech therapists help patients with aphasia. The nurse should collaborate with other health care providers who have expertise in communication strategies

A patient states that he or she is experiencing pain in the lower back. What is the best way for the nurse to document this subjective information? a. Seems back is hurting. b. States My lower back hurts. c. Grimaces when moving; I believe patient has lower back pain. d. Appears to be uncomfortable with lower back pain.

b. States My lower back hurts. Rationale: The only subjective data included in a record are what the patient says. For example, a patients statement of My lower back hurts is subjective and acceptable documentation

A postsurgical patient is being taught about wound care before being discharged from the hospital and is in a semiprivate room with another patient. The other patient is upset with a family member and is crying. The television is on to try to provide some distraction from the roommate. Which action should the nurse take to best facilitate patient education for wound care? a. Explain to the patient that everything is in the handout. b. Take the patient to a quiet area to do the patient teaching. c. Ask the roommate to please be considerate of the patient because patient education is occurring. d. Request that a home health nurse follow up with the patient at home to teach about wound care.

b. Take the patient to a quiet area to do the patient teaching.

The ______________ deals with physicians. a. The Board of Nursing b. The American Medical Association c. The National League for Nursing d. The American Nurses Association

b. The American Medical Association

The parents of a 3-month-old infant are preparing to take their child home from the hospital. Before being discharged, the parents must be educated on infant CPR. What is the most appropriate learning objective for this situation? a. The parents will be able to understand CPR skills. b. The parents will demonstrate infant CPR skills. c. The infant will not require further hospitalization. d. The parents will call the hospital for help.

b. The parents will demonstrate infant CPR skills. Rationale: A learning objective describes what the patient or guardian(s) will be able to do after successful instruction. The objective contains an active verb describing what the learner will do after the objective is met (demonstrate). Understand does not specify the behavior or content to be learned and is not an active verb. The learning objectives should focus on the parents as they are the learners; it should not focus on the infant. The parents should call the hospital for help but this does not relate to the skill being taught, CPR.

A patient who experienced a stroke 4 days ago has been discharged from the hospital and will be undergoing outpatient rehabilitation. How should the nurse prepare the patient for this level of care? a. The patient will be admitted to the rehabilitative unit of the hospital. b. The patient will have scheduled appointment times for therapy. c. The patient will have home visits from all members of the multidisciplinary team. d. The patient will be at home for all of the treatments ordered by the primary health care provider.

b. The patient will have scheduled appointment times for therapy. Rationale: When patients receive rehabilitation services in outpatient settings, patients get treatment at specified times during the week but remain at home the rest of the time.

A 15-year-old patient was admitted to the hospital with a bowel obstruction. The patient underwent surgery and was experiencing postoperative pain. The nurse caring for the patient had recently read a research article in which a study had been done with neonatal (infant) patients and the use of therapeutic touch to assist with pain control. Which factor is most important for the nurse to consider in this case when applying research to clinical practice? a. The patients gender b. The patients preference c. The patients allergies d. The patients roommate

b. The patients preference Rationale: Using clinical expertise and considering patients values and preferences ensures that a nurse will apply the available evidence to practice both safely and appropriately. Even when you use the best evidence available, application and outcomes differ based on your patients values, state of health, preferences, concerns, and/or expectations. Patients allergies, gender, and roommate are not important in this scenario as it does not affect therapeutic touch.

The nurse is caring for a patient of a culture different from her own. To provide culturally competent care for this patient, what does the nurse need to do? a. Not be curious about other ways of being in the world b. Understand the forces that influence her own world view c. Recognize that she must not hold any bias toward the patient d. Have no predispositions relative toward the patients culture

b. Understand the forces that influence her own world view Rationale: Although curiosity about other ways of being in the world is an important attitude for cultural competence, it is also important for a nurse to understand the forces that influence his or her own world view. Everyone holds biases about human behavior. Bias means a predisposition to see people or things in a certain light, positive or negative (Aguilar, 2006). Becoming more aware of ones biases and attitudes about human behavior is the first step on the ladder of cultural competence that can lead to positive change.

A nurse manager is interested in supporting more involvement of the staff nurses on the unit. What is one approach the nurse manager can take to facilitate this involvement? a. Inform the staff of decisions made. b. Use decentralized management. c. Avoid unit goals. d. Discourage input from other personnel.

b. Use decentralized management. Rationale: Decentralized management, in which decision making is made at the staff level, is very common within health care organizations. Advantages of decentralization include increased morale and improved interpersonal relationships among staff. Staff members feel more important and are more willing to contribute. The staff should be making the decisions, not being informed of decisions made. To make decentralized decision making work, managers need to move it down to the staff level. On a nursing unit it is important for all staff members (RNs, LPNs, and LVNs), nursing assistive personnel (NAP), and unit secretaries to feel involved, particularly with issues affecting their ability to care for patients. One of the responsibilities of a nurse manager is to help the staff establish annual goals for the unit. Avoiding unit goals will decrease involvement, not increase the participation

Which action should the nurse take when handling and disposing of patient information? a. Keep patient information to take home for disposal. b. Use programmed speed-dial keys when faxing. c. Throw hand-written notes about the patient in the trash. d. Place fax machines in a public place

b. Use programmed speed-dial keys when faxing. Rationale: Use programmed speed-dial keys when faxing to eliminate the chance of a dialing error and misdirected information. Place fax machines in a secure area, not a public area. Patient information must be shredded, and taking patient information home or throwing in the trash is breaking confidentiality.

_______________ of assessment data is the comparison of data with another source to confirm accuracy. a. Culture b. Validation c. Collaborative problem d. Defining characteristics

b. Validation

A registered nurse has recently been reassigned to the gynecology unit at the hospital. The nurse is strongly against abortion because of religious beliefs and contacts the nursing supervisor regarding the assignment because the unit cares for women who are undergoing abortions. The nurse is having a conflict in which area? a. Confidentiality b. Values c. Social networking d. Culture

b. Values Rationale: The nurse is having a conflict in values because of religious beliefs and abortion. A value is a personal belief about the worth of an idea, a custom, or an object

A woman is attending a nurse-facilitated grief support group. The womans son was killed in Iraq 18 months earlier. She confides that while at the gravesite yesterday, she broke down and the feelings of hurt were as deep as the day she found out about the death. She states, I will never get over this feeling of intense grief. The nurse discovers that yesterday would have been her sons 21st birthday. What is the nurses best response? a. That kind of reaction is very rare after so long a time. It would be best to avoid the cemetery on dates that might trigger this type of reaction. b. What happened to you yesterday is understandable and common in people who have lost loved ones. c. I find that hard to believe. We all grieve basically the same way, and I know that I would not react that way after such a long time. d. The fact that you reacted so strongly is concerning to me. This could be the beginning of some bigger issues.

b. What happened to you yesterday is understandable and common in people who have lost loved ones. Rationale: Reinforce the understanding that people grieve differently and that feelings change or resolve over time. Some people have anniversary reactions (heightened or renewed feelings of loss or grief) months or years after a loss. They worry that they are losing ground when signs of grief reappear after a period of relative calm. Offer reassurance that anniversary reactions are common, and encourage pleasant reminiscence.

A patient complains of pain. The nursing order calls for pain medication via injection. The patient is afraid of needles. The nurse can assist the patient through this stressful incident by encouraging the patient to think of a relaxing situation. The nurses actions can be identified as: a. restorative care. b. cognitive therapy. c. assertiveness training. d. progressive muscle relaxation

b. cognitive therapy. Rationale: Cognitive therapy teaches patients how certain thinking patterns cause symptoms of stress or depression. Cognitive therapy focuses on changing ways of thinking so that a patient feels empowered and in control of his or her own life. Restorative care occurs when a person has recovered from a stressful situation, and is taught stress management skills to reduce the number and intensity of stress responses in future situations. Assertiveness training teaches individuals to communicate effectively regarding their needs and desires. The ability to resolve conflict with others through assertiveness training reduces stress. When a group leader teaches assertiveness, the effects of interacting with other people increase the benefits of the experience. Progressive muscle relaxation diminishes physiological tension through a systematic approach to releasing tension in major muscle groups.

______________ which tries to understand a patients experience, sympathy takes a subjective look at the patients world (Oh, I know just what you mean. I hate feeling that way.). a. Sympathy b. Empathy c. Focusing d. Self-disclosure

b. empathy

A postoperative patient has denied the need for pain medication. The nurse has noted that the patient describes the pain as a 1 on a 0 to 10 scale. The nurse also notes that the patient grimaces when he or she changes position and guards the incision. The nurse believes that the patient is experiencing pain based on the information gathered in the assessment. What is this phenomenon known as? a. Cue b. Inference c. Diagnosis d. Health pattern

b. inference Rationale: The nurse made a judgment, which is an inference, that the patient is experiencing pain. An inference is a nurses judgment or interpretation of a cue.

________ refers to the principle of fairness: fair treatment and fair distribution of health care resources. a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

b. justice

A nurse is caring for a patient with a debilitating chronic illness. The patient mentions several times that faith would guide her healing. The nurse knows that faith can best be defined as a: a. system of organized beliefs and worship. b. relationship with a higher power, authority, or spirit. c. source of energy needed to cope with difficult situations. d. multidimensional concept that gives comfort while a person endures hardship.

b. relationship with a higher power, authority, or spirit. Rationale: Faith is a relationship with a divinity, higher power, authority, or spirit that incorporates a reasoning faith (belief) and a trusting faith (action). Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Spirituality exists in all people regardless of their religious beliefs and it gives people the energy needed to maintain health and cope with difficult situations. Hope is multidimensional and gives comfort while a person endures hardship and personal challenges.

A patient refuses to remove a specific spiritual garment for daily bathing. The most appropriate action for the nurse would be to: a. remove the article anyway because the garment hinders daily care delivery. b. respect the patients wishes and work around it. c. explain to the patient that the garment has no real spiritual value. d. identify the refusal as a sign of spiritual distress.

b. respect the patients wishes and work around it. Rationale: To care for and meet the spiritual needs of your patients, it is essential to respect each patients personal beliefs. People experience the world and find meaning in life in different ways and the spiritual garment has meaning for the patient. Caring for your patients spiritual needs requires you to be compassionate and remove any personal biases or misconceptions. You need to recognize that not all patients have spiritual problems. Patients bring certain spiritual resources that help them assume healthier lives, recover from illness, or face impending death.

Polypharmacy is: a. the use of unprescribed medication for recreational use. b. the prescription, use, or administration of more medications than are needed. c. very rare in older adults. d. rarely a problem as long as the medications are taken together.

b. the prescription, use, or administration of more medications than are needed. Rationale: Polypharmacy, the prescription, use, or administration of more medications than are indicated clinically, is a common problem of older adults. The combined use of multiple drugs causes serious problematic effects.

____________ involves speaking up for patient care issues from your unique perspective and advocating for humane and dignified care a. Competency b. Judgment c. Advocacy d. Utilitarianism

c. Advocacy

A _________________- is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patients status. a. Culture b. Validation c. Collaborative problem d. Defining characteristics

c. Collaborative problem

_____________ directs conversation to a specific topic or issue when a discussion becomes unclear. a. Sympathy b. Empathy c. Focusing d. Self-disclosure

c. Focusing

A young widower who lost his wife in Afghanistan has worked through the first task of Wordens mourning theory. He asks you if he will ever feel able to move forward with his life. According to Wordens theory, what is your best response? a. You will never love anyone as much as your wife. b. Nobody will ever be able to take your wifes place. c. It takes time to adjust to this type of loss, typically at least a year. d. Some people are able to move forward faster by suppressing the pain.

c. It takes time to adjust to this type of loss, typically at least a year. Rationale: Although the time needed varies from person to person, moving through Wordens tasks typically takes a minimum of 1 year. The other responses are not helpful to the patient.

A registered nurse working in a restorative care setting will focus on which areas? (Select all that apply.) a. Providing extensive supportive care b. Providing one-on-one care to patients c. Promoting patient self-care d. Promoting independence e. Promoting dying at home

c. Promoting patient self-care d. Promoting independence

_______________ communication is the interaction of one individual with large groups of people a. Interpersonal b. Intrapersonal c. Public d. Private

c. Public

A registered nurse is concerned about the patients perceptions and feelings about the quality of life that they experience after a diagnosis of liver cancer. Which is the most appropriate type of research study the nurse should use to gather information about this situation? a. Quantitative study b. Randomized trial c. Qualitative study d. Case controlled study

c. Qualitative study Rationale: Qualitative research offers analysis of interviews, observations, and/or surveys to measure peoples perceptions, feelings, or views of phenomena about which little is known.

A nurse who grew up in Korea has been in the United States for the past 4 years. The nurse is especially sensitive about the differences in how mourning is different between the native culture and that of Western society. The nurse should use which model of mourning to help understand an action-oriented process of grieving? a. Bowlbys Four Phases b. Wordens Four Tasks c. Randos R Process d. Kbler-Ross Five Stages

c. Randos R Process Rationale: Randos R Process Model of mourning is specific to Western society. Mourning is an action-oriented process involving recognizing the loss, reacting to the pain of separation, reminiscence, relinquishing old attachments, and readjusting to life after loss. Attachment, the foundation of Bowlbys (1980) four phases of mourning, is an instinctive behavior, which leads to the development of life-long bonds of affection between children and their primary caregivers. The four tasks of mourning theory (Worden, 1982) describes how individuals help themselves through mourning and ask others for help. Kbler-Ross (1969) classic theory identifies five responses to loss: denial, anger, bargaining, depression, and acceptance.

According to Maslow, which is the desire to become everything that one is capable of becoming. a. Basic needs b. Physiological needs c. Self-actualization d. Love and belongingness

c. Self-actualization Rationale: The highest level of needs on the hierarchy is self-actualization, which is the desire to become everything that one is capable of becoming

The ______________________ help produce guidelines for clinical practice. a. The Joint Commission b. A magnet-designated hospital c. The Centers for Disease Control and Prevention d. The American Association of Critical Care Nurses

c. The Centers for Disease Control and Prevention

A registered nurse has been working for an oncology unit for the past year and has a passion for caring for oncology patients undergoing chemotherapy. Whose responsibility is it for the nurse to become competent in administering chemotherapy? a. The hospital where the nurse is employed b. The charge nurse c. The nurse herself or himself d. The oncologist who admits patients to the unit

c. The nurse herself or himself Rationale: A nurses responsibility is to follow policies and procedures and to know the most current practice standards. As a nurse progresses in a career, it becomes his or her responsibility to obtain necessary continued education and earn certifications when he or she chooses to practice in specialty areas. Nurses must be accountable for their own actions; it is not the responsibility of the hospital, charge nurse, or oncologist for the nurse to be competent.

A mother of five children is admitted to the hospital for abdominal pain. The nurse asks a series of questions before performing a physical assessment. The patient answers the questions. When asking the patient some other questions, the patients spouse starts to answer. As the admission process progresses and the nurse gathers subjective data, the nurse requests that the patient answer the next questions. What is the rationale for the nurses behavior? a. The patient is exhibiting confusion. b. The spouse is being obnoxious. c. The patient is the best source of information. d. The spouse is too controlling.

c. The patient is the best source of information. Rationale: A patient is usually the best source of information. A patient who is alert and answers questions appropriately provides the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living. There is no evidence in the scenario to indicate confusion on the patients part or that the spouse was obnoxious or too controlling. The nurse needs more data before saying the spouse is obnoxious or controlling.

A nurse must give feedback to a nursing assistant that did not take vital signs. How should the nurse give feedback? a. How can I trust you when things dont get done like I asked? b. You are a bad assistant because you didnt do your tasks. c. The vital signs were not taken. What happened? d. Where did you learn to take vital signs?

c. The vital signs were not taken. What happened? Rationale: The best approach is: The vital signs were not taken. What happened? When you give feedback, make sure to focus on things that are changeable, choose only one issue at a time, and give specific details. Feedback given should be specific regarding any mistakes that staff members make, explaining how to avoid the mistake or a better way to handle the situation. Saying, How can I trust you? and You are a bad assistant. are both derogatory and they do not tell what specific task was not done. Where did you learn to take vital signs is not something that can be changed.

Which information indicates the nurse has a correct understanding of the purpose of a patients medical record? a. To invoice the nurse for reimbursement b. To protect the patient in case of a malpractice suit c. To ensure everyone is working toward a common goal of providing safe care d. To contribute to a worldwide databank for trends in health care

c. To ensure everyone is working toward a common goal of providing safe care Rationale: The medical record helps to ensure that all health team members are working toward a common goal of providing safe and effective care

A community health nurse states, I wish we had just a portion of the dollars spent repairing atherosclerotic hearts to teach the community about cardiovascular risk factors. The nurses statement stems from what philosophy? a. Deontology b. Feminist ethic c. Utilitarianism d. Ethics of care

c. Utilitarianism Rationale: Utilitarianism determines the value of something based primarily on its usefulness.

A nurse bases ethical decisions on the effect, or consequences, an act will have and uses the following guidelines: the greatest good for the greatest number of people. Which ethical system is the nurse using? a. Legal b. Deontology c. Utilitarianism d. Ethics of care

c. Utilitarianism Rationale: Utilitarianism guides us to measure the effect, or consequences, that an act will have. The greatest good for the greatest number of people is the guiding principle for action in this system

A patient is confused and is attempting to get out of the hospital bed. The nurse is tired after working for more than 10 hours and is concerned for the patients safety. What is the best action that the nurse should take to prevent the patient from harm? a. Restrain the patient with wrist restraints. b. Place the patient with a belt restraint in a chair. c. Sedate the patient with medication. d. Ask a family member to sit with the patient.

d. Ask a family member to sit with the patient. Rationale: Asking a family member to sit with the patient is the best answer because it does not restrain the patient physically or chemically.

A nurse is processing an ethical dilemma by focusing on relationships and stories of the participants. Which ethical system is the nurse using? a. Deontology b. Utilitarianism c. Feminist ethics d. Ethics of care

d. Ethics of care Rationale: Ethics of care suggest that health care workers resolve ethical dilemmas by paying attention to relationships and stories of the participants and by promoting a fundamental act of caring

A nursing student is working on a clinical assignment. Which information is acceptable for the student to write on the clinical care plan that will be given to the instructor? a. Patient room number b. Patient date of birth c. Patient medical record number d. Patient nursing diagnosis

d. Patient nursing diagnosis Rationale: The nursing diagnosis is acceptable information to give to a nursing instructor

A student nurse in the last semester of nursing school found that keeping a journal of clinical experiences helped the student nurse understand why certain actions were taken and to evaluate whether there was a better way of approaching the task. The student nurse has found that this has helped strengthen critical thinking skills. Which skill for developing critical thinking did the student nurse use? a. Professional standards b. Nursing process c. Concept mapping d. Purposeful reflection

d. Purposeful reflection Rationale: Purposeful reflection leads to a deeper understanding of issues and the development of judgment and skill. One activity that will help a nurse develop into a critical thinker is reflective journaling.

A 4-year-old boy has been admitted to the hospital with pneumonia. He has been in the hospital for 3 days and has suddenly started to become incontinent of urine. The nurse knows that this is most likely a result of what ego-defense mechanism? a. Compensation b. Conversion c. Denial d. Regression

d. Regression Rationale: Regression is coping with a stressor through actions and behaviors associated with an earlier developmental period. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite). Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain.

A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data? a. Heart rate of 96 b. Incisional erythema c. Emesis of 150 mL d. Sharp, burning pain

d. Sharp, burning pain Rationale: Sharp, burning pain is subjective. Subjective data are patients verbal descriptions of their health problems. Only patients provide subjective data

The patient was admitted to the hospital with advanced-stage cancer. As the nurse was admitting her, the patient told her about how her little dog learned a new trick, and could play dead when she said bang-bang. Why did the nurse listen attentively to the patients story? a. She knew it was easy to do and she had nothing else to do at that time. b. It was little more than two people talking back and forth. c. She knew it was probably not going to affect the patient-nurse relationship. d. She knew it was a way to know and respond to what matters to the patient.

d. She knew it was a way to know and respond to what matters to the patient. Rationale: True listening leads to knowing and responding to what really matters to a patient and family. Learning to listen to a patient is sometimes difficult. It is easy to become distracted by tasks at hand, colleagues shouting instructions, or other patients waiting to have their needs met. Caring is an interpersonal interaction that is much more than two persons simply talking back and forth. In a caring relationship a nurse establishes trust, opens lines of communication, and listens to what a patient has to say. Listening to the meaning of what a patient says creates a mutual relationship.

A registered nurse is documenting patient assessments. Which documentation written by the nurse is most clear? a. Seems comfortable at this time. b. Is asleep, appears not to be experiencing pain. c. Apparently is not in pain because patient didnt rate it high on the scale. d. States pain is a 2 on a 0 to 10 scale.

d. States pain is a 2 on a 0 to 10 scale. Rationale: States pain is a 2 is factual. To be factual, avoid words such as appears, seems, or apparently because they are vague and lead to conclusions that cannot be supported by objective information.

_____________ is a national agency that provides important sources of new scientific information that include standards and practice guidelines a. The Joint Commission b. Quality and Safety Education for Nurses (QSEN) c. The National Database of Nursing Quality Improvement (NDNQI) d. The Agency for Health care Research and Quality (AHRQ)

d. The Agency for Health care Research and Quality (AHRQ)

________________ refers to judgment about right and wrong behavior. a. Responsibility b. Privacy c. Ethics d. Moral behavior

d. moral behavior

_____________ are personal statements intentionally revealed to the other person. a. Sympathy b. Empathy c. Focusing d. Self-disclosure

d. self-disclosure

A nurse is an advanced practice registered nurse (APRN) who cares for geriatrics. This nurse is which type of advanced practice nurse? a. Clinical nurse specialist b. Nurse practitioner c. Certified nurse-midwife d. Certified registered nurse anesthetist

A. Clinical nurse specialist

Which will best assist a nurse in understanding a patients use of tying a silver dollar to the stomach of a newborn infant to heal an umbilical hernia? a. Cultural background b. Maslows Hierarchy of Needs c. World Health Organizations definition of health d. Primary prevention

A. Cultural background Rationale: Cultural background influences a persons beliefs, values, and customs. It influences personal health practices.

___________ exists when the right thing to do is not clear or when members of the health care team cannot agree on the right thing to do a. Ethical dilemma b. Code of ethics c. Bioethics d. Feminist ethics

A. Ethical dilemma

______________ level would be directed at the entire United States. a. National b. Community c. Individual d. Family

A. National level

A patient is depressed after a divorce and is not eating. The nurse is using Maslow to prioritize care. Which patient need should the nurse address first? a. Nutrition b. Emotional safety c. Depression d. Love and belonging

A. Nutrition Rationale: According to Maslow, individuals have to meet lower-level needs before they are able to satisfy higher-level needs

Health ___________ activities such as routine exercise and good nutrition help patients maintain or enhance their present levels of health and reduce their risks for developing certain diseases. a. Health promotion b. Health practices c. Health beliefs d. Holistic health

A. Promotion

Which information by a patient indicates teaching by the nurse was successful for the best definition of health? a. State of complete well-being b. Absence of disease c. Vital signs within normal range d. Maintenance of a normal weight

A. State of complete well-being. Rationale: -The World Health Organization defines health as a state of complete physical, mental, and social well-being, NOT merely the absence of disease or infirmary. -People without disease are NOT necessarily healthy. -Vital signs within normal range and maintenance of a normal weight DO NOT encompass the holistic definition of health

The _______ level of needs on the hierarchy consists of very basic physiological needs such as oxygen, water, food, sleep, and sex. A. Lowest B. Highest c. Third D. No level exist

A. lowest Rationale: Basic human needs (bottom on Maslow's model)

_______________ risk factors involve the physical functioning of the body. For example, conditions such as pregnancy or obesity place increased stress on __________ systems. A: physiological B: psychological C: spiritual D: Emotional

A: Physiological

Weight reduction and smoking cessation programs require patients to be _________ involved in measures to improve their present and future levels of wellness while decreasing the risk for disease. a. Active b. Passive c. Environmental d. Sociological

A: active

A nurse wants to use the most important competency in community nursing. Which competency should the nurse use? a. Caregiver b. Case manager c. Educator d. Epidemiologist

A: caregiver Rationale: The most important role is caregiving. Using the nursing process and critical thinking skills, a nurse develops appropriate, individualized nursing care for specific patients and their families.

___________ rehabilitation services would require admission to an _____________ facility. A: inpatient B: outpatient

A: inpatient

_______-term care insurance focuses on skilled nursing, not managed care. A: long B: short C: preterm D: incomplete

A: long

A nurse is teaching the importance of breast self-examination to a group of 20-year-old women. The nurse is promoting which type of care? a. Primary b. Secondary c. Tertiary d. Restorative

A: primary Rationale: Primary care is centered on prevention of disease.

________ illness is short term and intense but resolves.

Acute

External variables influencing a patients illness behavior include the: (select all that apply) A: visibility of symptoms B: social group C: cultural background D: economic variables E: accessibility of the health care system F: social support

Answer: A-F A: visibility of symptoms B: social group C: cultural background D: economic variables E: accessibility of the health care system F: social support All are external variables influencing a patients illness behavior

Family practices is an ____1______ variable, not an ____2_______ variable. A. 1: internal, 2: external B. 1: external, 2: internal C. 1: external, 2: independent D. 1: internal, 2: dependent

B. 1: external, 2: internal Rationale: Family practices is an external variable, not an internal variable.

A nurse teaches a patient about physiological risk factors. Which information by the patient indicates more teaching is needed? a. A physiological risk factor is heredity. b. A physiological risk factor is environment. c. A physiological risk factor is pregnancy. d. A physiological risk factor is obesity.

B. A physiological risk factor is environment. Rationale: The environment is not a physiological risk factor; the other options are physiological risk factors.

A nurse listens to a patients lungs and determines that the patient needs to cough and deep breath. The nurse has the patient cough and deep breath. Which concept did the nurse demonstrate? a. Accountability b. Autonomy c. Licensure d. Certification

B. Autonomy

A nurse working in a rural public health clinic is developing a smoking cessation program for patients in the county. This corresponds with Healthy People 2020s efforts to provide direction for health care efforts on what level? a. National b. Community c. Individual d. Family

B. Community Rationale: This is an example of a community program because it is for people in the county

__________ variables include family practices, socioeconomic factors, and cultural background. a. Cultural factor b. External variable c. Socioeconomic factor d. Internal variable

B. External

A patient with diabetes is diligent about testing blood sugar before meals. Which model is the nurse using when the nurse realizes the patient is taking preventative actions for health and represents the third component of this model? a. Basic Human Needs b. Health Belief c. Holistic Health d. Tertiary Prevention

B. Health Belief Rationale: The third component of the Health Belief model is the likelihood that a patient will take preventative action

__________ _________ are activities that individuals perform to care for themselves. a. Health promotion b. Health practices c. Health beliefs d. Holistic health

B. Health practices

A nurse must follow legal laws that protect public health, safety, and welfare. Which law is the nurse following? a. Code of Ethics b. Nurse Practice Act c. Standards of practice d. Quality and safety education for nurses

B. Nurse Practice Act

_______________ activities such as routine exercise and good nutrition help patients maintain or enhance their present levels of health and reduce their risks for developing certain diseases. a. This is an example of a health belief. b. This is an example of health promotion. c. This is an example of a negative health behavior. d. This is an example of a basic physiological human need

B. This is an example of health promotion.

_____________ is a service that provides short-term relief or time off for people providing home care to an ill, disabled, or frail older adult. a. Assisted living b. Respite care c. Nursing center d. Rehabilitation center

B. respite care

_____________ care focuses on health and staying out of the hospital. _____________care aims to increase access to care while decreasing costs. A: long B: managed C: short D: imcomplete

B: managed

A patient does not want the treatment that was prescribed. The nurse helps the patient talk to the primary health care provider and even talks to the primary health care provider when needed. The nurse is acting in which professional role? a. Educator b. Manager c. Advocate d. Provider of care

C. Advocate

A patient with newly diagnosed diabetes is concerned about the risk for developing foot ulcers because the mother had a foot amputated as a result of the disease. This is an example of which of the following? a. Health promotion b. Health practices c. Health beliefs d. Holistic health

C. Health beliefs Rationale: Health beliefs are a persons ideas and attitudes about health.

The _______ ________ model focuses on physical, social, psychological, and spiritual health and does not contain distinct components. a. Basic Human Needs b. Health Belief c. Holistic Health d. Tertiary Prevention

C. Holistic Health

Individual would focus on one person. a. National b. Community c. Individual d. Family

C. Individual

Influenza immunization and tetanus booster are illness __________ strategies. A: restorative B: Stress management C: prevention D: Treatment

C. Prevention

The ___________________ for nursing is an agency concerned with nursing education a. The Board of Nursing b. The American Medical Association c. The National League for Nursing d. The American Nurses Association

C. The National League for Nursing

Upon taking a history of a patient, the nurse learns the patient smokes a pack of cigarettes per day. How should the nurse interpret this finding? a. This is an example of a health belief. b. This is an example of health promotion. c. This is an example of a negative health behavior. d. This is an example of a basic physiological human need

C. This is an example of a negative health behavior.

A married father of four has recently been diagnosed with emphysema resulting from a long history of smoking. At a family counseling session a nurse helps the family to understand that this diagnosis is classified as a(n): a. acute illness. b. tertiary prevention. c. chronic illness. d. internal variable

C. chronic illness Rationale: Chronic illness is one that lasts more than 6 months.

The spouse of a patient with terminal cancer is refusing pain medication for the patient because of previous experiences with soldiers who became addicted to pain medication. A nurse will need to focus on which internal variable when approaching this situation? a. Developmental stage b. Family practices c. Intellectual background d. Spiritual factors

C. intellectual background Rationale: Intellectual background is a persons beliefs about health shaped in part by knowledge (or misinformation) about body functions and illnesses, educational background, and past experiences.

A patient needs long-term assistance with activities of daily living. a. Primary care center b. Restorative care center c. Assisted living center d. Respite center

C: assisted living centers

_____________ is intentional offensive touching without consent or lawful justification. a. Assault b. Unintentional tort c. Battery d. Felony

C: battery

"I have a problem with drinking, and I really think I need to work on it" is an example of the _____________ stage. a. Contemplation b. Precontemplation c. Maintenance d. Engagement

C: contemplation

A patient states, I will avoid social situations where people are drinking alcohol so I am not tempted to start drinking again. The nurse assesses the patient to be in which stage of change? a. Contemplation b. Precontemplation c. Maintenance d. Engagement

C: maintenance Rationale: Maintenance is the ability for sustained change over time. This stage begins 6 months after action has started and continues indefinitely. It is important to avoid relapse

_____________ involves health promotion such as prenatal care and well-baby care. a. Continuing care b. Restorative care c. Primary care d. Tertiary care

C: primary care

What form of insurance is a fee-for-service plan. a. Medicaid b. Medicare c. Private insurance d. A managed care organization

C: private insurance

_____________________ involves emergency and radiological procedures. a. Continuing care b. Preventative care c. Secondary acute care d. Restorative care

C: secondary acute care

_______________________ occurs when a disability is permanent, irreversible, and stabilized. a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health prevention

C: tertiary prevention

Antisocial behavior involves socially unacceptable actions. a. Illness b. Wellness c. Social d. Antisocial

D. Antisocial

A registered nurse is required to participate in a simulation to learn how to triage patients who are arriving to the hospital after exposure to an unknown gas. This is an example of a response to what type of influence on nursing? a. Workplace hazards b. Nursing shortage c. Professionalism d. Emergency preparedness

D. Emergency preparedness

15.When assessing what influences a patients health beliefs and practices, a nurse should consider both internal and external variables. Which is an example of an external variable? a. Intellectual background b. Emotional factors c. Spiritual factors d. Family practices

D. Family practices Rationale: Family practices is an external variable. Intellectual background, emotion factors, and spiritual factors are internal variable.

