Foundations Test 3

The nurse is caring for a client who is admitted for hypertension (HTN). The nurse notes that the client has not been eating the food provided, and family members have brought in homemade food. What would be the best response by the nurse?

"Can you tell me what foods you prefer to eat and what your family is bringing you?" Rationale: The nurse should attempt to provide culturally sensitive food; however, the nurse should assess what foods the client wants to eat. The nurse should educate the client on food preferences that are also appropriate to the disease-specific dietary restrictions. Even though the diet may be healthier, the nurse should first assess the client's preferences. The nurse should verify the client's understanding of the diet but should avoid closed-ended questions such as asking if the client understands the specific diet for HTN.

A nurse is teaching a client about healthy food choices using a holistic approach. The nurse determines that additional teaching is needed based on which client statement?

"I can have a can of soda as often as I want to." Rationale: The client needs more instruction based on the statement about having a soda whenever desired. Soft drinks are "fake food" and have no nutritional value. Reducing the amount of processed food, such as using frozen over canned foods and using natural sweeteners, reflects understanding of the teaching.

The parents of a hospitalized 10-year-old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?

"I will arrange access for you to review the record after you put your request in writing." Rationale: Arranging access for the parents to review the record after they put their request in writing is in compliance with most health care institution policy and is the standard practice for most health institutions. Because the child is a minor, it is the parents' right to view the client's record. Therefore, the statements about the physician not giving the parents access to review the records and asking if the parents are questioning the care of their child are incorrect.

Which nursing group provides a definition and scope of practice for nursing?

American Nurses Association (ANA)

Which ethical principle is related to the idea of self-determination?

Autonomy Rationale: Autonomy refers to self-rule, or self-determination; it respects the rights of clients or their surrogates to make healthcare decisions. Beneficence is the duty to do good and the active promotion of benevolent acts. Confidentiality is related to the concept of privacy. Nonmaleficence is the duty not to inflict harm, as well as to prevent and remove harm.

A nurse is teaching a client experiencing stress about how relaxation helps to reduce the effects of stress on the body. Which underlying concept would the nurse integrate into the explanation about how relaxation works?

Helps to increase the effects of parasympathetic nervous system on the mind and body. Rationale: Relaxation techniques promote parasympathetic nervous system activity, helping to reduce sympathetic activity and restore the balance of the two systems. The ultimate goal is to increase the parasympathetic system influence in the mind-body and thus reduce the effect of stress and stress-related illness on the body. Natural products can boost the body's immunity. Energy healing activates natural pleasure centers. Hands-on techniques such as massage promote circulation throughout the body.

Ayurvedic medicine has its roots in which of the following areas?

India Rationale: Ayurvedic medicine has its roots in India.

For the nurse become a nurse practitioner, what is the minimal degree the nurse will need to acquire?

Master's Rationale: A master's degree is the minimal degree for a nurse to become a nurse practitioner. Diploma, associate, and baccalaureate degrees are the minimal degree for an RN.

What might a nurse need to do to ensure the continuation of his or her nursing license?

Obtain continuing education credits. Rationale: In many states, continuing education is required for an RN to maintain licensure. These are defined as professional development experiences designed to enrich the nurse's contribution to health. Obtainment of an ongoing degree is not necessary to maintain licensure. While hospital in-services may provide continuing education, not all in-services are designed to do so.

A nurse obtains an order for a bed alarm for a confused client. This is an example of which ethical principle?

Paternalism Rationale: Making a decision for a client who is confused to prevent an injury is an example of paternalism. Deception occurs when the true nature or reason is concealed and the client is deprived of basic human rights. Confidentiality requires a health care provider to keep a client's personal health information private unless consent to release the information is provided by the client. Conflict is a disagreement or argument and does not represent the example in this question.

A client uses meditation as part of treatment for a neuromuscular disease. How can the nurse best facilitate continuation of this treatment while the client is hospitalized?

Provide a quiet uninterrupted period for medication

In SBAR, what does R stand for?

Recommendations

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise?

SBAR Rationale: The nurse should use SBAR (situation, background, assessment, recommendation) when communicating with the health care provider. SOAP and PIE are nursing notes in the medical record, and MAR is medication administration record.

Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)?

Submitting a written notice to all clients identifying the uses and disclosures of their health information Rationale: Submitting a written notice to all clients identifying the uses and disclosures of their health information is required by HIPAA, which is the law that protects the privacy of health records and the security of that data. Disclosing a client's health information for research purposes requires the client's permission, not the physician's permission. Releasing the client's entire health record when only portions of the information are needed and obtaining only the client's verbal acknowledgement, rather than a written signature, indicating that the client was informed of the disclosure of information are HIPAA violations.

A new graduate is working at a first job. Which statement is most important for the new nurse to follow?

Use abbreviations approved by the facility. Rationale: Use abbreviations, but only those that are commonly accepted and approved by the facility. All documentation requires proper grammar and writing techniques. The nurse should be using the particular charting method for the employing institution. All care and observations should be documented - not only changes in a client's status.

When obtaining information for a database, which of the following represents a nurse commitment and interest in reflected integrative medicine (CAM)?

"Do you take any vitamins or minerals, and if so, what?" Rationale: Starting with the initial contact with a client, the nurse includes a basic assessment of the client's use of CAM in an intake interview. The nurse asks about vitamins and supplements as well as any healing practices.

The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state:

"Everything in nature is alive with invisible forces." Rationale: The theory of animism attempts to explain the cause of mysterious changes in bodily functions. This theory is based on the belief that everything in nature is alive with invisible forces and endowed with power. Good spirits bring health; evil spirits bring sickness and death. In cultures that ascribe to animism, the roles of the physician and the nurse are separate and distinct. The physician is the medicine man who treats disease by chanting, inspiring fear, or opening the skull to release evil spirits (Dolan, Fitzpatrick, & Herrmann, 1983). The nurse usually is the mother who cares for her family during sickness by providing physical care and herbal remedies. Pets are not involved in the theory of animism.

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor?

"You can make extra money with overtime pay with end-of-shift charting." Rationale: There are many benefits to electronic charting, though there may be some learning curves involved in knowing how to use electronic formats. It is incorrect to suggest that overtime pay can be earned with end-of-shift charting. Therefore, this statement requires intervention. The other statements are appropriate.

When providing nursing care to clients, the nurse is required to adhere to ethical values and legal rules to guide practice behavior. Which values would be included? Select all that apply.

- Veracity - Fidelity - Privacy - Confidentiality Rationale: Ethical values and legal rules guide the behavior of health care professionals toward clients and their families. These include veracity, fidelity, privacy, and confidentiality. Safety is a basic human need and something the nurse should be concerned about but not an ethical value.

A community health nurse is providing care to a group of Hispanic people living in an area that is predominantly populated by white people. What are the Hispanic people in this community an example of?

A minority Rationale: The term minority refers to a group of people whose physical and cultural characteristics differ from the majority of people in a society. Subcultures are relatively large groups of people who are members of an even larger cultural group but who have certain ethnic, occupational, or physical characteristics that are not common to that larger group. A subgroup is a division of a group that is in some way distinguished from the larger group. A majority is most of the people in a large group.

The first nursing journal owned, operated, and published by nurses was:

American Journal of Nursing

Which nursing intervention reflects practice according to Madeline Leininger's transcultural nursing theory?

Incorporating the client's request for complementary treatment therapy Rationale: Leininger's theory of transcultural nursing includes assessing a cultural nature, accepting each client as an individual, having knowledge of health problems that affect particular cultural groups, and planning of care within the client's health belief system to achieve the best health outcomes. Therefore, incorporating the client's request for complementary treatment therapy is an example of this theory. The others do not support this theory.

A nurse believes that abortion is an acceptable option if a pregnancy results from a situation of rape. What is the best description of this belief?

