Taylor Fundamentals End of Chapter NCLEX Questions (CH 1,6,7,8,9,10,11,12,13,14,15,22,23,24,26)

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1. A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed? Perform the focused assessment. This is an independent nurse-initiated intervention. Request an order from Jill's physician since this is a physician-initiated intervention. Request an order from Jill's physician since this is a collaborative intervention. Request an order from the nutritionist since this is a collaborative intervention.

1. a. Performing a focused assessment is an independent nurse-initiated intervention, thus the nurse does not need an order from the physician or the nutritionist.

1. A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best describe a characteristic of the development of a personal value system? Select all that apply. People are born with values. Values act as standards to guide behavior. Values are ranked on a continuum of importance. Values influence beliefs about health and illness. Value systems are not related to personal codes of conduct. Nurses should not let their values influence patient care.

1. b, c, d. A value is a belief about the worth of something, about what matters, which acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A person's values influence beliefs about human needs, health, and illness; the practice of health behaviors; and human responses to illness. Values guide the practice of nursing care. An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family, and culture.

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

1. b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the plan of nursing care. Although all these steps may overlap, formulating and validating nursing diagnoses occurs most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

1. A nurse who is a discharge planner in a large metropolitan hospital is preparing a discharge plan for a patient after a kidney transplant. Which actions would this nurse typically perform to ensure continuity of care as the patient moves from acute care to home care? Select all that apply. Performing an admission health assessment Evaluating the nursing plan for effectiveness of care Participating in the transfer of the patient to the postoperative care unit Making referrals to appropriate agencies Maintaining records of patient satisfaction with services Assessing the strengths and limitations of the patient and family

1. b, d, f. The primary roles of the discharge planner as patients move from acute to home care are evaluating the nursing plan for effectiveness of care, making referrals for patients, and assessing the strengths of patients and their families. Although in smaller facilities a discharge planner may perform an admission health assessment and assist with patient transfers, it is not the usual job of the discharge planner. In most facilities, maintaining records of patient satisfaction is the role of the public relations manager or office manager.

1. A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. The nurse uses the nursing interview to collect patient data. The nurse analyzes data collected in the nursing assessment. The nurse develops a care plan for the patient. The nurse points out the patient's strengths. The nurse assesses the patient's mental status. The nurse identifies community resources to help his family cope.

1. b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

1. A nurse is caring for a patient in the ICU who is being monitored for a possible cerebral aneurysm following a loss of consciousness in the emergency room. The nurse anticipates preparing the patient for ordered diagnostic tests. This nurse's knowledge of the diagnostic procedures for this condition reflects which aspect of nursing? The art of nursing The science of nursing The caring aspect of nursing The holistic approach to nursing

1. b. The science of nursing is the knowledge base for care that is provided. In contrast, the skilled application of that knowledge is the art of nursing. Providing holistic care to patients based on the science of nursing is considered the art of nursing.

1. Nursing students are reviewing information about health care delivery systems in preparation for a quiz the next day. Which statements describe current U.S. health care delivery practices? Select all that apply. Access to care depends only on the ability to pay, not the availability of services. The Patient Protection and Affordable Care Act provides private health care insurance to the underserved populations. Every health insurance plan in the Marketplace offers comprehensive coverage, from doctors to medications to hospital visits. The uninsured pay for more than one-third of their care out of pocket and are usually charged lower amounts for their care than the insured pay. Fifty years ago, half of the doctors in America practiced primary care, but today fewer than one in three do. Quality of care can be defined as the right care for the right person at the right time.

1. c, e, f. The Marketplace is designed to help people more easily find health insurance that fits their budget. Every health insurance plan in the Marketplace offers comprehensive coverage, from doctors to medications to hospital visits. Fifty years ago, half of the doctors in America practiced primary care, but today fewer than one in three do. Quality is the right care for the right person at the right time. Access to care depends on both the ability to pay and the availability of services. The Patient Protection and Affordable Care Act provides Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty. The uninsured pay for more than one-third of their care out of pocket and are often charged higher amounts for their care than the insured pay.