________ __________ generally is a comprehensive view of a person as a biopsychosocial and spiritual being. a. Health promotion b. Health practices c. Health beliefs d. Holistic health

D. Holistic Health

_________ is reflected in how a person lives his or her life, including the values and beliefs exercised, the relationships established with family and friends, and the ability to find hope and meaning in life. a. Values b. Family practices c. Intellectual background d. Spirituality

D. spirituality

___________________ provides evidenced-based objectives to: (1) achieve increased quality and years of healthy life, and (2) eliminate health disparities. a. Basic Human Needs Model b. Absence of Disease Model c. Holistic Health Model d. Healthy People 2020 Model

D: Healthy People 2020 Model

A registered nurse is working in a community clinic that provides services for chronically ill patients. Which condition would be considered chronic? a. Appendicitis b. Pneumonia c. Flu d. Diabetes

D: diabetes Rationale: A chronic illness usually lasts longer than 6 months; diabetes is a chronic illness

A student nurse is beginning the community-based primary care rotation. The student nurse anticipates that the assignment in community-based health care will most likely be at which organization? a. An acute care hospital b. A rehabilitation hospital c. A nursing home d. A high school

D: high schools Rationale: High schools focus on primary rather than acute care and provide knowledge about health and health promotion that occurs outside traditional health care institutions, such as hospitals, rehabilitation hospitals, and nursing homes.

A nurse allows a patient to place pictures of the family in the room. Which need is being met? a. Basic needs b. Physiological needs c. Self-actualization d. Love and belongingness

D: love and belongingness Rationale: In Maslow's hierarchy of needs, the third level on the hierarchy is love and belongingness, which is a desire to belong to groups. It consists of the need to feel love by others and to be accepted.

Upon taking a health history from a patient, the nurse notices the patient uses positive health behaviors. Which behavior did the nurse find? a. Smokes b. Eats poorly c. Has sedentary lifestyle d. Maintains proper sleep patterns

D: maintains proper sleep patterns Rationale: Positive health behaviors are activities related to maintaining, attaining, or regaining good health and preventing illness

_______________ focuses on health promotion. a. The Joint Commission b. National Priorities Partnership c. Accountable Care Organization d. Managed Care

D: managed care

A nurse must take into consideration illness behaviors of patients. Which is an internal variable the nurse should assess? a. Social support b. Visibility of symptoms c. Accessibility of the health care system d. Nature of the illness

D: nature of the illness Rationale: Internal variables influence the way patients behave when they are ill. These are a patients perceptions of symptoms and the nature of the illness.

A patient needs care of: short-term relief to persons who provide full-time care to an older adult. a. Primary care center b. Restorative care center c. Assisted living center d. Respite center

D: respite center

___________________ involves rehabilitation services and home care. a. Continuing care b. Preventative care c. Secondary acute care d. Restorative care

D: restorative care

_______________ involves intensive care and psychiatric facilities. a. Primary care b. Continuing care c. Restorative care d. Tertiary care

D: tertiary care

_______________ involves relatively short stays with the purpose of stabilizing patients before transfer to outpatient treatment centers.

Hospitalization

____________ variables include a patients developmental stage, and intellectual, emotional, and cultural background.

Internal

__________ health behaviors include activities that are harmful to health, including smoking. Health beliefs are a persons ideas, convictions, and attitudes about health and illness

Negative

_____________-___________ interventions are the independent nursing interventions or actions that nurses initiate.

Nurse Initiated

Administering a medication, implementing an invasive procedure (catheter and intravenous fluids), and preparing a patient for diagnostic tests are examples of what type of ____________________ interventions.

Physician-initiated Rationale: are dependent nursing interventions or actions that require an order from a physician or another health care professional.

Taking blood pressure medication every day is a ___________ prevention because the patient is trying to prevent further complications.

Secondary

Physical therapy after a cerebrovascular accident is intended to prevent further complications and deterioration and is ___________ prevention.

Tertiary Rationale: Instructing a patient to live with a known disability is tertiary prevention.

Which information by a nurse indicates more teaching is needed about The Joint Commissions requirements for writing plans of care? a. A care plan must be developed for patients in a clinic. b. A care plan must be developed for patients in an acute care hospital. c. A care plan must be developed for patients in a rehabilitation agency. d. A care plan must be developed for patients in an extended care facility.

a. A care plan must be developed for patients in a clinic. Rationale: The question indicates the nurse needs more teaching and The Joint Commission does not require a care plan for clinic patients. The Joint Commission standards require that a care plan, also called a plan of care, be developed for all patients on admission to acute, subacute, rehabilitation, or extended care agencies.

Which of the following is true for a patient to receive home hospice care? a. A primary caregiver must be living in the home. b. Caregiver support is available 9 AM to 5 PM daily. c. If the patient goes to the hospital, all prehospital orders are canceled. d. In the hospital, the home hospice care person must provide personal care.

a. A primary caregiver must be living in the home. Rationale: For a patient to receive home hospice care, a primary caregiver must be living in the home. The primary caregiver receives support from professional and volunteer hospice team members who are available 24 hours a day. If a patient receiving home hospice care goes to the hospital for the management of acute symptoms, a hospice nurse coordinates care between the home and hospital settings.

A nurse is performing an admission assessment on a middle-age patient. A normal change seen in this age group includes which of the following? (Select all that apply.) a. A progressive decrease in skin turgor b. Decreased visual acuity c. Decreased ability to solve practical problems d. Decreased strength of abdominal muscles e. Loss of accommodation

a. A progressive decrease in skin turgor b. Decreased visual acuity d. Decreased strength of abdominal muscles e. Loss of accommodation Rationale: Middle adulthood usually refers to those years between 40 and 65. Expected physical changes include a slow, progressive decrease in skin turgor, decreased abdominal strength, decreased visual acuity, and loss of accommodation of lens to focus light on near objects. The ability to solve practical problems based on experience peaks at midlife because of the ability for integrative thinking.

A college student with severe depression was recently admitted to the psychiatric ward of a local hospital. The family is concerned about the student finishing the college term. Which is the best information for the nurse to give regarding how long psychiatric patients are typically hospitalized? a. A relatively short inpatient stay is followed by outpatient treatment. b. A long inpatient hospitalization is normal for the majority of patients. c. Patients with emotional or behavioral problems generally are not hospitalized. d. Most are automatically placed in a long-term care facility.

a. A relatively short inpatient stay is followed by outpatient treatment. Rationale: Patients who have emotional and behavioral problems, such as depression, violent behavior, and eating disorders, often require special counseling and treatment in psychiatric facilities

A nurse is caring for a group of 6 and 7 year olds. The nurse remembers that, according to Kohlberg, moral development is a component of psychosocial development. Moral development depends on the childs ability to do which of the following? (Select all that apply.) a. Accept social responsibility. b. Respect the integrity and rights of others. c. Integrate principles of justice and fairness. d. Use symbols and objects on the way to abstract thinking. e. Perform repetitive motion responses.

a. Accept social responsibility. b. Respect the integrity and rights of others. c. Integrate principles of justice and fairness. Rationale: Moral development depends on the childs ability to accept social responsibility and integrate personal principles of justice and fairness. In addition, the childs knowledge of right and wrong and behavioral expression of this knowledge must be founded on respect and regard for the integrity and rights of others. Piagets theory, not Kohlbergs, states that as the child grows from infancy into adolescence, the intellectual development progresses, starting with reflex and repetitive motion responses, to the use of symbols and objects from the childs point of view, to logical thinking, and finally to abstract thinking.

A nurse is using critical pathways to care for a patient. Which area will the nurse address according to the pathway? a. Activity b. Nursing diagnosis c. Times to chart d. Admission form

a. Activity Rationale: Critical pathways are usually organized according to categories such as activity, diet, treatments, protocols, and discharge planning.

Which action indicates the new nurse is fulfilling entry-level competencies? a. Acts as a patient advocate b. Develops a theoretical framework for how to practice c. Manages care of one patient d. Establishes a quality improvement plan for the unit

a. Acts as a patient advocate Rationale: One of the competencies of an entry-level nurse is to be a patient advocate. Developing a theoretical framework is not a competency of a new nurse; that comes with experience and advanced education. An entry-level nurse should be able to care for several patients, not one. Establishing a quality improvement plan for the unit is a nurse managers role, not an entry-level competency.

The nursing student has severe test anxiety. When he receives a test in class, his heart rate increases, he feels more mentally alert, and his pupils dilate. According to the general adaptation theory, the nursing student should identify this response as what stage of the bodys reaction to stress? a. Alarm b. Resistance c. Adaptation d. Exhaustion

a. Alarm Rationale: During the alarm reaction, rising hormone levels result in increased blood volume, blood glucose levels, epinephrine and norepinephrine levels, heart rate, blood flow to muscles, oxygen intake, and mental alertness. In addition, the pupils of the eyes dilate to produce a greater visual field. During the resistance stage the body stabilizes and responds in an opposite manner to the alarm reaction. In the adaptation stage, antiinflammatory adrenocortical hormones are released, and healing occurs. However, if the stressor remains and adaptation does not happen, the person enters the third stage, exhaustion. The exhaustion stage occurs when the body is no longer able to resist the effects of the stressor and the struggle to maintain adaptation drains all available energy.

A nurse is caring for a 5-year-old child who is hospitalized for stabilization of asthma. To provide age-specific care, which of the following is the most appropriate action by the nurse? a. Allow the child to handle medical equipment. b. Have a parental presence at all times. c. Have the child lie flat and still during procedures. d. Tell the child as little as possible about expectations and care.

a. Allow the child to handle medical equipment. Rationale: These strategies can be used to reduce preschoolers fears when they are hospitalized: allowing children to sit up when performing assessments and procedures; allowing the child to see and handle equipment; allowing the child to assist with the procedure if appropriate; giving simple and factual information to these children because they have a great sense of imagination. Although preschoolers have developed object permanence and recognize their parents still exist when out of sight, most tolerate only short absences without becoming distressed. Encourage parents to tell the child when they are leaving and when they will return in terms the child can understand (e.g., I am leaving and will be back after lunch.).

A nurse tells a patient with a recent back injury that damage to the nerves is comparable to a water hose that has been pinched off and that time is needed to allow normal nerve transmission. Which technique did the nurse use? a. Analogy b. Discovery c. Role-playing d. Demonstration

a. Analogy Rationale: Analogies add to verbal instruction by providing familiar images that make complex information more real and understandable. Discovery is a useful tool for teaching problem solving and is a technique for cognitive learning. During role-play your patients play themselves or someone else in the situation. Demonstrations are useful when teaching psychomotor skills.

A middle-age patient with a terminal disease is speaking harshly to the nurse every time the call light is answered. The nurse identifies that this patient is experiencing the second stage of Kbler-Ross stages of dying. What is the second stage? a. Anger b. Denial c. Bargaining d. Acceptance e. Depression

a. Anger Rationale: Kbler-Ross (1969) classic theory identifies five responses to loss: denial, anger, bargaining, depression, and acceptance. Individuals in the denial stage act as though nothing has changed. They cannot believe or understand that a loss has occurred. In the anger stage, a person resists the loss, is angry about the situation, and sometimes becomes angry with God. During bargaining, the individual postpones awareness of the loss and tries to prevent the loss from happening by making deals or promises. A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interactions with others. During the stage of acceptance, the individual begins to accept the reality and inevitability of loss and looks to the future.

A registered nurse is working in a community clinic that provides services for acutely ill patients. Which condition would be considered acute? (select all that apply) a. Appendicitis b. Pneumonia c. Flu d. Diabetes

a. Appendicitis b. Pneumonia c. Flu Rationale: Appendicitis, pneumonia, and the flu are considered acute. The symptoms appear abruptly, are intense, and often subside after a relatively short period.

The nurse is caring for a patient who refuses to cooperate for a dressing change. The nurse tells the patient that he or she will tie the patient down if the patient does not hold still. Which action did the nurse commit? a. Assault b. Unintentional tort c. Battery d. Felony

a. Assault Rationale: Assault is an intentional threat toward another person that gives that person a reasonable fear of harmful contact. No actual contact is required for an assault to occur. An example of an assault in nursing practice is to threaten to restrain a patient for an x-ray procedure when the patient has refused consent

.A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process? a. Assessment b. Implementation c. Evaluation d. Diagnosing

a. Assessment Rationale: Assessment is the deliberate and systematic collection of data about a patient. The data will reveal a patients current and past health status, functional status, and present and past coping patterns

A nurse is teaching a group of nursing students about the nursing process. In which order should the nurse list the steps? a. Assessment, diagnosis, planning, implementation, and evaluation b. Diagnosis, assessment, planning, implementation, and evaluation c. Planning, evaluation, diagnosis, implementation, and assessment d. Evaluation, diagnosis, planning, implementation, and assessment

a. Assessment, diagnosis, planning, implementation, and evaluation

A 78-year-old widow needs assistance with medications, housekeeping, and laundry, and would like to maintain independence. Which is the best option for the nurse to suggest? a. Assisted living b. Respite care c. Nursing center d. Rehabilitation center

a. Assisted living Rationale: Assisted living provides independence, security, and privacy at the same time. These facilities promote independence and physical and psychosocial health. Services in an assisted living facility include medication management, exercise and educational activities, social activities, laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping.

Bowlbys phases of mourning are founded on which of the following human instincts? a. Attachment b. Numbing c. Searching d. Grief

a. Attachment Rationale: Attachment, the foundation of Bowlbys (1980) four phases of mourning, is an instinctive behavior, which leads to the development of life-long bonds of affection between children and their primary caregivers. In the numbing phase, a person has periods of extremely intense emotion and reports feeling stunned or unreal. The numbing phase lasts from several hours to a week. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, people need to experience this painful phase of grief.

A nurse is describing risk taking, creativity, and integrity in nursing care. What is the nurse explaining? a. Attitudes of critical thinking b. Competencies of critical thinking c. Standards for critical thinking d. Nursing process for critical thinking

a. Attitudes of critical thinking Rationale: The fourth component of the critical thinking model is attitudes. Paul (1993) identifies 11 attitudes that are central features of a critical thinker of which risk taking, creativity, and integrity are examples.

A 73-year-old patient with hypertension is awaiting a triple cardiac bypass surgery. The patient is hard of hearing and did not understand what the surgeon said regarding the surgery. The daughter is concerned that the patient does not understand the risks of the surgery. If not clarified, this would be a violation of what principle? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

a. Autonomy Rationale: Autonomy refers to a persons independence

Nurses working at a progressive health care organization participate in a decentralized decision-making framework where they are actively involved in nursing unit decisions. These nurses know that decentralization decision making includes which key elements? (Select all that apply.) a. Autonomy b. Prioritization c. Responsibility d. Authority e. Accountability

a. Autonomy c. Responsibility d. Authority e. Accountability Rationale: Decentralized decision making includes responsibility, autonomy, authority, and accountability. Prioritization is not a key element but does help with organizing care

A nurse has just admitted a 5-year-old child for suspected appendicitis. Which therapeutic communication techniques should the nurse use while communicating with this child? (Select all that apply.) a. Avoid sudden movements or gestures. b. Use simple, direct language. c. Sit at the childs eye level. d. Tell the child exactly what can do. e. Use drawing or toys as needed.

a. Avoid sudden movements or gestures. b. Use simple, direct language. c. Sit at the childs eye level. e. Use drawing or toys as needed. Rationale: Sudden movements or gestures can be frightening so they need to be avoided. When giving explanations or directions, use simple, direct language and be honest. Meet a child at eye level. Drawing and playing with young children allows them to communicate nonverbally (making the drawing) and verbally (explaining the picture). Telling the child exactly what can do is inappropriate. Remain calm and gentle and, if possible, let a child make the first move.

A 74-year-old patient was admitted to the hospital with diabetic ketoacidosis. How will the hospital be reimbursed by Medicare? a. Based upon the diagnostic-related group b. Based upon the cost of care c. Based upon the actual length of stay d. Based upon the number of medications

a. Based upon the diagnostic-related group Rationale: Payment is based upon the diagnostic-related group. Established by Congress in 1983, the prospective payment system eliminated cost-based reimbursement.

The mother of an 8-year-old girl has brought her daughter to the health clinic for her annual check-up. She is concerned about the high blood pressure in her family and asks the nurse if there is some way to know if the child is at risk for hypertension. What is the nurses best response? a. Blood pressure elevation in childhood is the single best predictor of adult hypertension. b. Well lets take her blood pressure and see if its up. If it is, she has hypertension. c. She looks pretty plump to me, and that indicates good health. As long as shes eating, she should be OK. d. If you think that shes gaining weight, put her on an exercise program, but wait until shes in her teens.

a. Blood pressure elevation in childhood is the single best predictor of adult hypertension. Rationale: Blood pressure elevation in childhood is the single best predictor of adult hypertension. This recognition has reinforced the significance of making blood pressure measurement a part of every annual assessment of the child. Measure on at least three separate occasions with the appropriate-size cuff and in a relaxed situation before concluding that the childs blood pressure is elevated and needs further medical attention. Childhood obesity is a prominent health problem, which increases the childs risk for hypertension, diabetes, coronary artery disease, and other chronic health problems. Daily exercise and maintaining normal body weight are important as both interventions and prevention even while in the preteen years.

When a person has difficulty progressing through his or her loss experience, he or she experiences complicated grief. What are the types of complicated grief? (Select all that apply.) a. Chronic b. Delayed c. Exaggerated d. Masked e. Disenfranchised

a. Chronic b. Delayed c. Exaggerated d. Masked Rationale: The four types of complicated grief are chronic, delayed, exaggerated, and masked. Disenfranchised grief occurs in situations in which others view a persons loss as insignificant or invalid. This is not a type of complicated grief.

A nurse walks into a room and finds a patient to be severely confused. The nurse examines and observes the patient closely and thinks about other situations with severely confused patients before making a nursing diagnosis. Which skill is the nurse using? a. Clinical inferences b. Reflective journaling c. Accountability d. Intuition

a. Clinical inferences Rationale: Part of diagnostic reasoning is clinical inference, the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a nursing diagnosis

A nurse is using a computer to locate and review laboratory test results, and chart and order sterile supplies. What type of system is the nurse using? a. Clinical information system b. Computerized provider order entry system c. Administrative information system d. Clinical decision support system

a. Clinical information system Rationale: Clinical information systems can be used by any clinician, including nurses, to plan, implement and evaluate care and can be used for charting, reviewing laboratory test results, and ordering sterile supplies. Administrative information systems comprise databases such as payroll, financial, and quality assurance systems. Computerized provider order entry (CPOE) refers to a process by which the health care provider directly enters orders for patient care into the hospital information system. The clinical decision support system (CDSS) links the nurse to the latest evidence-based practice guidelines at the point of care.

A nurse wants to become an advanced practice registered nurse (APRN) and have a higher degree of independence. Which advanced roles could the nurse pursue? (Select all that apply.) a. Clinical nurse specialist b. Nurse manager c. Nurse practitioner d. Nurse midwife e. Nurse anesthetist

a. Clinical nurse specialist c. Nurse practitioner d. Nurse midwife e. Nurse anesthetist

A nurse is evaluating care for a patient. Which action should the nurse take? a. Compares patient findings with the goals and outcomes b. Determines if interventions were completed c. Develops a nursing diagnosis d. Writes a care plan

a. Compares patient findings with the goals and outcomes Rationale: During evaluation you compare your findings with the goals and expected outcomes set for your patient. You conduct an evaluation to determine if expected outcomes are met, not if nursing interventions were completed. Develops a nursing diagnosis is the second step of the nursing process (diagnosis), not the last (evaluation). Writes a care plan occurs in the planning phase.

Although a registered nurse has been working for several years as a staff nurse on an adult oncology unit, the nurse recently transferred to a pediatric unit in the hospital. The nurse will be in orientation for several days to learn about the different systems and will need to demonstrate proficiency in various pediatric areas such as medication administration. Which behavior is the nurse demonstrating? a. Competency b. Judgment c. Advocacy d. Utilitarianism

a. Competency Rationale: In the practice of nursing, competence ensures the provision of safe nursing care (proficiency in pediatric medication administration). The agreement to practice with competence is a common denominator for all state regulations and is in the nursing code of ethics

A new nurse who has just begun working for an oncology unit is frustrated with trying to figure out the relationships between a patients problems and appropriate nursing interventions. What is the best tool that the nurse can use to synthesize data into meaningful information? a. Concept map b. Reflective journal c. Plan of care d. Intellectual standards

a. Concept map Rationale: A concept map is a visual representation of meaningful relationships between concepts (e.g., patient problems or nursing diagnoses and interventions), which then form propositions. Concept maps are visual road maps that highlight the meanings of these relationships. The primary purpose of a concept map is to synthesize relevant data about a patient such as assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures

Only one nurse was scheduled to care for 12 postsurgical patients with a nursing assistant. The nurse is concerned for the safety of the patients and the nursing license. What is the most appropriate first step in this situation? a. Contacting the nursing supervisor and documenting the action b. Refusing to care for the patients without appropriate help and leaving c. Contacting the State Board of Nursing and documenting the action d. Contacting the hospital administrator on call to complain and documenting the action

a. Contacting the nursing supervisor and documenting the action Rationale: If a nurse is assigned to care for more patients than is reasonable for safe care, he or she should notify the nursing supervisor. If the nurse is required to accept the assignment, he or she must document this information in writing and provide the document to nursing administrators. Although documentation does not relieve a nurse of responsibility if patients suffer harm because of inattention, it shows that the nurse attempted to act appropriately. Refusing to care for the patients without appropriate help and leaving could be regarded as abandonment

A registered nurse works as a case manager in the local hospital. What primary role will the nurse be fulfilling? a. Coordinating care for patients with a specific condition b. Only working with primary health care providers c. Directing care of all patients in the hospital setting d. Providing direct care to specific patients

a. Coordinating care for patients with a specific condition Rationale:What is unique about case management is that clinicians, either as individuals or as part of a collaborative group, oversee the management of patients with specific case types, focusing on length of stay and improving clinical outcomes (e.g., patients with specific diagnoses presenting complex nursing and medical problems such as heart failure or diabetes). Case managers work with social services, dietitians, and physical therapists to name a few. Case managers do not care for all patients, just a specific case type. Case managers do not provide direct care. Instead they collaborate with and supervise the care that other staff members deliver.

A postoperative patient is continuing to have incisional pain. As part of the nurses assessment, the nurse notes that the patient is grimacing when he or she changes position. The patients grimace can be useful in the assessment and can be described as which of the following? a. Cue b. Inference c. Diagnosis d. Health pattern

a. Cue Rationale: Grimacing is a cue. A cue is information that a nurse obtains through use of the senses

A 67-year-old male patient of French heritage is admitted to the hospital. The patient is interviewed by a nurse from a Korean family. The nurse did not make eye contact with the patient while conducting the interview. This disturbed the patient because the patient thought that the nurse might be trying to hide something. Which factor most likely influenced the behavior of the nurse and patient? a. Culture b. Validation c. Collaborative problem d. Defining characteristics

a. Culture Rationale: Communication and culture are interrelated in the way individuals express feelings verbally and nonverbally. When a nurse learns the variations in how people of different cultures communicate, he or she will likely gather more accurate information from patients.

Which behavior best indicates that the nurse is fulfilling ethical responsibilities? a. Delivers competent care b. Applies the scientific process c. Forms interpersonal relationships d. Evaluates new computerized technologies

a. Delivers competent care Rationale: Delivers competent care is the best example because the American Nurses Association (ANA) and the International Council of Nurses (ICN) publish codes of ethics for nurses that set principles of behavior for nurses to embrace.

A nurse is working in a busy emergency department of an urban hospital. The family of a patient brought in by ambulance asks the nurse what the doctor meant when he or she said that the patient was coding. In this situation, the word coding is an example of which of the following? a. Denotative meaning b. Connotative meaning c. Intonation d. Pacing

a. Denotative meaning Rationale: Coding in this instance is a denotative meaning. A single word sometimes has several meanings. Individuals who use a common language share the denotative meaning of a word. The word baseball has the same meaning for all individuals who speak English, but the word code denotes cardiac arrest primarily to health care providers.

The nurse is caring for a 65-year-old mother of three who recently underwent abdominal surgery and has a colostomy as a result. The patient has a history of multiple surgeries, including a tracheostomy after lung surgery about 20 years earlier that has since healed over. To determine how to best work with this patient, the nurse should do which of the following? a. Determine how the patient dealt with her previous surgeries. b. Realize that past coping mechanisms are always positive in nature. c. Approach care in a standard method because all patients are the same. d. Avoid using family input in determining the course of care.

a. Determine how the patient dealt with her previous surgeries. Rationale: Your nursing assessment includes consideration of previous coping behaviors. Knowing how a patient has dealt with self-concept stressors in the past provides insight into the patients style of coping. Not all patients address issues in the same way, but often a person uses a familiar coping pattern for newly encountered stressors. As you identify previous coping patterns, it is useful to determine whether these patterns have contributed to healthy functioning or created more problems. Exploring resources and strengths, such as availability of significant others or prior use of community resources, is important when formulating a realistic and effective plan.

A 34-year-old single mother of three had been involved in a secret relationship with her boss, a married man who was 24 years her senior. When her boss suddenly died as the result of a heart attack, the woman had difficulty expressing the extent of her loss. The grief that she was experiencing could best be described as which of the following? a. Disenfranchised b. Complicated c. Normal d. Anticipatory

a. Disenfranchised Rationale: Disenfranchised grief occurs in situations in which others view a persons loss as insignificant or invalid. For example, a grieving woman does not experience support from her parents when experiencing the loss of her ex-husband. Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away. Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). The process of letting go before an actual loss or death has occurred is called anticipatory grief.

A patient receiving blood after an abdominal surgery notified the nurse that the IV pump was alarming. The nurse checked the pump and determined that the tubing was kinked. The tubing was straightened out and the nurse left the room. Five minutes later the IV pump again alarmed. The nurse returned to find the tubing was again kinked. On further investigation, the nurse discovered that the IV tubing had become twisted. This is an example of which behavior on the part of the nurse? a. Effective problem solving b. Diagnostic reasoning c. Scientific method d. Commitment level of critical thinking

a. Effective problem solving Rationale: Effective problem solving involves evaluating the solution over time to be sure that it is still effective and if a problem occurs you try different options, which the nurse did in this scenario.

A nurse is teaching a patient the side effects of a medication as the nurse is giving the medication to the patient. Which attribute did the nurse display? a. Efficient care b. Effective care c. Using resources d. Using team communication

a. Efficient care Rationale: The nurse used efficient care. Efficient care conserves effort and minimizes interruptions. One way to be efficient is by combining various nursing activities (i.e., doing more than one thing at a time). This takes practice. For example, during medication administration or while obtaining a specimen, combine therapeutic communication skills, teaching interventions, and assessment and evaluation. Effective care is doing the right things, whereas efficient care is doing things right. The nurse did not use resources (equipment, other staff nurses) or team communication (talking to other nursing personnel) in this scenario

A nurse who works in a diabetes clinic has been asked to help a 12-year-old male patient learn to give his own insulin injections. The nurse demonstrates the technique on a teaching manikin and then asks the patient to demonstrate the task on the manikin while providing assistance. Which teaching approach did the nurse use? a. Entrusting b. Telling c. Participating d. Reinforcing

a. Entrusting Rationale: The entrusting approach provides the patient the opportunity to manage self-care. The patient accepts responsibilities and correctly performs the task while a nurse observes the patients progress and remains available for assistance

After a practice change has taken place in an organization because of a nurse following evidence-based practice in a task force, which final step should the nurse take? a. Evaluate b. Encourage c. Engage d. Execute

a. Evaluate Rationale: After applying evidence in practice, the next step is to evaluate the effect. Newhouse and White (2011) recommend that to be successful in changing practice within an organization, it is essential to Engage, Educate, Execute, and Evaluate. Engage and execute have already occurred because the change has taken place. Encourage is not a step in the evidence-based process.

male patient shares that, although he has a satisfying relationship with his wife, he is also attracted to men. He is confused and does not know how to deal with this issue. The nurse should do which of the following? a. Explain that the patients problem is one of orientation and high risk. b. Tell the patient that he has a sexual dysfunction and needs medication. c. Inform the patient that having relationships with other men is normal and risk free. d. Teach that STIs are fewer with men because most STIs are spread vaginally.

a. Explain that the patients problem is one of orientation and high risk. Rationale: Lesbian, gay, bisexual, or transgender (LGBT) individuals have unique stressors related to their sexual orientation. Peer, family, and social support is often lacking for this population that is at high risk for health issues such as STIs, HIV, depression, and victimization. Sexual dysfunction interferes with sexual health and is a problem with desire, arousal, or orgasm. Sexually transmitted infections (STI) are infections spread through oral, anal, or vaginal activity. The use of latex condoms can reduce the risk of STIs via any route of transmission.

A nurse is teaching the staff about the characteristics of a profession. Which information should the nurse include? (Select all that apply.) a. Extended education b. Theoretical body of knowledge c. Code of ethics for practice d. Practice developments e. Provision of a specific service

a. Extended education b. Theoretical body of knowledge c. Code of ethics for practice e. Provision of a specific service

A community-based nurse is working with a family. The nurse needs to be knowledgeable in what key areas? (Select all that apply.) a. Family theory b. Group dynamics c. Political affiliations d. Cultural diversity e. Communication principles

a. Family theory b. Group dynamics d. Cultural diversity e. Communication principles Rationale: The context of community-based nursing is family-centered care within the community. This focus requires the nurse to be knowledgeable about family theory, principles of communication, and group dynamics and cultural diversity. Political affiliations are not a key component of family-centered care.

A nurse is discharging a patient who required teaching about how to change a foot dressing. The nurse wants to ensure that the patient understands the signs and symptoms of infection and is preparing written materials the patient can take home and refer to as needed. Because the nurse does not know the patients reading ability, at which grade level should the nurse prepare the written materials? a. Fifth b. Sixth c. Eighth d. Ninth

a. Fifth Rationale: Individualize teaching materials to meet the patients needs and match the patients reading level; if a nurse does not know the patients reading level, information should be provided at a fifth-grade or lower level. Sixth-, eighth-, and ninth-grade levels are too high.

A nursing student is seeing a patient for the first time this morning. Which action should the nursing student perform first? a. Focused patient assessment b. Patient health history c. Medication administration d. Documentation

a. Focused patient assessment Rationale: When beginning a patient assignment, always conduct a focused but complete assessment of the patients condition and ask what outcomes the patient expects in his or her care. A patient health history is usually taken upon admission. Medication administration and documentation will occur after an assessment.

The nurse is beginning an assessment of a newly admitted patient. What are some recommended comprehensive assessment approaches the nurses can use? (Select all that apply.) a. Functional Health Patterns b. Nursing Diagnosis c. Problem-Focused Approach d. Nursing Intervention Classification e. Nursing Outcome Classification

a. Functional Health Patterns c. Problem-Focused Approach

Nurses demonstrate caring behaviors when they do which of the following? (Select all that apply.) a. Give clear explanations. b. Make the patient do everything for himself or herself. c. Tell the patient that getting pain medication depends on his or her cooperation. d. Share information about the patients responses with other staff members. e. Ask permission before doing something to the patient.

a. Give clear explanations. e. Ask permission before doing something to the patient. Rationale: Caring behaviors include being honest, advocating for the patients care preferences, giving clear explanations, keeping family members informed, asking permission before doing something to a patient, and providing comfort: Offering a warm blanket, finding food a patient can swallow, rubbing a patients back, reading patients passages from religious texts, a favorite book, cards or mail, providing for and maintaining patient privacy, assuring patients that nursing services will be available, helping patients to do as much for themselves as possible, and teaching families how to keep patients physically comfortable.

Interventions a nurse can use to establish presence with a patient include which of the following? (Select all that apply.) a. Giving attention b. Answering questions c. Listening d. Administering medication e. Speaking with the family

a. Giving attention b. Answering questions c. Listening Rationale: Behaviors that establish your presence include giving attention, answering questions, listening, and having a positive and encouraging (but realistic) attitude. Presence is part of the art of nursing that involves being with a patient versus doing for a patient, as in administering medication and speaking with the family. Presence is being able to offer closeness with the patient, which helps to prevent emotional and environmental isolation

______ is the measurable aspect of a persons increase in physical dimensions. a. Growth b. Development c. Maturation d. The latency stage of development

a. Growth Rationale: Growth is the measurable aspect of a persons increase in physical dimensions. Measurable growth indicators include changes in height, weight, teeth and bone, and sexual characteristics. Development is an interaction of biological, sociological and psychological forces. It occurs gradually and refers to changes in skill and capacity to function. These changes are qualitative in nature and difficult to measure in exact units. Maturation is the biological plan for the predictable milestones for growth and development. Physical growth and motor development are a function of maturation. The latency stage of development is part of Freuds psychoanalytic model of personality development. In the latency stage, Freud believed that the sexual urges from the earlier phallic stage are repressed and channeled into productive activities that are socially acceptable.