Personal moral Rationale: A personal moral is a standard of right and wrong that helps a person determine the correct or permissible action in a given situation. Professional values in nursing are a set of beliefs about the worth of things, about what matters, that provide the foundation for nursing practice and guide the nurse's interactions with clients, colleagues, and the public. Ethical principles are a set of specific concepts that guide a person's actions. A legal obligation is something that is required by law.

A legal document that states a client's health-related wishes — such as a preference for pain management if the client becomes terminally ill — and also allows the client's adult child to direct the client's care, is:

an advance directive Rationale: Clients communicate their wishes to health care providers by verbally participating in health care decision making and by employing written documents called advance directives. A will is a legal document where one communicates wishes of how to dispose of personal effects and belongings upon one's death. The terms license and standard of care have no application in this scenario.

In the role of entrepreneur, the nurse's primary responsibility is:

managing a health-related business. Rationale: A nurse entrepreneur is primarily concerned with organizing, developing, and managing a clinic or health-related business. Although a nurse entrepreneur may also administer resources, manage personnel, and teach, the primary responsibility of this role is managing a health-related business. A nurse administrator is primarily concerned with administering resources and managing personnel. A nurse educator is primarily concerned with teaching in a clinical setting.

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate?

"Clipboards with client data should not leave the unit."

Which scenario is the best example of the nurse implementing the ANA standard relating to diagnosis?

Determining a client is at risk for falls Rationale: When the nurse is implementing the ANA standards relating to diagnosis, the nurse analyzes the assessment data (e.g., lab results, apical pulse) to determine a nursing diagnosis or issue to be addressed by nursing. Determining a client is at risk for falls is an example of the nurse identifying/diagnosing a nursing issue. Assessing a client's apical pulse is assessment. Evaluating a client's laboratory results is part of analysis. Teaching a diabetic client to inject insulin is an intervention.

A nurse overhears another nurse make a statement that indicates racism. The nurse makes this determination based on which characteristic indicative of social value?

Skin color Rationale: Racism uses skin color, not size, language or dress, as the primary indicator of social value.

A client being discharged from the hospital asks the nurse, "When I go visit my family out of state, should I take my living will with me, or do I need a new one for that state?" Which is the mostappropriate response by the nurse?

"Take it with you. It is recognized universally in the United States." Rationale: A separate or different advance directive is not needed for each state; an advance directive can be used in any state, regardless of where it was created. The nurse should advise the client to take it when travelling out of state. The client should not assume that the family knows the client's wishes; the whole purpose of having an advance directive is to avoid the ambiguity and potential confusion that making such assumptions can cause. Other hospitals may not know who to contact to request a copy of the advance directive; therefore, it would be much safer for the client to take a copy of it while travelling.

The nurse is educating a client of Chinese descent regarding the reduction and elimination of lactose in the diet. Which statement(s) made by the client indicates that the education was effective? Select all that apply.

- "When I drink coffee or tea, I should use a non-dairy creamer instead of milk or cream." - "I should replace 2% milk with lactose-free milk." - "I can use kosher parve foods because they are prepared without milk."

The nursing process includes step(s)? Select all that apply.

- Assess - Plan - Implement - Evaluate Rationale: The nursing process consists of assessing the client, planning the client's care, implementing the planned interventions, and evaluating the effectiveness of those interventions. Prescribing is not a part of the nursing process.

While assessing a client, the client tells the nurse that he is a follower of traditional Chinese medicine and the concept of qi. Based on the nurse's understanding of this concept, which treatment modality would the nurse expect the client to mention?

Acupuncture Rationale: Acupuncture is based on energy regulation of qi through meridians. It is a core principle in traditional Chinese medicine. Therapeutic Touch (TT) is not a form of traditional Chinese medicine and is based on the consciously directed process of energy exchange. Physiotherapy and allopathy are not based on the concept of qi.

A nurse is reading an online journal article about different approaches to health. The nurse is reading about a practice approach that is supported by evidence-based practice and is particularly effective when aggressive treatment is needed in an emergency situation. The nurse is reading about which type of approach?

Allopathic Rationale: Allopathic medicine (or conventional medicine) is evidence-based practice that includes remarkable advances in biotechnology, surgical interventions, pharmaceutical approaches, and diagnostic tools. Allopathic medical care is particularly effective when aggressive treatment is needed in emergency or acute situations. Traditional Chinese medicine uses eight principles to analyze symptoms and categorize conditions, and uses the theory of five elements to explain how the body works. Naturopathy involves the belief that health is a dynamic state of being that provides abundant energy for people to deal with life in our complex society. Ayurveda involves the integration and balance of the body, mind and spirit.

The nursing student is reading the plan of care established by the RN in the clinical facility. The students ask the nursing instructor why rationales are not written on the hospital care plan. The nursing instructor states:

Although not written, the nurse must know or question the rationale before performing an action Rationale: Although the scientific rationale is not documented in the clinical plan, it is no less important than in the instructional plan. Nurses and other members of the healthcare team must know the rationale behind the intervention or must question and review the rationale before performing the action.

When talking with a client, the nurse notes that the client keeps backing up. What would be the most appropriate response?

Ask the client about personal space preferences Rationale: It is most appropriate to ask the client what is preferred in regard to personal space. If the nurse needs to invade the client's personal space to do an examination or take vital signs, it is important to discuss the matter. It is not appropriate to back away without assessing preference. It may make the client feel judged if the nurse asks why he or she is backing away. Moving closer to the client just perpetuates the problem.

Having recently completed a specialty nursing program in neonatal care, a nurse is now preparing to leave the medical unit and begin providing care in the hospital's neonatal intensive care unit (NICU). The nurse has completed which process of credentialing?

Certification Rationale: The process of certification involves the attainment and validation of specialized nursing knowledge and skills. Certification is often necessary to ensure that the nursing care provided in specialized and high-acuity settings is safe and appropriate. Accreditation is the process by which an educational program, rather than an individual nurse, is identified as meeting standards. The process of licensure involves the determination that a nurse meets minimum requirements to practice but not necessarily that the nurse has the specialized knowledge that is necessary for some care settings. Validation is not a specific aspect of the process of credentialing.

A client is distraught because a recent computed tomography (CT) scan shows that the client's colon cancer has metastasized to the lungs. Which nursing aim should the nurse prioritize in the immediate care of this client?

Facilitating coping Rationale: This client's care in the coming weeks or months will likely encompass all of the four foundational roles of the nurse. However, because the client has just recently received bad news and is emotionally distraught, helping the client cope is an appropriate priority in immediate care. Preventing illness is focused on preventing an infection or disease from occurring such as through immunizations, hand hygiene, exercising and diet. Restoring health would more appropriately occur after the client has accepted the disease and would involve taking medication and working to get back to baseline with the disease. Health promotion is the process of enabling people to increase control over, and to improve, their health.

The nurse is caring for a client who requests to see a copy of the client's own health care records. What action by the nurse is most appropriate?

Review the hospital's process for allowing clients to view their health care records. Rationale: The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.

A nurse is reviewing the nurse practice act of the state in which the nurse is licensed. The nurse understands that this act was derived from which source of law?

Statutory Rationale: Nurse practice acts are an example of statutory laws, which are enacted by a legislative body. Constitutional law is based on federal and state constitutions, which indicate how the federal and state governments are created, grant them authority, and list the principles and provisions for establishing specific laws. Administrative law is administered by agencies that, among other functions, are responsible for law enforcement. Common law has evolved from accumulated judiciary decisions. Common law is thus court-made law.

A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care?

The client receiving the care Rationale: The client receiving the care is always the central focus of the nursing care provided. The central focus is not the nurse, the nursing actions, or nursing as a profession.

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

To improve quality of care Rationale: The primary reason to fill out an incident report is to improve the quality of care. Incident reports are not designed to be a means for disciplinary action. Incident reports are designed to identify actual or potential risks that can be addressed to improve quality of care. Incident reports are not intended to initiate litigation or document everyday occurrences.

Professional regulations and laws that govern nursing practice are in place for which reason?