1. A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? Public law Private law Civil law Criminal law

1. d. Criminal law concerns state and federal criminal statutes, which define criminal actions such as murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry.

10. A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements reflect a correct understanding of advocacy? Select all that apply. Advocacy is the protection and support of another's rights. Patient advocacy is primarily done by nurses. Patients with special advocacy needs include the very young and the elderly, those who are seriously ill, and those with disabilities. Nurse advocates make good health care decisions for patients and residents. Nurse advocates do whatever patients and residents want. Effective advocacy may entail becoming politically active.

10. a, c, f. Advocacy is the protection and support of another's rights. Among the patients with special advocacy needs are the very young and the elderly, those who are seriously ill, and those with disabilities; this is not a comprehensive list. Effective advocacy may entail becoming politically active. Patient advocacy is the responsibility of every member of the professional caregiving team—not just nurses. Nurse advocates do not make health care decisions for their patients and residents. Instead, they facilitate their decision making. Advocacy does not entail supporting patients in all their preferences.

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

10. a. The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.

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

10. b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement.

10. A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? Students are not responsible for their acts of negligence resulting in patient injury. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary.

10. b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student's competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance.

10. The National Advisory Council on Nurse Education and Practice identifies critical challenges to nursing practice in the 21st century. What is a current health care trend contributing to these challenges? Decreased numbers of hospitalized patients Older and more acutely ill patients Decreasing health care costs due to managed care Slowed advances in medical knowledge and technology

10. b. The National Advisory Council on Nurse Education and Practice identifies the following critical challenges to nursing practice in the 21st century: A growing population of hospitalized patients who are older and more acutely ill, increasing health care costs, and the need to stay current with rapid advances in medical knowledge and technology.

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

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

10. A nurse ensures that a hospital room prepared by an aide is ready for a new ambulatory patient. Which condition would the nurse ask the aide to correct? The bed linens are folded back. A hospital gown is on the bed. Equipment for taking vital signs is in the room. The bed is in the highest position.

10. d. A properly prepared hospital room includes: a bed in the lowest position for an ambulatory patient, an open bed with top linens folded back, routine equipment and supplies and special equipment and supplies assembled, and the physical environment of the room adjusted.

10. A student nurse is organizing clinical responsibilities for an 84-year-old female patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. Schedule the testing and meal planning first and complete hygiene as time permits. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

10. d. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.

10. A nurse is evaluating a patient diagnosed with renaldisease for treatment in a Hospital at Home program. Whichstatement accurately describes a step in this program? The patient is evaluated upon hospital admission and is given daily nursing care in the home after discharge for as long as necessary. Any urgent or emergent situation requires an ambulance trip from the home to the hospital. Patients are transported to physicians' offices from the home for weekly evaluations. The clinicians use care pathways, clinical outcome evaluations, and specific discharge criteria.

10. d. In the Hospital at Home program, the clinicians use care pathways including illness-specific care maps, clinical outcome evaluations, and specific discharge criteria. A patient requiring admission for one of the target illnesses is identified in the emergency department or ambulatory site. Staff assess whether the patient is a good candidate for the program using validated criteria. If the patient is eligible and consents to participate, the Hospital at Home physician evaluates the patient, who is then transported home, usually by ambulance. Nurses are available 24 hours a day/7 days a week for any urgent or emergent situations. The patient is evaluated daily in the home by the Hospital at Home physician, who completes an assessment and continues to implement appropriate diagnostic and therapeutic measures.

10. A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is not an example of a well-stated nursing intervention? Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. Manage patient's pain.

10. d. This statement lacks sufficient detail to effectively guide nursing intervention. The set of nursing interventions written to assist a patient to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what observations (assessments) need to be made and how often, what nursing interventions need to be done and when they must be done, and what teaching, counseling, and advocacy needs patients and families may have.