A nurse is presenting at an interdisciplinary meeting about the multiple external forces that are influencing nursing today. Which examples should the nurse include? (Select all that apply.) a. Health care reform b. Threat of bioterrorism c. Population demographics d. Role of nurse manager e. Nursing shortage

a. Health care reform b. Threat of bioterrorism c. Population demographics e. Nursing shortage

For a nurse to be effective in assisting patients with problems associated with loss and grief, what should the nurse do? (Select all that apply.) a. Help people acknowledge the reality of their loss. b. Encourage the use of a support network. c. Reinforce that people all grieve in the same way. d. Assure people that it will take a year to get over the loss, but it will end. e. Provide continuing support even after an extended time.

a. Help people acknowledge the reality of their loss. b. Encourage the use of a support network. c. Reinforce that people all grieve in the same way. e. Provide continuing support even after an extended time. Rationale: Nursing interventions help people acknowledge the reality of their loss. Encourage them to rely on their support network of family members, friends, professionals, and community resources. Reinforce the understanding that people grieve differently and that feelings change or resolve over time. Some people have anniversary reactions (heightened or renewed feelings of loss or grief) months or years after a loss. Offer reassurance that anniversary reactions are common, and encourage pleasant reminiscence. Provide continuing support. If you see the patient or family after an extended time, it is appropriate to ask them how they are doing after the loss. This gives them the opportunity to talk and lets them know that their loved one is remembered. The nurse should not tell people there is a specific timeline for grieving.

Using the health promotion model while rendering care enables a nurse to do which of the following? (Select all that apply.) a. Help the patient pursue health. b. Detect the presence of illness. c. Promote health behaviors in a patient. d. Assess a family's response to illness. e. Plan interventions to achieve self-actualization.

a. Help the patient pursue health. c. Promote health behaviors in a patient. Rationale: The purpose of the health promotion model is to explain the reasons that individuals engage in health activities and is not for use with families or communities. You will use this model to help your patients carry out healthy behaviors in their daily lives. This model helps the patient pursue health. Self-actualization is the final stage in Maslows hierarchy and does not relate to the health promotion model. This model does not focus on illness.

A businessman has been diagnosed with multiple sclerosis and has poor prognosis because the disease is progressing very quickly. To help the patient maintain a sense of hope, what should the nurse do? a. Help the patient set realistic goals. b. Assure the patient that he will be well cared for and does not need to do anything. c. Impress on the family the importance of limiting visiting hours to provide rest. d. Withhold negative information about the patients disease processes.

a. Help the patient set realistic goals. Rationale: To help patients feel more hopeful, remind them of their strengths and reinforce their expressions of courage, positive thinking, and realistic goal setting. Patients feel more hopeful when they have a sense of control. Family members of dying persons identified the importance of maintaining connections. When people have strong relationships and a sense of emotional connectedness to others, they know that help is available. Offer information to patients about their illness, correct misinformation, and clarify patients perceptions.

A patient was recently diagnosed with heart failure. The health care provider has ordered a low-sodium diet. A nurse is planning patient education for diet instruction. Which information should the nurse present first? a. How much daily intake of sodium is recommended b. How to read food labels at the grocery store c. How to understand the metric system of measurement d. How to cook different meals with low-sodium foods

a. How much daily intake of sodium is recommended Rationale: Present the daily intake of sodium first because material should progress from simple to complex because a person learns simple facts and concepts before learning how to make associations or complex interpretations of ideas. How to read food labels, the metric system, and how to cook different meals are more complex than the daily intake of sodium.

A patients daughter died in a ski accident. The patient stated, I cannot believe my daughter has died. According to Wordens tasks of mourning, the patient is experiencing task: a. I. b. II. c. III. d. IV.

a. I Rationale: Task II is working through the pain of grief. It is impossible to experience a loss without some degree of emotional pain. Individuals who deny or suppress the pain often prolong their grief. Task I occurs when the individual accepts the reality of the loss. Task III occurs when people adjust to the environment in which the deceased is missing. Task IV occurs when the person emotionally relocates the deceased and moves on with life.

A patient with newly diagnosed diabetes is being discharged from the hospital. The patient will be going to an outpatient diabetic center to learn more about diet, exercise, disease management, and insulin administration. Which statement made by the patient indicates that effective teaching can take place? a. I dont want to get sick again so I will do what is needed. b. I am so happy to be going home so I dont have to eat hospital food anymore. c. I will be glad when they find a cure for diabetes. d. I dont think I will need to take insulin for very long because I already feel better.

a. I dont want to get sick again so I will do what is needed. Rationale: Generally teaching and learning begin when a person identifies a need for knowing or acquiring an ability to do something. Focusing on hospital food, finding a cure, and not taking medications because feeling better indicate the patient is not motivated to learn at this time

A nurse is assessing a patients stage of behavioral change. Which statement by the patient will indicate to the nurse that the patient is in the preparation stage? a. I started to exercise regularly, but it didnt last long. Ill probably try again in a few weeks. b. I have a problem, and I really think I need to work on it. c. I am really working hard to stop smoking. d. There is nothing that I really need to change

a. I started to exercise regularly, but it didnt last long. Ill probably try again in a few weeks.

Which benchmarks will indicate to the nurse that the agency has computerized information systems that demonstrate meaningful use? (Select all that apply.) a. Improves quality and safety b. Improves patient compliance c. Improves care coordination d. Improves public health e. Improves hospitals reputation

a. Improves quality and safety c. Improves care coordination d. Improves public health Rationale: Meaningful use refers to the level with which information technology is available and used to support clinical decision making to improve quality, safety, and efficiency; reduce health disparities; engage patients and families in their health care; improve care coordination; improve population and public health; and maintain privacy and security. Patient compliance and hospitals reputation are not benchmarks for the mandates from the Patient Protection and Affordable Care Act.

Health care regulatory agencies, national think tanks, and government agencies expect health care organizations to incorporate cultural competence into policies and practices to ensure effective communication, patient safety and quality, and patient-centered care. Some examples of such organizational policies and practices include which of the following? (Select all that apply.) a. Instituting a requirement for all staff to be trained in cultural competence b. Maintaining the traditional description of family in written policies c. Enforcing strict visitation policies and practices d. Ensuring that persons who are deaf or speak limited English have access to an interpreter e. Embedding health literacy principles in written and verbal communication

a. Instituting a requirement for all staff to be trained in cultural competence d. Ensuring that persons who are deaf or speak limited English have access to an interpreter e. Embedding health literacy principles in written and verbal communication Rationale: Health care regulatory agencies, national think tanks, and government agencies expect health care organizations to incorporate cultural competence into policies and practices to ensure effective communication, patient safety and quality, and patient-centered care. Some examples of such organizational policies and practices include: instituting a requirement for all staff to be trained in cultural competence, embedding a broad description of family in written policies, expanding visitation policies and practices to include a patients preferences, requiring nursing staff to conduct and document a cultural assessment on all patients within the clinical documentation system, ensuring that persons who are deaf or speak limited English have access to an interpreter, and embedding health literacy principles in written and verbal communication.

A middle-age single woman has breast cancer and needs a mastectomy. She is concerned with future male relationships. She is crying and indicates that her life is over. According to Erikson, she occupies which stage? a. Intimacy versus Isolation b. Autonomy versus Shame and Doubt c. Identity versus Role Confusion d. Ego Integrity versus Despair

a. Intimacy versus Isolation Rationale: Intimacy versus Isolation (mid-20s to mid-40s): Intimate relationships with family and significant others; has stable, positive feelings about self; experiences successful role transitions and increased responsibilities. Autonomy versus Same and Doubt is usually found in children (1 year old to 3 years old) and involves increasing independence in thoughts and actions. In the Identity versus Role Confusion stage (usually in people 12 to 20 years of age) the individual accepts body changes/maturation, examines attitudes, values and beliefs, and feels positive about an expanded sense of self. In the late 60s until death, the person is usually in the Ego Integrity versus Despair stage and is interested in providing a legacy for the next generation

Which information indicates the nurse has a correct understanding of critical thinking? a. It is a continuous process characterized by open-mindedness. b. It is the same thing as the nursing process. c. It is a haphazard method of providing nursing care. d. It is moving from writing a plan of care to thinking.

a. It is a continuous process characterized by open-mindedness. Rationale: Critical thinking is a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant.

A nurse is caring for a patient with a terminal illness whose prognosis is grim. The nurse informs the family about hospice care. What should the nurse let them know about hospice care? a. It is designed for people who have less than a 6-month life expectancy. b. It is provided in the hospital setting. c. It helps to hasten the death process to relieve suffering. d. It has predetermined goals that will be explained at the right time.

a. It is designed for people who have less than a 6-month life expectancy. Rationale: Hospice care provides services for patients who are at the end of life. Patients who meet the criteria for hospice care generally have less than 6 months to live. Hospice teams provide care in many settingshome, hospital, or extended care facilitiesand provide physical, emotional, and spiritual care for patients and family members. Hospice care focuses exclusively on palliative care interventions to relieve the symptoms and burdens of illness or treatment and help patients live as fully as possible until death. Nurses base hospice care on a patients goals and support patient and family preferences for maintaining comfort and a high quality of life.

A smoker has confided to the nurse that he or she feels like a failure because he or she began smoking again after not having had a cigarette for more than a week. What is the nurses best response? a. Lets discuss what triggered you to start smoking again so you can avoid it in the future. b. You understand that smoking is the number one cause of death in the United States, correct? c. Did you know that your insurance premiums will increase if you continue to smoke? d. My mother died last year of lung cancer.

a. Lets discuss what triggered you to start smoking again so you can avoid it in the future. Rationale: -Relapse often feels like a failure, but the person needs to view it as a learning process. -Discussing possible triggers will allow learning to take place. ---What he or she learns from relapse can be applied to the next attempt to change. -Saying that smoking is the number one cause of death and insurance premiums will increase do not allow for learning to take place. -Saying that your mother died last year of lung cancer does not focus on patient learning, but rather focuses on the nurse, which is inappropriate.

A student nurse is administering an enema with an instructor in the room. The patient states that he or she can no longer hold the enema solution. The student nurse acknowledges the patients request and begins to tell the patient to go to the bathroom but asks the instructor if this is OK. The instructor suggests that the patient wait a few minutes to give the enema solution time to be absorbed into the bowel. In this situation the student nurse demonstrates what level of critical thinking according to Kataoka-Yahiro and Saylors model? a. Level 1: Basic b. Level 2: Complex c. Level 3: Commitment d. Level 4: Expert

a. Level 1: Basic Rationale: The student nurse is at the basic level because he or she asked the instructor what to do. At the basic level of critical thinking a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles. Complex critical thinkers begin to separate themselves from experts. In complex critical thinking you learn to synthesize knowledge. This means that you develop a new thought or idea based on your experience and knowledge over time. The third level of critical thinking is commitment. You anticipate the need to make choices without assistance from others. You accept accountability for whatever decisions you make. There is no level 4 in this model.

When dealing with cultural awareness, the nurse realizes that the term oppression involves which of the following? a. Maintaining advantages based on social group membership b. Systems that maintain disadvantages aimed purely at individuals c. Intentional discrepancies alone d. Issues at institutional levels independent of individual or cultural factors

a. Maintaining advantages based on social group membership Rationale: Oppression involves systems that maintain advantages and disadvantages based on social group membership and operate intentionally and unintentionally, at individual, cultural, and institutional levels.

A parent of three children has the oldest child start school this year, and the parent cries as the child is left at kindergarten on the first day. How is the loss that the parent is experiencing best described? a. Maturational b. Situational c. Actual d. Perceived

a. Maturational Rationale: People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain, changes in living arrangements. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include the loss job. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem.

A nurse working on a PICO question has found a large amount of literature available on the topic with multiple studies that have been published. Which type of study should have the best evidence? a. Meta-analysis of randomized control trials b. Opinion of an expert committee c. One well-designed randomized control trial d. Systematic review of descriptive and qualitative studies

a. Meta-analysis of randomized control trials Rationale: Systematic reviews or meta-analyses are state-of-the-science summaries from an individual researcher or panel of experts and are on the highest level of the hierarchy. These research summaries are the perfect answers to PICO(T) questions because the researchers have rigorously summarized all current evidence on the question. A single RCT is not as conclusive as a review of several RCTs on the same question. Opinion of an expert committee is on the lowest level of the hierarchy of evidence. Systematic review is above opinions but is below meta-analysis on the hierarchy of evidence.

The student nurse is discussing her 4-year-old patient with her nursing instructor. The instructor asks her about how Eriksons Developmental Tasks have an impact on a 4-year-old childs self-concept and sexuality. What is the best response? a. Mike identifies with his father. b. Mike likes to help dress himself. c. Mike is aware that he is too small to play football. d. Mike is looking forward to going to college when he gets bigger.

a. Mike identifies with his father. Rationale: Identifying with his father shows that the patient is in the proper stage for his age. In the Initiative Versus Guilt (3 to 6 years) the individual takes initiative, identifies with a gender, enhances self-awareness, and increases language skills, including identification of feelings. In the Autonomy Versus Shame and Doubt (1 to 3 years) the individual begins to communicate likes and dislikes, becomes increasingly independent in thoughts and actions, and appreciates body appearance and function (including dressing, feeding, talking, and walking). In the Industry Versus Inferiority stage (6 to 12 years) the individual incorporates feedback from peers and teachers, increases self-esteem with new skill mastery (e.g., reading, math, sports, music), strengthens sexual identity, and becomes aware of strengths and limitations. In the Identity Versus Role Confusion stage (12 to 20 years) the individual accepts body changes/maturation, examines attitudes, values, and beliefs; establishes goals for the future, and feels positive about expanded sense of self.

The nurse manager of a large medical unit in a busy urban teaching hospital reviews the unit trends for staffing, which are determined by an acuity system. The nurse manager notices that the acuity level is high. What should the nurse manager do? a. More staff may be needed. b. Talk to the patients. c. Less staff may be needed. d. Talk to the families.

a. More staff may be needed. Rationale: A high acuity means more staff may be needed. An acuity recording system determines the hours of care for a nursing unit and the number of staff required to care for a given group of patients. A low acuity would mean less staff is needed. Talking to the patients or family is not related to the acuity level.

A nurse wants to follow the American Nurses Associations Social Media Policy (2011). Which actions should the nurse take? (Select all that apply.) a. Never name or describe a patient. b. Never have a blog. c. Never post an image of the patient. d. Never disparage a fellow employee. e. Never report breaches of privacy.

a. Never name or describe a patient. c. Never post an image of the patient. d. Never disparage a fellow employee. Rationale: The American Nurses Association has developed a Social Media Policy (2011), which recommends that when using social media sites, a nurse should never name or describe a patient, never post an image of a patient, and never disparage a fellow employee or employer. In addition, the professional nurse has an obligation to report breaches of privacy and confidentiality. Never having a blog is not a recommendation

Which guidelines must the nurse follow to appropriately manage electronic patient information? (Select all that apply.) a. Never share passwords with co-workers. b. Only the supervisor should have the nurses password and it should be stored in a protected place. c. Leave the computer terminal unattended when logged on. d. Avoid leaving patient information displayed on a computer where others can see it. e. Keep the same password for as long as the nurse works at the agency.

a. Never share passwords with co-workers. d. Avoid leaving patient information displayed on a computer where others can see it.

A patient died from suspicious circumstances. What should the nurse do next? a. Notify the coroner. b. Notify the newspaper. c. Chart what the nurse thinks happened. d. Chart opinions from the health care staff.

a. Notify the coroner. Rationale: State statutes specify that, when there are reasonable grounds to believe that a patient died as a result of violence, homicide, suicide, accident, or death occurring in any unusual or suspicious manner, you need to notify the coroner.

A nurse is about to administer a medication and notices that the physicians or primary health care providers order looks incorrect regarding the amount of the medication. What should the nurse do? (Select all that apply.) a. Notify the physician or health care provider. b. Do not carry out the order. c. Document the suspicion that the dosage is incorrect. d. Administer the medication. e. Notify the supervisor or nurse manager.

a. Notify the physician or health care provider. b. Do not carry out the order. e. Notify the supervisor or nurse manager. Rationale: Nurses are responsible for carrying out medical treatment unless the physicians or health care providers order is in error, violates hospital policy, or is harmful to the patient. Therefore it is imperative to assess all orders and, if they appear to be erroneous or harmful to the patient, to obtain further clarification from the physician or health care provider. Do not carry out the order if there is a risk that harm will come to your patient; therefore do not administer the medication. Inform the nurse manager or the nursing supervisor. The nurse does not document suspicions or opinions, just objective, factual information.

A nurse completes an occurrence report. Which is the best way for the nurse to document this occurrence? a. Patient found lying on right side on floor. No noted injuries, patient stated, I slipped on a wet spot on the floor. I dont think I am injured. b. Patient slipped on a wet spot on the floor. No noted injuries, physician notified. c. Patient in too much of a hurry and was walking too fast and fell. Was not injured. Patient instructed to slow down and not be in such a hurry. Health care provider notified. d. Patient fell while going outside to smoke. Patient denied any injuries. Health care provider notified. Patient counseled.

a. Patient found lying on right side on floor. No noted injuries, patient stated, I slipped on a wet spot on the floor. I dont think I am injured.

A nurse is frustrated about the lack of staffing for the shift. When one of the patients fell and broke a hip, the nurse documented the incident in the patients chart. Which entry is the best way that the nurse should document what happened? a. Patient stated that fell while going to the bathroom. Physician notified. b. Nobody available to answer call bell; patient got up on own and fell. c. Patient fell because of unsafe staffing levels on unit. d. Patient waited as long as possible but nobody there to help and fell.

a. Patient stated that fell while going to the bathroom. Physician notified. Rationale: Charting should be factual. Patient stated that fell is the most factual. Do not write retaliatory or critical comments about patient or care by other health care professionals. Statements that are retaliatory or critical can be used as evidence for nonprofessional behavior or poor quality of care. Nobody available to answer call bell, fell because of unsafe staffing levels, or nobody to help are all retaliatory or critical comments and should not be used.

A registered nurse recently changed jobs and is now working in home health. What must the nurse chart to obtain reimbursement from Medicare, Medicaid, and private insurance companies? a. Patients response to care b. Whether patient had a good or bad day c. Whether family liked nurse or not d. Patients number of marriages

a. Patients response to care Rationale: When you provide home care, your documentation must specifically address the category of care and your patients response to care. Good or bad day is not factual or objective information. Whether family liked nurse or not and the number of marriages does not affect reimbursement.

A nurse is teaching the staff about the International Council of Nurses Code of Ethics. Which major element of the Code should the nurse include in the teaching session? a. People b. Pride c. Power d. Problems

a. People Rationale: The major elements of the Code include: Nurses and People; Nurses and Practice; Nurses and the Profession; and Nurses and Co-workers. It does not include pride, power, and problems.

The nurse is investigating an area of practice in which no research evidence is available. What types of non-research information should the nurse consider? (Select all that apply.) a. Performance improvement and risk management data b. International, national and local standards of care c. Study with pre- and post-test design d. Benchmarking e. Retrospective or concurrent chart reviews

a. Performance improvement and risk management data b. International, national and local standards of care d. Benchmarking e. Retrospective or concurrent chart reviews Rationale: Other sources of information from non-research evidence include: performance improvement and risk management data, international, national and local standards of care, infection control data, benchmarking, clinicians expertise, and retrospective or concurrent chart reviews. Study with a pre- and post-test design is a research study. The question asked for non-research information.

A nurse began working at a local hospital and learned that the hospital had just instituted a hand-off protocol. What will the nurse be doing? a. Performing transfer reports b. Completing IV fluid flow sheets c. Using standardized care plans d. Reviewing laboratory reports

a. Performing transfer reports Rationale: Examples of hand-off reports include change-of-shift reports and transfer reports. A hand-off report occurs any time one health care provider transfers care of a patient to another health care provider. The purpose of hand-off reports is to provide better continuity and individualized care for patients.

The mother of a 7-year-old boy asked the nurse what factors tended to increase self-esteem in boys. Which of the following is the nurses best response? a. Positive family communication supporting the childs self-worth. b. It does not really matter because self-esteem varies widely throughout life. c. Avoid situational crises because they lead to permanent changes in self-esteem. d. Let the child know that it is OK to be incompetent.

a. Positive family communication supporting the childs self-worth. Rationale: Self-esteem is an individuals overall sense of personal worth or value. Self-esteem is positive when one feels capable, worthwhile, and competent. Once established, basic feelings about the self tend to be constant, even though there is sometimes a little fluctuation. A situational crisis, like a hospitalization, often temporarily affects ones self-esteem.

A nurse is teaching the staff about the stages of change. Which information should the nurse include in the teaching session? a. Precontemplation, contemplation, preparation, action, maintenance b. Contemplation, preparation, action, maintenance, postmaintenance c. Contemplation, procrastination, preparation, action, maintenance d. Precontemplation, contemplation, preparation, action, engagement

a. Precontemplation, contemplation, preparation, action, maintenance Rationale: Precontemplation, contemplation, preparation, action, and maintenance are the five phases of change

The nurse is administering flu vaccines. One of the children who is scheduled to receive the vaccine is afraid of needles and is tearful, and his younger brother is trying to calm him down. The nurse knows that the tearful child has evaluated this event as challenging and therefore is experiencing psychological stress caused by which of the following? a. Primary appraisal b. Coping c. Secondary appraisal d. Dissociation

a. Primary appraisal Rationale: When a person encounters an event, there is an immediate process of primary appraisal or rating of the event. If this appraisal results in the event being identified as a potential harm, loss, threat, or challenge, the person has stress. Coping refers to strategies or practices that help people deal with stress. Following the recognition of stress, secondary appraisal focuses on the resources or coping strategies that can meet the stress. Dissociation is experiencing a subjective sense of numbing and a reduced awareness of ones surroundings.

Which leadership skills should a nursing student use when caring for patients? (Select all that apply.) a. Priority setting b. Time management c. Case management d. Delegation e. Team communication

a. Priority setting b. Time management d. Delegation e. Team communication Rationale: Priority setting, time management, delegation, and team communication are all leadership skills. Student nurses do not perform case management and case management is not a leadership skill but an approach to delivery of patient care.

A nurse is told during orientation that the organization is very patient focused and that it uses a documentation system with the acronym PIE. What will the nurse be charting? a. Problem, intervention, evaluation b. Patient, interview, evaluation c. Population, intervention, encourage d. Plan, interview, enhance

a. Problem, intervention, evaluation Rationale: PIE is an acronym for problem, interventions, evaluation as follows: P: Problem or nursing diagnosis applicable to patient I: Interventions or actions taken E: Evaluation of the outcomes of nursing interventions

The patient is on a ventilator and has a heartbeat, but is brain dead. What should the nurse do? a. Provide a private area to discuss organ donation. b. Explain that as long as the heart is beating, the patient is alive. c. Inform the family that the organs will be harvested when he is off the ventilator. d. Stress the importance of leaving the patient on the ventilator to harvest the corneas.

a. Provide a private area to discuss organ donation Rationale: Provide a private area for the family to discuss organ donation if this is an option. Many people do not understand brain death. Family members often believe that the person is still alive because his or her heart is still beating. For their loved one to donate major organs (e.g., heart, lungs, liver), the body must be kept in good functional condition so the organs will not become damaged before donation. The patient remains on a ventilator until his or her organs are removed. Nonvital tissues such as corneas, skin, long bones, and middle ear bones can be removed at the time of death without maintaining vital functions.

A public health nurse knows that for those patients who already have a chronic disease, the best way to help them manage their illness is to take which action? a. Provide holistic patient education. b. Consult with a disease specialist. c. Review their long-term health insurance policy. d. Provide disease-specific patient education

a. Provide holistic patient education. Rationale: The nurse should use a holistic approach to patient education to help patients manage their disease. This education enhances wellness and improves quality of life for patients living with chronic illnesses or disabilities. Consulting with a disease specialist, reviewing insurance, and providing disease-specific education are too narrow a focus

The ANA, National League for Nursing, AONE, and American Association of Colleges of Nursing recommend strategies to reverse the current nursing shortage. A number of the strategies have potential for creating work environments that enable nurses to demonstrate more caring behaviors. Which of the following provisions is advocated to create a more desirable work environment? a. Provide nurses with autonomy over their practice. b. Increase the rigor in the work environment structure. c. Increase the availability of technology. d. Stress the cost-effectiveness of health care.

a. Provide nurses with autonomy over their practice. Rationale: To create environments conducive to caring, health care organizations must introduce greater flexibility into the work environment structure, reward experienced nurse mentors, offer programs for compassion fatigue, improve nurse staffing, and provide nurses with autonomy over their practice. A reliance on technology and cost-effective health care strategies and efforts to standardize and refine work processes all undermine the nature of caring.

The nurse is caring for a patient who has just passed away. What should she do? a. Provide postmortem care in a manner consistent with religious or cultural beliefs. b. Place the body in a supine position to prevent disfigurement. c. Ask family to leave the room since they do not know how to provide care. d. Remove all tubes before determining if an autopsy will be done.

a. Provide postmortem care in a manner consistent with religious or cultural beliefs. Rationale: A nurse assumes responsibility for postmortem care (i.e., care of the body after death). Give postmortem care with dignity and sensitivity and in a manner consistent with a patients religious or cultural beliefs. Because a body undergoes many physical changes after death, elevate the head of the bed to 30 degrees or place the patients head on pillows to prevent pooling of blood, which can discolor the face. Ask family members if and how they would like to help care for the body. Make arrangements for a member of the professional staff (e.g., spiritual care provider) to stay with family members if they do not wish to participate in body care. Remove all catheters, tubes, or indwelling devices from the patients body, except in the case of autopsy. In that case leave medical devices in place.

A registered nurse who worked in an extended care facility could see that a patient was in the process of dying. The lab technician came to draw his blood. The nurse requested that the blood draw be postponed for a while so that the patients wife, who was at his bedside, could spend some quiet time with her husband. This is an example of which caring behavior? a. Providing presence b. Encouraging manner c. Healing environment d. Affiliation needs

a. Providing presence Rationale: Providing presence is a person-to-person encounter conveying closeness and a sense of caring. Presence occurs within an atmosphere of intimacy and sensitivity and is characterized by open and honest interactions. An encouraging manner occurs when a nurse is poised and cheerful and points out the good in a difficult situation, patients perceive these behaviors as caring. Having an encouraging manner also involves helping patients deal with bad feelings. A healing environment, for example, is one in which nurses check patients frequently, respect patient privacy, reduce noise, and treat the body carefully. Attending to affiliation needs occurs in nursing practice with the inclusion of family members in a patients care. It is a key element in discharge planning. Hospitalized patients perceive nurses as caring when they are responsive to patients families and allow them to be involved in the patients health care situation. Often these behaviors overlap.

A patient recently had a stroke and suffered right-sided weakness. The patient is being discharged from a rehabilitation hospital after learning to use a walker. Which learning domain was primarily used to teach the patient to be independent with the walker? a. Psychomotor b. Affective c. Cognitive d. Motivational

a. Psychomotor Rationale: Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills. Examples of psychomotor learning include learning to walk with a walker or giving an insulin injection

The nurse is attempting to teach a patient how to perform wound care for when he goes home. Using the teach back method the nurse should do which of the following? a. Repeat the instructions until the patient understands. b. Present the information and clarify with closed-ended questions. c. Ask the patient if he understands the instructions. d. Ask if the patient has any questions about the technique.

a. Repeat the instructions until the patient understands. Rationale: The teach back technique is an ongoing process of asking patients for feedback, through explanation or demonstration, and presenting information in a new way until you feel confident that you communicated clearly and patients have a full understanding of the information presented. Using teach back can also help you identify explanations and communication strategies that patients most commonly understand. When using the teach back technique, do not ask the patient, Do you understand? or Do you have any questions? Instead you should ask open-ended questions to verify the patients understanding.

When a nurse suspects child abuse or neglect, which action must the nurse take? a. Report it to the proper legal authority. b. Inform the parents that their actions are illegal. c. Call the security department to handle the problem. d. Prevent the parents from seeing the child during hospitalization.

a. Report it to the proper legal authority Rationale: Health care providers are required to report incidents such as child, spousal, or elder abuse; rape; gunshot wounds; attempted suicide; and certain communicable diseases. Health care providers are provided legal immunity if the report is made in good faith. Not reporting suspected child abuse or neglect can cause a nurse to be liable in civil or criminal legal actions. It is not the nurses responsibility to inform the parents of illegal activity or to prevent the parents from seeing the child. The nurse is responsible for reporting the suspected abuse, not call security to handle the problem.

A primary nurse caring for a patient with kidney failure develops a plan of care for the patient after consulting with the patient on the best way to manage the patients diet. As the staff delivers the plan of care the primary nurse evaluates whether the plan is working. Which attribute is the primary nurse displaying? a. Responsibility b. Interprofessional collaboration c. Delegation d. Staff involvement

a. Responsibility Rationale: Responsibility refers to the duties and activities that an individual is employed to perform. For example, a primary nurse is responsible for completing a nursing assessment of all assigned patients and developing a plan of care that addresses each of the patients nursing diagnoses. As the staff delivers the plan of care, the primary nurse is responsible for evaluating whether the plan is successful and what to do when it is not successful

A nurse decides to withhold a medication because it will further lower a patients respiratory rate. In this case, the nurse is practicing what principle? a. Responsibility b. Privacy c. Ethics d. Moral behavior

a. Responsibility Rationale: Responsibility refers to the execution of duties associated with a nurses role. For example, when administering a medication, you are responsible for assessing the patients need for the medication, giving it safely and correctly, and evaluating the patients response to it.

A patient is admitted to the hospital for hip replacement surgery after falling at home and breaking a hip. The patient has developed pneumonia while in the hospital and has required frequent suctioning from the tracheostomy. The nurse decides to delegate I&O to the unlicensed assistive personnel but does not delegate suctioning. This is an example of which of the five rights of delegation? a. Right task b. Right direction/communication c. Right intervention d. Right supervision

a. Right task Rationale: This is the right task because the nurse delegated I&O, but not tracheostomy suctioning. The right task is one that you can delegate for a specific patient, such as tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have minimal potential risk.

A nurse is caring for an adult patient who retired last year. While rendering care, the nurse identifies that the patient is struggling emotionally with this change. This situation is most likely associated with what self-concept component? a. Role performance b. Identity stressors c. Self-esteem d. Body image stressors

a. Role performance Rationale: Role performance is the way in which a person views his or her ability to carry out significant roles. Common roles include mother or father, wife or husband, daughter or son, sister or brother, employee or employer, and nurse or patient. Identity stressors affect an individuals identity, but identity is particularly vulnerable during adolescence. Self-esteem stressors vary with developmental stages. Potential self-esteem stressors in older adults include health problems, declining socioeconomic status, spousal loss or bereavement, loss of social support. Body image stressors involve attitudes related to the body, including appearance, femininity and masculinity, youthfulness, health, and strength.

An elderly patient is dying, and begins talking to loved ones who have died before him. The nurse feels a sense of inner peace as his patient quietly dies. What is the best term for this feeling of peace? a. Self-transcendence b. Intrapersonal connectedness c. Interpersonal connectedness d. Transpersonal connectedness

a. Self-transcendence Rationale: Self-transcendence refers to connecting to your inner self, which allows you to go beyond yourself to understand the meanings of experiences, whereas transcendence is the belief that there is a positive force outside of and greater than oneself that allows you to develop new perspectives that are beyond physical boundaries. Examples of transcendent moments include the feelings of awe when holding a new baby or watching the sun rise over the mountains. Spirituality offers a sense of connectedness intrapersonally (connected with oneself), interpersonally (connected with others and the environment), and transpersonally (connected with God, the unseen, or a higher power).