To protect the safety of the public Rationale: Governing bodies, professional regulations, and laws are in place to protect the public by ensuring that nurses are accountable for safe, competent, and ethical nursing practice. The other options do not describe accurately the role and responsibility of the governing bodies and the regulations and laws of nursing.

A client was admitted to a postoperative nursing unit after undergoing abdominal surgery. During this time, the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which legal term describes the case?

Tort Rationale: A tort is a litigation in which one person asserts that a physical, emotional, or financial injury was a consequence of another person's actions or failure to act. The lack of action on the nurse's part indicates unintentional tort. A misdemeanor or felony would be an offense under criminal law, and neither is applicable in this case. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property.

According to survey results, who are the most prevalent users of complementary or alternative therapies?

Women, ages 35-50, with college degree, former smokers Rationale: The most prevalent users of CAT are women, ages 35-50, with higher levels of education, who are former smokers.

The new nursing graduate is concerned about some of the critical changes that will be occurring in nursing. What changes does the nurse anticipate will impact nursing care?

Difficulty for nurses to remain current in a rapidly changing medical and technology environment Rationale: The National Advisory Council on Nurse Education and Practice (NACNEP) identifies critical challenges to nursing practice in the 21st century: a growing population of hospitalized clients 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. Nursing is limitless and, with opportunities for furthering education, there are many various ways nurses can practice. Health costs are rising and there are more citizens needing health care. There is a projected nursing shortage that may be severe and there are no shortages of jobs for nurses.

The nurse is performing a quality improvement audit and gathering client records to begin the audit. How would the nurse use client records for quality assurance purposes?

Randomly select client records to determine whether certain standards of care were met and documented. Rationale: Quality assurance is when records are randomly selected to determine whether certain standards of care were met and documented. Care planning is when the nurse considers all data on the client record when developing, goals, outcome criteria, interventions, and evaluation criteria for and with clients. Research is performed when data are gathered from groups of records to determine significant similarities in disease presentation, to identify contributing factors, or to determine the effectiveness of therapies. The medical record can be used for educational purposes, such as when it is used by a student to learn how a disease might present itself in certain clients.

The nurse is caring for several clients of different cultures. Which client situation would the nurse recognize as the client with highest risk of culture shock?

The client from Ethiopia states, "All these machines attached to me scare me and I need to get them off." Rationale: Culture shock occurs when a person is immersed in an environment different from the one the person is accustomed to, resulting in rapid disorientation and distress. The client stating the machines scare him is experiencing culture shock. Difficulty reading a different language, missing absent family, and not understanding the purpose of medications are not indicative of culture shock.

Which is the best example of a client-centered approach to care?

The nurse asks the client about health goals. Rationale: Client-centered care is one of the quality and safety education requirements for nursing competencies (QSEN). The intent of client-centered care is to ensure that care is centered on the client, and not the needs of the nurse. An example of this is the nurse asking the client about personal health goals so that they can be addressed on the client's plan of care. Helping the client ambulate, asking the client what he or she would like from the menu, and drawing a blood sample are examples of client care, but are not client-centered care.

A nurse is preparing a client for discharge from the cardiac unit and observes cigarettes in the client's belongings. The nurse asks the client to consider the client's health and that of the client's spouse. This is an example of:

values clarification. Rationale: Values clarification is a process that allows an individual to examine and understand what choices to make. Moral distress is the emotional state that arises from a situation when a nurse feels that the ethically correct action to take is different from what the nurse is tasked with doing. An example of this is the nurse taking away the cigarettes out of the client's belongings bag. Ethical distress occurs when a decision is made regarding what one believes to be the right course of action, but barriers prevent the nurse from carrying out or completing the action. The nurse can expect ethical distress if removing the cigarettes from the client's belongings bag. Social justice is a concept of fair and just relations between the individual and society. An example is the selling of cigarettes to those who had a cardiac event. Moral distress, ethical dilemma, and social justice are not reflected in this scenario.

A nurse volunteers to serve on the hospital ethics committee. Which action should the nurse expect to take as a member of the ethics committee?

Assist in decision making based on the client's best interests. Rationale: One reason an ethics committee convenes is when a client is unable to make an end-of-life decision and the family cannot come to a consensus. In this case, the committee members are there to advocate for the best interest of the client and to promote shared decision making between the client (or surrogates, if the client is legally incapacitated) and the clinicians. The committee would not convince, decide, or present options about the type of care. This is not the role of an ethics committee.

Nurses practicing in a critical care unit must acquire specialized skills and knowledge to provide care to the critically ill client. These nurses can validate this specialty competence through what process?

Certification Rationale: Certification validates specialty knowledge, experience, and clinical judgment. A nurse in a critical care unit having specialized skills and knowledge to provide care would be an example of certification. Licensure is a specialized form of credentialing based on laws passed by a state legislature. Licensure endorses entry-level competence. Legal accreditation is granted to educational programs by state agencies endorsing the approval of the program's design and mission to meet the needs of state requirements. Litigation is not a method for validation.

A nurse manager is teaching staff how to use a new piece of hospital equipment. Which educational setting would be most appropriate for this process?

In-service education Rationale: In-service education is designed to increase the knowledge and skills of the nursing staff. Education about a new piece of hospital equipment would fall into this category. Continuing education is educational experiences designed to enrich the nurse's contribution to health. Many state nursing organizations require continuing education hours to maintain licensure. Undergraduate studies are the educational programs for pre-licensure in the field of nursing. For the nurse, this could be a diploma, associate degree, or baccalaureate in nursing. Graduate education would include the educational programs for the advanced practice nurse. This could be master's degree or doctoral preparation.

Massage therapy is being used on clients during chemotherapy treatments. How does massage therapy help these patients?

It relaxes muscles to increase circulation and release tension Rationale: Massage therapy relaxes muscles to increase circulation and release tension. Acupressure uses pressure to balance and increase the flow of energy. Chi gong uses slow, gentle physical movements to cleanse the body. Chiropractic therapy physically moves joints into proper alignment to relieve stress.

A nurse who comments to coworkers at lunch that a client with a sexually transmitted infection has been sexually active in the community may be guilty of what tort?

Slander Rationale: Defamation of character is an intentional tort in which one party makes derogatory remarks about another, with those remarks harming the other party's reputation. Slander is spoken defamation of character; libel is written defamation. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property.

The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize?

Work effectively in interdisciplinary teams Rationale: The RN working with administrators to transform care will need to be able to work effectively as part of an interdisciplinary team. The nurse will need to work as a team member with members of the administration, as well as representatives from other health disciplines involved in the project. The ability to use and troubleshoot equipment and to navigate the electronic medical records are important to the nurse, but will not necessarily help when working with administration to transform care. Doing things the way they have always been done is a barrier to transformation of care.

The need for university-based nursing education programs was brought to light during which important historical time?

World War II Rationale: During the middle of the twentieth century, Esther Lucile Brown, in her report on nursing education published at that time, wrote that nursing education belonged in colleges and universities, not in hospitals. During the Spanish-American War, nursing was still in its earliest phase of development. Even with the input of Florence Nightingale and her followers after WWI, nursing continued to struggle. Professional nursing began during the period and crisis needs of WWII. Nursing continues to evolve today.

A nurse practitioner is conducting a presentation at a local community center about complementary health approaches. One of the participants asks the nurse practitioner, "Everybody is talking about relaxation. Just how does relaxation help a person?" The nurse responds, integrating which effect as being associated with relaxation? Select all that apply.

- Better sleep and rest - Less anxiety - Reduced muscle tension - Improved sense of well-being Rationale: Relaxation can be useful whether a client is experiencing a single stressful event, such as surgery, or chronic stress. Client benefits include reduced anxiety, reduced muscle tension and pain, improved functioning of the immune system, enhanced sleep and rest, and an improved overall sense of well-being.

During the course of any given day of work in the acute care setting, the nurse may need to perform which roles? Select all that apply.