2. A discharge nurse is evaluating patients and their families to determine the need for a formal discharge plan and/or referrals to another agency. Which patients would most likely be a candidate for these services? Select all that apply. An older patient who is diagnosed with dementia in the hospital A 45-year-old male who is diagnosed with Parkinson's disease A 35-year-old female who is receiving chemotherapy for breast cancer A 16-year-old who is being discharged with a cast on his leg A new mother who delivered a healthy infant via a cesarean birth A 59-year-old male who is diagnosed with end-stage bladder cancer

2. a, b, f. The patients who are most likely to need a formal discharge plan and/or referral to another agency are those who are emotionally or mentally unstable (e.g., dementia), have recently diagnosed chronic disease (e.g., Parkinson disease), or have a terminal illness (e.g., end-stage cancer). Other candidates include patients who do not understand the treatment plan, are socially isolated, have had major surgery or illness, need a complex home care regimen, or lack financial services or referral sources.

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

2. a, d, f. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

2. Newly hired nurses in a busy suburban hospital are required to read the state Nurse Practice Act as part of their training. Which topics are covered by this act? Select all that apply. Violations that may result in disciplinary action Clinical procedures Medication administration Scope of practice Delegation policies Medicare reimbursement

2. a, d. Each state has a Nurse Practice Act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state Nurse Practice Act. Nurse Practice Acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing Medicare reimbursement are enacted through Federal legislation.

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

2. b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

2. A nurse is providing secondary health care to patients in a health care facility. Which patients are receiving this level of care? Select all that apply. A patient enters a community clinic with signs of strep throat. A patient is admitted to the hospital following a myocardial infarction. A mother brings her son to the emergency department following a seizure. A patient with osteogenesis imperfecta is being treated in a medical center. A mother brings her son to a specialist to correct a congenital heart defect. A woman has a hernia repair in an ambulatory care center.

2. b, c, f. Secondary health care treats problems that require specialized clinical expertise, such as an MI, a seizure, and a hernia repair. Treating strep throat is primary health care.Tertiary health care involves management of rare and complex disorders, such as osteogenesis imperfecta and congenital heart malformations.

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

2. b, d, e. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

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

2. c. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

2. Which nurse who was influential in the development of nursing in North America is regarded as the founder of American nursing? Clara Barton Lillian Wald Lavinia Dock Florence Nightingal

2. d. Florence Nightingale elevated the status of nursing to a respected occupation, improved the quality of nursing care, and founded modern nursing education. Clara Barton established the Red Cross in the United States in 1882. Lillian Wald is the founder of public health nursing. Lavinia Dock was a nursing leader and women's rights activist instrumental in womens' right to vote.

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

2. d. Quick priority assessments (QPA) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care agency or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

2. Five-year-old Bobby has dietary modifications related to his diabetes. His parents want him to value good nutritional habits and they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission? Modeling Moralizing Laissez-faire Rewarding and punishing

2. d.When rewarding and punishing are used to transmit values, children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values. Through modeling, children learn what is of high or low value by observing parents, peers, and significant others. Children whose caregivers use the moralizing mode of value transmission are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values. Those who use the laissez-faire approach to value transmission leave children to explore values on their own (no single set of values is presented as best for all) and to develop a personal value system.

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

3. a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

3. A nurse working in a physician's office prepares insurance forms in which the provider is given a fixed amount per enrollee of the health plan. What is the term for this type of reimbursement? Capitation Prospective payment system Bundled payment Rate setting

3. a. Capitation plans give providers a fixed amount per enrollee in the health plan in an effort to build a payment plan that consists of the best standards of care at the lowest cost. The prospective payment system groups inpatient hospital services for Medicare patients into DRGs. With bundled payments, providers receive a fixed sum of money to provide a range of services. Rate setting means that the government could set targets or caps for spending on health care services.

3. A nurse who is working in a hospital setting after graduation from a local college uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply. A patient decides to quit smoking following a diagnosis of lung cancer. A patient shows off a new outfit that she is wearing after losing 20 pounds. A patient chooses to work fewer hours following a stress-related myocardial infarction. A patient incorporates a new low-cholesterol diet into his daily routine. A patient joins a gym and schedules classes throughout the year. A patient proudly displays his certificate for completing a marathon.

3. b, f. Prizing something one values involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, one chooses freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts by combining choice into one's behavior with consistency and regularity on the value, such as joining a gym for the year and following a low-cholesterol diet faithfully.