______ psychoanalytic model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and instinctive forces. Each of the five stages is associated with a pleasurable zone, serving as the focus of gratification. a. Sigmund Freud b. Jean Piaget c. Erik Erikson d. Lawrence Kohlberg

a. Sigmund Freud

This model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and aggressive energies. Who is responsible for developing this theory? a. Sigmund Freud b. Jean Piaget c. Erik Erikson d. Lawrence Kohlberg

a. Sigmund Freud Rationale: Sigmund Freud (1856-1939) provided the first formal structured theory of personality development. Freuds psychoanalytic model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and aggressive energies

An 8-year-old boy has been diagnosed with diabetes. A nurse is teaching his mother how to plan meals that are appropriate for him. The nurse asks the mother to put together a 24-hour meal plan for her son and then reviews the plan with her. What type of teaching method did the nurse use? a. Simulation b. Role-play c. Analogy d. Demonstration

a. Simulation Rationale: Simulation is a useful technique for teaching problem solving, application, and independent thinking. During individual or group discussion, the nurse presents a problem or situation pertaining to the patients learning for patients to solve

A registered nurse is caring for a postoperative patient who is experiencing respiratory distress after the administration of pain medication. The nurse called the patients primary health care provider immediately. The information regarding the patient was conveyed using the SBAR format. Which information did the nurse convey to the primary health care provider? a. Situation, background, assessment, recommendation b. STAT, background, assessment, requirement c. Status, background, analysis, recommendation d. Setting, belief, assessment, requirement

a. Situation, background, assessment, recommendation

A nurse is describing types of performance improvement models. Which information should the nurse include? (Select all that apply.) a. Six Sigma b. Balanced scorecard c. Plan-Do-Study-Act d. Root cause analysis e. Human subjects committee

a. Six Sigma b. Balanced scorecard c. Plan-Do-Study-Act d. Root cause analysis Rationale: Performance improvement models include Six Sigma, balanced scorecard, Plan-Do-Study-Act, and root cause analysis. Research studies must be approved by an institutional review board (IRB), also called a human subjects committee, which is not involved with performance improvement models but with research.

A patient must learn to apply a lower leg orthotic device but has a minor paralysis of the right upper extremity. Before teaching this skill, the nurse must assess the patients physical capabilities. Which areas will the nurse assess? (Select all that apply.) a. Size b. Strength c. Coordination d. Sensory acuity e. Learning environment

a. Size b. Strength c. Coordination d. Sensory acuity Rationale:The nurse is assessing physical capability, which includes size, strength, coordination, and sensory acuity

The quality improvement or performance improvement (QI/PI) process should begin at which level of nursing? a. Staff nurse b. Nurse manager c. Nurse administrator d. Advanced practice registered nurse

a. Staff nurse Rationale: The QI/PI process begins at the staff level, where all disciplines become involved in identifying quality problems. Although all those listed can do QI/PI, the process begins at the staff level.

Nurses care for a variety of patients. What is an activity that best demonstrates the caring role of a nurse? a. Staying with a patient and developing a plan of care before surgery b. Performing IV insertion with confidence c. Assessing the patients entire health history d. Inserting a urinary catheter using aseptic technique

a. Staying with a patient and developing a plan of care before surgery Rationale: Caring is highly relational. A nurse and a patient enter into a relationship that is much more than one person simply doing tasks for another. There is a mutual give-and-take that develops as nurse and patient begin to know and care for one another. As a nurse-patient relationship forms, a nurse becomes a coach and partner rather than a detached provider of care. Performing an IV insertion, assessing a health history, and inserting a catheter are all tasks that can be accomplished with or without a caring nurse-patient relationship being developed.

A nurse is performing a community assessment. Which areas should the nurse include? (Select all that apply.) a. Structure b. Population c. Social systems d. Environment e. Vital signs

a. Structure b. Population c. Social systems Rationale: A complete assessment examines structure or locale, population or people, and social systems.

A registered nurse (RN) works on a unit with other registered nurses, licensed practical nurses (LPN), and nursing assistive technicians. Usually a RN, LPN, and nursing assistive technician provide direct care for a group of patients. The RN coordinates all of the care the others provide. Which type of nursing care delivery models is the RN using? a. Team nursing b. Case management c. Primary nursing d. Total patient care

a. Team nursing Rationale: In team nursing the RN leads a team of other RNs, practical nurses, and unlicensed assistive personnel (UAP). Team members provide direct patient care under supervision of the RN. The team leader develops patient care plans, coordinates care among team members, and provides care requiring complex nursing skills. Total patient care is a nurse delivering total care to one or two patients. Case management is one nurse managing care for a specific type of patient from admission to discharge to home. The case management nurse does not provide direct patient care. When one primary RN assumes responsibility for a caseload of patients with the help of associate nurses, primary nursing is being implemented.

A nurse is caring for a patient who is having abdominal pain and is experiencing difficulty sleeping. The nurse sits at the bedside of the patient and takes the patients hand. The patient quickly pulls back. How should the nurse interpret this patients behavior? a. The patient is uncomfortable with being touched. b. The patient is unable to express feelings. c. The patient has impaired social skills with others. d. The patient has difficulty with nonverbal communication

a. The patient is uncomfortable with being touched.

To establish the elements of malpractice against a nurse, which must be proved by the patient? a. The patient must have been harmed as a result of the injury. b. The patient must have paid for the health care services. c. The patient must show evidence of malicious intent. d. The patient must demonstrate personal accountability.

a. The patient must have been harmed as a result of the injury. Rationale: To establish the elements of malpractice, the patient or plaintiff must prove the following: (1) the nurse defendant owed a duty to the patient, (2) the nurse breached that duty, (3) the patient was injured because of the nurses breach of duty, and (4) the patient has accrued damages as a result of the injury. The patient paying, showing evidence of malicious intent, and demonstrating personal accountability are not elements of malpractice.

The nurse has just completed an assessment on a patient with a fractured right femur. Which data will the nurse categorize as objective? a. The patients toes of right foot are warm and pink. b. The patient reports a dull ache in the right hip. c. The patient says feels tired all the time. d. The patient is concerned about insurance coverage.

a. The patients toes of right foot are warm and pink. Rationale: Toes pink and warm are objective data. Objective data are observations or measurements of a patients health status.

The nurse is performing a cultural assessment on a patient. What does the nurse know about cultural assessments? a. They are intrusive and time consuming. b. They are not dependent on a trusting relationship. c. They are rarely plagued by miscommunication. d. They are based in similarities of behavior

a. They are intrusive and time consuming. Rationale: In contrast to other types of interviews, cultural assessment is intrusive and time consuming and requires a trusting relationship between participants. Miscommunication commonly occurs in intercultural transactions. This is because of language communication differences between and among participants and differences in interpreting each others behaviors. Nurses use transcultural communication skills to interpret a patients behavior within his or her own context of meanings and to behave in a culturally congruent way.

Which information by the staff indicates teaching by the nurse was successful for the purposes of documentation? (Select all that apply.) a. To aid in clinical research b. To maintain a legal and financial record of care c. To include a step-by-step description of how to perform procedures d. To evaluate quality process and performance improvement e. To communicate patient needs and progress toward meeting outcomes

a. To aid in clinical research b. To maintain a legal and financial record of care d. To evaluate quality process and performance improvement e. To communicate patient needs and progress toward meeting outcomes Rationale: Documentation serves multiple purposes, including communication, legal documentation, reimbursement, education, research, and quality process and performance improvement. Step-by-step description of how to perform procedures is in a policy and procedure manual, not a chart

A community health nurse is using the goals of the Healthy People 2020 to focus care. Which goal is the priority? a. To increase the life expectancy of people in the United States b. To increase the health status of people throughout the world c. To eradicate the human immunodeficiency virus (HIV) d. To reduce health care costs

a. To increase the life expectancy of people in the United States Rationale: The overall goals of Healthy People 2020 are to increase the life expectancy and quality of life and to eliminate health disparities through an improved delivery of health care services to people in the United States. The focus is on the United States, not the world. It does not focus on one disease or on reducing health care costs.

A new registered nurse who recently began working in a nursing center has been asked to complete a Resident Assessment Instrument (RAI) on a newly admitted resident. What is the primary purpose of this instrument? a. To provide a database to better understand the health care needs of this population b. To provide the nursing staff with an overall physical assessment of the resident c. To provide statistical evidence to support a universal health care policy d. To provide medications for the residents to take on a daily basis

a. To provide a database to better understand the health care needs of this population Rationale: The facility needs to complete the RAI on all residents. The RAI consists of the Minimum Data Set (MDS), Resident Assessment Protocols (RAPs), and utilization guidelines of each state. The RAI ultimately provides a national database for nursing facilities so that policy makers will better understand the health care needs of the long-term care population. Although it does provide a physical assessment, the primary purpose is to better understand the needs of this population. It does not provide evidence for a universal health care policy or medications to be used for this population group.

A nurse is caring for a patient and performs several interventions. Which action by the nurse is an independent nursing intervention? a. Turning every 2 hours b. Administering a medication c. Inserting an indwelling catheter d. Starting an intravenous (IV) for intravenous fluids

a. Turning every 2 hours Rationale: According to state Nurse Practice Acts, independent nursing interventions pertain to ADLs (turning), health education and promotion, and counseling

A middle-age female model is admitted for a double mastectomy. On admission the nurse notes that she is depressed and withdrawn. The most appropriate patient-centered nursing intervention(s) might be which of the following? (Select all that apply.) a. Use a positive and matter-of-fact approach to care. b. Include the patient in decision making about her care. c. Be aware of nonverbal behaviors when providing care. d. Focus on the task when an unpleasant task must be done. e. Focus matter-of-fact statements on positive aspects of patient healing.

a. Use a positive and matter-of-fact approach to care. b. Include the patient in decision making about her care. c. Be aware of nonverbal behaviors when providing care. e. Focus matter-of-fact statements on positive aspects of patient healing. Rationale: A positive and matter-of-fact approach to care provides a model for the patient and family to follow. General nursing interventions, such as appropriately including the patient in decision making, supports most patients self-concept. Your nonverbal behavior conveys the level of caring that exists for your patient and affects your patients self-esteem. For example, when an incontinent patient perceives that you find the situation unpleasant, this threatens the patients self-concept. Anticipate your own reactions, acknowledge them, and focus on the patient instead of the unpleasant task or situation. Matter-of-fact statements such as, This wound is healing nicely or This looks healthy enhance the body image of the patient.

A nurse wants to provide patient-centered care to a patient of another culture. Which question is the most culturally sensitive when talking about a patients illness? a. What do you call your problem? b. How long has your child had the runs? c. When did you last void today? d. Has anyone else in your family had diarrhea?

a. What do you call your problem? Rationale: To start an assessment, Seidel and others (2011) offer useful questions to begin to explore a patients illness or health care problem in context of the patients culture: What do you call your problem?

A nurse is teaching the staff about informatics and describing the key concepts. Which information should the nurse include during the teaching session? a. Wisdom b. Charting c. Assessment d. Evaluation

a. Wisdom Rationale: The concepts are data, information, knowledge, and wisdom. Wisdom answers the why. Charting is documentation. Assessment and evaluation are included in the nursing process.

Which competencies should the nurse follow to be an effective team member in interprofessional collaboration? (Select all that apply.) a. Work to maintain a climate of mutual respect. b. Use your role specific knowledge to address health care needs. c. Apply relationship-building values and principles of team dynamics. d. Use a top-down communication strategy. e. Support a team approach to the maintenance of health.

a. Work to maintain a climate of mutual respect. b. Use your role specific knowledge to address health care needs. c. Apply relationship-building values and principles of team dynamics. e. Support a team approach to the maintenance of health. Rationale: Competencies needed for effective interprofessional collaboration include: 1. Work with individuals of other professions to maintain a climate of mutual respect and shared values. 2. Use the knowledge of ones own role and those of other professions to appropriately assess and address the health care needs of patients and populations served. 3. Communicate with patients, families, communities and other health care professionals in a responsive and responsible manner that supports a team approach to the maintenance of health and treatment of disease. 4. Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient- and population-centered care that is safe, timely, efficient, effective, and equitable. Using a top-down communication strategy does not apply as a team approach, but is needed for interprofessional collaboration.

A nurse wants to practice using the Institute of Medicine Competencies. Which competencies should the nurse use? (Select all that apply.) a. Working in interdisciplinary teams b. Using informatics c. Providing physical comfort d. Offering access to care e. Preventing catheter-associated urinary tract infections

a. Working in interdisciplinary teams b. Using informatics

A 90-year-old patient constantly tells the nurse stories about life many years ago. The nurse encourages this behavior because reminiscence or life review is: a. a technique that prepares the individual for the end of life. b. a review of dispelling past experiences as meaningless. c. helpful although it is unnatural in the older adult. d. a way for the elderly to realize that conflicts cannot be reconciled.

a. a technique that prepares the individual for the end of life. Rationale: Reminiscence, or life review, is a technique that facilitates the individuals preparation for the end of life. It is an adaptive function of older adults that allows them to recall the past for the purpose of assigning new meaning to past experiences. Reminiscence is the natural way older adults revive their past in an attempt to establish order and meaning and to reconcile conflicts and disappointments as they prepare for death.

When individuals become ill, there may be a story about the meaning of the illness. When a nurse listens, the patient is: a. able to break the distress of illness. b. unable to express what he actually needed when he was ill. c. usually not able to determine what is at stake because of his illness. d. able keep the nurse from prying into his more personal life.

a. able to break the distress of illness. Rationale: When an individual becomes ill, he or she usually has a story to tell about the meaning of the illness. Being able to tell that story helps a patient break the distress of illness. He needs to be able to express what he needs when ill. The personal concerns that are part of a patients illness story determine what is at stake for the patient. Caring through listening enables you to participate in a patients life.

The nurse should complete an ____________ report when anything unusual happens that could potentially cause harm to a patient, visitor, or employee a. complete an occurrence report b. Call the ethics committee. c. Submit an incident report. d. Insist that the patient have a radiograph done.

a. complete an occurrence report

To be _____________ is to feel certain in your ability to accomplish a task or goal such as performing a nursing procedure or making a diagnostic decision; do not let a patient think that you are unsure of performing care safely. a. Confidence b. Risk taking c. Fairness d. Curiosity

a. confidence

The nurse is interviewing a patient who claims to be in the middle of a crisis situation. The nurse should: (Select all that apply.) a. determine the patients view of the situation. b. be aware that denial is never a coping mechanism for people in crisis. c. point out that the patient is repeating information and ask him to stop. d. assess for the potential for suicide/homicide. e. assess coping mechanisms and support systems.

a. determine the patients view of the situation. d. assess for the potential for suicide/homicide. e. assess coping mechanisms and support systems. Rationale: Use the interview to determine a patients view of the situation that provoked stress, assess safety issues, coping resources, any possible maladaptive coping, and adherence to prescribed medical recommendations, such as medication or diet. If your patient is experiencing a crisis, assess safety concerns such as potential for suicide or homicide and ability to care for ones own activities of daily living. Finally, assess alternatives, coping mechanisms, and support systems. If the patient uses denial as a coping mechanism, be alert to whether the person overlooks necessary information. Listen for any recurrent themes in the patients conversation.

____________ is an immediate threat to a patients survival or safety, such as a physiological episode of obstructed airway, loss of consciousness, or a psychological episode of an anxiety attack. a. High priority b. Low priority c. Mid priority d. Intermediate priority

a. high priority

A nurse is caring for a patient who underwent an above-the-knee amputation that requires a dressing change, a skill the nurse has never done. The nurse asks another nurse to help with the dressing change for the amputated leg. The nurse is demonstrating which critical thinking attitude? a. Humility b. Confidence c. Risk-taking d. Fairness

a. humility Rationale: Critical thinkers who use humility admit what they do not know and try to find the knowledge they need to make a proper decision. Humility is recognizing when one needs more information to make a decision.

A 48-year-old nurse is complaining of being continually exhausted because of the workload on her unit. She states that the patients are getting heavier and the halls are getting longer. Sometimes I just dont think I can get through the day. The nurse is dealing with stress caused by: a. situational factors. b. maturational factors. c. sociocultural factors. d. compassion fatigue.

a. situational factors. Rationale: Situational factors include work stress that happens with work overload (patient load, distractions, conflicting priorities), heavy physical work, long hour work shifts, patient concerns (dealing with death and medical treatment), and interpersonal problems with other health care professionals and staff. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Compassion fatigue is a term used to describe a state of burnout and secondary traumatic stress.

A patient and family attend a counseling session. The patient has become depressed after a job loss. The nurse leading the counseling session informs the patient and his family that this type of crisis is caused by: a. situational factors. b. maturational factors. c. sociocultural factors. d. compassion fatigue.

a. situational factors. Rationale: Situational factors include work-related stress. Coping strategies vary with the individual and the situation. Maturational factors involve stressors and coping strategies that vary with life stage. Sociocultural factors include prolonged poverty, physical handicap, and chronic illness. Compassion fatigue is a term used to describe a state of burnout and secondary traumatic stress.

Health systems, and available colleges and schools are ________________________. a. social systems b. Available colleges and schools c. Geographical boundaries d. Predominant religious groups

a. social systems

____________ is the concern, sorrow, or pity that you feel for a patient when you personally identify with his or her needs. a. Sympathy b. Empathy c. Focusing d. Self-disclosure

a. sympathy

When caring for patients, a nurse must understand the difference between religion and spirituality. Religious care helps patients maintain their faithfulness to: a. their belief systems and worship practices. b. a relationship to a higher being or life force. c. a sense of connectedness. d. the awareness of ones inner self.

a. their belief systems and worship practices. Rationale: Religious care helps patients follow their belief systems and worship practices. Spirituality is an awareness of ones inner self and a sense of connection to a higher being, nature, or some purpose greater than oneself. Spirituality offers a sense of connectedness. Spirituality is unique for each person. It is a unifying theme in life and a state of being.

A nurse is teaching the staff about Quality and Safety Education in Nursing, which identified six competencies for nursing. Which information should the nurse include in the teaching session? (Select all that apply.) a.Informatics b. Safety c. Health policies d. Informatics e. Quality improvement

a.Informatics b. Safety d. Informatics e. Quality improvement

Which order should the nurse prioritize care for the patient using Maslows theory from lower-level needs to higher-level needs? a. Self-esteem b. Physiological needs c. Self-actualization d. Love and belonging e. Safety and security a: b, e, d, a, c b: d, b, c, a, e c: b, e, d, c, a d: d, b, a, c, e

a: b, e, d, a, c Rationale: Maslows (1987) model describes human needs using a hierarchical pyramid divided into five levels: physiological needs, safety and security, love and belonging, self-esteem, and self-actualization

Which entry by the nurse demonstrates the most accurate and safe documentation of patient care? a. Sm. amt. of emesis. b. 150 mL of cloudy dark yellow urine. c. Had a good day. d. Looks bad

b. 150 mL of cloudy dark yellow urine Rationale: 150 mL of cloudy dark yellow urine is the best. The use of precise measurements makes documentation more accurate

Which patient should a nurse consider as being the most ill? a. A 25-year-old patient with cystic fibrosis who is attending yoga classes b. A 13-year-old adolescent with newly diagnosed diabetes who does not want to check blood sugar at school c. A 43-year-old patient with breast cancer who has recently adopted a vegetarian diet d. A 77-year-old patient with alcohol hepatitis who attends weekly Alcoholics Anonymous meetings

b. A 13-year-old adolescent with newly diagnosed diabetes who does not want to check blood sugar at school. Rationale: A 13 year old who does not want to check blood sugar is the most ill out of the patients listed because illness is not synonymous with disease; it includes not only the disease, but also the effects on functioning and well-being in all dimension

Which patient would the nurse consider to be competent to give informed consent? a. A 27-year-old unconscious patient b. A 16-year-old emancipated minor c. A 43-year-old patient who is drunk d. A 33-year-old patient who has been declared legally incompetent

b. A 16-year-old emancipated minor Rationale: Even though an emancipated minor has not achieved the legal age of consent, he or she may give consent for procedures and treatment. -If a patient is unconscious, you need to obtain consent from a person legally authorized to give consent on his or her behalf. -A patient who is legally incompetent needs to have the consent of a legal guardian, which is determined through a legal proceeding. -A person who is drunk cannot fully understand the procedure and cannot sign the consent form.

Which patient is most suitable for admission into hospice? a. A 63-year-old man with a fractured femur b. A 45-year-old woman with terminal end-stage renal failure c. A 14-year-old patient with leukemia that is in remission d. A 78-year-old patient with dementia that wanders

b. A 45-year-old woman with terminal end-stage renal failure Rationale: A patient entering a hospice is at the terminal phase of illness, and the patient, family, and physician agree that no further treatment will reverse the disease process

A nurse works for a facility in which the facility sends information to The National Data Base for Nursing Quality Improvement (NDNQI) regarding patient falls, pressure ulcer incidence, and nursing satisfaction. The nurse works at which facility? a. The Joint Commission b. A magnet-designated hospital c. The Centers for Disease Control and Prevention d. The American Association of Critical Care Nurses

b. A magnet-designated hospital Rationale: All magnet-designated hospitals maintain the National Database of Nursing Quality Improvement (NDNQI). The database includes information from Magnet hospitals on falls, pressure ulcer incidence, and nurse satisfaction.

A __________________ is a nursing home; it is too early for this because the widow can provide self-care. a. A rehabilitation center b. A nursing center c. An adult day care center d. A hospice center

b. A nursing center

The charge nurse on the evening shift of a busy medical unit in an acute care hospital received a call from a physicians office that they are admitting a patient who is dying of lung cancer. She is told that the patients family is out of town and is not expected to make it to the hospital before the patient expires. What is the best room for the nurse to place this patient? a. A private room near the nurses station b. A semiprivate room halfway down the hall with another terminally ill patient c. A private room at the end of the hall d. A semiprivate room with instructions for staff to enter only when necessary

b. A semiprivate room halfway down the hall with another terminally ill patient Rationale: Unless family members need privacy or are remaining with the patient around the clock, avoid placing patients in a private room. Patients who are dying often feel a sense of involvement and companionship when sharing a room and have more opportunities to interact with staff and visitors.

A student nurse is looking for research articles that can be used to complete a research paper. Where can the nursing student look to quickly find out if an article is research or clinically based? a. p value b. Abstract c. Analysis d. Literature review

b. Abstract Rationale: An abstract is a brief summary of the article that quickly shows whether the article is research or clinically based. An abstract summarizes the purpose of the study or clinical review, the major themes or findings, and the implications for nursing practice

The transition from childhood to adulthood, in terms of the psychological maturation of the individual, is known as which of the following? a. Puberty b. Adolescence c. Menarche d. Preadolescence

b. Adolescence Rationale: The term adolescence refers to the psychological maturation of the individual, whereas puberty refers to the point at which reproduction is possible. Menarche refers to the onset of menstruation. The transitional period between childhood and adolescence is preadolescence. Others refer to this period as late childhood, early adolescence, pubescence, and transescence

The patient has been diagnosed with progressive Alzheimers disease. Characteristics of this disease include which of the following? (Select all that apply.) a. Delirium b. Agnosia c. Apraxia d. Aphasia e. Amnesia

b. Agnosia c. Apraxia d. Aphasia e. Amnesia Rationale: Alzheimers disease is the most common form of dementia. Alzheimers disease is a progressive loss of memory (amnesia), loss of ability to recognize objects (agnosia), loss of the ability to perform familiar tasks (apraxia), and loss of language skills (aphasia). As the disease progresses, some patients also experience changes in personality and behavior, such as anxiety, suspiciousness, or agitation, as well as delusions or hallucinations. Delirium is an acute confusional state and requires prompt assessment. It is a potentially reversible cognitive impairment that is often a result of physiological causes. Some of these causes include electrolyte imbalance, hypoglycemia, infection, and medications.

A nurse is alert to potentially problematic situations in a patient and is using evidence-based knowledge. Which concept for a critical thinker is the nurse using? a. Maturity b. Analyticity c. Systematicity d. Inquisitiveness

b. Analyticity Rationale: Analyticity is being alert to potentially problematic situations and using evidence-based knowledge

A patient has been suffering from liver cancer for more than a year. The family has requested hospice services. The family members are taking turns staying with the patient. They have been reminiscing with the patient about her life and are now saying their good-byes. The type of grief that this family is experiencing is best described as which of the following? a. Normal b. Anticipatory c. Complicated d. Disenfranchised

b. Anticipatory Rationale: The process of letting go that occurs before an actual loss or death has occurred is called anticipatory grief. Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away. Disenfranchised grief occurs in situations in which others view a persons loss as insignificant or invalid.

A newly graduated nurse has been assigned to work with one assistive personnel staff member. When delegating skills, which guidelines should the nurse use? (Select all that apply.) a. Assign just bed making skills and feeding tasks. b. Assess the knowledge of the assistive personnel. c. Match tasks to the assistants skills. d. Have the nursing assistant document assessment findings. e. Assess skill levels of assistive personnel.

b. Assess the knowledge of the assistive personnel. c. Match tasks to the assistants skills. e. Assess skill levels of assistive personnel. Rationale: The guidelines for delegation include the following: assess the knowledge and skills of the person to whom you are delegating; match tasks to the assistants skills; and provide feedback. It is the nurses responsibility, not the assistants, to complete documentation of assessment findings. The nurse can assign/delegate more than just bed making skills and feeding tasks.

A nurse is teaching the staff about the major elements in the critical thinking model. Which information should the nurse include in the teaching session? (Select all that apply.) a. Intricate b. Attitudes c. Standards d. Experience e. Competence

b. Attitudes c. Standards d. Experience e. Competence Rationale: According to the model, there are five elements of critical thinking: knowledge base, experience, competence (e.g., problem solving or clinical decision making), attitudes, and standards. Intricate is not an element in the critical thinking model.

The nurse is caring for a patient who has been diagnosed with chronic pain. The nurse is especially concerned about the patients self-concept because chronic pain does which of the following? a. Normally has no effect on the ability to function once patients learn to deal with it b. Can often cause increased irritability that can affect self-concept c. Often leads to increased sleep as patients try to escape the pain d. Requires pain medication that prevents self-concept alterations

b. Can often cause increased irritability that can affect self-concept Rationale: When you care for patients who have alterations in self-concept, be particularly alert to the patient who is experiencing chronic pain. Chronic pain predisposes a person to decreased ability to function, irritability, and decreased sleep. These changes negatively affect self-concept. Many medications have actions and side effects that influence a patients self-concept and sexuality.

While a patent is being interviewed by the nurse, a family member states, What my father really means is that he doesnt know for sure what the physician meant about the medical diagnosis. Which communication technique did the family member use? a. Focusing b. Clarifying c. Summarizing d. Sharing observations

b. Clarifying Rationale: The family members statement is clarifying. Clarifying validates whether the person interpreted the message correctly.

A patient on a pediatric unit who underwent an appendectomy for a ruptured appendix 3 days ago complains of acute pain and has a high fever. The nurse is concerned that the patient may have an infection and notifies the primary health care provider of the change in the patients condition. This concern is based on the nurses experience as a pediatric nurse. The nurses ability to make a tentative conclusion regarding this patients situation based on observed data is known as what? a. Scientific method b. Clinical inference c. Effective problem solving d. Data collection

b. Clinical inference Rationale: The nurse used clinical inference because of previous experience as a pediatric nurse and pieces of evidence of acute pain and a high fever. Clinical inference is the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a nursing diagnosis

A registered nurse is working on a pediatric oncology unit and caring for four children undergoing chemotherapy. Today a new nursing assistive personnel (NAP) who has passed a competency examination is assigned to the team. The nurse will delegate a portion of the fundamental nursing tasks to the NAP during the shift, but realizes that he or she is still responsible for his or her own actions and is accountable for the care. The nurse is following which principle of behavior? a. Ethical dilemma b. Code of ethics c. Bioethics d. Feminist ethics

b. Code of ethics Rationale: The code of ethics reflects underlying principles that include responsibility, accountability, respect for confidentiality, competency, judgment, and advocacy

A nurse is in the process of admitting an ethnically diverse patient. To plan culturally competent care, what must the nurse do? (Select all that apply.) a. Assume that cultural processes are the same within a social group. b. Conduct a systematic cultural assessment. c. Communicate effectively. d. Negotiate world view differences.

b. Conduct a systematic cultural assessment. c. Communicate effectively. d. Negotiate world view differences. Rationale: Critical to success is your ability to conduct a systematic cultural assessment, communicate effectively, and have the skills to negotiate world view differences with others. Cultural processes frequently differ within the same social group (a family, a group of white people, a group of women friends, an immigrant family, a group of nurses) because of differences, for example, in age, gender, political association, class, or religion.

A nurse is maintaining precise records regarding the dispensing, wasting, and storage of a drug that is securely locked. Which drug is the nurse administering? a. Routine medication b. Controlled substance c. Over-the-counter medication d. Substance not requiring an order

b. Controlled substance Rationale: Controlled substances are securely locked away, and only authorized personnel have access to them. Maintain precise records regarding the dispensing, wasting, and storage of controlled substances. There are criminal penalties for the misuse of controlled substances. Routine and over-the-counter drugs are not controlled substances. Controlled substances required an order by a licensed physician or in some states advanced practice nurses.

A registered nurse is caring for a patient in the trauma unit who had been involved in a motor vehicle accident. Although the patient denied pain, during the nurses assessment, the nurse observed that the patient groaned when moving and was protective of the right arm. The nurse believed the patient had pain and reported it to the primary health care provider, who ordered a radiograph (x-ray) of the right arm. The radiograph revealed a fractured arm. Which technique did the nurse use? a. Intuition b. Critical thinking c. Perseverance d. Reflection

b. Critical thinking Rationale: The nurse used critical thinking. Critical thinking involves recognizing that an issue (e.g., patient problem) exists

A patient telephones a crisis intervention hotline. The nurse assigned to this center assesses that the patient is experiencing a crisis. What is the most appropriate action for the nurse to take? a. Take control of the situation and tell the patient what needs to be done. b. Define the problem at hand and ensure that the patient is safe. c. Ask the patient how he would like to handle the crisis and follow through. d. Ask the patient to list all of his problems and prioritize which to deal with first.

b. Define the problem at hand and ensure that the patient is safe. Rationale: Crisis intervention begins with defining the problem, ensuring patient safety, and providing support. First determine that a patient is safe and is not at risk for injury to self or others, and then use crisis intervention to examine alternatives, make plans, and obtain a commitment to positive action from the patient. Ideally these last three steps are completed collaboratively with a patient, but a patient in crisis may be unable to participate actively and may need a very directive approach or a crisis interventionist. Emphasize focusing on the specific problem, and help a patient to avoid all-encompassing, catastrophic interpretations.

______ is an interaction of biological, sociological, and psychological forces. a. Growth b. Development c. Maturation d. The latency stage of development

b. Development Rationale: Development is an interaction of biological, sociological, and psychological forces. It occurs gradually and refers to changes in skill and capacity to function. These changes are qualitative in nature and difficult to measure in exact units. Growth is the measurable aspect of a persons increase in physical dimensions. Measurable growth indicators include changes in height, weight, teeth and bone, and sexual characteristics. Maturation is the biological plan for the predictable milestones for growth and development. Physical growth and motor development are a function of maturation. The latency stage of development is part of Freuds psychoanalytic model of personality development. In the latency stage, Freud believed that the sexual urges from the earlier phallic stage are repressed and channeled into productive activities that are socially acceptable.

A nurse is spending time with a patient, who has recently been diagnosed with breast cancer. The patient states that he or she is frightened about the diagnosis and feels overwhelmed. The nurse responds, It sounds to me like you are feeling very scared right now. Which communication technique did the nurse use? a. Sympathy b. Empathy c. Focusing d. Self-disclosure

b. Empathy Rationale: Empathy is the ability to understand and accept another persons perspective. Although no one can ever totally know anothers experiences, a nurse can try to understand what the person is experiencing.

The patient was hospitalized with pneumonia. He had always been very healthy and was concerned that now his family would have to take care of him. During one conversation the nurse said to him, This gives the ones who love you a chance to show you how much they care for you. The comment that the nurse made best demonstrated which behavior? a. Human respect b. Encouraging manner c. Healing environment d. Affiliation needs

b. Encouraging manner

The nurse is talking to a patient who was involved in a motor vehicle accident. The patient asks the nurse why there was no sensation of pain at the time of the accident. The best explanation would be: a. Vasopressin was released to decrease pain sensation. b. Endorphins are released during a time of stress to reduce pain. c. Alcohol reduces the perception of stress when injury occurs. d. You probably have chronic high levels of cortisol to help with chronic pain.

b. Endorphins are released during a time of stress to reduce pain. Rationale: Endorphins are hormones that interact with the opiate receptors in the brain to reduce our perception of pain and produce a sense of well-being. Vasopressin increases reabsorption of water by the kidneys and induces vasoconstriction, thereby raising blood pressure. It has no effect on pain sensation. Unhealthy coping choices, such as the use of alcohol or tobacco, negatively affect a persons health as well as increasing the perception of stress. Persistent elevated cortisol levels are associated with chronic health conditions, such as obesity, heart disease, depression and anxiety, diabetes, and osteoporosis.

A nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. To help the parents resolve this conflict, which steps should the nurse take to process the ethical dilemma? (Select all that apply.) a. Identifying people who can solve this dilemma b. Gathering all relevant information surrounding this dilemma c. Clarifying own values and opinions about the issues d. Consulting a professional ethicist regarding how to proceed with this dilemma e. Considering possible courses of action

b. Gathering all relevant information surrounding this dilemma c. Clarifying own values and opinions about the issues e. Considering possible courses of action Rationale: : (1) Asking is it an ethical dilemma?, (2) gathering all information, (3) examining and determining ones own values and opinions about the issue, (4) stating the problem clearly, (5) considering possible courses of action, (6) negotiating an outcome, and (7) evaluating the action. Identifying people who can solve this dilemma and consulting a professional ethicist are not steps of the process

A clinic nurse stopped at an automobile accident to assist. There was one victim who was not breathing. The nurse provided CPR at the scene, but the victim died. The victims family sued the nurse. Which will provide the best protection to the nurse in this case? a. Clinics malpractice insurance policy b. Good Samaritan Law c. State Board of Nursing d. Institute of Medicine

b. Good Samaritan Law Rationale: The Good Samaritan Law protects the nurse because CPR is within a nurses scope of practice. Although Good Samaritan Laws provide immunity to the nurse who does what is reasonable to save a persons life, if the nurse performs a procedure for which he or she has no training, the nurse will be liable for any injury resulting from that act. Therefore, provide only care that is consistent with your level of expertise. The insurance policy, state boards of nursing, and Institute of Medicine do not provide protection to the nurse under the Good Samaritan Law.

The nurse is caring for a patient with terminal lung cancer. The patient is in a great deal of pain and is anxious. The nurse contacts the health care provider to request pain medication for the patient and is given an order for morphine, but the family of the patient refuses to let the patient have it based on religious grounds. This is most likely because the patient and family are members of which of the following faiths? a. Jewish b. Hindu c. Catholic d. Christian

b. Hindu Rationale: Members of religious faiths that believe in reincarnation (e.g., Hindu religion) support refusal of nourishment and pain medications because of the implications for the dying persons next life. Orthodox Jews stay with a person who is dying throughout the entire process and have community members (minyan) praying at the bedside. Members of the Catholic Church often receive an anointing by a priest and Holy Communion. Christians usually believe in heaven or an afterlife.

A patient with a history of seizures is being admitted to the hospital after a grand mal seizure took place at a shopping mall. The patients spouse accompanied the patient to the hospital and is being interviewed by the nurse. Which question should the nurse ask to quickly focus on the patients symptoms? a. What made you choose this hospital? b. How long did the seizure last? c. Tell me how the seizure disorder has affected the family. d. Tell me why you brought your spouse to the hospital today.

b. How long did the seizure last? Rationale: How long did the seizure last? is the question that will quickly focus on the patients symptoms. Once patients tell their story, use a problem-seeking interview technique. This approach takes the information provided in the patients story and then more fully describes and identifies specific problem areas. For example, focus on the symptoms the patient identifies and ask closed-ended questions that limit the patients answers to one or two words such as yes or no or a number or frequency of a symptom. What made you choose this hospital does not focus on the seizure. Tell me will not get information quickly as these are open-ended.

A nurse is using the scientific method to solve a patient situation. Which action should the nurse take first? a. Collect data. b. Identify a problem. c. Formulate a question. d. Evaluate the results.

b. Identify a problem. Rationale: Identifying the problem is the first step in the scientific method. The steps of the scientific method are as follows: Identify the problem; Collect data; Form a question or hypothesis; Test the question or hypothesis; Evaluate results of the study. Collect data is the second step. Formulate a question is the third step. Evaluate the results is the last step.

A nurse is preparing to help patients with health promotion, wellness education, and illness prevention activities. Which action should the nurse take first? a. Explore available support groups. b. Identify risk factors. c. Provide patient teaching. d. Implement risk factor modification.

b. Identify risk factors. Rationale: Identifying risk factors is the first step in health promotion, wellness education, and illness prevention activities. Once you identify risk factors, implement appropriate and relevant health education programs that help a person to change a risky health behavior. Support groups, teaching, and risk factor modification follow after identifying risk factors.

A nurse is caring for a patient who is visually impaired. Which technique should the nurse use to facilitate communication? a. Touch the patient before speaking. b. Identify self when entering the room. c. Quietly leave the room when finished. d. Keep the room dimly lit for calmness.

b. Identify self when entering the room Rationale: For a visually impaired patient, identify yourself when entering the room. The nurse should communicate verbally before touching the patient who is visually impaired. Notify the patient when leaving the room; do not quietly leave the room when finished as the patient will think you are still in the room. Ensure that lighting is adequate for the patient to see the speaker; do not keep it dimly lit.

The patient is a 16-year-old teenager who is in the clinic for his annual check-up. During the assessment, the nurse asks the patient about his use of tobacco. Although he denies smoking, he tells the nurse that he dips snuff. He tells the nurse that he started last year because all his friends do it. The nurse recognized this as a stressor of which of the following? a. Body image b. Identity c. Role performance d. Sexuality

b. Identity Rationale: Identity involves the sense of individuality and being distinct and separate from others. Cultural identity develops from identifying and socializing within an established group and through incorporating the responses of individuals who do not belong to that group into ones self-concept. Body image involves attitudes related to the perception of the body, including physical appearance, femininity and masculinity, youthfulness, health, and strength. Role performance is the way in which a person views his or her ability to carry out significant roles. Common roles include mother or father, wife or husband. Sexuality is a broad term that refers to all aspects of being sexual. Our sexual health is based on our ability to form healthy relationships with others

A registered nurse is caring for an older adult patient with lung cancer. The daughter, who is also a nurse, asks to see the chart. What is the nurses best response? a. Come with me and we will look at it together. b. Im sorry; this information is confidential. c. Let me ask my supervisor if it is okay. d. You should know better than to ask me that.

b. Im sorry; this information is confidential. Rationale: Do not disclose information about patients status to other patients, family members (unless granted by the patient), or health care staff not involved in their care. Looking at it together is not acceptable because confidentiality would be broken. Asking a supervisor is inappropriate because the nurse should already know the legalities for confidentiality. Saying, You should know better than to ask me that is inappropriate and condescending.

Upon assessment the nurse finds the following: a 46-year-old immigrant patient from the Czech Republic has diabetes and hypertension and just recently moved in to live with a family member who must travel frequently. The patient speaks English very well. The community health nurse knows that this patient may be vulnerable because of which assessment finding? a. Age b. Immigration status c. Diabetes d. Language

b. Immigration status Rationale: Vulnerable populations include individuals living in poverty, elderly people, homeless individuals, those in abusive relationships, people with substance abuse problems and/or mental illnesses, and new immigrants. For some immigrants access to health care is limited because of legal status, language barriers and lack of benefits, resources, and transportation.

A nurse admits an older adult patient who states that he or she has no living relatives and only two close friends. Upon admission to the hospital, which action should the nurse initiate first? a. Implement a process of payment. b. Implement a discharge plan. c. Implement a visit with the family. d. Implement a resource utilization group.

b. Implement a discharge plan. Rationale: Discharge planning with coordination of services begins the moment a patient is admitted to a health care facility

A registered nurse is a new nurse manager who needs to council an employee regarding attendance. Because the nurse manager is new to the position, the nurse is rehearsing what is planning to say to the employee before the meeting. The nurse is using which form of communication? a. Interpersonal b. Intrapersonal c. Public d. Private

b. Intrapersonal Rationale: Intrapersonal communication, also called self-talk, is a powerful form of communication that occurs within an individual. People talk to themselves by forming thoughts internally that strongly influence perceptions, feelings, behavior, self-concept, and performance. Self-talk is a mental rehearsal for difficult tasks or situations so that individuals deal with them more effectively

A nurse develops a nursing diagnosis for a patient. What is the rationale for the nurses actions? a. It allows a nurse to compete with physicians or health care providers. b. It allows a nurse to develop an individualized plan of care. c. It allows a nurse to treat nursing problems and medical problems. d. It allows a nurse to manage patient care for the entire health team.

b. It allows a nurse to develop an individualized plan of care. Rationale: The diagnostic process results in the formation of a total diagnostic statement that allows a nurse to develop an appropriate, patient-centered plan of care. A nursing diagnosis provides direction for nursing, not for medical problems or for the entire health team. It is not used to compete with physicians or health care providers.

As part of the admission process the nurse asks if the patient has an advance directive. The patient doesnt know for sure. What is the nurses best response? a. It is autopsy permission. b. It is a living will. c. It is informed consent. d. It is an organ donation card.

b. It is a living will Rationale: Many times the decision regarding lifesaving treatment is in writing in the patients living will or advance directive. Living wills are documents instructing the health care provider to withhold or withdraw life-sustaining procedures in a patient who is terminally ill.

________________ developed the theory of cognitive development, which describes childrens intellectual organization and how they think, reason, and perceive the world. The theory includes four periods: sensorimotor, preoperational, concrete operations and formal operations. a. Sigmund Freud b. Jean Piaget c. Erik Erikson d. Lawrence Kohlberg

b. Jean Piaget

Which of the following people developed the theory of cognitive development that describes childrens intellectual organization and how they think, reason, and perceive the world? a. Sigmund Freud b. Jean Piaget c. Erik Erikson d. Lawrence Kohlberg

b. Jean Piaget Rationale: Jean Piaget (1896-1980) developed the theory of cognitive development, which describes childrens intellectual organization and how they think, reason, and perceive the world.

A 45-year-old mother of two children has cirrhosis of the liver and is on a waiting list for a liver transplant. She had to meet certain criteria to be eligible to receive a liver. She understands that she is next on the list for a donor liver that matches. This is an example of which ethical principle? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

b. Justice

A pediatric nurse who works evenings on a surgical floor in a childrens hospital has been working with a 5-year-old patient who has undergone abdominal surgery. The nurse gives the patient a sticker each time the incentive spirometer is used. What type of reinforcement did the nurse use? a. Social b. Material c. Activity d. Negative

b. Material Rationale: Examples of material reinforcers are food, toys, and music. These work best with young children. Use social reinforcers (e.g., smiles, compliments, words of encouragement, or physical contact) to acknowledge a learned behavior. Activity reinforcers (e.g., physical therapy) rely on the principle that a person is motivated to engage in an activity if there is an opportunity to participate in more desirable activity upon completion of this first activity. Negative reinforcement (frowning) may work but people usually respond better to positive reinforcement.

An 11-year-old boy is being seen at the clinic for his annual check-up. As part of anticipatory guidance, the nurse instructs the boys father that accidents and injuries are major health problems affecting school-age children and that the number one cause of death is in this age group is which of the following? a. Drowning b. Motor vehicle accidents c. Fire d. Firearms

b. Motor vehicle accidents Rationale: Accidents and injuries are major health problems affecting school-age children and are the causative factor in a large number of deaths in this age group. Motor vehicle accidents, followed by drowning, fires, burns, and firearms are the most frequent fatal accidents.

____________________ is a group of 51 organizations from a variety of health care disciplines that joined together to work toward transforming health care by focusing on eight national priorities. a. The Joint Commission b. National Priorities Partnership c. Accountable Care Organization d. Managed Care

b. National Priorities Partnership

_______________ is an unintentional tort. a. Assault b. Negligence c. Battery d. Felony

b. Negligence

Which other term can the nurse use to describe the Omnibus Budget Reconciliation Act of 1987? a. Medicaid Act b. Nursing Home Reform Act c. Diagnostic Related Group Act d. Magnet Recognition Act

b. Nursing Home Reform Act Rationale: The nursing center industry has become one of the most highly regulated industries in the United States. The Omnibus Budget Reconciliation Act of 1987, also known as the Nursing Home Reform Act, raised the standard of services provided by nursing centers

A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation. The nurse charts the following: Discuss alternatives for pain control. Which component of SOAP did the nurse chart? a. S b. O c. A d. P

b. O Rationale: Discuss alternatives for pain control is a Plan. SOAP is an acronym for the following: S: Subjective data (verbalizations of the patient) O: Objective data (data that are measured and observed) A: Assessment (diagnosis based on the subjective and objective data) P: Plan (what the caregiver plans to do)

A nurse is planning to care for a patient with a disease that is a major cause of death and disability in the United States. The nurse is caring for which patient? a. One with an acute disease b. One with a chronic disease c. One with an infectious disease d. One with an exotic disease

b. One with a chronic disease Rationale: Because of successes in public health, medicine, and biomedical technology, acute and infectious diseases are no longer major causes of death, disease, and disability in the United States. Many health care analysts believe that the heaviest burden of illness today is caused by chronic diseases. Exotic diseases are rare.

A patient asked a nurse when the primary health care provider would make rounds. The nurse was taking another patient for a stat test and replied very quickly, I have no idea. The patient most likely interpreted the nurse as uncaring because of which factor? a. Vocabulary b. Pacing c. Timing d. Personal appearance

b. Pacing Rationale: Because the nurse replied very quickly it is pacing. Talking rapidly, using awkward pauses, or speaking extremely slowly and deliberately conveys an unintended message.

A patient is drinking milk that has been fortified with vitamin D. Which type of health promotion strategy is the patient using? a. Active b. Passive c. Environmental d. Sociological

b. Passive Rationale: With passive strategies of health promotion, individuals gain from the activities of others without acting themselves. For example, the city puts fluoride in the municipal drinking water, or milk manufacturers fortify homogenized milk with vitamin D

A new nurse is learning how to prioritize time. One of the best ways that this can be accomplished is for the new nurse to focus on which of the following? a. Nursing tasks b. Patient priorities c. Medication schedule d. Ancillary procedures

b. Patient priorities Rationale: Because nurses have a limited amount of time with patients, it is essential to remain goal oriented and focused on patients priorities. For example, priorities of care help you determine which procedures you perform first, patient assessments that you will do on an ongoing basis, and the anticipated response of your patient to care activities. The better you manage yourself leads to better management of your time. Patient priorities take precedence over nursing tasks, medication schedules, and ancillary procedures.

A new registered nurse working for a busy unit of an acute care teaching hospital begins the shift with four patients. Which patient should the nurse attend to first? a. Patient who needs assistance in ambulating the hall b. Patient whose blood pressure suddenly drops and who passes out (faints) c. Recovering stable surgical patient whose family has just arrived d. Recovering patient who is resting quietly watching television

b. Patient whose blood pressure suddenly drops and who passes out (faints) Rationale: A patients whose blood pressure drops and faints needs to be addressed first. Critical thinking and clinical decision making are complicated because nurses care for multiple patients in fast-paced and unpredictable environments.

A community health nurse is caring for vulnerable populations. The nurse is caring for which patients? (Select all that apply.) a. Patients living at home b. Patients with abusive habits c. Immigration patients d. Middle-aged patients e. Patients living in poverty

b. Patients with abusive habits c. Immigration patients e. Patients living in poverty Rationale: Individuals living in poverty, elderly people, homeless individuals, those in abusive relationships, people with substance abuse problems and/or mental illnesses, and new immigrants are examples of vulnerable populations

A patient is admitted to the hospital after a motorcycle accident. The nurse in the emergency room is assessing vital signs, general appearance and behavior, and performing a head-to-toe examination of all body systems. What is the nurse doing? a. Making a medical diagnosis b. Performing a physical examination c. Making an evaluation d. Performing data validation

b. Performing a physical examination Rationale: A physical examination involves use of the techniques of inspection, palpation, percussion, auscultation, and smell.

A nurse is preparing to teach a patient about ostomy care. The patient appears anxious and is crying. What should the nurse do? a. Let the patient know it is time to learn about ostomy care. b. Postpone the teaching session about ostomy care. c. Show a video about ostomy care. d. Implement role-play.

b. Postpone the teaching session about ostomy care Rationale: Any condition (e.g., fatigue, breathing difficulty, or depression) that drains a persons energy impairs the ability to learn. Postpone teaching when an illness becomes aggravated by complications such as pain, fever, or respiratory difficulty. Letting the patient know it is time to learn, implementing role-play, and showing a video will not enhance learning. The crying needs to be addressed first.

Which behavior is the best way for a nurse to avoid being liable for malpractice? a. Purchasing quality malpractice insurance coverage on a yearly basis b. Practicing nursing that meets the generally accepted standard of care c. Not sharing his or her last name with patients and families d. Not delegating any tasks to unlicensed assistive personnel

b. Practicing nursing that meets the generally accepted standard of care Rationale: The best way to avoid being liable for malpractice is to give nursing care that meets the generally accepted standard of care.

Which technique should the nurse use when providing information to a patient with a health literacy level of fifth grade? a. Use the passive voice of language. b. Present the most important information first. c. Shift from subject to subject until the patient responds. d. Explain using jargon so the patient will understand others on the health care team.

b. Present the most important information first. Rationale: To promote understanding in a patient with a health literacy level of fifth grade is to present the most important information first.

A single mother with three children uses the public health department services in the county to immunize her children. Which level of health care did the mother use? a. Continuing care b. Preventative care c. Secondary acute care d. Restorative care

b. Preventative care Rationale: Preventative care includes services such as immunizations, screenings, poison control information, mental health counseling and crisis prevention, and community legislation.

A registered nurse who works in a womens hospital assumes care for the same patients from the time they are admitted to the time they are discharged home. The nurse has associate nurses helping with the care. Which type of nursing care delivery model is the nurse using? a. Team nursing b. Primary care nursing c. Case management d. Total care

b. Primary care nursing Rationale: Primary nursing is a model of care delivery in which a registered nurse assumes responsibility for a caseload of patients over time (e.g., a length of stay in a hospital or a series of home care visits). Typically the registered nurse selects the patients for his or her caseload and cares for the same patients during their hospitalization or stay in the health care setting. Associate nurses help with patient care.

A nurse is assuming responsibility for a caseload of patients over a period of time. Which type of nursing care delivery models is the nurse practicing? a. Team nursing b. Primary nursing c. Interprofessional collaboration d. Decentralized management

b. Primary nursing Rationale: Primary nursing is a model of care delivery in which a registered nurse assumes responsibility for a caseload of patients over time (e.g., a length of stay in a hospital or a series of home care visits). In team nursing, licensed vocational nurses/licensed practical nurses and assistive personnel work under the direction of the registered nurse. Interprofessional collaboration involves bringing representatives of the various disciplines together to work with patients and families to deliver quality care. Decentralized management includes decision making, which is moved down to the level of staff, involving all employees at all levels of activities.

Which organization is preparing future nurses to have the knowledge, skills, and attitudes (KSAs) of evidence-based practices necessary to continuously improve the quality and safety of the health care systems within which they work? a. The Joint Commission b. Quality and Safety Education for Nurses (QSEN) c. The National Database of Nursing Quality Improvement (NDNQI) d. The Agency for Health care Research and Quality (AHRQ)

b. Quality and Safety Education for Nurses (QSEN) Rationale: Evidence-based practice is also one of the Quality and Safety Education for Nurses (QSEN) competencies, with the overall goal for the QSEN project being to meet the challenge of preparing future nurses to have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work (QSEN, 2012).

_________________ has participants divided into groups to test for the same outcome to determine if there is a difference in the effect of a treatment or intervention compared with a standard of care. a. Quantitative study b. Randomized trial c. Qualitative study d. Case controlled study

b. Randomized trial

A patient has an outcome of ambulating three times a day. The patient does not ambulate the entire day. What should the nurse do next? a. Walk the patient. b. Reassess the patient. c. Change the goal for the patient. d. Continue with the plan for the patient.

b. Reassess the patient. Rationale: When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs. A complete reassessment of all patient factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. The plan cannot continue because the goal was not met. The goal cannot be changed and walking the patient cannot occur until reassessment has been completed.

The nurse is caring for an older adult who seems depressed and states that I hate going to Bingo. Id really like to get back in shape. Maybe if I could join a health club, I could get back to feeling like myself. The nurse should do which of the following? a. Inform the patient that at his age its probably not a good idea to join a health club. b. Recommend that the patient have a complete physical examination. c. Explain that physical impairments would prevent any worthwhile exercising. d. Tell the patient that at his age he would probably hurt himself.

b. Recommend that the patient have a complete physical examination. Rationale: It is not too late for an older person to begin an exercise program; however, older adults need to have a complete physical examination, which usually includes a stress cardiogram or stress test. Assessment of activity tolerance will help you and the patient plan a program that meets physical needs while allowing for physical impairments. Most older adults are capable of taking charge of their lives and assume responsibility for preventing disability.

The teen pregnancy rate in one community significantly increased; as a result, the school system was seeing an increase in the dropout rate of teenage mothers. A nurse recently worked with the local school system to develop a day care program for the children of high school students so that they could return to school. Which technique did the nurse use? a. Incorporating immunizations for the infants and mothers b. Responding to changes within the community c. Influencing chronic environmental factors d. Managing disease

b. Responding to changes within the community Rationale: Successful community health nursing practice involves building relationships with the community and responding to changes within the community.

A registered nurse has a patient assignment of caring for six postoperative patients in the orthopedic unit. The nurse completes the patient assessments, distributes medications, and provides care to the patients as outlined within the job (position) description. Which term best describes the nurses behavior? a. Interprofessional collaboration b. Responsibility c. Interprofessional rounding d. Case management

b. Responsibility

A patient admitted to the intensive care unit was placed on ventilator support. The nurse caring for this patient identified on the plan of care that one of the outcomes was that the patient would not develop ventilator-acquired pneumonia (VAP). To achieve this outcome, the nurse delegates the following to the unlicensed assistive personnel: Please perform oral care on the patient every 2 hours. In this situation oral care would include using the special swabs we have for our patients on VAP precautions so we can prevent pneumonia. Which of the five rights of delegation did the nurse use? a. Right route b. Right direction/communication c. Right dose d. Right supervision

b. Right direction/communication Rationale: The nurse used right direction/communication. Give a clear, concise description of the task, including its objective, limits, and expectations. Communication must be ongoing between the nurse and nursing assistive personnel during a shift of care.

The patient is a 66-year-old patient who has been admitted to the hospital for a transient ischemic attack (TIA). Her health care provider has told her that she should consider retiring from her high-stress position as a hospital administrator. The patient is distraught over this suggestion. The nurse caring for her recognizes the most likely cause of distress is a result of a change in which of the following? a. Body image b. Role performance c. Self-esteem d. Identity

b. Role performance Rationale: Role performance is the way in which a person views his or her ability to carry out significant roles. This patient is being told that she will have to give up her role as an administrator. Body image involves attitudes related to the perception of the body, including physical appearance, femininity and masculinity, youthfulness, health, and strength. There are no overt bodily changes here. Self-esteem is an individuals overall sense of personal worth or value. This could be an issue, but it is based in the change in her role. Identity involves the sense of individuality and being distinct and separate from others. Being oneself or living a life that is genuine and authentic is the basis of true identity. What was true of self-esteem can be true of identity.

A 9-year-old patient who is hospitalized for bowel surgery appears very frightened. To appear less threatening to the child, which action should the nurse take? a. Stand over the bed when talking to the patient. b. Sit in a chair next to the bed when talking to the patient. c. Maintain constant eye contact with the patient at all times. d. Stay within 12 inches of the patient when talking to the patient.

b. Sit in a chair next to the bed when talking to the patient. Rationale: The nurse should sit in a chair next to the bed. A nurse appears less dominant and less threatening when interacting at the patients eye level. Looking down on a person (standing by the bed) establishes authority, but interacting at the same eye level indicates equality in the relationship. Constant eye contact can be intrusive or threatening to some people. Twelve inches is within the intimate zone and can be threatening.

A patient has just been admitted to the hospital with a broken hip from a fall in the home. The nurse admitting the patient is practicing active listening. Which behavior best conveys to the patient that the nurse is using active listening? a. Keeping arms crossed b. Sitting facing the patient c. Standing facing the patient d. Leaning away from the patient

b. Sitting facing the patient Rationale: Several nonverbal skills facilitate attentive listening, which are identified by the acronym SOLER: Sit facing the patient. Observe an open posture. Lean toward the patient. Establish and maintain eye contact. Relax

A recently widowed mother of two worked with her late husband while he was starting his own business and was managing the accounting paperwork. The family had no life or health insurance. When her husband suddenly died, she was left with a large hospital bill, funeral expenses, unemployment, and no means of support. How are the multiple losses that this woman is experiencing best described? a. Maturational b. Situational c. Actual d. Perceived

b. Situational Rationale: Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain and changes in living arrangements.

A patient is suffering from shortness of breath. How should the nurse write the expected outcome for this patient? a. The patient will be comfortable by the morning. b. The patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift. c. The patient will not complain of breathing problems. d. The patient will appear less short of breath

b. The patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift. Rationale: Each patient outcome contains the following aspects in order to be correctly written: (1) patient-centered, (2) singular, (3) observable, (4) measurable, (5) time limited, (6) mutual factors, and (7) realistic.

The nurse is admitting a 75-year-old patient into the gastrointestinal laboratory for a routine colonoscopy. During the assessment, the nurse learns that the patients spouse died 4 months earlier because of stomach cancer and that the patient has not been sleeping well. Which phase of Bowlbys mourning phases does the nurse suspect? a. The numbing phase b. The yearning/searching phase c. The disorganization phase d. The reorganization phase

b. The yearning/searching phase Rationale: The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. Common physical symptoms include tightness in the chest and throat, shortness of breath, a feeling of weakness and lethargy, insomnia, and loss of appetite. In the numbing phase, a person has periods of extremely intense emotion and reports feeling stunned or unreal. The person often expresses anger at anyone he or she believes to be responsible. During the final phase of reorganization, the person accepts unaccustomed roles, acquires new skills, and builds new relationships.

Which situation will enable a nurse to use restraints? a. To punish a patient b. To ensure the patients safety c. To retaliate against poor behavior d. To ensure staff convenience

b. To ensure the patients safety Rationale: Regulations set the standard that all patients have the right to be free from seclusion and physical or chemical restraints except to ensure the patients safety in emergency situations. The standards specifically prohibit restraining patients for staff convenience, punishment, or retaliation.

Which documentation by the nurse best describes patient data? a. Moderate amount of clear yellow urine voided. b. Voided 220 mL clear yellow urine. c. A small amount of urine voided into absorbent pad. d. Patient incontinent of urine.

b. Voided 220 mL clear yellow urine. Rationale: The use of precise measurements makes documentation more accurate. For example, documenting Voided 450 mL clear urine is more accurate than Voided an adequate amount.

Which behavior by the nurse would be considered most professional? a. Addressing a patient by dear b. Wearing small earrings c. Being task oriented d. Avoiding troublesome patients

b. Wearing small earrings

A specific phase or period when the presence of a function or reasoning has its greatest effect on a specific aspect of development is referred to as: a. Freuds psychoanalytic model of personality. b. a critical period of development. c. Eriksons stages of development. d. Piagets theory of cognitive development.

b. a critical period of development. Rationale: A critical period of development refers to a specific phase or period when the presence of a function or reasoning has its greatest effect on a specific aspect of development. For example, if a child does not walk by 20 months, there is delayed gross motor ability, which slows exploration and manipulation of the environment. Freuds psychoanalytic model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and instinctive forces. Erik Erikson (1902-1994) expanded Freuds psychoanalytic stages into a psychosocial model that covered the whole life span. In this theory, Erikson divided life into eight stages, known as Eriksons eight stages of development. Jean Piaget (1896-1980) developed the theory of cognitive development, which describes childrens intellectual organization and how they think, reason, and perceive the world.

Reviewing sexuality changes associated with aging is important because: a. very few older women experience any type of sexual problems. b. in older men, the penis does not become firm as quickly. c. ejaculation remains the same throughout life. d. ejaculation is quicker with aging.

b. in older men, the penis does not become firm as quickly. Rationale: Approximately 50% of older women experience some type of sexual problem such as low desire or vaginal dryness. In men, the penis does not become firm as quickly and is not as firm as it is at a younger age. Ejaculation takes longer to achieve and is shorter in duration, and the erection often diminishes more quickly.

A patient who was injured in a motor vehicle accident is taken via ambulance to the emergency department. The nurse performing the physical assessment knows that, according to the general adaptation syndrome, the patient should be expected to exhibit: a. increased blood flow to the intestines. b. increased heart rate. c. decreased blood pressure. d. decreased blood glucose levels.

b. increased heart rate. Rationale: In the early part of the twentieth century, the fight-or-flight response was described. This arousal of the sympathetic nervous system prepares a person for action by increasing heart rate; diverting blood from the intestines to the brain and striated muscles; and increasing blood pressure, heart rate, respiratory rate, and blood glucose levels.

________________ problems are actual or potential problems that may not be directly related to the patients illness or disease. They are often related to the patients developmental and/or long-term health care needs (e.g., teaching for self-care in the home before discharge of a patient who has just been admitted to the hospital) a. High priority b. Low priority c. Mid priority d. Intermediate priority

b. low priority

A nurse enters a patients room and is very methodical in her assessment skills and in providing a safe environment, but only speaks with the patient when necessary to gather data. This nurse is: a. uncaring and probably always will be. b. most likely a product of a less caring environment. c. probably more caring with other patients. d. a product of a caring environment.

b. most likely a product of a less caring environment. Rationale: There are no known ways that will ensure you will become a caring professional. For those who find caring a normal part of their life, caring is a product of their culture, values, experiences, and relationships with others. Persons who do not experience care in their lives often find it difficult to act in caring ways. As nurses deal with health and illness in their practice, most grow in the ability to care. Caring nurses use a caring approach in each patient encounter.

A nurse is teaching the staff about how to process an ethical dilemma. Which order should the nurse use to present the steps? a. Evaluate the action. b. Negotiate the outcome. c. State the problem clearly. d. Gather all relevant information. e. Examine own values and opinions. f. Consider possible courses of action. a: d, e, c, f, a, b b: d, e, c, f, b, a c: d, c, e, f, a, b d: d, e, c, b, f, a

b: d, e, c, f, b, a The steps to process an ethical dilemma include the following: (1) Is this an ethical dilemma? (2) Gather all information relevant to the case. (3) Examine and determine your own values and opinions about the issues. (4) State the problem clearly. (5) Consider possible courses of action. (6) Negotiate the outcome. (7) Evaluate the action

An older adult patient in a long-term care facility recently had a stroke after experiencing a myocardial infarction. The patient is not speaking or eating. The nurse notices an adverse change in vital signs. When a patient is unable to resist the effects of a stressor, the nurse can identify this stage of the general adaptation system as: a. an alarm reaction. b. the resistance stage. c. the exhaustion stage. d. a fight-or-flight response.

c . the exhaustion stage. Rationale: The exhaustion stage occurs when the body is no longer able to resist the effects of the stressor and the struggle to maintain adaptation drains all available energy. The physiological response intensifies, but the person has so little energy left that adaptation to the stressor diminishes. The body can no longer defend itself against the impact of the event, and if the stress continues, it damages the heart along with other bodily organs and lowers resistance to illness. In the alarm stage, rising hormones result in an increased blood pressure, blood glucose levels, epinephrine and norepinephrine levels, heart rate, blood flow to muscles, oxygen intake, and mental alertness. This change in body systems prepares an individual for fight or flight and lasts from 1 minute to many hours. During the resistance stage, the body stabilizes and responds in an opposite manner to the alarm stage.

Data ______1______________ such as physical measurements and scores on surveys are collected, statistical results from the study are explained. _________2___________ data do not focus on perceptions and feelings. a. 1. Quantitative study, 2. Qualitative study b. 1. Randomized trial, 2. Quantitative study c. 1. Quantitative study, 2. Quantitative study d. 1. Case controlled study, 2. Randomized trial

c. 1. Quantitative study, 2. Quantitative study

A student nurse who works in a pediatric clinic is assisting with an assessment on a young child who is not yet walking. She knows that it is considered a delayed gross motor ability if the child does not walk by _____ months. a. 16 b. 18 c. 20 d. 22

c. 20 Rationale: A critical period of development refers to a specific phase or period when the presence of a function or reasoning has its greatest effect on a specific aspect of development. For example, if a child does not walk by the age of 20 months, there is delayed gross motor ability, which slows exploration and manipulation of the environment. The success or failure experienced within a phase affects the childs ability to complete the next phases.