- Communicator - Counselor - Teacher Rationale: The roles and functions of the nurse are many and include caregiver, communicator, teacher, counselor, leader, researcher, and advocate. Acting as financier and statistician are not the roles of the nurse.

The nurse is creating a plan of care for a client. Which actions by the nurse demonstrate the components of the nursing process? Select all that apply.

- Identifies the needs of the client - Evaluates the effectiveness of the plan of care - Plans interventions to meet the client's health care needs Rationale: Nurses implement their roles through the nursing process by identifying the needs of the client, planning the care of the client to meet those needs, and evaluating the effectiveness of the interventions. Although the rationales should be readily known when creating the plan of care, it is important for the nurse to explain and include the client in the plan of care. This is not part of the nursing process. Medical needs are not a part of the nursing process.

The nursing supervisor is preparing to delegate some aspects of the nursing care plan interventions to other healthcare providers on the unit. Which are the responsibilities of nursing supervisors? Select all that apply.

- Knowing the job descriptions and capabilities of each person on the team in depth - Assigning to registered nurses rather than nonprofessional staff the practice-pervasive functions of assessment - Ensuring that care is delivered accurately and appropriately Rationale: Nursing supervisors must know the job descriptions and capabilities of each person on the team in depth. Nursing supervisors should not assign tasks to staff according to each member's preference to improve staff moral but rather according to each member's capabilities and scope of practice. Nursing supervisors and other registered nurses may delegate specific aspects of care to nonprofessional staff but must select appropriate nursing care measures for these personnel to perform are held accountable ultimately for the care that is provided. Nursing supervisors and other registered nurses may not delegate the practice-pervasive functions of assessment, planning, diagnosis, evaluation, and nursing judgment to nonprofessional staff (NCSBN, 2005). Nursing supervisors and other registered nurses may delegate technical activities (i.e., feeding, ambulating) or provision of amenities (i.e., hospitality services, including making beds, setting up meals, cleaning the care environment), but the activities must not require critical thinking or professional judgment (American Nurses Association, 2005). Nursing supervisors also must ensure that nursing care measures have been carried out correctly.

A new graduate wants to be knowledgeable about state-mandated rules to better practice within the scope of nursing. What are the best resources for this nurse to research? Select all that apply.

- Nurse practice acts - Nursing educational requirements - Composition and disciplinary authority of board of nursing Rationale: Examples of state-mandated rules would include nurse practice acts, nursing educational requirements, and composition and disciplinary authority of boards of nursing. Delegation trees, medication administration, and Medicare and Medicaid provision for reimbursement of nursing services are not examples of state-mandated rules.

A nurse is part of a group named in a malpractice lawsuit. The plaintiff is suing for general damages. Which items would be addressed? Select all that apply.

- Pain - Suffering - Disfigurement - Disability Rationale: For a plaintiff to prevail in a malpractice suit, the plaintiff must have sustained damages. The purpose of the suit is to compensate for these damages. General damages include pain and suffering, disfigurement, and disability. Special damages are for losses and expenses related to the injury, such as medical expenses and lost wages.

The nurse is developing a plan of care for a client. Which nursing action is defined as an activity(ies)/intervention(s)? Select all that apply.

- holding the client's hand - starting an IV - educating clients Rationale: Nursing care involves a wide range of activities, from carrying out complicated technical procedures to something as simple as holding a client's hand. It includes inserting an IV, holding a client's hand, and educating clients. Reading an x-ray and diagnosing a medical condition are completed by health care providers.

An RN enters a client's room and observes the unlicensed assistive personnel (UAP) forcefully pushing a client down on the bed. The client starts crying and informs the UAP of the need to go to the bathroom. What action is the RN witnessing that should be immediately reported to the supervisor?

Battery Rationale: The UAP is engaging in battery, which is an assault that is carried out and includes willful, angry, and violent or negligent touching of another person's body or clothes or anything attached to (or held by) that other person. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Defamation of character is an intentional tort in which one party makes derogatory remarks about another that harm the other party's reputation.

The nurse is helping the unlicensed assistive personnel (UAP) bathe the client, who is experiencing a lot of pain when repositioned in bed. Which nursing responsibility is the nurse demonstrating?

Client advocate Rationale: Nurses act as client advocates in many situations. Examples include communicating the needs and concerns of clients and ensuring that clients understand their treatments. In this case, the nurse is advocating for the client by providing the client dignity of personal hygiene and cleanliness. The nurse is not teaching as in the role of the educator. The nurse is not deciding on what is best for the client as a decision maker. The nurse is not managing the client nor coordinating care with other health care providers.

A middle-aged nurse is concerned about a potential shortage of nurses when the baby boomer generation retires. What proactive intervention can the nurse take to address this anticipated deficit of nurses?

Develop a community program related to healthy nutrition and exercise Rationale: The promotion of wellness is important not only in community, but also in nationwide health. Promotion of healthy habits and nutrition/exercise will be able to decrease some of the risk factors leading to acute and chronic illnesses and will lead to a decrease in hospital admissions. If effective, it would contribute to the management of issues that require an increase in the number of nurses required. Nurses fill roles other than in acute care facilities and the recruitment of more nurses to those facilities does not address the issue of the shortage in other areas of nursing. Immunization of children does not affect the nursing shortage directly because there is not a relationship between the lack of immunization increasing the risk of illness to the present nurses employed in the field . Increasing the retirement age can have a detrimental affect on those nurses being required to work with age-related changes affecting health.

Which is the most important role of the nurse in using complementary and alternative therapies?

Educating the public about safety and effectiveness Rationale: The most important role of the nurse in using CAT is educating the public about the safety and effectiveness of using the therapies. Administering herbal supplements for anxiety and providing nutrition supplements for weight gain may be considered part of a treatment plan but they are not the most important aspects of CAT. Guided imagery is one aspect of treatment included in CAT.

What is the best nursing intervention to promote health in a client at risk for heart disease?

Emphasizing a client's strengths to encourage weight loss Rationale: Nurses promote health by identifying, analyzing, and maximizing each client's own individual strengths as components of preventing illness, restoring health, and facilitating coping with disability or death. Emphasizing the client's strengths to encourage weight loss is the most effective way to promote this client's health. Informing the client that the client must lose weight would not help the client use his or her strengths to accomplish the goal. Low-sodium diets can prevent heart disease. Taking the pulse daily would not prevent heart disease.

A client rings the call bell to request pain medication. On performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. After a few moments, the nurse returns with the pain medication. The nurse's returning with the pain medication is an example of which principle of bioethics?

Fidelity Rationale: Fidelity is keeping one's promises and never abandoning a client entrusted to one's care without first providing for the client's needs. Autonomy respects the rights of clients or their surrogates to make healthcare decisions. Nonmaleficence is preventing harm from being done to a client. Justice involves meeting the needs of each client equitably and acting fairly.

A family has immigrated and settled in a neighborhood that primarily speaks their native language. The nurse caring for this family recognizes that which family member will likely require the greatest amount of time to learn the dominant language?

The 45-year-old mother in the family who does not work outside the home Rationale: The 45-year-old mother will have the greatest challenge in learning the dominant language due to not working outside the home and living in a community that speaks the native language. Children usually assimilate more rapidly and learn the language of the dominant culture quickly because they leave home each day to go to school, making new friends in the dominant culture. Wage earners also tend to learn a new language more quickly through the work setting. Language acquisition is tied to necessity and assimilation, rather than to the degree of difficulty.

The registered nurse communicates with the physical therapist that a client is now on strict bed rest due to bradycardia. Which statement best explains the standard exemplified by the nurse?