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

3. b, interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.

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

3. b. The Nursing Interventions Classification Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

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

3. b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

3. A home health care nurse is scheduled to visit a 38-year-old female client who has been discharged from the hospital with a new colostomy. Which duties would the nurse perform for this patient in the entry phase of the home visit? Select all that apply. Collect information about the patient's diagnosis, surgery, and treatments. Call the patient to make initial contact and schedule a visit. Develop rapport with the patient and her family. Assess the patient to identify her needs. Assess the physical environment of the home. Evaluate safety issues including the neighborhood in which she lives.

3. c, d, e. In the entry phase of the home visit, the nurse develops rapport with the patient and family, makes assessments, determines nursing diagnoses, establishes desired outcomes, plans and implements prescribed care, and provides teaching. In the pre-entry phase of the home visit, the nurse collects information about the patient's diagnoses, surgical experience, socioeconomic status, and treatment orders. In the pre-entry phase, the nurse also gathers supplies needed, makes an initial phone contact with the patient to arrange a visit, and assesses the patient's environment for safety issues.

3. When helping a patient turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of what type of planning? Initial planning Standardized planning Ongoing planning Discharge planning

3. c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

3. c. The person or government bringing suit against another is called the plaintiff. Appellates are courts of law, defendants are the ones being accused of a crime or tort, and attorneys are the lawyers representing both the plaintiff and defendant.

3. In early civilizations, the theory of animism attempted to explain the mysterious changes occurring in bodily functions. Which statement describes a component of the development of nursing that occurred in this era? Women who committed crimes were recruited into nursing the sick in lieu of serving jail sentences. Nurses identified the personal needs of the patient and their role in meeting those needs. Women called deaconesses made the first visits to the sick and male religious orders cared for the sick and buried the dead. The nurse was the mother who cared for her family during sickness by using herbal remedies.

3. d. The theory of animism was based on the belief that everything in nature was alive with invisible forces and endowed with power. In this era, the nurse usually was the mother who cared for her family during sickness by providing physical care and herbal remedies. At the beginning of the 16th century the shortage of nurses led to the recruitment of women who had committed crimes to provide nursing care instead of going to jail. In the early Christian period, women called deaconesses made the first organized visits to sick people, and members of male religious orders gave nursing care and buried the dead. The influences of Florence Nightingale were apparent from the middle of the 19th century to the 20th century; one of her accomplishments was identifying the personal needs of the patient and the nurse's role in meeting those needs.

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

4. a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

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

4. a. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

4. World War II had a tremendous effect on the nursing profession. Which development occurred during this period? The role of the nurse was broadened. There was a decreased emphasis on education. Nursing was practiced mainly in hospital settings. There was an overabundance of nurses.

4. a. During World War II, large numbers of women worked outside the home. They became more independent and assertive, which led to an increased emphasis on education. The war itself created a need for more nurses and resulted in a knowledge explosion in medicine and technology. This trend broadened the role of nurses to include practicing in a wide variety of health care settings.

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

4. b."Related to prescribed bedrest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

"Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. 4. Jean's attorney was careful to explain in her defense that Jean had specialty knowledge, experience, and clinical judgment and had met certain criteria established by a nongovernmental association, as a result of which she was granted recognition in a specified practice area. What is this sort of credential called? Accreditation Licensure Certification Board approval

4. c. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing.

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

4. c. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

4. When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate? Correct the initial assessment form. Redo the initial assessment and document current findings. Conduct and document an emergency assessment. Perform and document a focused assessment of skin integrity.

4. d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.

4. The American Association of Colleges of Nursing identified five values that epitomize the caring professional nurse. Which of these is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? Altruism Autonomy Human dignity Integrity

4. d. The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations.

4. A hospital nurse is admitting a patient who sustained a head injury in a motor vehicle accident. Which activities could the nurse delegate to licensed assistive personnel? Collecting information for a health history Performing a physical assessment Contacting the physician for medical orders Preparing the bed and collecting needed supplies

4. d. The nurse may delegate preparation of the bed and collection of needed supplies to unlicensed personnel but would perform the other activities listed.