A nurse is using SBAR and tells the primary health care provider that the abdomen is distended and firm with a pain rating of 8 on a 0-10 scale. Which component of SBAR did the nurse communicate? a. S b. B c. A d. R

c. A Rationale: For assessment (A) data include significant findings in your head-to-toe physical assessment, recent vital signs, current treatment measures, restrictions, recent laboratory results and diagnostics, and pain status. Some institutions use SBAR, an acronym that stands for situation, background, assessment, and recommendation. SBAR standardizes telephone communication of significant events or changes in a patients condition. Therefore it is a communication strategy designed to improve patient safety. When describing the situation (S), you include the admitting and secondary diagnoses and the problem your patient is having as the current issue. Background (B) information includes pertinent medical history, previous laboratory tests and treatments, psychosocial issues, allergies, and current code status. Provide your recommendation (R), in which you suggest a plan of care and request orders and other needs to be addressed.

A registered nurse is prioritizing care for four patients. Which patient should the nurse see first? a. A 44-year-old woman 1 day postoperative b. A 64-year-old man who had a stroke 2 days ago c. A 56-year-old woman with an acute asthma attack d. A 67-year-old man with a fractured hip

c. A 56-year-old woman with an acute asthma attack Rationale: An acute asthma attack is a disruption in oxygen and must be addressed first. According to Maslow, meet the patients physiological needs such as oxygen, food, water, sleep, and elimination firs

Which patient is the most likely to be motivated to learn? a. A 23-year-old smoker being taught about weight control b. A 45-year-old man being taught about importance of prostate cancer screening c. A 63-year-old knee replacement patient being taught postsurgical knee rehabilitation d. A 15-year-old girl being taught about safe sex

c. A 63-year-old knee replacement patient being taught postsurgical knee rehabilitation Rationale:Motivation to learn is often dependent on the patients situation, needs, previous knowledge, attitudes, and sociocultural factors. For example, patients who need knowledge for survival or to return to a previous level of functioning (knee replacement for knee rehabilitation) have a stronger motivation to learn than patients who need knowledge for promoting health.

Which patient is most in need of discharge planning by the nurse? a. A 29-year-old mother with strong family support who has a healthy newborn b. A 59-year-old patient with an active lifestyle who has had an appendectomy c. A 64-year-old patient with heart failure who has a limited income d. A 56-year-old patient with a supporting spouse who has had a hysterectomy

c. A 64-year-old patient with heart failure who has a limited income Rationale: The 64-year-old patient with heart failure has a chronic disease and more risks than the other patients because of age and income. Some patients are more in need of discharge planning because of their risks. For example, some patients have limited financial resources or limited family support; others may have long-term disabilities or chronic illnesses. Early discharge teaching is especially important as a way to decrease readmission to the hospital. Appendectomy and hysterectomy are acute conditions and do not have as many risks as heart failure. A healthy newborn is stable, whereas heart failure is chronic.

Which patient is in the most expensive place to deliver care per day? a. A patient in a rehabilitation unit b. A patient in a long-term care facility c. A patient in an intensive care unit d. A patient in a private hospital room

c. A patient in an intensive care unit. Rationale: An intensive care unit is the most expensive delivery site for medical care because each nurse is usually assigned to care for only one or two patients at a time and because of the types of treatments and procedures the patients in the intensive care unit typically require.

A registered nurse delegates vital signs on a patient to the unlicensed assistive personnel (UAP). The nurse reviews the documented vital signs from the UAP to determine if they are within normal parameters for the patient. The nurse in this example is demonstrating which attribute when following up on the vital signs? a. Interprofessional collaboration b. Staff education c. Accountability d. Delegation

c. Accountability Rationale: Accountability refers to liability or individuals being answerable for their actions. It involves follow up and a reflective analysis of your decisions to evaluate their effectiveness. A primary nurse delegates responsibility but is accountable for his or her patients outcomes

A retired high school teacher has been admitted to the hospital with complications of diabetes. To ensure the patient is discharged home with the right care, at the right time, and without duplication, which health care reform system was developed? a. The Joint Commission b. National Priorities Partnership c. Accountable Care Organization d. Managed Care

c. Accountable Care Organization Rationale: An ACO works to make sure that patients receive the right care at the right time, without duplication of services or incidence of medical errors. Accountable care organizations (ACO) were developed to coordinate medical care by primary care and specialty physicians, hospitals, and other health care providers with the goal of providing high-quality coordinated care

A businessman who had been employed at one company since graduating from college was recently downsized at work and is unemployed. He was always very proud of this job and is grieving the loss. What type of loss is this? a. Maturational b. Situational c. Actual d. Perceived

c. Actual Rationale: People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include job loss. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain and changes in living arrangements. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem.

Which technique by the nurse will facilitate communication with an older adult? a. Have the TV play lightly in the background. b. Ask several questions in a row. c. Allow reminiscing. d. Use long sentences.

c. Allow reminiscing. Rationale: Allow older adults the opportunity to reminisce. Reminiscing has therapeutic properties that increase the sense of well-being. During conversation maintain a quiet environment that is free from background noise (turn off the TV). Allow time for conversation; do not ask several questions in a row. Avoid long sentences to explain the subject. Try to keep it short, simple, and to the point.

An 81-year-old widow with mild dementia has self-care capabilities. The widow recently moved in with her daughter, a 46-year-old working mother with three children. In considering how to have care for her mother when she is working, what is the most appropriate option the nurse should suggest? a. A rehabilitation center b. A nursing center c. An adult day care center d. A hospice center

c. An adult day care center Rationale: Services offered by adult day care centers allow family members to maintain their lifestyles and employment and still provide home care for their relatives. A hospice is a system of family-centered care that allows patients to live and remain at home with comfort, independence, and dignity while alleviating the strains caused by terminal illness; this is inappropriate because the widow does not have a terminal illness.

A surgical unit uses Betadine to prep the skin before surgery. A nurse is using the scientific method to decide if soap and water is better than Betadine for preparing the skin for surgery. A nurse washes one group of patients with soap and water and washes another group of patients with Betadine. Which step did the nurse implement? a. Identifying the problem b. Forming the question or hypothesis c. Answering the question or hypothesis d. Evaluating the results of the test or study

c. Answering the question or hypothesis Rationale: When the nurse washes one group with soap and water and the other with Betadine, the nurse is answering the question or hypothesis.

An older extended care resident was dying. The family came to visit, but one of the great-granddaughters had difficulty accepting the impending death. What is the best thing that the nurse can do to help her feel more comfortable? a. Telling her that she probably should not visit if it upsets her so much. b. Tell her to avoid talking about the past and focus on the present. c. Ask her if she would like to brush the residents hair. d. Ask the family to leave at the end of visiting hours so that they can rest.

c. Ask her if she would like to brush the residents hair. Rationale: Suggest simple and appropriate tasks for family members to perform (e.g., offering help with meals, simple hygiene or comfort activities, or filling out a menu). Family members who are having difficulty accepting the patients impending death sometimes avoid visits. When family members visit, reassure them that their presence is important, encourage interaction, and offer information about what the patient was talking about or has recently experienced. Encourage family members to discuss normal family activities, reminisce about enjoyable times, and ask about the patients concerns. Some people feel lonely or fearful at night and want a family member to stay with them. In acute care settings or extended care facilities, allow visitors to remain with patients who are dying, and relax other visiting restrictions.

A nurse is caring for a patient who cannot speak clearly. Which technique should the nurse use to enhance conversation with this patient? a. Speak loudly. b. Finish the patients sentences. c. Ask question that require yes or no answers. d. Avoid communication aids to prevent embarrassment.

c. Ask question that require yes or no answers. Rationale: For patients who are mute, unable to speak, or cannot speak clearly, ask simple questions that require yes or no answers. Use normal volume and do not shout or speak too loudly. Do not finish the patients sentences. Use communication aids as needed; do not avoid them.

The nurse is caring for a 34-year-old woman, who was admitted to the hospital with multiple rib fractures. The patient states, I fell down the stairs. It was all my fault. I can be so stupid at times. The nurse notices healing bruises on the patients back and buttocks. The patients husband seems very caring, always holding her hand and often answering questions for her. The nurse should do which of the following? a. Direct her questions toward the husband because he answers most of them anyway. b. Accept the patients report on how she received her broken ribs. c. Ask the husband to step into the waiting room while the patient is examined. d. Treat the patients wounds and discharge her home.

c. Ask the husband to step into the waiting room while the patient is examined. Rationale: If you suspect abuse, interview the patient privately. A patient will probably not admit to problems of abuse with the abuser present. Sexual abuse, assault, and rape are also stressors that affect self-concept. Be alert to clues that suggest abuse. In addition, observe the interaction between the patient and partner for additional clues. Controlling behaviors such as speaking for the person or refusing to leave him or her alone with a caregiver are suggestive of emotional and perhaps physical or sexual abuse.

The nurse is admitting a patient to the unit and asks the patient about the health history. The nurse is engaged in which component of the nursing process? a. Evaluation b. Diagnosis c. Assessment d. Planning

c. Assessment Rationale: The nurse is in the assessment phase. An assessment database includes a patients comprehensive health history, which includes information about a patients physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system. The database also includes physical examination findings and a summary of results from laboratory and diagnostic testing

Which behavior by a new nurse will cause the nurse manager to intervene? a. Initiates teaching of a patient b. Uses discovery learning techniques with a patient c. Assigns nursing assistive personnel to teach a patient d. Implements the teach-back method to evaluate patient understanding

c. Assigns nursing assistive personnel to teach a patient Rationale: In most situations it is not appropriate to delegate educational interventions to nursing assistive personnel (NAP); therefore the nurse manager would have to intervene. Nurses should initiate teaching; that is a component of the nurses role. Discovery is a useful technique for teaching problem-solving application and independent thinking. Regardless of the method used to teach, use the teach-back method to evaluate the patients understanding of the material.

As a nurse is obtaining a health history from a patient, the nurse uses comments such as go on. Which technique is the nurse using? a. Cues b. Inferences c. Back-channeling d. Termination

c. Back-channeling Rationale: This is known as back-channeling, which is the practice of giving positive comments such as all right, go on, or uh-huh to the speaker. These indicate that a nurse has heard what the patient says and is attentive to hear the full story

.An RN has been caring for a patient. The nurse received an erroneous order for a medication. The primary health care provider has a reputation for impatience and irritability. Knowing this health care providers nature, which action by the nurse would be most appropriate? a. Clarify the order with the pharmacy. b. Ask the patient to remember. c. Clarify the order with the primary health care provider. d. Ask another nurse to look at the order to try to clarify it.

c. Clarify the order with the primary health care provider. Rationale: A nurse will assess all physician or health care provider orders, and if the nurse determines they are erroneous or harmful, obtain clarification from that physician or health care provider. Calling pharmacy, asking the patient, and asking another nurse are not the best ways to handle erroneous orders.

Which task can a nurse safely delegate to a student nurse who is working as a nursing assistant? a. Distributing medications to patients b. Administering insulin injections c. Collecting intake and output data d. Assessing patients

c. Collecting intake and output data Rationale: During the time when a student nurse works as an employee of a health care facility, perform only tasks that appear in a job description for a nurses aide or nursing assistant. For example, even if a student nurse has learned how to administer intramuscular medications, do not perform this task as a nurses aide.

When caring for a patient from another culture, what is the best strategy for the nurse to use in communicating with the patient? a. Using a cultural joke to break the ice b. Stereotyping the patient within his or her culture c. Considering the context of the patients background d. Assuming the patient or the family member speaks English

c. Considering the context of the patients background Rationale: When a patient is from another culture, the nurse should consider the context of the patients background. Accept patients rights to adhere to cultural customs and norms. Persons of different cultures use different types of verbal and nonverbal cues to convey meaning. A nurse should make a conscious effort not to interpret messages through his or her own cultural perspective; instead, a nurse considers the context of the other individuals background. Avoid stereotyping persons from other cultures or making jokes about them. With patients from another culture, the nurse cannot assume the patient or family members can speak English.

The nurse has recently been promoted to a new management position in her hospital. She is concerned about her new responsibilities and has found that she is having difficulty sleeping at night. This is an example of what ego-defense mechanism? a. Compensation b. Denial c. Conversion d. Displacement

c. Conversion Rationale: Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite). Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Displacement is transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute. (Example: A person transfers anger over a job conflict to a malfunctioning computer.)

A new registered nurse is working on a pediatric unit in a large teaching hospital that uses focus charting with the acronym DAR. What will the nurse be charting? a. Data, assessment, reaction b. Data, assessment, recommendation c. Data, actions, response d. Data, actions, recovery

c. Data, actions, response Rationale: Each entry includes data, actions, and patient response (DAR) for the particular patient situation. Focus charting (DAR) is a unique narrative format in that it places less emphasis on patient problems and instead focuses on patient concerns such as a sign or symptom, a condition, a behavior, or a significant event. There are no reaction, recommendation, recovery, or assessment in DAR.

The nurse works in a small clinic with two other nurses and a nurse practitioner. Recently the nurse has been staying at work longer than usual. His neighbor, a patient at the clinic, asks one of the other employees at the clinic how the nurse is coping since his wife left him. The nurse had not shared this information with his co-workers. The nurse may be coping with his loss with which of the following? a. Compensation b. Conversion c. Denial d. Dissociation

c. Denial Rationale: Denial is avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain. Compensation is making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset. Conversion is unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms (e.g., difficulty sleeping, loss of appetite). Dissociation is experiencing a subjective sense of numbing and a reduced awareness of ones surroundings.

A nurse is caring for an elderly lady who recently experienced a stroke and who coughs/chokes after eating or drinking. The nurse knew that the patient was at risk for aspiration because of the stroke and was concerned that the patient may have impaired swallowing. The nurse develops a care plan based on the nursing diagnosis Impaired Swallowing. Which skill is the nurse using to make this nursing diagnosis? a. Medical diagnosis b. Scientific method c. Diagnostic reasoning d. Data collection

c. Diagnostic reasoning

A patient with cancer is undergoing outpatient chemotherapy. The clinic nurse notes that the patients white blood cell count is very low and has little energy. The plan of care is based upon the nursing diagnosis Risk for Infection. The nurse provides patient teaching in order to reduce the risk for infection. The nurse is using which skill in this situation? a. Medical diagnosis b. Scientific method c. Diagnostic reasoning d. Data collection

c. Diagnostic reasoning Rationale: The nurse used diagnostic reasoning by using data (low white blood cells and little energy) to arrive at a patients health problem/nursing diagnosis (Risk for Infection). Diagnostic reasoning is the analytical process for determining a patients health problems. It requires you to assign meaning to the behaviors and physical signs and symptoms presented by a patient. Nurses do not make medical diagnoses; they make nursing diagnoses

A nurse wants learning to take place in the affective domain of learning. Which techniques should the nurse implement that are the best for this type of learning? (Select all that apply.) a. Lecture b. Practice c. Discussion d. Role play e. Return demonstration

c. Discussion d. Role play Rationale: Teaching methods for affective learning include role-play and discussion. Lecture is effective for cognitive learning. Practice and return demonstration are best for psychomotor learning.

The parent of a child who drowned in a neighbors pool that was not secured, would most likely file a wrongful death lawsuit against the neighbor during which of Bowlbys phases of mourning? a. Numbing b. Yearning and searching c. Disorganization and despair d. Reorganization

c. Disorganization and despair Rationale: During the phase of disorganization and despair an individual spends much time thinking about how and why the loss occurred. The person often expresses anger at anyone he or she believes to be responsible. In the numbing phase, a person has periods of extremely intense emotion and reports feeling stunned or unreal. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, people need to experience this painful phase of grief. During the final phase of reorganization, which usually requires a year or more, the person accepts unaccustomed roles, acquires new skills, and builds new relationships.

A nurse notices that a particular area of the community had food poisoning. The nurse collected data from the people who were affected, identified a local restaurant that served all the people, and determined it was the chicken dish that caused the poisoning. Which community health nurse competency did the nurse demonstrate? a. Public health b. Educator c. Epidemiologist d. Case manager

c. Epidemiologist Rationale: As epidemiologist, community health nurses use basic principles of epidemiology such as tracking health problems; collecting and analyzing data to identify disease trends, outbreaks of illnesses, and disease incidence rates; and planning strategies to prevent or contain outbreaks.

According to one growth and development theorist, individuals need to accomplish a particular task before successfully completing the stage of growth and development. Each task is framed with opposing conflicts, such as trust versus mistrust. Who developed this theory? a. Sigmund Freud b. Jean Piaget c. Erik Erikson d. Lawrence Kohlberg

c. Erik Erikson

_______________ divided life into eight stages, known as _________ eight stages of development. According to this theory, individuals need to accomplish a particular task before successfully completing each stage. Each task is framed with opposing conflicts, such as trust versus mistrust. Each stage builds upon the successful attainment of the previous developmental conflict. a. Sigmund Freud b. Jean Piaget c. Erik Erikson d. Lawrence Kohlberg

c. Erik Erikson

____________ to the consideration of standards of conduct, particularly the study of right and wrong behavior. a. Responsibility b. Privacy c. Ethics d. Moral behavior

c. Ethics Rationale: The ethics of care suggests that health care workers solve ethical dilemmas by the promotion of the fundamental act of caring.

A registered nurse questioned the nurses on the neonatal intensive care unit about the practice of kangaroo care for neonates. The nurse had read literature supporting the practice, but the nurses that work on the neonatal unit stated that they had never done anything like that at their institution. The nurse continued to ask questions and began a literature review. Which behavior was the nurse demonstrating? a. Variables b. Peer review c. Evidence-based practice d. Process measurement

c. Evidence-based practice

A 45-year-old widow, who is being seen in a mental health clinic for clinical depression and alcohol dependency, lost her husband and her son in a boating accident 10 months earlier, and has become increasingly despondent and withdrawn. She verbalizes that she feels overwhelmed by her loss. Her daughter urged her mother to seek help. Which type of complicated grief best explains Eleanors behavior? a. Chronic b. Delayed c. Exaggerated d. Masked

c. Exaggerated Rationale: People having an exaggerated grief response are overwhelmed by their loss, have difficulties functioning, and display significant behavioral dysfunction. Chronic grief occurs when the active acute mourning experienced in normal grief reactions does not decrease and continues over long periods of time. When people consciously or unconsciously avoid the pain of loss and do not experience common grief reactions at the time of the loss, they have a delayed grief reaction. Masked grief occurs after a significant loss in which some people are unable to recognize that the behaviors making normal functioning difficult are a result of their loss. For example, a person who loses a pet develops changes in sleeping patterns but does not see the connection between the two events.

A nurse is using scientific knowledge and experience to choose strategies to use in the care of a patient. Which critical thinking skill is the nurse using? a. Analysis b. Evaluation c. Explanation d. Self-regulation

c. Explanation Rationale: Scientific knowledge and experience to choose strategies you use in the care of patient is explanation; it supports your findings and conclusions.

A registered nurse who works on an oncology unit discussed pain control options that the primary health care provider had ordered with a patient undergoing treatment for pancreatic cancer. The patient requested that the intravenous (IV) pain medication be given on a regular basis. The nurse agreed to provide the IV pain medication as requested and continued to reevaluate the pain levels. The nurse is following which ethical principle? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

c. Fidelity Rationale: Fidelity refers to the agreement to keep promises. The principle of fidelity also promotes the obligation of a nurse to follow through with the care offered to patients

A new nurse is looking for a staff nurse position. She had several instances during clinical rotations in nursing school in which she was late because she studied until the early hours of the morning. According to her circadian rhythm she would be best suited for which of the following positions? a. Full-time 8-hour day/evening rotation b. Part-time 12-hour day/night rotation position c. Full-time 12-hour night position d. Full-time 8-hour day position

c. Full-time 12-hour night position Rationale: In general, people doing shift work need to maintain as consistent a sleep and mealtime schedule as possible. Some nurses often ease their coping with shift work by knowing their own circadian rhythms. A nurse who typically thinks well at night and tends to sleep late in the morning will adapt better to night shift than to day shift. Rotating shifts prevent establishment of a consistent sleep and mealtime schedule.

A community health nurse is assessing the structure of a community. Which component will the nurse assess? a. Available health systems b. Available colleges and schools c. Geographical boundaries d. Predominant religious groups

c. Geographical boundaries Rationale: Geographical boundaries are a component of the structure of a community

A registered nurse who works for an orthopedic unit of an acute care hospital makes hourly rounds on his patients. He also closes the door and pulls the curtains around the beds of patients in semiprivate rooms before exposing them for treatments. This is an example of which of the following behaviors? a. Human respect b. Encouraging manner c. Healing environment d. Affiliation needs

c. Healing environment Rationale: A healing environment, for example, is one in which nurses check patients frequently, respect patient privacy, and treat the body carefully. Such an environment leads patients to a sense of security and protection from harm. Human respect refers to nurses being able to appreciate the value of human beings and displaying behaviors that demonstrate value, such as accepting or paying attention to a patient. By showing respect, a nurse honors the worth of individuals. Having an encouraging manner also involves helping patients deal with bad feelings. Affiliation needs refers to inclusion of family members in a patients care. It is a key element in discharge planning. Hospitalized patients perceive nurses as caring when they are responsive to patients families and allow them to be involved in the patients health care situation.

A nurse wants to follow nursing standards of care. Which document should the nurse follow? a. World Health Organization guidelines b. National League for Nursing brochure c. Health care facility's written procedure manual d. Department of Health and Human Services guidelines

c. Health care facility's written procedure manual Rationale: The health care facilitys written procedure manual is defined as a standard of care. Standards of care are defined by the following: (1) State Nurse Practice Acts, (2) state and federal hospital licensing laws and accreditation rules, (3) professional and specialty organizations, and (4) written policies and procedures of the nurses health care facility.

A patient who is a migrant farm worker did not graduate from high school and speaks English as a second language. The nurse will be providing discharge teaching after a hysterectomy. The nurse is concerned about the patients ability to understand the discharge instructions. Which of the following should be of most concern in this situation? a. Motivation b. Developmental stage c. Health literacy d. Psychomotor learning

c. Health literacy Rationale: Health literacy includes patients reading and math skills, comprehension, the ability to make health-related decisions, and successful functioning as a consumer of health care. It is a strong predictor of health status and patient outcomes.

Which model exemplifies a patient who states the following, I am responsible for my own health and well-being and I will partner with you (my nurse) to make sure I am ready to be discharged after surgery? a. Basic Human Needs Model b. Absence of Disease Model c. Holistic Health Model d. Healthy People 2020 Model

c. Holistic Health Model Rationale: The intent of the holistic health model is to empower patients to engage in their own recovery, thereby assuming some responsibility for health maintenance

A nurse gives a hand-off report to the oncoming staff nurse. Which type of communication does this illustrate? a. Gossip b. Validation c. Interpersonal d. Intrapersonal

c. Interpersonal Rationale: Interpersonal communication is interaction that occurs between two people or within a small group.

A nurse works in a trauma intensive care unit in a busy urban hospital. Once a week, staff members from all the disciplines caring for the trauma patients get together to discuss their progress. The patients family can be included in the discussion if it is approved by the patient. This is best described as which of the following? a. Nursing practice b. Staff communication c. Interprofessional collaboration d. Staff education

c. Interprofessional collaboration Rationale: Interprofessional collaboration involves bringing representatives of the various disciplines together to work with patients and families to deliver quality care. This brings different points of view to the table to identify, clarify, and solve complex patient problems. Nursing practice is all nursing areas involved in ones professional career

Which information indicates the nurse has an accurate understanding of the State Nurse Practice Act? a. It is a federal senate bill. b. It is a law enacted by the federal government. c. It is a statute enacted by state legislature. d. It is a judicial decision.

c. It is a statute enacted by state legislature. Rationale: Nurse Practice Acts are examples of statutes enacted by state legislatures to regulate the practice of nursing

A registered nurse who works for a surgical intensive care unit (ICU) has recently read several articles in professional nursing journals about the use of quiet time in the ICU to enhance patient outcomes. The nurse would like to apply the research findings to the unit. How did the nurse formulate the clinical question? a. Measurement-focused trigger b. Problem-focused trigger c. Knowledge-focused trigger d. Expectations-focused trigger

c. Knowledge-focused trigger

A registered nurse wants to review the latest information regarding prevention of a health care acquired infection. Where is the best place for the nurse to obtain this information? a. Online information b. Peer-reviewed nursing journal c. Latest edition of a nursing textbook d. Most recent edition of a popular magazine

c. Latest edition of a nursing textbook

A nurse is teaching the staff about managed care. Which information should the nurse include? a. Managed care focuses on long-term care services for skilled nursing. b. Managed care focuses on hospital admissions and illnesses for a group of people. c. Managed care focuses on control over primary health services for a defined population. d. Managed care focuses on decreased access to care while increasing costs.

c. Managed care focuses on control over primary health services for a defined population. Rationale: The term managed care describes systems in which the payer has control over primary health care services delivery for a defined patient population.

A nurse is caring for a patient who has become depressed because her children have gone away to college. The nurse assesses this type of depression as what type of loss? a. Actual b. Perceived c. Maturational d. Situational

c. Maturational Rationale: People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include the loss of a body part, pet, friend, life partner, or job. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had the loss. For example, a person perceives that she is less loved by her parents and experiences a loss of self-esteem. Situational loss occurs as a result of an unpredictable life event.

The nursing unit staff has used evidence-based practice to implement a practice change. What is the next step in the process the nursing staff should implement? a. Review literature. b. Engage companies. c. Measure outcomes. d. Ask a clinical question.

c. Measure outcomes Rationale: After implementing the change, the practice decision or change should be evaluated by using outcome or process measurements. Remember the O in your PICO(T) question. It represents the outcomes you choose to measure as you integrate the evidence. These outcomes tell you how well the evidence-based intervention works. Reviewing literature and asking a clinical question occurred before the change. Companies are not a part of this process.

student nurse is in her community health clinical rotation. She is visiting a family with a new baby. Which of the following statements made by the mother of a 1-month-old infant indicates the need for client education? a. My baby should double his birth weight by the time he is 6 months old. b. I shouldnt give my baby any cows milk until he is at least a year old. c. My baby has been fussy lately; I believe he is probably cutting his teeth. d. I shouldnt put my baby on a fluffy pillow to sleep.

c. My baby has been fussy lately; I believe he is probably cutting his teeth. Rationale: The first tooth to erupt is usually one of the lower central incisors at the average age of 7 months. Most babies have six teeth by their first birthday. Typically infants double their birth weight by 5 to 6 months and triple it by 12 months. Infants should not have any type of cows milk during the first year because the high protein content may increase the chance of food allergies. The American Academy of Pediatrics recommends infants not sleep with a blanket until they are a year old.

A nurse is delegating care of patients to the nursing assistant personnel (NAP) and a licensed practical nurse (LPN). Which situation indicates the nurse needs more instruction on delegation? a. LPN to change a sterile dressing b. NAP to provide skin care c. NAP to insert an indwelling catheter d. LPN to administer an enema

c. NAP to insert an indwelling catheter Rationale: The question indicates the nurse made an incorrect delegation assignment. An NAP cannot insert indwelling catheter, an LPN or RN can do that skill. Noninvasive and frequently repetitive interventions such as skin care, ambulation, grooming, and hygiene measures are examples of activities that you assign to NAP such as certified nurse assistants. Licensed practical nurses perform these measures in addition to medication administration and many invasive tasks (e.g., dressing care and catheterization). It is appropriate for an RN to delegate, a sterile dressing change and enema to an LPN. It is appropriate for an RN to delegate skin care to an NAP.

A nurse records the following at 1800: patient states that the abdominal pain is worse now than last nightBetty Smith, RN. The nurse is using which type of charting? a. PIE documentation b. SOAP documentation c. Narrative charting d. Charting by exception

c. Narrative charting Rationale: Narrative charting uses a storylike format to document information specific to patient conditions and nursing care. PIE charting focuses on problem, intervention, and evaluation. SOAP documentation addresses subjective data, objective data, assessment, and the plan. Charting by exception reduces the time required to complete documentation, using a flow sheet to indicate normal findings or routine interventions.

A nurse went into a patients room at 0900, shortly after the patient was told that he or she had liver cancer. The patient asked the nurse to stay because he or she did not want to be alone. The nurse stood very close to the patient, held the patients hand, and told the patient that he or she had plenty of time. A few minutes later, the nurse thought to check the time on the wristwatch because the nurse was supposed to take another patient for a test at 0945. The patient saw the nurse look at the wrist watch and told the nurse it was now okay to be alone. What was the most likely reason the patient said it was okay for the nurse to leave? a. Invasion of personal space b. Verbal communication c. Nurses gesture d. Intonation

c. Nurses gesture Rationale: The nurses gesture of looking at the wrist watch most likely caused the request. Gestures alone carry specific meanings, or they may create messages with other communication cues. There was no invasion of personal space because the patient allowed the nurse to sit very close and hold hands. There was no inappropriate verbal communication (words or phrases), nor was there any inappropriate intonation (tone of voice).

A nurse is teaching the staff about the Prospective Payment System (PPS). Which information should the nurse include in the teaching session? a. PPS establishes cost-based reimbursement for health care. b. PPS provides reimbursement for every service the patient receives. c. PPS establishes reimbursement rates based upon diagnosis-related groups (DRGs). d. PPS provides money to the patient for health promotion use

c. PPS establishes reimbursement rates based upon diagnosis-related groups (DRGs). Rationale: PPS established diagnosis-related groups (DRGs). Established by Congress in 1983, the PPS eliminated cost-based reimbursement, which is reimbursement for every service the patient receives. Hospitals serving patients using Medicare were no longer paid for all costs incurred in delivering care to a patient. Instead, inpatient hospital services for patients using Medicare were combined into 468 DRGs. PPS provides a preset amount of money to hospitals and health care providers for DRGs, not for health promotion. Managed care focuses on health promotion.

A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy. Which will provide the best primary source of information for what comforts the patient when stressed? a. Patient chart b. Patient c. Parents d. Surgeon

c. Parents Rationale: Family members and significant others are primary sources of information for infants, children, critically ill adults, patients with mental handicaps, or patients who are unconscious or have reduced cognitive function. The patient is too young. The patients chart is a source but not a primary source. The parents are a better source than the surgeon.

A staff nurse is caring for six patients and is working with nursing assistive personnel. Which task can the nurse safely delegate to the nursing assistive personnel? a. Patient assessment b. Patient discharge teaching c. Patient bed bath d. Patient medication administration

c. Patient bed bath Rationale: Daily, repetitive tasks of care such as basic hygiene, specimen collection, and feeding patients can be delegated. Delegation is the process of assigning part of one persons responsibility to another qualified person in a specific situation. The nurse cannot delegate assessments or discharge teaching. Some medication administration can be delegated to licensed practical nurses, but not to nursing assistive personnel.

A nurses manager has suggested that a nurse formulate a PICO question to clarify the topic before doing a literature review. When the nurse asks what the acronym PICO stands for, how should the nurse manager respond? a. Policy, information, comparison, outcome b. Patient, information, collection, outcome c. Patient, intervention, comparison, outcome d. Policy, intervention, communication, outcome

c. Patient, intervention, comparison, outcome Rationale: P: Patient population of interest. Identify patients by age, gender, ethnicity, disease, or health problem. I: Intervention of interest. Which intervention do you want to use in practice (e.g., a treatment, diagnostic test, educational approach)? C: Comparison of interest. What is the usual standard of care or current intervention that you now use in practice? O: Outcome. What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, patient perception)?

A home health nurse is providing care to a patient. Which action by the nurse is a physical care technique? a. Dressing a patient b. Assisting a patient to learn how to shop c. Performing range-of-motion exercises d. Administering cardiopulmonary resuscitation

c. Performing range-of-motion exercises Rationale: Physical care techniques involve the safe and competent administration of nursing procedures (e.g., inserting a urinary catheter, performing range-of-motion exercises). Dressing a patient is an activity of daily living. Shopping is an instrumental activity of daily living. Cardiopulmonary resuscitation is a lifesaving measure.

A small business owner has consulted with an occupational health nurse regarding health promotion activities for the employees. The registered nurse explores the possibility of providing an area outside the new office complex where employees can walk during their breaks. Which level of care did the nurse use? a. Continuing care b. Restorative care c. Primary care d. Tertiary care

c. Primary care Rationale: In the settings that deliver preventative and primary care, such as schools, physicians or health care providers offices, occupational health clinics, and nursing centers, health promotion is a major theme.