The RN coordinates care delivery Rationale: There are 12 Standards of Practice: assessment, diagnosis, outcomes identification, planning, implementation, evaluation, ethics, culturally congruent practice, communication, collaboration, leadership, and education. The standard exemplified by the nurse is 5a, implementation via coordination of care in which the RN coordinates care delivery. Standard 5b is health teaching and health promotion in which the registered nurse employs strategies to promote health and a safe environment. Standard 3 is outcomes identification, in which the registered nurse identifies expected outcomes for a plan individualized to the health care consumer or the situation. Standard 2, diagnosis, is when the registered nurse analyzes the assessment data to determine the actual or potential diagnoses, problems, and issues. Standard 1 is assessment, in which the registered nurse collects pertinent data and information relative to the health care consumer's health or the situation.

A client is scheduled for a CABG procedure. What information should the nurse provide to the client?

"A coronary artery bypass graft will benefit your heart." Rationale: Coronary artery bypass graft is abbreviated CABG. It does not identify nutritional needs, decrease liver inflammation, or increase intestinal motility.

A client made a formal request to review his or her medical records. With review, the client believes there are errors within the medical record. What is the most appropriate nursing response?

"According to HIPAA legislation, you have a right to request changes to inaccurate information." Rationale: The Health Insurance Portability and Accountability Act (HIPAA) gives clients the right to see their own medical records. They may also update their health record if inaccurate, get a list of the disclosures that a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations, request a restriction on certain uses or disclosures, and choose how to receive health information.

The nurse has just attended a seminar on concepts of cultural diversity. Which statement made by the nurse would require further education?

"Culture cannot be influenced, and you are born with your culture." Rationale: Culture is learned through life experiences from one generation to the next. Culture helping to define identity, language being the primary way that people share their culture, and culture being seen in attitudes of certain populations are correct options; these are all components that define culture.

A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?

"It will allow for us to see the client and possibly increase client participation in care." Rationale: Beside reports are done to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

The staff nurse overhears the charge nurse, who is of Italian heritage, talking to the unlicensed assistive personnel. Which statement made by the charge nurse is an example of ethnocentrism?

"Italians are best at everything."

An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? Select all that apply.

- "We've noticed that this system really helps to save us valuable time." - "Using the system is highly intuitive." - "This system fits nicely into how we work." Rationale: The National Institute of Standards and Technology defines usability as "the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use" (NIST, 2017). Sometimes the way screens are formatted can be confusing, making it a real challenge to perform nursing tasks in a way that makes sense. Making clinical systems easy to use, intuitive, and supportive of nurses' workflow is what usability is all about. A system with effective usability can save time, reduce errors, and improve end-user satisfaction. A system that makes it challenging to complete tasks or screens that contain large amounts of information do not promote usability.

A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply.

- Documenting entries that are up to date and comprehensive - Recording the date and time of all entries - Using approved agency abbreviations Rationale: Recording the date and time of all entries, documenting up-to-date and comprehensive entries, and using agency-approved abbreviations are examples of defensible charting. Documenting entries that have unidentifiable writers' names and titles and entries that are subjective are not in line with the principles of defensible charting, as these could impede clients' safety and continuity of care.

A nurse is reading a journal article about health information technology and the need for this technology to demonstrate meaningful use. Which information would the nurse anticipate reading about as reflective of meaningful use? Select all that apply

- Improvement in health care quality - Greater client engagement - Reduction in privacy breaches of client information

The nurse is caring for a client who does not speak the dominant language. In order to facilitate unencumbered communication with the client, the nurse will take which action(s)? Select all that apply.

- Schedule a certified interpreter when collecting client health history. - Determine in which language the client communicates effectively. - Review facility policy on communication with clients who do not speak the dominant language. Rationale: All clients have the right to unencumbered communication with a health care provider. Using children as interpreters or requiring clients to provide their own interpreters is a civil rights violation. In addition, the use of untrained interpreters, volunteers, or family is considered inappropriate because it undermines confidentiality and privacy. It also violates family roles and boundaries. The best form of communication with a client who does not speak or has limited ability in the dominant language is through a certified interpreter. A certified interpreter is a translator who is certified by a professional organization through rigorous testing based on appropriate and consistent criteria.

With input from the staff, the nurse manager has determined that bedside reporting will begin for all client handoff at shift change to improve client safety and quality. When performing bedside reporting, what information should the nurse include? Select all that apply.

- any abnormal occurrences with the client during the shift - identifying demographics, including diagnosis - current orders Rationale: Any identifying information regarding the client's demographics such as name, age, gender, diagnosis, and so on should be communicated to the oncoming nurse caring for the client. Any current orders or orders that have not been completed during the shift should be communicated as well. The oncoming nurse should be informed of any occurrences with the client that have been out of the norm and what actions, if any, were taken. Information about what the client watched for entertainment is not of relevance and should be eliminated from the report, as well as what time the nurse will be working next.

The nursing instructor is leading a class discussion concerning the challenges of providing optimal care to clients who speak a different language. The instructor determines the session is successful when the students correctly choose which as an appropriate reason(s) to always request a certified interpreter? Select all that apply.

- avoid civil rights violation - can break confidentiality - potential for modifying information - misunderstanding of medical terminology

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of:

A referral Rationale: Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

A client is asking for the nurse to explain acupuncture. What would the nurse tell the client?

Acupuncture is used to correct disharmony Rationale: Acupuncture can be used to correct disharmony or prevent disharmony from developing.

The nurse admits a client to the critical care unit to rule out a myocardial infarction. The client has several family members in the waiting room. Which nursing action is most appropriate?

Assess the client's beliefs about family support during hospitalization Rationale: Asking the client about the client's beliefs exemplifies that the nurse recognizes the importance of respecting differences rather than imposing standards. If the client believes family support is significant to health and recovery, the nurse should respect the client's beliefs and allow the visitors into the room.

A nurse is caring for a client with bacterial pneumonia and a temperature of 104°F (40.0°C). Yesterday, the client's temperature was 102°F (38.9°C). The health care provider on call prescribes cool compresses for the client to help lower the fever. The client insists that the nurse bring warm blankets because they will help the client to recover more quickly. The nurse recognizes that the client's request is an example of:

Cultural ritual Rationale: Clients and families often express rituals, or practices habitually repeated in certain contexts, during times of stress, such as during an acute hospitalization. Keeping the body covered and warm is a home remedy used by many cultures to help heal the body. As in this example, cultural rituals may conflict with Western medical beliefs. Cultural competence is an approach to health care in which one is aware of one's one cultural beliefs and biases and understands the effects that a client's culture has on the client's health care. Stereotyping involves applying a preconceived and untested generalization to a whole group of people. Ethnocentrism is the belief that one's culture is superior to another.

The emergency department nurse is caring for a client injured in a motor vehicle collision. The client recently immigrated to the country. The nurse should implement interventions aimed at addressing which issue?

Culture shock Rationale: Culture shock is bewilderment over behavior that is culturally atypical for the client. The client who recently immigrated from another country would experience culture shock over being in a new culture, including a new culture of health care in the new country of residence. Ethnocentrism is the belief that one's culture is better than other cultures. Generalization is the belief that a person shares cultural characteristics with others from a similar background. Ageism is a negative belief that older adults are physically and cognitively impaired.

An informatics nurse specialist is describing the framework underlying informatics practice. Which component of the framework would the nurse specialist describe as discrete entities without interpretation?

Data Rationale: Data is the component that involves discrete entities that are described without interpretation. Information refers to data that have been interpreted, organized, or structured. Knowledge refers to information that is synthesized so that relationships are identified. Wisdom refers to the appropriate use of knowledge to manage and solve human problems.

An informatics nurse specialist is working on a team that is considering a new technological system for the facility. Which aspect would be most important for the team to do as the first step?

Determine the need or problem to be solved Rationale: Before considering the use of any new technology or an update to the system, analysis and planning must occur. This involves determining the need for the technology or update or identifying the problem to be solved. Once that step is completed, then design (such as using standard terminology), testing and training would occur.

An informatics nurse is evaluating a new clinical information system for usability. The nurse notes that the system requires the user to complete a maximum of 3 steps to complete a task. The system also provides shortcuts to frequent users of the system. The nurse would determine that which concept of usability is being addressed?