4. A nursing instructor is teaching students about the utilization of health care services and how the U.S. health care dollar is spent. Place the following care areas in order from the highest percentage of health care money spent to the lowest. Physician/clinical services Home health care Long-term care facility services Retail prescription drugs Government administration Hospital care

4. f, a, d, c, b, e. The national health expenditures in 2010 were hospital care 31%, physician/clinical services 20%, retail prescription drugs 10%, long-term care facility services 5%, home health care 3%, and government administration 1%.

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

5. a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

5. A nurse researcher keeps current on the trends to watch in healthcare delivery. What trends are likely included? Select all that apply. Globalization of economy and society Slowdown in technology development Decreasing diversity Increasing complexity of patient care Changing demographics Shortages of key health care professionals and educators

5. a, d, e, f. Trends to watch in health care delivery include: globalization of the economy and society, increasing complexity of patient care, changing demographics, shortages of key health care professionals and educators, technology explosion, and increasing diversity.

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

5. a, d. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

5. b. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact by another person unless consent is granted. The Fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment.

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

5. b. Once you learn what constitutes the minimum data set, you can adapt this to any patient situation. It is not true that each assessment is the same even when you are using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard agency assessment tools does not allow for individualized patient care or critical thinking.

5. A professional nurse with a commitment to social justice is most apt to: Provide honest information to patients and the public Promote universal access to health care Plan care in partnership with patients Document care accurately and honestly

5. b. The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honestly are examples of integrity, and planning care in partnership with patients is an example of autonomy.

5. Which phrase describes a purpose of the ANA's Nursing's Social Policy Statement? Select all that apply. To describe the nurse as a dependent caregiver To provide standards for nursing educational programs To define the scope of nursing practice To establish a knowledge base for nursing practice To describe nursing's social responsibility To regulate nursing research

5. c, d, e. The ANA Social Policy Statement (2010) describes the social context of nursing, a definition of nursing, the knowledge base for nursing practice, the scope of nursing practice, standards of professional nursing practice, and the regulation of professional nursing.

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

5. c, d, f. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician. Consulting with a psychiatrist is a collaborative intervention.

5. A nurse is preparing an infant and his family for a hernia repair to be performed in an ambulatory care facility. What is the primary role of the nurse during the admission process? Assist with screening tests. Provide patient teaching. Assess what has been done and what still needs to be done. Assist with hernia repair.

5. c. Although all the options may be performed by the ambulatory care nurse, it is the nurse's primary responsibility to assess what has been done and to tailor the plan of care to the patient's needs. Screening tests and teaching are usually completed prior to the patient entering an ambulatory care facility.

5. A nurse is counseling a 60-year-old female patient who refuses to look at or care for a new colostomy. She tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? Collaborative problem Interdisciplinary problem Medical problem Nursing problem

5. d. Nursing Problem, because it describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

6. One of the four broad aims of nursing practice is to restore health. Which examples of nursing interventions reflect this goal? Select all that apply. A nurse counsels adolescents in a drug rehabilitation program. A nurse performs range-of-motion exercises for a patient on bedrest. A nurse shows a diabetic patient how to inject insulin. A nurse recommends a yoga class for a busy executive. A nurse provides hospice care for a patient with end-stage cancer. A nurse teaches a nutrition class at a local high school.

6. a, b, c. Activities to restore health focus on the individual with an illness and range from early detection of a disease to rehabilitation and teaching during recovery. These activities include drug counseling, teaching patients how to administer their medications, and performing range-of-motion exercises for bedridden patients. Recommending a yoga class for stress reduction is a goal of preventing illness, and teaching a nutrition class is a goal of promoting health. A hospice care nurse helps to facilitate coping with disability and death.

6. The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply. A patient tells the nurse that she is feeling nauseous. A patient's ankles are swollen. A patient tells the nurse that she is nervous about her test results. A patient complains of having a rash on her arm that is itchy. A patient rates his pain as a 7 on a scale of 1 to 10. A patient vomits after eating supper.