A female patient has just found a large lump in her breast. The health care provider needs to perform a breast biopsy. The nurse assists the patient into the proper position and offers support during the biopsy. What is the nurse doing? a. Creating a healing environment b. Fulfilling affiliation needs c. Providing a sense of presence d. Demonstrating an encouraging manner

c. Providing a sense of presence Rationale: A sense of presence is something a nurse offers to patients with the purpose of achieving some goal, such as support, comfort, or encouragement; to diminish the intensity of unwanted feelings; or for reassurance. Establishing presence when patients are experiencing stressful events or situations is very important. A nurses presence calms anxiety and fear related to stressful situations. Giving reassurance and thorough explanations about a procedure, remaining at a patients side, and coaching a patient through the experience all convey a presence that is invaluable to a patients well-being. A healing environment, for example, is one in which nurses check patients frequently, respect patient privacy, reduce noise, and treat the body carefully. Affiliation need in nursing practice occurs with the inclusion of family members in a patients care. It is a key element in discharge planning. Having an encouraging manner occurs when a nurse is poised and cheerful and points out the good in a difficult situation. Patients perceive these behaviors as caring.

After a nurse receives a medication telephone order for a patient, what is the proper action? a. Withholding the medication until the physician or health care provider signs the order b. Verifying the physicians or health care providers order with the pharmacy c. Reading it back to the person who gave the order d. Clarifying the new medication order with another registered nurse

c. Reading it back to the person who gave the order Rationale: The nurse receiving a verbal order or telephone order writes down the complete order or enters it into the computer as it is being given. Then the nurse reads it back, called read-back, and receives confirmation from the person who gave the order. The medication will still be given because in most institutions the health care provider has 24 hours to sign the order. Verification is in the read back with the person who ordered the medication, not with pharmacy or another nurse.

Which situation represents a nurse using clinical decision-making skills? a. Collecting information about a patient and coming to a conclusion about his or her health problems b. Developing a new idea based on experience and knowledge over time c. Selecting appropriate treatment after forming diagnostic conclusions d. Clarifying the problem and analyzing possible causes

c. Selecting appropriate treatment after forming diagnostic conclusions

A nurse working in an acute care setting wanted to determine the most accurate way to take patients temperatures. The nurse noticed that the tympanic thermometers used by the unit were often not accurate. The nurse found that the literature showed tympanic thermometers were not the most accurate method of obtaining a temperature. The nurse wants to change the nursing practice of the unit. What is the nurses most logical next step? a. Discuss the findings with a patient to gain support. b. Tell the aides to stop taking temperatures. c. Share the findings with the nursing policy and procedure committee. d. Write an editorial in the public newspaper to bring the community into the process.

c. Share the findings with the nursing policy and procedure committee.

A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse. As the student nurse charts the interaction, which statement is the best way to document what happened? a. Appears to be in pain as evidenced by grouchy behavior b. Behavior is inappropriate, requests registered nurse do the assessment c. States, I want a registered nurse to do my assessment d. Is grumpy, registered nurse notified

c. States, I want a registered nurse to do my assessment Rationale: When a nurse collects objective data, he or she should apply critical thinking intellectual standards (e.g., clear, precise, and consistent). Nurses do not include personal interpretive statements.

A registered nurse is caring for a patient 2 days after a colon resection. The patient called for assistance to go to the bathroom. Instead of waiting for help, the patient decided to get up without help. The patient fell but was not injured. After contacting the patients primary health care provider, which action should the nurse take next? a. Nothing; the patient was not injured. b. Call the ethics committee. c. Submit an incident report. d. Insist that the patient have a radiograph done.

c. Submit an incident report. Rationale: When there is a deviation from the standard of care, such as a patient or visitor falls or an error is made, a nurse makes specific documentation of the event or incident in the form of an occurrence/incident report.

A nurse uses effective strategies to communicate and handle conflict with nurses and other health care professionals. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating? a.Informatics b. Quality improvement c. Teamwork and collaboration d. Evidence-based practice

c. Teamwork and collaboration

Which question or comment should the nurse initially use that would best gather the most information during a health history assessment? a. Let us help you. b. Did you seek help when it first started? c. Tell me about the problems you are having. d. Do you have a family history of this problem?

c. Tell me about the problems you are having. Rationale: Initially use open-ended questions/comments. The use of open-ended questions/comments prompts patients to describe a situation in more than one or two words. This technique leads to a discussion in which patients actively describe their health status. Once patients tell their story, focus on the symptoms that the patient identifies and ask closed-ended questions that limit his or her answers to one or two words such as yes or no or a number or frequency of a symptom. The questions that start with Do and Did are closed-ended. Let us help you will not get the patients perspective.

A nurse is preparing to take a 5-year-old childs blood pressure. What is the best way for the nurse to reduce the childs anxiety about this procedure? a. Do nothing because the more fuss that is made about a procedure, the more anxiety it causes the patient. b. Explain to the patient that the blood pressure is a vital sign that the doctor has ordered. c. Tell the child that the blood pressure cuff will hug the arm. d. Ask the childs mother to step outside the room because children frequently do better when alone.

c. Tell the child that the blood pressure cuff will hug the arm Rationale: Describe physical sensations that will occur during the procedure by telling the child that the cuff will hug the arm. Providing information about procedures helps patients feel less anxious because they understand what to expect during the procedure.

A nurse is caring for a 3-year-old niece whose mother has recently died of cancer. Because of the childs stage of development, the nurse expects that the child will most likely see the loss of her mother as which of the following? a. An opportunity to re-examine their lives b. A threat to her self-concept c. Temporary d. A challenge to her emerging identity

c. Temporary Rationale: Expressions of grief evolve as individuals mature. Toddlers, for example, cannot understand the permanence of death but feel anxiety over loss of objects and separation from parents. School-age children, although able to understand the significance of loss more completely, see their loss as a challenge to their emerging identity or self-concept. Middle-age adults often use grief experiences to re-examine or reprioritize their lives. Older adults anticipate grief as they encounter declining physical function or life opportunities, give up employment or social status, or lose loved ones.

A nurse is working in an agency with standards that require a nurses documentation to be within the context of the nursing process. The nurse is working for which agency? a. Centers for Disease Control and Prevention accredited hospital b. World Health Organization hospital c. The Joint Commission accredited hospital d. Agency for Healthcare Research and Quality hospital

c. The Joint Commission accredited hospital Rationale: The Joint Commission standard for record of care, treatment, and services requires that your documentation be within the context of the nursing process, including evidence of patient and family teaching and discharge planning

A registered nurse was accused of patient abandonment when the nurse became angry, quit the job, and left the hospital before the end of the shift. This is an example of violating legal standards/guidelines set by which organization? a. The State Department of Health b. The Joint Commission c. The State Board of Nursing d. The National League for Nursing

c. The State Board of Nursing

A nurse is caring for a patient who smokes two packs a day. The nurse knows that the patient is in the contemplation stage regarding smoking cessation. What is the nurses best response to help the patient move into the preparation stage? a. You need to stop smoking as soon as possible. b. Smoking will kill you if you dont stop. c. The negative effects of smoking can be reversed. d. Tobacco use killed 435,000 people in 2000

c. The negative effects of smoking can be reversed. Rationale: The fact that the negative effects can be reversed may prompt the patient to think about the benefits of quitting and move the patient into the preparation stage of change.

Which patient situation indicates the nurse used fairness? a. The nurse used original thinking to find solutions outside the standard routine. b. The nurse asked why the interventions were used to help the patient. c. The nurse did not allow personal attitudes to influence delivery of care. d. The nurse followed the six rights when giving medication to a patient.

c. The nurse did not allow personal attitudes to influence delivery of care. Rationale: Fairness means the nurse deals with situations justly. This means that bias or prejudice does not enter into a decision. For example, regardless of how you feel about obesity, you do not allow personal attitudes to influence the way you deliver care to patients who are overweight. Creativity involves original thinking. This means you find solutions outside of the standard routines of care while still following standards of practice. A critical thinkers favorite question is, Why? and represents curiosity. Following the six rights is being responsible and accountable.

Which finding will best indicate to the nurse that the teaching about a dressing change was successful? a. The patient understands how to change an abdominal dressing. b. The patient acknowledges the principles of an abdominal dressing change. c. The patient correctly demonstrates an abdominal dressing change as taught. d. The patient states, Yes, I know how to change the dressing.

c. The patient correctly demonstrates an abdominal dressing change as taught. Rationale: Demonstration is the best method to evaluate a psychomotor skill. Examples of evaluating the effectiveness of teaching include having patients show how to perform a newly learned skill (e.g., self-catheterization) or asking patients to explain how they will incorporate newly ordered medications into their daily routines. Evaluating the effectiveness of teaching for a psychomotor skill includes a demonstration, not understanding or acknowledging. Just stating, Yes does not indicate learning like a demonstration does.

A nurse has been asked to prepare patient education for Spanish-speaking patients regarding diabetes. This information will be available to patients in the diabetes clinic. What is the primary goal for this patient education? a. To reduce the legal liability of the clinic b. To teach Spanish-speaking patients some English c. To assist Spanish-speaking patients to reach optimal health d. To provide information so they can make a decision between oral and injectable medications

c. To assist Spanish-speaking patients to reach optimal health Rationale: The goal of patient education is to assist individuals, families, communities, or populations in achieving optimal levels of health, safety, and independence. The goal of patient education is not to reduce the legal liability, teach English, or make decisions about the different types of medications.

A patient tells the nurse that he or she does not understand the purpose of capitation. What is the nurses best response? a. To provide high-quality care at the highest cost to the hospital, not the patient b. To provide the least expensive care for patients regardless of outcomes c. To build a payment plan that includes the best standards of care at the lowest cost d. To ensure that all patients receive the same care for the same cost in all hospitals

c. To build a payment plan that includes the best standards of care at the lowest cost Rationale: -The purpose of capitation is to build a payment plan for select diagnoses or surgical procedures that includes the best standards of care and essential diagnostic and treatment procedures at the lowest cost. -Capitation does not cause the hospitals to pay the highest cost but to determine quality care for the lowest cost. - Capitation does not provide the least expensive care for patients for outcomes because best standards are the outcome. - Capitation does not make all patients receive the same care for the same cost in all hospitals.

The mother of a toddler is concerned that her son is not eating enough, although he has not lost any weight. She tells the nurse that her son used to have a very good appetite, but now does not eat as much as he did a couple of months ago. What is the best response for the nurse to provide? a. You need to make him eat. At this stage, he is growing too fast to not eat. b. I could show you a growth chart, but each child is different so it doesnt mean much. c. Toddlers have periods when they arent growing as fast and they dont need to eat as much. d. Make him eat with a spoon and dont feed him snacks. He will be hungrier at meal time.

c. Toddlers have periods when they arent growing as fast and they dont need to eat as much. Rationale: Slower growth rates often occur with a decrease in caloric needs and a smaller food intake. Confirming the childs pattern of growth with standard growth charts is reassuring to parents concerned about their toddlers decreased appetite (physiological anorexia). Encourage parents to offer a variety of nutritious foods, in reasonable servings, for mealtime and snacks. Finger foods allow the toddler to be independent.

The student nurse has been studying different cultures in relationship to nursing. She understands that transcultural nursing has been developed as a distinct discipline and can be defined as which of the following? a. Understanding that cultural patterns are generated from predetermined criteria b. Knowing that culturally congruent care is based on health care system values c. Understanding cultural similarities and differences among groups of people d. The realization that illness and disease are the same

c. Understanding cultural similarities and differences among groups of people Rationale: Leininger defines transcultural nursing as a comparative study of cultures to understand similarities (culture universal) and differences (culture-specific) across human groups. The goal of transcultural nursing is culturally congruent care, or care that fits a persons life patterns, values, and a set of meanings. Patterns and meanings are generated from people themselves rather than predetermined criteria. Culturally congruent care is sometimes different from the values and meanings of the professional health care system. To provide culturally congruent care, it is important for you to distinguish between disease and illness. Illness is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or psychological processes.

A nurse has worked in a variety of nursing areas and would like to find a unit within the hospital that mirrors the nurses own professional values. The best way for the nurse to find a unit that would be a good fit is for the nurse to examine which document? a. Hospital mission statement b. Unit policies and procedures c. Unit philosophy of care d. Hospital vision statement

c. Unit philosophy of care Rationale: A philosophy of care incorporates the professional nursing staffs values and concerns for the way that they view and care for patients. For example, a philosophy addresses the nursing units purpose, how staff will work with patients and families, and the standards of care for the work unit. A philosophy is a vision for how to practice nursing. A hospitals mission statement and/or philosophy are for the entire hospital, not just the specific nursing unit. Unit policies and procedures will not give the nurse a good idea about the units values and beliefs.

A nurse who works in a neonatal intensive care unit is caring for a critically ill infant with a poor prognosis. She is Christian and feels responsible to care for both the physical and spiritual needs of the infant and his parents. What is the best statement for the nurse to make to the parents of the infant? a. You should have the child baptized so that its soul will be saved. b. Would you like me to call the chaplain to christen your child at the bedside? c. What can I do to support your spiritual needs? d. I have asked my pastor to stop by and talk to you.

c. What can I do to support your spiritual needs? Rationale: Differentiate your personal spirituality from that of the patient. Your role is not to solve the spiritual problems of patients, but to provide an environment for your patients to express their spirituality. Having the child baptized or asking your pastor to come talk to the patient is applying your spiritual values on the patient. Asking permission to call the chaplain is assuming that the patient has value regarding that religious denomination

The study of __________ represents a particular branch of ethics (i.e., the study of ethics within the field of health care). a. Ethical dilemma b. Code of ethics c. Bioethics d. Feminist ethics

c. bioethics

____________ is listening to both sides in any discussion and dealing with situations justly. a. Confidence b. Risk taking c. Fairness d. Curiosity

c. fairness

_________ refers to the agreement to keep promises and is based on the virtue of caring. a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

c. fidelity

A _______________ trigger is a question that arises as a result of new information available on a topic, such as current information in literature a. Literature-focused trigger b. Problem-focused trigger c. Knowledge-focused trigger d. Expectations-focused trigger

c. knowledge-focused trigger

A patient suffering from lung cancer experiences nausea and vomiting. When rendering palliative care, the nurse knows that this type of care: a. is only done in intensive care units. b. is for the elderly. c. requires an interdisciplinary team. d. utilizes standard medical treatments to provide care.

c. requires an interdisciplinary team. Rationale: Palliative care is practiced in any setting and focuses on the prevention, reduction, or relief of physical, emotional, social, and spiritual symptoms of disease or treatment at the end of life when cure is no longer possible. People of any age or diagnosis receive palliative care at any time and in any setting. Expert palliative care involves an interdisciplinary team composed of health care professionalsnurses, social workers, spiritual care professionals, nutritionists, physicians, psychologists, and pharmacists. Therapists who use complementary healing interventions (e.g., massage, music, healing touch, or aromatherapy) also work with palliative care

A nurse has been working overtime because of high hospital census and a decreased work force. The nurse is concerned about the danger of work-related burnout or compassion fatigue. To combat this risk, the nurse should: a. increase nursing responsibilities at work. b. take control over new areas at work to reduce stress. c. strengthen relationships outside of the hospital. d. hang out with co-workers when not at work

c. strengthen relationships outside of the hospital. Rationale: Compassion fatigue occurs as a result of chronic stress and is often associated with the human service professions. Make a clear separation between work and home life. Strengthening friendships outside of the workplace, socially isolating oneself for personal recharging of emotional energy, and spending off-duty hours in interesting activities all help reduce burnout. Identify the limits and scope of your responsibilities at work. Recognize the areas over which you have control and the ability to change and those for which you do not have responsibility.

_____________ is being organized, focusing, and working hard in any inquiry. a. Maturity b. Analyticity c. Systematicity d. Inquisitiveness

c. systematically

A nurse must ask a family member to consider an organ donation. In which order should the nurse contact the individuals? a. Spouse b. Parent c. Guardian d. Grandparent e. Adult son or daughter f. Adult brother or sister a: a, c, e, f, b, d b: a, e, f, b, d, c c: a, e, b, f, d, c d: a, b, e, f, d, c

c: a, e, b, f, d, c Rationale: You approach individuals in the following order to consider organ or tissue donations: (1) spouse, (2) adult son or daughter, (3) parent, (4) adult brother or sister, (5) grandparent, and (6) guardian.

Which chart entry by a nurse would require follow up? a. 0815 Patient found on floor. b. 0816 Patient assessed and helped back to bed. c. 0818 Physician notified of incident. d. 0820 Occurrence report completed

d. 0820 Occurrence report completed Rationale: Do not document in the nurses notes that an occurrence report was completed. All the other entries are accurate. Objectively record the details of the event and any statements the patient makes. At the time of the event, always assess the patient thoroughly, and then contact the health care provider to examine him or her.

A nurse is documenting the last entry for the day. It is 3:15 PM and the agency uses military time. Which time should the nurse enter? a. 315 b. 0315 c. 1315 d. 1515

d. 1515 Rationale: 3:15 is 1515 in military time (1200 + 315 = 1515). The military clock begins at 1 minute after midnight as 0001 and ends with midnight at 2400. For example, 10:22 AM is 1022 military time; 1:00 PM is 1300 military time

A nurse will be teaching a prepared childbirth class for the first time at a neighborhood church. The nurse has gone to the church to determine which room would be best suited to teach a group of six couples. Which room configurations would be most appropriate for teaching this group? a. A small carpeted room with no furniture b. A large auditorium with a stage and theater-style seating c. A lunchroom with stationary tables and chairs d. A Sunday-school classroom with tables and chairs

d. A Sunday-school classroom with tables and chairs Rationale: A Sunday-school classroom allows everyone to be seated comfortably and within hearing distance of the teacher and, the room can comfortably hold all members of the group. Arranging the group to allow participants to observe one another (e.g., in a circle) further enhances learning. A small carpeted room would not allow much room for six couples. A large auditorium is too big. Stationary tables and chairs do not allow for rearranging if needed, and a lunchroom is usually too big.

A recent graduate nurse has been assigned to be a primary nurse on a geriatric unit. After completing a review of development and aging, the nurse recalls that changes during the climacteric signify which of the following? a. A characteristic of young adulthood b. The increased reproductive ability of the older adult c. A time of significant change in cognitive performance in middle age d. A decline of reproductive capacity caused by a decrease in sexual hormones

d. A decline of reproductive capacity caused by a decrease in sexual hormones Rationale: Climacteric is a term used to describe the decline of reproductive capacity and accompanying changes brought about by the decrease in sexual hormones. This affects men and women differently. Men begin to experience decreased fertility, but they are able to continue to father children. Menopause, when a woman stops ovulating and menstruating, occurs only when 12 months have passed since the last menstrual flow. Climacteric is a characteristic of middle adulthood usually referring to those years between 40 and 65. Changes in the cognitive function of middle-age adults are few except during illness or trauma.

________________________ provides care to a specific group of voluntarily enrolled patients. a. Medicaid b. Medicare c. Private insurance d. A managed care organization

d. A managed care organization

The nurse must teach grieving patients about future skills and knowledge. Which patients will most likely be ready to learn? (Select all that apply.) a. A patient in denial b. A patient in anger c. A patient in bargaining d. A patient in resolution e. A patient in acceptance

d. A patient in resolution e. A patient in acceptance Rationale: Patients in resolution and acceptance are ready to learn about future skills and knowledge. Patients in denial, anger, and bargaining should only be taught in the present tense (explain current therapy); they are not ready to accept future learning.

The nurse is caring for a terminally ill patient. In order to provide optimal care, the nurse tries to anticipate patient needs. What does the nurse understand about this patient? a. As patients approach death, they breathe more through their nose. b. Eye blinking may increase as well as tear production. c. Immobility and opioid medications can lead to diarrhea. d. Anxiety in the dying may have a physical cause.

d. Anxiety in the dying may have a physical cause. Rationale: Anxiety has physical causes such as shortness of breath, pain, fear of death, spiritual concerns, and relationship concerns. As patients approach death, they breathe through the mouth, the tongue becomes dry, and lips become dry and cracked. Blinking reflexes diminish near death; and eyes often remain open, causing drying of cornea. Opioid medications and immobility slow peristalsis.

A nurse is using evidence-based practice (EBP) to provide care. Which action should the nurse take first? a. Collect the most relevant and best evidence. b. Integrate evidence with ones clinical expertise. c. Critically appraise the evidence gathered. d. Ask a clinical question

d. Ask a clinical question Rationale: (1) Ask a clinical question; (2) Collect the most relevant and best evidence; (3) Critically review and evaluate/appraise the evidence gathered; (4) Combine/Integrate evidence with ones clinical expertise and patient preferences and values in making a practice decision or change; (5) Evaluate the practice decision or change; (6) Communicate results of the change.

Which action is the nurse required by law to perform when a patient is admitted? a. Notify the family. b. Notify the attorney. c. Ask how payment will be made. d. Ask about advance directives

d. Ask about advance directives Rationale: The Patient Self-Determination Act (1991) requires health care institutions to inquire whether a patient has created an advance directive, give patients information on advance directives, and document whether a patient states that he or she has an advance directive. Notifying the family and attorney is breaking confidentiality. Asking how payment will be made is not required by law and is not the responsibility of the nurse.

A patient who has been diagnosed with terminal liver cancer states that he does not believe in God, but he has had a meaningful life by contributing to the lives of those around him. This person is most likely which of the following? a. Buddhist b. Christian c. Agnostic d. Atheist

d. Atheist Rationale: Atheists search for meaning in life through their work and relationships with others. It is important for agnostics to discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that we, as people, bring meaning to what we do. A Buddhist turns inward, valuing self-control, whereas a Christian looks to the love of God to provide enlightenment and direction in life.

Body image is an important concept relative to psychosocial development. In dealing with body image issues, the nurse must do which of the following? a. Understand that skinny people always see themselves as thin. b. Realize that body image is never associated with self-esteem. c. Recognize that physical changes always lead to changes in body image. d. Be aware that female adolescents more frequently struggle with issues than males.

d. Be aware that female adolescents more frequently struggle with issues than males. Rationale: The development of secondary sex characteristics and changes in body fat distribution has a tremendous impact on the self-concept of an adolescent. Female adolescents struggle more with body image issues than do their male counterparts. Body image depends only partly on the reality of the body. When physical changes occur, individuals may or may not incorporate these changes into their body image. For example, people who have experienced significant weight loss do not perceive themselves as thin and may still tell you there is still a fat person inside. Body image issues are often associated with negative self-concept and self-esteem.

A 9-year-old patient was severely burned and has been undergoing whirlpool treatments to debride the wounds. The patient is crying and does not want to go to the physical therapy department for treatment. The registered nurse caring for the patient knows that, even though it is uncomfortable, the patient needs to have the therapy for the wounds to heal properly. The nurse is demonstrating which ethical principle? a. Autonomy b. Bioethics c. Justice d. Beneficence

d. Beneficence Rationale: The principle of beneficence promotes taking positive, active steps to help others. It encourages a nurse to do good for the patient. Beneficence guides decisions in which the benefits of a treatment pose a risk to the patients well-being or dignity.

After a large weight loss a patient tells the nurse, There still is a fat person inside of me. This type of statement illustrates a flaw in what self-concept component? a. Role performance b. Identity stressor c. Self-esteem d. Body image

d. Body image Rationale: Body image depends only partly on the reality of the body. When physical changes occur, individuals may or may not incorporate these changes into their body image. For example, people who have experienced significant weight loss do not perceive themselves as thin and may still tell you there is still a fat person inside. Role performance is the way in which a person views his or her ability to carry out significant roles. Common roles include mother or father, wife or husband, daughter or son, sister or brother, employee or employer, and nurse or patient. Identity stressors affect an individuals identity, but identity is particularly vulnerable during adolescence. Self-esteem is an individuals overall sense of personal worth or value.

As a nurse caring for a patient with a colostomy that resulted from the treatment of a benign tumor of the bowel. The most appropriate classification of this self-concept component is which of the following? a. Role performance stressor b. Sexuality stressor c. Identity stressor d. Body image stressor

d. Body image stressor Rationale: Changes in the appearance or function of a body part require an adjustment in body image. An individuals perception of the change and the relative importance placed on body image in the individuals self-concept will affect the significance of the loss or change. Throughout life a person undergoes many role changes. Normal changes associated with maturation result in changes in role performance. Sexuality stressors are issues related to sexuality on a regular basis. Identity stressors affect an individuals identity, but identity is particularly vulnerable during adolescence.

Madeleine Leininger identifies the concept of care as the essence and unifying domain that sets nursing apart from other health care disciplines. Which of the following is true in her view? a. Care and cure are synonymous. b. Care is designed to focus only on individuals. c. Caring acts are independent of patient values. d. Caring depends on communication.

d. Caring depends on communication. Rationale: Caring is very personal. One challenge is to find ways to communicate with patients so as to learn the culturally specific behaviors and words that reflect human caring. Care is an essential human need, necessary for the health and survival of all individuals. Care, unlike cure, assists an individual or group in improving a human condition. A caring act depends on the needs, problems, and values of a patient.

A _____________________ compares patients who have a disease or outcome of interest with patients who do not have the disease or outcome. The researcher looks back to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and disease. a. Quantitative study b. Randomized trial c. Qualitative study d. Case controlled study

d. Case controlled study

____________________ means making an appropriate plan of care based on assessment of patients and families and coordinating needed resources and services for the patients well-being across a continuum of care. a. Public health b. Educator c. Epidemiologist d. Case manager

d. Case manager

______________________ are the clinical criteria or assessment findings that support an actual nursing diagnosis. a. Culture b. Validation c. Collaborative problem d. Defining characteristics

d. Defining characteristics

.A nurse needs to begin teaching about crutch walking with a 14-year-old patient. Which action should the nurse take first? a. Motivate the patient to comply with the use of crutches. b. Prevent diseases and learn good health promotion activities for crutch walking. c. Allow the entire health care team to give the patient a variety of strategies for crutch walking. d. Determine the patients level of knowledge and perception of the learning needed for crutch walking.

d. Determine the patients level of knowledge and perception of the learning needed for crutch walking. Rationale:Determining a patients level of knowledge is the first step. Assess the patients level of knowledge, intellectual skills, and literacy level before beginning a teaching plan. The first step is not to motivate a patient. A patients motivation to learn is an important factor; however, a patients motivation helps to determine if the patient is prepared and willing to learn, not what needs to be taught. Health education is not focused on disease prevention as a primary goal, but on assisting patients to achieve optimal levels of health. Although the entire health care team may be involved with patient education, the educator must select the appropriate teaching strategy for the patients ability to learn.

A nurse works at a health care organization that is accredited by The Joint Commission. What is the best method for this health care organization to demonstrate that it is providing quality patient care? a. Cost of care per patient day b. Number of registered nurses c. Absence of sentinel events d. Documentation audits

d. Documentation audits Rationale: Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require health care institutions to monitor and evaluate the quality and appropriateness of patient care. Typically, such monitoring and evaluations occur through the auditing of information health care providers document in patient records. It does not include cost of care per patient day, number of RNs, nor absence of sentinel events.

The current focus on promoting a culturally competent health care environment is on which of the following? a. The health care providers efforts to become self-aware b. The health care provider learning about other cultures c. Avoiding the systematic provision of care d. Ensuring that cultural competence is integrated into administrative processes

d. Ensuring that cultural competence is integrated into administrative processes Rationale: The current focus is toward systemic approaches to ensure that cultural competence is integrated into the administrative processes and the provision of care, rather than avoidance of systematic approaches. In the past, many of the methods to promote a culturally competent health care environment focused on health care providers efforts to become self-aware and learn about other cultures.

A nurse is caring for a 64-year-old patient who has survived cardiopulmonary resuscitation after a triple coronary artery bypass graft surgery. To help this patient cope with this experience, what is the best thing for the nurse to do? a. Recommend that the patient not discuss the experience with family. b. Assume that the near death experience was a positive experience. c. Explain that people who have not had that experience will not understand. d. Explore what happened with the patient.

d. Explore what happened with the patient Rationale: After patients have survived a near death experience (NDE), promote spiritual well-being by remaining open, giving patients a chance to explore what happened, and supporting patients as they share the experience with significant others. Patients who have an NDE are often reluctant to discuss it, thinking family or caregivers will not understand. Isolation and depression often occur. Furthermore, not all NDEs are positive experiences. However, individuals experiencing an NDE who discuss it openly with family or caregivers find acceptance and meaning from this powerful experience.

An RN suffers from chronic back pain that was the result of an injury suffered when pulling a patient up in bed. The nurse is addicted to pain medication and has recently been accused of stealing narcotics. This is an example of which violation of the law? a. Misdemeanor b. Tort c. Malpractice d. Felony

d. Felony Rationale: A felony is a serious offense that results in significant harm to another person or society in general. Felony crimes may carry penalties of monetary restitution, imprisonment for greater than 1 year, or death.

___________ proposes that we routinely ask how ethical decisions will affect women as a way to repair a history of inequality a. Ethical dilemma b. Code of ethics c. Bioethics d. Feminist ethics

d. Feminist ethics

A nurse is assigned to care for a dying patient. To deal with this experience and future experiences with dying patients, the nurse should do which of the following? a. Avoid going to funerals of former patients. b. Develop a hard shell against emotional stress to avoid compassion fatigue. c. Understand that people dying is part of the job to get used to. d. Frequently evaluate his or her own emotional well-being.

d. Frequently evaluate his or her own emotional well-being. Rationale: Frequently evaluate your own emotional well-being. We all have feelings and memories about previous illnesses and death. Knowing more about your own grief and past experiences will help you care for others more insightfully. Being a professional caregiver involves knowing when to get away from a situation and how best to take care of ones self. Many nurses, especially those who routinely provide hospice care, attend a viewing at the mortuary or the funeral to show support for the family, honor the deceaseds memory, and cope with their own grief. Develop your own support systems, take restful time away from your work, and find a person with whom you can safely share your feelings and concerns. Experiencing repeated deaths of patients can feel overwhelming at times. If you work in an area in which you experience multiple losses and fail to acknowledge your own feelings of loss, you may begin to feel overwhelmed by intense emotions (e.g., frustration, anger, guilt, sadness, or dissatisfaction with life) and become vulnerable to compassion fatigue.

A nurse works on an oncology unit and has a lot of stress in her life. Which of the following situational factors would be considered work stress? a. Caring for a family member who has Alzheimers disease b. Being diagnosed with a chronic back injury c. Finding out that a parent has lung cancer d. Having a disagreement with her nurse manager

d. Having a disagreement with her nurse manager Rationale: Work stress for nurses happens with work overload, heavy physical work, shift work, patient concerns (dealing with death and medical treatment), and interpersonal problems with other health care professionals and staff. Adjusting to chronic illness can result in situational stress, but is not work related. Furthermore, the stress experienced while caring for someone with a chronic illness (such as Alzheimers disease) can lead to adverse health consequences but is also not work related. Another nonwork-related stressor would be caring for a family member who has cancer. Those family members caring for cancer patients have been shown to display immunologic changes that can contribute to the development of inflammatory disease.

A student nurse assigned to a female, observant Muslim patient noticed her discomfort with several of the male health care providers. She wonders if this discomfort is related to the patients religious beliefs. In her preparation for clinical, she learned that Muslims differ in their adherence to tradition, but that modesty is the overarching Islamic ethic pertaining to interaction between the sexes (Rabin, 2010). The student nurse states which of the following to the patient? a. Im going to request that you only have female physicians see you. Does having male nurses bother you as well? b. I know that its hard to get used to, but you just have to get used to it. Thats how it is in America. c. It must be difficult for people like you to adjust to our ways, but there are limitations for all of us. d. I know that for many of our Muslim patients modesty is very important. Is there some way I can make you more comfortable?

d. I know that for many of our Muslim patients modesty is very important. Is there some way I can make you more comfortable? Rationale: Delivering culturally congruent care to individuals and communities requires specific knowledge, skills, and attitudes. Nurses who provide culturally competent care bridge cultural gaps to provide meaningful and supportive care for all patients. The student nurse states to the patient, I know that for many of our Muslim patients modesty is very important. Is there some way I can make you more comfortable? The student did not assume that the information will automatically apply to this patient. Instead, the student combined her knowledge about a cultural group with the attitude of helpfulness and flexibility so as to provide quality patient-centered culturally congruent care.

The mother of a 45-year-old patient is a retired physician and requests to discuss the patients plan of care with the nurse caring for the patient. What is the nurses best response to this request? a. I will need to ask permission from my supervisor before I can share that information. b. I will show you the chart, just follow me and we can discuss your questions and concerns. c. I would suggest that you leave me out of your family problems. I am here to care for the patient. d. I will have to get the patients permission before I can share that information

d. I will have to get the patients permission before I can share that information Rationale: Even family members or friends of the patient are not permitted access to the patients personal health information without the patients consent. Federal legislation known as HIPAA (Health Insurance Portability and Accountability Act of 1996) requires that those with access to personal health information not disclose the information to a third party without patient consent. The nurse does not need to ask permission from the supervisor because HIPAA laws state what the nurse can do. I would suggest that you leave me out of your family problems is inappropriate because it ignores the request of the family member. Showing the chart and discussing the care is a violation of HIPAA.