Efficient interactions Rationale: Efficient interactions is demonstrated by actions that facilitate efficient user interactions. An example is to minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users. Consistency involves the ability of the users to apply prior experience to a new system so that the lower the learning curve, the more effective their usage, and the fewer their errors. Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user.

A group of nurses are participating in being the first group of staff to use a new electronic pain assessment tool. The group is discussing whether or not the system is easy to use. During the discussion, the group mentions that "the shortcuts provided are really helpful and save valuable time." The informatics nurse specialist interprets this statement as reflecting which concept?

Efficient interactions Rationale: The statement reflects efficient interactions. One of the most direct ways to facilitate efficient user interaction is to that minimize the number of steps it takes to complete tasks and to provide shortcuts for use by frequent and/or experienced users. Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results. Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user. Effective use of language involves the use of concise, unambiguous language with terminology that is familiar and meaningful to the end users in the context of their work.

A nurse takes a client's pulse, respiratory rate, blood pressure, and body temperature. On which form would the nurse most likely document the results?

Graphic Sheets Rationale: The graphic record is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Flow sheets are documentation tools used to efficiently record routine aspects of nursing care, not data as asked in the question. The purpose of progress notes is to inform caregivers of the progress a client is making toward achieving expected outcomes. The medical record is a general term for all of the client's medical information, which would include progress notes, flow sheet, and graphic sheets, to name a few.

A nurse is providing care to a client who has come to the outpatient clinic for chemotherapy. The client tells the nurse that to cope with the stress of chemotherapy, he uses a technique in which he "goes to my happy place, the beach, and I picture myself lying there under the warm sun, with the sound of the waves lapping at the shore." The nurse interprets this as which technique?

Guided imagery Rationale: Guided imagery focuses on evoking pleasant images to replace negative or stressful feelings and to promote relaxation. It involves using all five senses to imagine an event or body process unfolding according to a plan. During a painful or stressful event, the client can "go to a favorite place" and imagine being there with all the pleasant experiences related to that space. Meditation refers to a group of techniques in which the person learns to focus attention. Tai chi is a martial art, mind-body practice that involves physical movement, mental focus, deep breathing and relaxation. Yoga is a mind-body practice that involves the combination of physical movements, breathing practices, and relaxation techniques.

A client is extremely anxious while awaiting the results of a biopsy. What action by the nurse will assist the client with progressive relaxation techniques?

Have the client tighten and release different muscle groups. Rationale: Relaxation is to progressively tighten and release different muscle groups to relax. This is called progressive relaxation. To visualize is the use of guided imagery to mentally challenge one's physical reality. To focus the mind is meditation. To apply pressure is using acupressure to balance and increase flow of energy.

Nurses are socialized into the:

Healthcare culture Rationale: Culture enables people of similar cultural heritage to understand the meanings of each other's words as part of the particular context, to read each other's nonverbal behavior fairly accurately, and to communicate through symbols. All of these characteristics apply to health care, so health care can be considered a culture into which one can be socialized. The other answers pertain to the career, practice, or intellectual aspects of nursing but not as much to the social aspect of nursing.

A home care nurse delivers care that incorporates a philosophy that focuses on connections and interactions between parts of the whole. Which term best describes this philosophy?

Holism Rationale: Holism is a theory and philosophy that focuses on connections and interactions between parts of the whole. Complementary therapy can be used to complement traditional medical interventions. Integrative care often incorporates sharing the responsibility in coordinating the best possible treatment plan for a client, including the client's choices for care and the provider's expertise. Homeopathy is based on the belief of supporting the body while the symptoms are allowed to "run their course."

The nursing instructor is discussing alternative therapy with a group of students. She explains that living organisms are "continuously connecting and interacting with their environment." Furthermore, the connecting and interacting signifies that the human body is a unified dynamic whole. The instructor is describing what theory to the students?

Holism Perspective Rationale: The instructor is describing the definition of holism. Integrative perspective is combining allopathic and complementary and alternative therapy (CAM). The medical system perspective is based on a philosophy and theory about health and illness along with specific types of treatment that may be based in culture. The allopathic perspective is based in biomedicine. Holism is the only perspective that is looking at parts interacting with each other and the environment.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report?

Incident Report Rationale:An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation?

It provides quick access to abnormal findings Rationale: Charting by exception (CBE) provides quick access to abnormal findings, as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

The nurse is caring for a client who perceives time differently. What action should the nurse take for this client?

Maintain flexibility when the client requests interventions at specific times. Rationale: People view time differently. Social time can reflect attitudes regarding punctuality that vary among cultures. The nurse should maintain a flexible attitude and adapt the time of interventions to the client's needs and requests. It is not realistic to have the client set all the times for the interventions or to have the interventions at a specific time or interventions at random times during the shift.

An informatics nurse specialist is interviewing several nurses who have participated in testing a new electronic assessment tool. The nurses report that the tool "feels so familiar, like we know exactly what it is that we're supposed to do." The nurse specialist interprets this as indicating which concept?

Naturalness Rationale: Naturalness refers to how automatically "familiar" and easy to use (intuitive) the application feels to the user. Consistency involves the user's ability to apply prior experience to a new system. The more that users can apply prior experience to a new system, the lower the learning curve, the more effective their usage, and the fewer their errors. Simplicity involves design and refers to everything from lack of visual clutter and concise information display to inclusion of only functions that are needed to effectively accomplish tasks. Forgiveness means that a design allows the user to discover it through exploration without fear of disastrous results.

A nurse is providing care to a client who is from a different culture. Which aspect about culture would be most important for the nurse to integrate into the client's care?

Not all members of the same culture act and think alike Rationale: Culture is shared unequally by its members; that is, not all members of the same culture act and think alike. Culture is also dynamic and changes as people come into contact with new beliefs and ideas. Some learning of culture is purposeful and some is absorbed without awareness. Much of culture is implicit, a combination of habit and assumptions about the world, such that habits are enacted without reflection in the daily course of living. This makes culture difficult for members to describe.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation?

Omitting clients' responses to nursing interventions Rationale: Omitting clients' responses to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health histories and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.

An informatics nurse specialist is involved with implementing strategies to improve the performance of the clinical information system being used. As part of this process, the nurse specialist is working on updating the plans of care in the system to reflect changes to a procedure based on new evidence. The nurse is also working to streamline the display screens to reduce the need to document the same information in three different areas. The nurse specialist is addressing which aspect of the system?

Optimization Rationale: Optimization commonly includes strategies to improve processes, maximize effective use, reduce errors, and eliminate workflow inefficiencies. Updating and streamlining reflect such strategies. Usability refers to the ease of use of the system. Standard terminology refers to the use of specific data entry elements that allow the development of reports and data. Interoperability reflects the ability of the system to share data across health care systems.

The nurse is assessing an infant of Asian descent and notes dark blue spots on the infant's lower back. What action should the nurse take next?

Press lightly on the pigmented area and observe the infant's reaction. Rationale: Mongolian spots are a type of hyperpigmentation that results in dark blue areas on the lower back, abdomen, thighs, and arms. To differentiate Mongolian spots from a bruise or injury, the nurse should press on the Mongolian spot. Mongolian spots do not produce pain when pressure is applied. The nurse will not ask the parents to leave the room as they are the legal guardians of the infant and should be present for the assessment. This action is only taken if suspicion of abuse is readily apparent. The nurse should assess before calling the health care provider. The nurse needs to complete the assessment before documenting it. Because this is not an ominous finding warranting further investigation, the nurse would not contact the authorities.

Which principle does not encompass the basic goals of integrative medicine?

Reject allopathic medicine and embrace CAM practices. Rationale: Integrative medicine is healing-oriented medicine that takes account of the whole person (body, mind, spirit, and community), including all aspects of lifestyle. It does not reject allopathic medicine and CAM practices. It includes establishing a partnership between client and practitioner, facilitating the body's innate healing abilities, and focusing on promoting health and preventing illness, as well as treating disease.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?