6. a, c, d, e. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, itchy, or chilly and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.

6. To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: Compare this reading to standards. Check the taxonomy of nursing diagnoses for a pertinent label. Check a medical text for the signs and symptoms of high blood pressure. Consult with colleagues.

6. a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.

6. A patient is being transferred from the ICU to a regular hospital room. What must the ICU nurse be prepared to do as part of this transfer? Provide a verbal report to the nurse on the new unit. Provide a detailed written report to the unit secretary. Delegate the responsibility for providing information. Make a copy of the patient's medical record.

6. a. The ICU nurse gives a verbal report on the patient's condition and nursing care needs to the nurse on the new unit. This information is not given to a unit secretary, nor is it delegated to others. The medical record is transferred with the patient; a copy is not made.

6. When an older nurse complains to a younger nurse that nurses just aren't ethical anymore, which reply reflects the best understanding of moral development? "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" "Ethics is genetically determined ... it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had." "I agree! It's impossible to be ethical when working in a practice setting like this!"

6. a. The ability to be ethical, to make decisions, and to act in an ethically justified manner begins in childhood and develops gradually.

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

6. b, c, e. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve (Alfaro-LeFevre, 2014).

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

6. b. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and if necessary administer pain medications.

6. A nurse is caring for patients in a primary care center. What is the most likely role of this nurse based on the setting? Assisting with major surgery Performing a health assessment Maintaining patients' function and independence Keeping student immunization records up to date

6. b. Performing patient assessments is a common role of the nurse in a primary care center. Assisting with major surgery is a role of the nurse in the hospital setting. Maintaining patients' function and independence is a role of the nurse in an extended-care facility, and keeping student immunization records up to date is a role of the school nurse.

6. A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An example of an affective outcome for this patient is: Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. By 6/12/15, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3″ to 2.5″). By 6/12/15, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

6. d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills. c is an outcome describing a physical change in the patient.

"Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. 6. What must be established to prove that malpractice or negligence has occurred in this case? The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The fact that this patient should not have died—she was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. The nurse intended to harm the patient and was willfully negligent. The nurse had a duty to monitor the patient's vital signs, failed to do so, the patient died, and it was Jean's failure to do her duty that caused the patient's death.

6. d. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse-patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient.

7. When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." Which of the following comments is the nurse most likely to hear from the instructor? "Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." "Job well done . . . you've identified this problem early and we can manage it before it becomes more acute." "Is this an actual or a possible diagnosis?" "This is a medical, not a nursing problem."

7. a. A data cluster is a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual's normal pattern.

7. A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a stroke that caused right-sided paresis. An example of this type of outcome is: After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. By 8/15/15, patient will be able to use right arm to dress, comb hair, and feed herself. Following physical therapy, patient will begin to gradually participate in walking/running events. By 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events.

7. a. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

"Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. 7. When the attorney representing the patient's family calls Jean and asks to talk with her about the case so that he can better understand her actions, how should Jean respond? "I'm sorry, but I can't talk with you. You'll have to contact my attorney." Answer the attorney's questions honestly and make sure that he understands her side of the story. Appeal to the attorney's sense of compassion and try to enlist his sympathy by telling him how busy it was that morning. "Why are you doing this to me? This could ruin me!"

7. a. One of the cardinal rules for nurse defendants is: Do not discuss the case with anyone at your agency (with the exception of the risk manager), with the plaintiff, with the plaintiff's lawyer, with anyone testifying for the plaintiff, or with reporters.

7. A caregiver asks a nurse to explain respite care. How would the nurse respond? "A service that allows time away for caregivers" "A special service for the terminally ill and their family" "Direct care provided to individuals in a long-term care facility" "Living units for people without regular shelter"

7. a. Respite care is provided to enable a primary caregiver time away from the day-to-day responsibilities of homebound patients.

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

7. a. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the plan of care. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

7. Which statements or questions would be appropriate in establishing a discharge plan for a patient who has had major abdominal surgery? "I'll bet you will be so glad to be home in your own bed." "What are your expectations for recovery from your surgery?" "Be sure and take your pain medications and change your dressing." "You will just be fine! Please stop worrying."