A registered nurse requests that a nursing assistant give a patient a bath in the morning because the patient is going to surgery. As the nurse prepares the patient for surgery, the nurse notes that the patient has not received the bath, and it is too late to give one because surgery is calling for the patient. The nurse needs to give feedback to the nursing assistant. Where would be the most appropriate place for the nurse to provide the nursing assistant this feedback? a. In the hallway b. At the nurses station c. In the patients room d. In a private conference room

d. In a private conference room Rationale: Give feedback in private to preserve the staff members dignity. If the staff members performance is not satisfactory, give constructive and appropriate feedback. Feedback given should be specific in regard to any mistakes that the staff members make, explaining how to avoid the mistake or a better way to handle the situation. When giving feedback, make sure to focus on things that are changeable, choose only one issue at a time, and give specific details. The hallway, nurses station, and patients room are too public for effective constructive feedback.

________________ is being eager to acquire knowledge and learning explanations even when applications of the knowledge are not immediately clear and to value learning for learnings sake. a. Maturity b. Analyticity c. Systematicity d. Inquisitiveness

d. Inquisitiveness

A nurse is in the acute care unit caring for a 67-year-old patient with a varicose ulcer in the right lower leg. The wound has been healing well but will require a dressing change during the shift. What priority level should the nurse classify this problem? a. High priority b. Low priority c. Mid priority d. Intermediate priority

d. Intermediate priority Rationale: Intermediate priority problems are nonemergency, nonlife-threatening actual or potential needs that the patient and family are experiencing. Anticipating teaching needs of patients related to a new drug or taking measures to decrease postoperative complications are examples of intermediate priorities

A 17-year-old patient was seriously injured in a motor vehicle accident and has been transferred from an acute care hospital to a rehabilitation/restorative facility. Which action should the nurse take to ensure the best outcome for this patient? a. Make sure that the patient gets enough rest. b. Push the patient beyond his or her limits. c. Request that nobody visit for the first few days. d. Involve the family early in the rehabilitation process

d. Involve the family early in the rehabilitation process Rationale: In restorative settings, nurses recognize that success is dependent on effective and early partnering with patients and their families. Although rest is good, family involvement is the priority. Pushing the patient beyond his or her limit is not helpful. Not letting anybody visit is contraindicated.

A patient with bilateral pneumonia is admitted to the intensive care unit. The nurse who initially prepared the plan of care identified that the patient had the collaborative problem of Potential complications: hypoxemia. What made the nurse classify this as a collaborative problem? a. It requires ensuring adequate hydration. b. It requires monitoring for signs of acid-base imbalance. c. It requires evaluating the effects of positioning on oxygenation. d. It requires both nursing and physician-prescribed interventions.

d. It requires both nursing and physician-prescribed interventions. Rationale: A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patients status. When collaborative problems develop, nurses collaborate with personnel from other health care disciplines, such as social workers and dietitians and physicians. Adequate hydration, acid-base imbalance, and oxygenation do not make a collaborative problem.

Which of the following would not be appropriate for a patient undergoing palliative care? a. Insertion of a peripherally inserted central line b. Chemotherapy c. Radiation treatment d. Knee replacement surgery

d. Knee replacement surgery Rationale: Palliative care is practiced in any setting and focuses on the prevention, reduction, or relief of physical, emotional, social, and spiritual symptoms of disease or treatment at the end of life when cure is no longer possible. The insertion of a peripherally inserted central line would be beneficial to provide the patient with medications to ease discomfort. Chemotherapy and radiation therapy would be useful in reducing disease symptoms. Knee replacement surgery would not be appropriate for an end-of-life patient.

According to __________ : moral development is one component of psychosocial development. It involves the reasons an individual makes a decision about right and wrong behaviors within a culture. a. Sigmund Freud b. Jean Piaget c. Erik Erikson d. Lawrence Kohlberg

d. Lawrence Kohlberg

According to one theorist, moral development depends on the childs ability to accept social responsibility and to integrate personal principles of justice and fairness. Which of the following individuals is responsible for the theory of moral development? a. Sigmund Freud b. Jean Piaget c. Erik Erikson d. Lawrence Kohlberg

d. Lawrence Kohlberg Rationale: According to Kohlberg (1964), moral development is one component of psychosocial development. It involves the reasons an individual makes a decision about right and wrong behaviors within a culture. Moral development depends on the childs ability to accept social responsibility and to integrate personal principles of justice and fairness.

The American Nurses Credentialing Center (ANCC) established the ____________________________ to recognize health care organizations that achieve excellence in nursing practice. a. Medicaid Act b. Nursing Home Reform Act c. Diagnostic Related Group Act d. Magnet Recognition Act

d. Magnet Recognition Act

A new nurse would like to work where clinical performance is valued and in an environment that uses evidence-based practice. Given the new nurses goals, which organization would be the best for this nurse? a. Private hospitals b. Community hospitals c. Not-for-profit hospitals d. Magnet-designated hospitals

d. Magnet-designated hospitals Rationale: A magnet-designated hospital will fit this new nurses goals better than a private, community, or not-for-profit hospital. Typically a magnet hospital has a system to recognize and reward nurses for clinical performance, has research programs, and uses evidence-based practice.

The relief of pain and suffering give a patient comfort, dignity, respect, and peace. To enhance the therapeutic environment, what should the nurse do? a. Make the environment as noise free as possible. b. Remove personal items so that the environment is as clinical as possible. c. Focus on removing negative physical stimuli. d. Make the environment a place to soothe mind, body, and spirit.

d. Make the environment a place to soothe mind, body, and spirit. Rationale: The relief of pain and suffering are caring nursing actions that give a patient comfort, dignity, respect, and peace. By ensuring that the patient care environment is clean, reasonably quiet, and pleasant and inclusive of personal items, you make the physical environment a place that soothes and heals the mind, body, and spirit.

A nurse is giving a change-of-shift report. Which action should the nurse take? a. Exchange judgments made about the patients attitudes. b. Include a description of how to perform procedures. c. Provide a concise and organized description of the patients normal findings. d. Make walking rounds with the nurse coming on duty to review the patients status and needs.

d. Make walking rounds with the nurse coming on duty to review the patients status and needs. Rationale: A change-of-shift report is a hand-off and provides information to ensure continuity and individualized care for patients. Walking rounds allow the nurse to obtain immediate feedback when questions arise about a patients plan of care. Walking rounds are one type of shift report used by health care facilities. Report elements should not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about a patient or family. A description of how to perform procedures is located in a policy and procedure manual.

_____________ is an internal impulse, such as an emotion or need, which prompts, guides, and sustains human behavior a. Psychomotor b. Affective c. Cognitive d. Motivational

d. Motivational

A student nurse must pass the NCLEX before practicing as a registered nurse. NCLEX stands for __________ Examination. a. Nursing Council of Licensing b. Nightingale Code of Licensure c. Nursing Code of Licensure d. National Council Licensure

d. National Council Licensure

A patient falls out of bed because the nurse did not raise the side rails. Which action did the nurse commit? a. Felony b. Assault c. Battery d. Negligence

d. Negligence Rationale: Negligence is conduct that falls below the generally accepted standard of care of a reasonably prudent person.

_______________ is actively seeking to do no harm. a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

d. Nonmaleficence

A patient is about to undergo a new, controversial bone marrow transplant procedure. The procedure may cause periods of pain and suffering. Although nurses agree to do no harm, this procedure may be necessary to promote health. This is an example of which ethnical principle? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

d. Nonmaleficence Rationale: Nonmaleficence refers to the fundamental agreement to do no harm. The principle of nonmaleficence promotes a continuing effort to consider the potential for harm even when it is necessary to promote health.

A registered nurse knows that an oncology patient undergoing a bone marrow transplant will spend weeks in isolation in the hospital. During that time the patient will be at an increased risk for infection and other complications and may not recover. The nurse ensures that the patient has been given information regarding the risks and potential benefits of the procedure. The nurse is following which ethical principle? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

d. Nonmaleficence Rationale: The principle of nonmaleficence (do no harm) promotes a continuing effort to consider the potential for harm even when it is necessary to promote health

When admitting a patient to the hospital, the nurse asks if has problems eating since the patient had a stroke. The patient denies any problems and states that does not require assistance. After lunch, the nurse notes that the patient has not eaten most of the food and has spilled much of the food. These cues lead the nurse to believe that the patient is not functioning at the level indicated upon admission. The nurse is using which type of information to make this deduction? a. Verbal behavior b. Physical assessment c. Nursing diagnosis d. Nonverbal behavior

d. Nonverbal behavior Rationale: Observation of the level of function is different from what a nurse learns about function during the interview. A nurse observes what the patient does, such as self-feeding or making a decision, rather than what the patient says he or she can do. The level of function involves a persons ability to perform during everyday activities. Observation of the patients behavior for level of function differs from a physical assessment

At a health care organization, patients are turned every 2 hours to help prevent pressure ulcers. Because of this nursing intervention, patients exhibit far fewer pressure ulcers than the national average. Which term should the nurse use to describe this finding? a. Sentinel event b. Qualitative research c. Manuscript narrative d. Nursing-sensitive outcome

d. Nursing-sensitive outcome Rationale: A nursing-sensitive outcome focuses on how patients and their health care problems are affected by nursing interventions (ONS, 2012). Nursing-sensitive outcomes look at the effects of interventions within the scope of nursing practice

Upon assessment, the nurse finds that a patient has a heart rate of 66 beats per minute, a respiratory rate of 12 breaths per minute, and a blood pressure of 120/80 mm Hg. The nurse obtained which type of data? a. Personal b. Demographic c. Subjective d. Objective

d. Objective Rationale: Objective data are observations or measurements of a patients health status. Personal and demographic data refer to patients name, age, sex, and so on.

A registered nurse is explaining a procedure to a patient who speaks another language. Which action by the nurse reflects critical thinking? a. Teach with unfamiliar explanations. b. Explain using medical jargon. c. Use vague descriptions. d. Obtain an interpreter.

d. Obtain an interpreter. Rationale: Critical thinkers use language precisely and clearly. If you do not obtain a professional interpreter when communicating with patients who speak a different language, you are taking the risk of miscommunicating important information. When you use incorrect terminology, jargon, or terminology with which a patient is unfamiliar, or vague descriptions, communication is ineffective.

A nurse forms a contract with the patient to specify roles during a therapeutic helping relationship. The nurse is in which phase of the therapeutic relationship? a. Working b. Termination c. Pre-interaction d. Orientation

d. Orientation Rationale: During the orientation phase when you and the patient meet and get to know one another is the time when the contract is formed. During the working phase the nurse and patient work together to solve problems and accomplish goals. During the termination phase the helping relationship is ended. In the pre-interaction stage the nurse gathers information from various sources about the patient.

A nursing student, who maintained a 4.0 GPA since starting nursing school, started working the past semester, is planning a wedding, and has moved into a new home. The student has not been able to maintain the 4.0 GPA this semester, and as a result is feeling like a failure. How is this loss best described? a. Maturational b. Situational c. Actual d. Perceived

d. Perceived Rationale: Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain, changes in living arrangements. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include job loss.

Postmenopausal women are at risk for skeletal changes. When developing a plan of care for postmenopausal women, a nurse should remember which of the following? a. Exercise provides little benefit for the middle-age adult. b. Middle-age women should avoid dietary calcium to prevent osteoporosis. c. Exercise and fitness clubs have limited activities. d. Physical activities help improve balance and coordination.

d. Physical activities help improve balance and coordination. Rationale: When middle-age adults seek health care, nurses need to develop goals for positive health behaviors. Simple things like increasing dietary calcium and calcium supplements are effective. In addition, exercise and fitness clubs, for example, give men and women the opportunity to participate in many physical activities. These activities help improve balance, coordination, and activity tolerance.

A nurse is asked the most frequently cited reason for death in the world. How should the nurse reply? a. Technological advances b. Old age c. Cancer d. Poverty

d. Poverty Rationale: Poverty is still deadlier than any disease and is the most frequently cited reason for death in the world today. Technological advances, old age, and cancer are not the most cited reason for death.

_________________ are a component of the population of a community. a. Available health systems b. Available colleges and schools c. Geographical boundaries d. Predominant religious groups

d. Predominant religious groups

A 75-year-old patient who is being discharged home after a stroke has no use of the right hand. Which teaching strategy is best for the nurse to use for this patient? a. Provide all the teaching at once, immediately before going home so the patient will remember it. b. Teach the patient with the aid of a computer to demonstrate that the discharge instructions are on the hospital webpage. c. Teach the patient using generic patient discharge information about strokes. d. Provide information based on the patients needs in frequent sessions.

d. Provide information based on the patients needs in frequent sessions. Rationale: Effective teaching strategies for the older adult include providing individualized information that is based on what the patient needs to know and presenting information slowly in frequent sessions. Allow more time for older learners to demonstrate learning. Do not provide the teaching all at once; use frequent sessions. Because the patient has no use of the right hand, navigating the computer could be cumbersome. The older adult needs individualized, not generic, information.

A patient needs to take daily injections of a blood thinner for 7 days after hospital discharge. The nurse observes the patients self-administration technique. What type of learning occurred? a. Affective b. Cognitive c. Motivational d. Psychomotor

d. Psychomotor Rationale: Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills.

The nurse is attempting to obtain a sexual history on a patient who is being evaluated for a possible hysterectomy. The nurse should do which of the following? a. Assume that the patient will not appreciate questions about sexual practices. b. Avoid information relative to medication effect on sexuality. c. Use specific gender terms to emphasize sexuality. d. Recognize that many patients welcome the chance to talk about their sexuality.

d. Recognize that many patients welcome the chance to talk about their sexuality. Rationale: With experience you will come to recognize that many patients welcome the opportunity to talk about their sexuality, especially when they are experiencing difficulty in sexual functioning. Once you approach the topic, the patient is able to talk about concerns and explore possible ways to resolve the problem. You may worry that the patient will not appreciate being asked about sexuality and sexual practices. However, patients want to know how medications, treatments, and surgical procedures influence their sexual relationships. Use gender-neutral terms and questions when completing the sexual history.

What is the nurses best proof against malpractice? a. The nurse supervisors memory of the event b. Recorded documentation written carelessly c. The nurses memory of the event d. Recorded documentation of nursing care

d. Recorded documentation of nursing care Rationale: Documentation of nursing care is the only record of what actually was done for a patient and will serve as proof that a nurse acted reasonably and safely. Nursing notes written at the time of the event, are seen as better evidence of the facts of the event than any one persons memory. Nurses notes written carelessly and without regard to detail or hospital standards of documentation do not reflect well on the health care providers credibility or appearance of accountability to a judge or jury.

A 35-year-old new mother returns to the clinic for her 6-week postpartum check. When discussing questions regarding the patients sexual health the nurse should do which of the following? a. Assume that permission to discuss sexuality issues is implied. b. Seek knowledge about sexual health in general. c. Make therapeutic suggestions early and adjust as needed. d. Refer the patient to a professional with advanced training if necessary.

d. Refer the patient to a professional with advanced training if necessary. Rationale: The PLISSIT Assessment of Sexuality method suggests that the nurse gain permission to discuss sexuality issues, limit information to sexual health problems being experienced, make specific suggestion only when the nurse is clear about the problem, and refer the patient to professionals with advanced training if necessary.

One of the five caring processes described by Swanson (1991) is knowing the patient. The concept comprises both a nurses understanding of a specific patient and subsequent selection of interventions. To become adept at knowing patients early, what should the nurse do? a. Check on patients at irregular times so they do not get used to a routine. b. Depend on other nurses assessments to evaluate your own. c. Assume that your interventions are effective because they have been ordered. d. Reflect about your patient interactions and evaluations.

d. Reflect about your patient interactions and evaluations. Rationale: Reflect about what you have learned, each time you either assess or evaluate a patient. Routinely round on patients at the beginning of a work shift and ongoing as appropriate. Do not depend on others observations be thorough and make your own assessment. Always go back and observe how a patient responded to your interventions.

A registered nurse is caring for a postoperative patient whose systolic blood pressure has dropped 10 points during the shift. The nurse remembers that this was similar to a situation that happened in the past when a patient developed an internal bleed. Based upon the nurses thoughts, which skill did the nurse use? a. Intuition b. Critical thinking c. Nursing process d. Reflection

d. Reflection Rationale: The nurse is using reflection when thinking about a situation in the past that was similar. Reflection is a part of critical thinking that involves the process of purposefully thinking about or recalling a situation to discover its purpose or meaning

The nurse is caring for a patient of the Chinese community who is dying. The nurse needs to understand the Chinese communitys beliefs regarding death, but it is most important to keep in mind which of the following? a. Most survivors in Chinese society wail loudly to communicate their loss. b. People in the Chinese culture believe that talking about death is healthy. c. Chinese people are strong believers in reincarnation. d. Regardless of cultural or religious beliefs, people respond to death in their own unique way.

d. Regardless of cultural or religious beliefs, people respond to death in their own unique way. Rationale: In Western societies, many people grieve privately and restrain their emotions. In other cultures, survivors wail loudly and publicly display their sorrow to communicate the significance of their loss to others. Some Chinese communities consider death to be a taboo subject and believe that discussion of the topic brings bad luck. Most people practicing the Hindu religion believe in reincarnation and use those beliefs to interpret events surrounding the death of a loved one. Although members of a cultural or religious group often share similar beliefs, people still respond in their own unique way.

A widow, whose spouse died 3 years ago, has recently started dating and is thinking about going back to school to complete a degree she had started at an earlier age. Which of Bowlbys phases of mourning best describes this behavior? a. Numbing b. Yearning and searching c. Disorganization and despair d. Reorganization

d. Reorganization Rationale:During the final phase of reorganization, which usually requires a year or more, the person accepts unaccustomed roles, acquires new skills, and builds new relationships. In the numbing phase, a person has periods of extremely intense emotion and reports feeling stunned or unreal. The numbing phase lasts from several hours to a week. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, people need to experience this painful phase of grief. During the phase of disorganization and despair an individual spends much time thinking about how and why the loss occurred. The person often expresses anger at anyone he or she believes to be responsible. Gradually this phase gives way to an acceptance that the loss is permanent.

Which documentation by the nurse is most appropriate? a. The patient states would except moving to a semi-private room. b. Developed aspiration pneumonia due to dysphasia. c. Bruise noted on right side over fractured abdimin. d. Right jugular vein distended.

d. Right jugular vein distended. Rationale: Right jugular vein distended is the only entry without spelling errors

A patient is experiencing incisional pain after an operation. When using Maslows hierarchy of needs, the nurse realizes that for the patient to return to a prehospitalized status, the patient needs to progress beyond which of the following? a. Belonging b. Self-esteem c. Self-actualization d. Safety and security

d. Safety and security Rationale: Maslow described an ordering (hierarchy) of needs that motivate human behavior. This ordering is often depicted as a pyramid composed of five levels. When the most basic needs, such as hunger and oxygen, are met, the person strives to satisfy those needs for safety and security on the next highest level. Disturbances at lower levels interfere with the highest level, self-actualization or the realization of ones potential. Individuals need to satisfy each level before moving on to the next. Belonging occupies the third stage, where threats to relationships create anticipatory loneliness and alienation. Self-esteem occupies the fourth stage, and threats create alienation. Self-actualization is the highest level that one can achieve the realization that one has reached his or her highest potential. Safety and security occupies the second stage, and threats to security (such as pain) produce feelings of insecurity.

A nurse who works for an oncology unit is preparing to bathe a patient who recently underwent surgery to remove an abdominal tumor. Before beginning the bath, the nurse explains the procedure. Which of the following best describes the nurses communication role? a. Channel b. Receiver c. Message d. Sender

d. Sender Rationale: The nurse is the sender in this scenario. The sender is the person who delivers the message. The roles of sender and receiver change back and forth as two persons interact.

The nurse is caring for an elderly patient who has a urinary catheter in place and is showing signs of altered self-concept. In dealing with this age group it is probably safe to assume which of the following? a. Sexuality concerns are not an issue. b. Sexual activity is probably harmful. c. Sexually active seniors are always heterosexual. d. Sexually active elderly adults have better overall health

d. Sexually active elderly adults have better overall health Rationale: Give priority to patients in middle and older adulthood when you address sexuality concerns caused by illness, medications, or physical changes. Research has shown middle and older age adults who are sexually active have greater independence, better overall health, and longer life expectancy. In addition, you should not assume all older patients are heterosexuals.

A grocery store clerk does not have a family health care provider. The clerk has had a sore throat for the past week and recently began running a fever. The clerk goes to the local community hospitals emergency room for treatment. Which level of care did the clerk use? a. Continuing care b. Restorative care c. Primary care d. Tertiary care

d. Tertiary care Rationale: Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units are sites that provide secondary and tertiary levels of care

___________________________ provides standards and practice guidelines for critical care nurses. a. The Joint Commission b. A magnet-designated hospital c. The Centers for Disease Control and Prevention d. The American Association of Critical Care Nurses

d. The American Association of Critical Care Nurses

The code of ethics for nursing sets forth ideals of nursing conduct and was developed by what organization? a. The Board of Nursing b. The American Medical Association c. The National League for Nursing d. The American Nurses Association

d. The American Nurses Association Rationale: The American Nurses Association (ANA) and the International Council of Nurses (ICN) publish codes of ethics for nurses that set principles of behavior for them to embrace

A nurse enters a patients room and sees the patient grimacing with each movement. When the nurse asks in a normal tone of voice how the patient is feeling, the patient states that he or she feels fine. Which finding will the nurse classify as nonverbal communication? a. The nurses tone of voice is normal. b. The patient states that he or she feels fine. c. The nurse asks how the patient is feeling. d. The patient grimaces with each movement.

d. The patient grimaces with each movement. Rationale: The patient grimacing with each movement is nonverbal communication. Nonverbal communication includes messages sent through the language of the body, without the use of words. Nonverbal forms of communication include use of facial expressions, eyes, gestures, posture, and physical appearance. Nonverbal communication often reveals physical feelings.

A nurse is assessing a patients risk factors for heart disease and finds that the patient has several risk factors. How should the nurse interpret this finding? a. The patient needs surgery for heart disease. b. The patient has a genetic disease. c. The patient will develop the disease. d. The patient has an increased chance to develop the disease.

d. The patient has an increased chance to develop the disease. Rationale: The presence of a risk factor does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease. Although genetics can be a risk factor, it does not mean the patient has a genetic disease. The patient does not need surgery for heart disease because risk factors only increase the probability of the disease occurring.

A nurse is writing a care plan for a newly admitted patient. Which outcome statement did the nurse correctly write? a. The patient will eat 80% of all meals. b. The nursing assistant will set up the patient for a bath every day. c. The nursing assistant will ambulate the patient three times a day by May 30. d. The patient will identify the need to increase dietary intake of fiber by July 4

d. The patient will identify the need to increase dietary intake of fiber by July 4 Rationale: The patient will identify the need to increase dietary intake of fiber by July 4 is measurable, reliable, valid, and focuses on the patien

A nurse completes an incident/occurrence report on a patient who fell while walking in the hallway. The nurse completes this report for what purpose? a. To exchange information among health care members b. To provide information about patients on one unit to another c. To prevent a legal lawsuit from the patient d. To aid in the hospitals quality improvement program

d. To aid in the hospitals quality improvement program Rationale: Incident reports are an important part of quality improvement. The overall goal is to identify changes needed to prevent future reoccurrence. A report is an exchange of information between health care members. Transfer reports involve communication of information about patients from one nurse on the sending unit to the nurse on the receiving unit. Occurrence reports do not prevent lawsuits.

A nurse works in a critical care area caring for two patients during a day shift and is accountable for all their care. Which type of nursing care delivery model is the nurse using? a. Team nursing b. Case management c. Primary nursing d. Total patient care

d. Total patient care Rationale: During total patient care, a registered nurse is responsible for all aspects of care for one or more patients during an assigned shift. In team nursing the RN leads a team of other RNs, practical nurses, and unlicensed assistive personnel (UAP). Team members provide direct patient care under the supervision of an RN. The team leader develops patient care plans, coordinates care among team members, and provides care requiring complex nursing skills. Case management is one nurse managing care for a specific type of patient from admission to discharge to home. The case management nurse does not provide direct patient care. When one primary RN assumes responsibility for a caseload of patients with the help of associate nurses, primary nursing is being implemented.

A nurse is assisting in the admission of a patient to the orthopedic unit of the hospital and is obtaining information for the database. Which technique is the best way for the nurse to obtain information from the patient? a. Ask personal questions so as to show interest. b. Use medical vocabulary to appear competent. c. Ask why the patient waited so long to get treatment. d. Use silence while the patient collects his or her thoughts.

d. Use silence while the patient collects his or her thoughts. Rationale: Most people have a natural tendency to fill empty spaces with words, but sometimes silence is useful when they face decisions that require much thought. Nontherapeutic techniques discourage further expression of feelings and ideas and engender negative responses or behaviors in others

Cultural competence is the ongoing process in which a health care professional continuously strives to achieve the ability to work effectively within the cultural context. To do this effectively, what must the nurse do? a. Understand the cultural norms of the patients community. b. See herself or himself as being culturally competent. c. Face the reality that cultural competence can take up to a year to achieve. d. View herself or himself as becoming culturally competent.

d. View herself or himself as becoming culturally competent. Rationale: Cultural competence is the ongoing process in which a health care professional continuously strives to achieve the ability to work effectively within the cultural context of a patient (individual, family, and community). There are a variety of models for how to acquire cultural competence. One model requires nurses to see themselves as becoming culturally competent rather than being culturally competent. It is a developmental process that evolves over a lifetime. Cultural competence goes beyond just understanding cultural norms with a patients community this is only a component of competence.

What is the most appropriate time for the nurse to begin discharge planning with a patient? a. The day of patient discharge from the health care agency b. As soon as the insurance provider has been identified c. When the health care provider writes the discharge order d. When the patient is admitted to the health care agency

d. When the patient is admitted to the health care agency. Rationale: Discharge planning begins the moment a patient is admitted to a health care facility. The day of discharge, when the insurance provider has been identified, and when the order is written are too late.

A student nurse is caring for a patient of Mexican descent. In an attempt to become culturally aware, the student should consciously think about which of the following? a. What people of Mexican descent believe b. The relationship between culture and ethnicity c. The fact that the patient belongs to an isolated social group d. Where the person is in the intersections of socially constructed categories

d. Where the person is in the intersections of socially constructed categories Rationale: We must understand a persons location in the intersections of socially constructed categories of privilege and oppression (e.g., race, class, gender, age, sexual orientation). This is necessary in order to, fully understand a persons actions, choices and outcomes. Culture has historically been associated with norms, values, and traditions passed down through generations. Culture has also been perceived as synonymous with ethnicity, race, nationality, and language. These outdated ideas about culture lead to statements such as, Mexicans believe this or Chinese patients are like this. In reality, culture is much more dynamic and includes race, ethnicity, gender, sexual orientation, class, immigration status, and other axes of identification. All of us are members of multiple social groups at the same time. These intersecting identities impact our experience of the world around us.

Which information indicates the nurse has an accurate understanding of when the institutions malpractice insurance covers the nurse? a. While driving to work b. While driving home from work c. While tending to people in the neighborhood d. While working within the scope of employment

d. While working within the scope of employment Rationale: If a nurse works for a health care institution, generally the institutions insurance will cover the nurse during employmen

A registered nurse in a rehabilitative unit is working with a veteran with chronic back pain that was caused as a result of an injury received while in military service in Iraq. The nurses goal is to assist the veteran to learn self-management skills to help promote health. Which statement by the nurse will best support this goal? a. Do you have plans to return to active duty? b. You need to take your pain medication as prescribed. c. Perhaps you need to consider going to a different health care provider. d. Why dont you keep a log of what causes the pain to become worse?

d. Why dont you keep a log of what causes the pain to become worse? Rationale: Self-management involves learning about responses to illnesses through daily life experiences and as a result of trial and error. Plans to return to active duty and going to a different health care provider do not focus on responses to the illness (chronic back pain). Just focusing on taking pain medication does not focus on the goal of self-management skills.

The nurse is assigned a patient who has experienced the alarm reaction and continues to recover. The nurse knows that the primary hormone impacting the stress response in the resistance stage of the general adaptation syndrome is: a. vasopressin. b. adrenaline. c. noradrenaline. d. cortisol.

d. cortisol. Rationale: Corticotropin stimulates the adrenal gland to increase the production of corticosteroids, including cortisol, the primary hormone impacting the stress response. Cortisol increases blood glucose, enhances the brains use of glucose, and increases the availability of substances for tissue repair. Vasopressin increases reabsorption of water by the kidneys and induces vasoconstriction, thereby raising blood pressure. The adrenal gland also releases catecholamines, adrenaline, and noradrenaline, which are important parts of the alarm reaction.

A ___________ is a serious offense that results in significant harm to another person or society in general, like misusing controlled substances. a. Assault b. Negligence c. no contact d. Felony

d. felony

The nurse is caring for a patient who states that he does not believe in the existence of God. The nurse realizes that this person: a. is not a spiritual person. b. is an agnostic. c. believes that people bring meaning into the world. d. finds meaning in life through work and relationships.

d. finds meaning in life through work and relationships. Rationale: Atheists search for meaning in life through their work and relationships with others. Spirituality exists in all people regardless of their religious beliefs and it gives people the energy needed to maintain health and cope with difficult situations. Spirituality is an important concept for individuals who either do not believe in the existence of God (atheist) or who believe that any ultimate reality is unknown or unknowable (agnostic). It is important for agnostics to discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that we, as people, bring meaning to what we do.

A patient has been diagnosed with a terminal disease. Hope may be used effectively with this type of patient. Nurses can support a patients use of hope because hope provides a: a. system of organized beliefs and worship. b. belief in a higher power, spirit guide, God, or Allah. c. cultural connectedness, structure, and guidance in difficult times. d. motivation to achieve and the resources to use toward that achievement.

d. motivation to achieve and the resources to use toward that achievement. Rationale: Hope is energizing, giving individuals a motivation to achieve and the resources to use toward that achievement. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Faith involves a belief in a higher power, spirit guide, God, or Allah. Spirituality offers a sense of connectedness. Spirituality is unique for each person. It is a unifying theme in life and a state of being.

The patient, a busy executive who works 80 hours a week, is admitted for angina. The patient is demonstrating physical signs of stress related to the work environment. An appropriate nursing intervention for this patient includes releasing muscle tension every 2 hours. This type of intervention is best known as: a. regular exercise. b. assertiveness training. c. cognitive therapy. d. progressive muscle relaxation

d. progressive muscle relaxation Rationale: Muscles tense in the presence of anxiety-provoking thoughts and events. With progressive muscle relaxation physiological tension diminishes through a systematic approach to releasing tension in major muscle groups. A regular exercise program improves muscle tone and posture, controls weight, reduces tension, improves circulation, triggers release of endorphins, and promotes relaxation. Assertiveness training teaches individuals to communicate effectively regarding their needs and desires. The ability to resolve conflict with others through assertiveness training reduces stress.

To assess, evaluate, and support a patients spirituality the best action a nurse should take includes: a. recognizing that spirituality does not enhance therapeutic relationships. b. performing a definitive spiritual assessment once because spirituality does not vary. c. focusing the assessment on religious doctrine and faith. d. remembering that spirituality is very subjective.

d. remembering that spirituality is very subjective. Rationale: Remember that spirituality is very subjective and has different meanings for different people. You are able to gather an accurate assessment of your patients spirituality when you take time to build therapeutic relationships with them. Conduct an ongoing spiritual assessment the entire time you care for a patient. Focus your assessment on aspects of spirituality most likely to be influenced by life experiences, events, and questions in the case of illness and hospitalization

A patient is being cared for by a nurse. The patient has questions regarding what time the surgery is scheduled. When the nurse responds to the question, the nurse is assuming which communication role? a. Channel b. Receiver c. Message d. Sender

d. sender

Community health nursing is nursing care provided in the community, with the primary focus on the health care of: __________, ____________, ___________ in the community.

individuals, families, and groups

A __________________________ is used in long-term care settings to manage patient costs.

resource utilization group.