Reporting Rationale: Reporting takes place when two or more people communicate information about client care, either face to face, audio recording, computer charting, or telephone. .Some facilities may use encrypted (protected) software programs such as Share Point or e-mail to add information to report. Dialogue is two-way communication, which is not always the case for reporting. Documentation verifies health care provided and serves as a communication tool among all caregivers in that regard.

The nurse is caring for a client admitted with an upper respiratory infection. The client tells the nurse about following the holistic belief of hot/cold. Which food items should the nurse provide to the client based on this information?

Soup, hot tea, and toast Rationale: The client believes in the hot/cold theory of disease, so the client needs to treat cold diseases with hot food and hot diseases with cold food. The most appropriate choice would be the soup, hot tea, and toast. The other options are all cold foods, which the client would not use to treat a cold disease such as an upper respiratory infection.

A nurse is assessing a client who comes to the clinic for an evaluation. During the assessment, the client tells the nurse, "I have this thing on my phone that reminds me to take my medicines when I'm supposed to." The nurse identifies this as reflecting which concept?

Telecare Rationale: Telecare generally refers to technology that allows consumers to stay safe and independent in their own homes. It may include consumer-oriented health and fitness apps, sensors and tools that connect consumers with family members or other caregivers, exercise tracking tools, digital medication reminder systems, and early warning and detection technologies. Telehealth refers to the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, client and professional health-related education, public health, and health administration. Telemedicine refers to the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Pharmacogenomics uses information about a person's genetic makeup to choose drugs and doses that are likely to work best for that person.

Which organization audits charts regularly?

The Joint Commission Rationale: The Joint Commission (TJC)audits client records regularly under specific guidelines that are announced annually and shared with each institution. TJC also encourages institutions to set up ongoing quality assurance programs. The National League for Nursing, American Nurses Association, and Sigma Theta Tau International are professional nursing organizations that provide services to nurses; they do not access client records. .

In addressing health promotion for a client who is a member of another culture, the nurse should be guided by which principle?

The client may have a very different understanding of health promotion. Rationale: As a component of cultural assessment, the nurse should seek to understand the cultural lens through which the client may understand health promotion. Health promotion is not a concept exclusive to Western cultures, though it may be considered differently among non-Western cultures. Even if health promotion is not a priority in a client's culture, the nurse should still address issues related to health promotion in a respectful and relevant manner. Health promotion is not directly linked to socioeconomic development levels.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at health care agencies?

The nurse locks out client information, except to those who have been authorized through appropriate security measures. Rationale: Locking out client information except to those who have been authorized through fingerprints or voice activation is correct. This action enhances confidentiality and protects electronic data in health care agencies. Less frequently changing access numbers and passwords could allow staff who have left the agency to compromise the system. Removing the automatic save and screen saver for data that have been displayed for prolonged periods could allow unscrupulous individuals onto the system. Providing unlimited data access to the multidisciplinary team so personnel from various departments can retrieve the data could allow all staff access to information that does not impact their jobs.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the clients family member who lives in a neighboring state. Rationale:Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

A nurse who "unblocks" and "clears" congested areas of energy in a client's body to promote comfort is applying the phenomenon known as:

Therapeutic Touch (TT) Rationale: Therapeutic Touch (TT) involves "unruffling," or clearing, congested areas of energy in the body and redirecting this energy. After assessing a client's "energy field," the nurse uses therapeutic touch to promote comfort, relaxation, healing, and a sense of well-being.

Which nurse-to-provider interaction correctly utilizes the SBAR format for improved communication?

"I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." Rationale: SBAR refers to: S (situation): what is the situation you are calling about?; B (background): pertinent background information related to the situation; A (assessment): what is your assessment of the situation?; R (recommendation): explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

A patient with dermatitis has sought care from a homeopathic practitioner seeking treatment for dry, itchy, and inflamed skin. Which statement is characteristic of homeopathy?

"I'm going to recommend a diluted solution that is derived from poison ivy." Rationale: Homeopathic practice is based on two fundamental laws. The Law of Similars states that a natural substance that produces a given symptom (such as pruritus) in a healthy person will cure it in a sick person. The Law of Infinitesimals states that the smallest dose possible (such as highly diluted preparation) will have the desired effect. Homeopathy does not prioritize the spiritual dimension of illness, herbal remedies, or the flow of energy.

An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate?

"It combines nursing science with information management and analytical sciences." Rationale: The ANA defines nursing informatics (NI) as "the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice." It is more than just working with computers or the electronic health record (although this is the core of informatics practice). Client education can be one component of a clinical information system with which nursing informatics may be involved.

The nurse in a medical unit is collecting a client's history and asks the client about the use of complementary and alternative therapies. The client asks why the nurse needs to know about this. What is the nurse's best response?

"It's important that we list all of your complementary health practices used to provide a full picture of what you do to manage your health. Rationale: Nurses need to include complementary and alternative therapy in assessment of the client's current treatments to ensure an understanding of the safety and effectiveness of the treatments, particularly if the client is also receiving allopathic treatment. The nurse would want to be positive with this questioning so that the client is not defensive regarding any complementary and alternative treatments.

An informatics nurse specialist has completed the evaluation of an update to a current clinical information system used by the staff at the local hospital and has documented the results. Documentation reveals the need for an improvement in the screen display. Which action would be next?

Analyze and plan Rationale: Evaluation may be the last phase of the system development lifecycle, but it represents an essential step for nurses to be involved in before circling back to Analyze and Plan based on the results of the evaluation. This step is important to complete before making updates or improvements to a system already in place. Once this step is completed, the other steps of the system development lifecycle would follow.

A nurse can best help a client who is undergoing chemotherapy and using guided imagery with this by doing which of the following?

Assisting the client to find an appropriate imagery tape to use. Rationale: Clients use imagery to help with relaxation and this can use all five senses. Many times, clients use a guided imagery tape that includes a script to help with imagery; clients also can record their own tape. Clients do not necessarily use poses with this; this would be more related to use of yoga. Guided imagery can help both during and after a stressful event to help the client relax.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy?

Calling the client information desk to find out the room number of the family member Rationale: Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

Which agency is responsible for monitoring compliance to Health Information Technology for Economic and Clinical Health (HITECH)?

Centers for Medicare and Medicaid Services Rationale: The HITECH Act was established in 2009 to create incentives for professionals and agencies to receive financial payment for the meaningful use of technology to improve client care. The Centers for Medicare and Medicaid Services is the agency responsible for monitoring compliance to HITECH. The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. The World Health Organization is a specialized agency of the United Nations that is concerned with international public health. There is a department of social services in each state that focuses on benefits and facilities such as education, food subsidies, health care, police, fire service, job training and subsidized housing, adoption, community management, policy research, and lobbying.

An informatics nurse specialist is collecting data from the clinical information system about the demographics of individuals diagnosed with heart failure admitted to the facility over the past five years. The nurse specialist is preparing a presentation to the facility's executive board. To promote understanding of this complex information, the nurse specialist prepares the data results using a pie chart and a bar graph. The nurse specialist is using which area of analytics?

Data Visualization Rationale: Data visualization is the presentation of data in a pictorial or graphical format. It enables decision makers to see analytics presented visually, so they can grasp difficult concepts or identify new patterns. Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. Big Data comprises the accumulation of health care-related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, and ultimately to wisdom. Data mining refers to the process of sorting through large amounts of data to identify patterns and solve problems.

A client's spouse has asked that the client be cared for exclusively by female nurses. How should the nurse incorporate this request into the care plan?

Document the request and make all reasonable efforts to honor it Rationale: Although cultural assessment in a tactful and respectful manner is likely appropriate in this situation, the care team's guiding principle and obligation should be to accommodate and respect the couple's request. It would be inappropriate for the care team to attempt to convince the couple to change their minds or assume that it is a personal preference. The nurse would not teach the couple that male nurses on the unit are empathetic, as having female nurses is the client's preference.