7. b. It is important to assess the expectations of the patient (and family) when assessing health care needs for discharge planning.

7. Nursing is recognized increasingly as a profession based on which defining criteria? Select all that apply. Well defined body of general knowledge Interventions dependent upon the medical practice Recognized authority by a professional group Regulation by the medical industry Code of ethics Ongoing research

7. c, e, f. Nursing is recognized increasingly as a profession based on the following defining criteria: well-defined body of specific and unique knowledge, strong service orientation, recognized authority by a professional group, code of ethics, professional organization that sets standards, ongoing research, and autonomy and self-regulation.

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

7. c. Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

7. When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. What should the nurse do? Introduce oneself and thank the wife for being present. Introduce oneself and ask the wife if she wants to remain. Introduce oneself and ask the wife to leave. Introduce oneself and ask the patient if he would like the wife to stay.

7. d. The patient has the right to indicate whom he would like to be present for the nursing history and exam. You should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.

7. A home health nurse who performs a careful safety assessment of the home of a frail elderly patient to prevent harm to the patient is acting in accordance with which of the principles of bioethics? Autonomy Beneficence Justice Fidelity Nonmaleficence

7. e. Nonmaleficence is defined as the obligation to prevent harm. Autonomy is respect for another's right to make decisions, beneficence obligates us to benefit the patient, justice obligates us to act fairly, and fidelity obligates us to keep our promises.

8. A nurse is assessing a 15-year-old female patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: Clinical judgment Clinical reasoning Critical thinking Blended competencies

8. a. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical/legal skills combined with the willingness to use them creatively and critically when working with patients.

8. A nurse caring for patients in a primary care setting submits paperwork for reimbursement from managed care plans for services performed. Which purpose best describes managed care as a framework for health care? A design to control the cost of care while maintaining the quality of care Care coordination to maximize positive outcomes to contain costs The delivery of services from initial contact through ongoing care Based on a philosophy of ensuring death in comfort and dignity

8. a. Managed care is a way of providing care designed to control costs while maintaining the quality of care.

8. A professional nurse committed to the principle of autonomy would be careful to: Provide the information and support a patient needed to make decisions to advance one's own interests Treat each patient fairly, trying to give everyone his or her due Keep any promises made to a patient or another professional caregiver Avoid causing harm to a patient

8. a. The principle of autonomy obligates nurses to provide the information and support patients and their surrogates need to make decisions that advance their interests. Acting with justice means giving each person his or her due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients.

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

8. b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.

8. A nurse is performing an initial comprehensive assessment of an 84-year-old male patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? Maslow's human needs Gordon's functional health patterns Human response patterns Body system model

8. b. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

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

8. b. The outcomes in a and c make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60 mL fluid every 2 hours while awake." Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/15." The outcome in d makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware."

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

8. c. When a patient does not follow the plan of care despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the plan of care is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

8. A nurse is practicing as a nurse-midwife in a busy OB-GYN office. Which degree in nursing is necessary to practice at this level? LPN ADN BSN MSN

8. d. A master's degree (MSN) prepares advanced practice nurses. Many master's graduates gain national certification in their specialty area, for example, as family nurse practitioners (FNPs) or nurse midwives.

8. A nurse administers the wrong medication to a patient and the patient is harmed. The physician who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? The nurse is not responsible, because the nurse was merely following the doctor's orders. Only the nurse is responsible, because the nurse actually administered the medication. Only the physician is responsible, because the physician actually ordered the drug. Both the nurse and the physician are responsible for their respective actions.

8. d. Nurses are legally responsible for carrying out the orders of the physician in charge of a patient unless an order would lead a reasonable person to anticipate injury if it were carried out. If the nurse should have anticipated injury and did not, both the prescribing physician and the administering nurse are responsible for the harms to which they contributed.

8. A nurse is counseling an older female patient hospitalized for dehydration secondary to a urinary tract infection. The patient tells the nurse: "I don't like being in the hospital. There are too many bad bugs in here. I'll probably go home sicker than I came in." She also insists that she is going to get dressed and go home. She has the capacity to make these decisions. What is the legal responsibility of the nurse in this situation?

8. d. The patient is legally free to leave the hospital against medical advice (AMA); however, patients who leave the hospital AMA must sign a form releasing the physician and hospital from legal responsibility for their health status. This signed form becomes part of the medical record.

9. A nurse decides to become a home health care nurse. Which personal qualities are key to being successful as a community-based nurse? Select all that apply. Making accurate assessments Researching new treatments for chronic diseases Communicating effectively Delegating tasks appropriately Performing clinical skills effectively Making independent decisions

9. a, c, e, f. Nurses working in the community must have the knowledge and skills to make accurate assessments, work independently, communicate effectively, and perform clinical skills accurately. Community-based nurses may be researchers and occasionally delegate care, but these are not key qualities for this type of nursing.

9. Nurse practice acts are established in each state of the United States to regulate nursing practice. What is a commonelement of every state practice act? Defining the legal scope of nursing practice Providing continuing education programs Determining the content covered in the NCLEXexamination Creating institutional policies for health care practices

9. a. Nurse practice acts are established in each state to regulate the practice of nursing by defining the legal scope of nursing practice, creating a state board of nursing to make and enforce rules and regulations, define important terms and activities in nursing, and establish criteria for the education and licensure of nurses. The acts do not determine the content covered on the NCLEX, but they do have the legal authority to allow graduates of approved schools of nursing to take the licensing examination. The acts also may determine educational requirements for licensure, but do not provide the education. Institutional policies are created by the institutions themselves.

9. An RN working on a busy hospital unit delegates patient care to unlicensed assistive personnel (UAPs). Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. Performing the initial patient assessments Making patient beds Giving patients bed baths Administering patient medications Ambulating patients Assisting patients with meals

9. b, c, e, f. Performing the initial patient assessment and administering medications are the responsibility of the registered nurse. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

9. A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe aspects of this procedure? Select all that apply. An incident report is used as disciplinary action against staff members. An incident report is used as a means of identifying risks. An incident report is used for quality control. The facility manager completes the incident report. An incident report makes facts available in case litigation occurs. Filing of an incident report should be documented in the patient record.

9. b, c, e. Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs and in some states, incident reports may be used in court as evidence. A physician completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed.

9. A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68-year-old male patient. What type of diagnosis does this intervention seek to confirm? Actual Possible Risk Collaborative

9. b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.

9. Janie wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. She believes his dying is being prolonged painfully. She is troubled when the patient's doctor tells her that she'll be fired if she raises questions about his care or calls the consult. This is a good example of: Ethical uncertainty Ethical distress Ethical dilemma Ethical residue

9. b. Ethical distress results from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, fear of losing her job). Ethical uncertainty results from feeling troubled by a situation but not knowing if it is an ethical problem. Ethical dilemmas occur when the principles of bioethics justify two or more conflicting courses of action. Ethical residue is what nurses experience when they seriously compromise themselves or allow themselves to be compromised.

9. A nurse cares for dying patients by providing physical, psychological, social, and spiritual care for the patients, their families, and other loved ones. This service is known as: Respite care Palliative care Hospice care Extended care

9. c. The hospice nurse combines the skills of the home care nurse with the ability to provide daily emotional support to dying patients and their families. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older patients. Palliative care, which can be used inconjunction with medical treatment and in all types of health care settings, is focused on the relief of physical, mental, and spiritual distress. Extended-care facilities include transitional subacute care, assisted-living facilities, intermediate and long-term care, homes for medically fragile children, retirement centers, and residential institutions for mentally and developmentally or physically disabled patients of all ages.

9. The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do? Inform the charge nurse. Inform the surgeon. Validate the finding. Document the finding.

9. c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate, thus all data should be validated before documentation if there are any doubts about accuracy.

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

9. d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

9. A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes the theory of which theorist? Travelbee Watson Benner Swanson

9. d. Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) write that caring is a basic way of being in the world and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.

Taylor Fundamentals End of Chapter NCLEX Questions (CH 1,6,7,8,9,10,11,12,13,14,15,22,23,24,26)

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