According to the Canadian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation Rationale: Documentation is the primary source of evidence used to measure performance outcomes, according to the CNA. Accreditation is the process whereby educational institutions are evaluated and, if approved, certified by a third party to validate their competency. Psychomotor skills are skills that require physical actions and muscular coordination to perform. Clinical judgment is an attribute of health care professionals that involves the use of critical thinking, intuition, and clinical experience when making a decision about a client's care to achieve the best outcome for the client.

An informatics nurse specialist is describing the role of informatics in health care to a group of staff at a facility. The nurse specialist determines that the teaching was successful when the group identifies which as a core practice area?

Electronic Health Record Rationale: The electronic health record (EHR) remains at the core of informatics practice. However, many areas within the scope of informatics deal with technologies peripheral or tangential to the EHR—for example, telehealth, mobile devices, patient portals, data analytics, and technologies for educating nurses in academic settings and for conducting research.

When reviewing the chart of an older adult client, the nurse notes that the client identifies as Japanese. The nurse realizes the client is referring to which ancestral and cultural factor?

Ethnicity Rationale: Ethnicity refers to a common bond of kinship with country of origin, for this client Japan. Race refers to biologic differences, for this client Asian. Ethnocentrism is the belief that one's personal heritage is superior to others. Values are beliefs and attitudes that are important to a person. The scenario does not provide details to determine if the client expresses ethnocentrism nor any personal values.

A nurse is caring for a postoperative client after knee arthroplasty. The nurse plans to help the client ambulate but is aware that the client may feel threatened by physical closeness because the client is from a culture that tends to prefer more personal space when interacting with others. Using the principles of culturally competent care, what would be the most appropriate nursing action?

Explain the purpose and need for assistance during ambulation Rationale: The nurse should explain the purpose of ambulation and the need for assistance while ambulating to the client. This would relieve the client's anxiety associated with physical closeness. However, the client won't be able to ambulate without assistance. Even though the nurse can instruct a family member to ambulate the client, this is not an appropriate action. Ambulating the client without recognizing the cultural difference is nontherapeutic, as the nurse would be not be performing culturally competent care by not acknowledging cultural practice.

A client who is receiving chemotherapy and experiencing significant nausea asks the nurse about using aromatherapy to help alleviate the nausea. Which essential oil would the nurse most likely suggest to address the client's nausea?

Ginger Rationale: Ginger or peppermint is an appropriate essential oil choice for addressing nausea. Chamomile, lavender, and cedarwood are used for insomnia.

An informatics nurse specialist is recommending the addition of an alert system tool to the facility's patient portal. The tool would be designed to send alerts to the client to schedule routine screenings and immunizations. This recommendation most likely reflects which ANA informatics competency?

Health teaching and health promotion Rationale: The alert system tool for screenings and immunizations would reflect the competency of health teaching and health promotion because it would signal the clients about important health promotion activities. The competency of collaboration would be reflected by the nurse specialist partnering with others to conduct nursing and informatics practice with the sharing of data, information, and knowledge about the health care consumer or situation. The competency of quality of practice is reflected by the nurse specialist's contributions to the quality and effectiveness of nursing and informatics practice, as evidenced by quality documentation and data analysis to improve practice and outcomes. The competency of leadership is reflected by the nurse specialist promoting the organization's goals and vision and mentoring colleagues.

An informatics nurse specialist is gathering data from electronic health records at the facility about clients who have had central venous catheters inserted for more than the recommended time as specified by the facility's protocol. The nurse specialist is collecting this data most likely for which purpose?

Identify clients at risk for infection Rationale: Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. In health care, organizations often use this information to identify clients who may be at risk for problems. This area of health care analytics is not involved with determining client satisfaction, evaluating client care, or correlating the client's diagnosis with interventions.

Which of the following has been known to achieve benefits for clients with cancer through the use of the mind to visualize a positive physiologic effect?

Imagery Rationale: Imagery is a physiologic technique that uses the mind to visualize a positive physiologic effect. When using imagery, clients conjure up mental images of their body waging and winning a battle with the disease process. Hypnosis is a therapeutic intervention that facilitates a physiologic change through the power of suggestion. Humor would not be appropriate in this situation. Biofeedback is a technique in which a person voluntarily controls one or more physiologic functions.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Limiting abbreviations to those approved for use by the institution Rationale: In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

An informatics nurse specialist is conducting an orientation for the staff of a primary care provider's office about a new web-based tool that they will be implementing. The goal of the tool is to promote patient engagement. The informatics nurse specialist is most likely orienting the staff to which system?

Patient Portal Rationale: A primary patient engagement tool is the patient portal, a web-based tool that can be securely accessed and provides several functions to increase engagement. Telehealth is defined as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Telemedicine involves the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Telecare generally refers to technology that allows consumers to stay safe and independent in their own homes.

An informatics nurse specialist is preparing a presentation for a local community group about advances in technology in health care. Part of the presentation will focus on technological advances to promote greater client participation in managing health. Which component would the nurse likely describe as playing a major role?

Patient Portal Rationale: Although the electronic health record and clinical information systems are important technological advances in health care, engaging clients in their care and working together to improve health with supportive technology is an area that continues to advance. A primary client engagement tool is the patient portal. This web-based tool can be securely accessed and provides several functions to increase engagement. Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. It does not involve client engagement.

An informatics nurse is teaching a client recently diagnosed with heart failure how to use a web-based tool to learn more about this condition. The tool is provided by the client's primary care provider. The informatics nurse is teaching the client about:

Patient Portal Rationale: Patient portals are web-based tools that provide several functions including access to educational materials based on a person's diagnosis or procedure. Telehealth refers to the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, client and professional health-related education, public health, and health administration. Technologies include videoconferencing, long-distance imaging review, streaming media, terrestrial and wireless communications, and remote nonclinical services such as provider training, administrative meetings, and continuing medical education. Telemedicine refers to the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Pharmacogenomics uses information about a person's genetic makeup, or genome, to choose the drugs and drug doses that are likely to work best for that particular person.

An informatics nurse specialist is preparing a presentation for a local community group about advances in technology in health care. Part of the presentation will focus on technological advances to promote greater client participation in managing health. Which component would the nurse likely describe as playing a major role?

Patient Portal Rationale: Although the electronic health record and clinical information systems are important technological advances in health care, engaging clients in their care and working together to improve health with supportive technology is an area that continues to advance. A primary client engagement tool is the patient portal. This web-based tool can be securely accessed and provides several functions to increase engagement. Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. It does not involve client engagement.

An informatics nurse specialist is extracting data from the facility's electronic health record in an attempt to identify clients at risk for developing catheter-related bloodstream infections. When gathering this data, the nurse specialist is using which technique?

Predictive analytics Rationale: Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. In health care, we see this used as organizations attempt to identify clients who are at risk for a condition, which in this case, would be catheter-associated bloodstream infections. Data visualization is the presentation of data in a pictorial or graphical format to enable decision makers to see analytics presented visually, so they can grasp difficult concepts or identify new patterns. Big data comprises the accumulation of health care-related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, and ultimately to wisdom. Genomics addresses all genes and their interrelationships in order to identify their combined influence on the growth and development of the organism.

The nurse overhears a colleague state, "All people from that client's country are rude." What is the appropriate nursing response?

Respond by saying, "Stereotypes keep us from accepting others as unique individuals." Rationale: Stereotypes are preconceived ideas usually unsupported by facts. They tend to be neither real nor accurate. They can be dangerous because they interfere with accepting others as unique individuals. The nurse can professionally educate the colleague about the harm involved in stereotyping individuals. Ignoring the comment or reporting the colleague to the nurse manager would result in a missed opportunity to educate the colleague on stereotyping. Agreeing would only strengthen this harmful practice.

A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology?

Telemedicine and mobile technology Rationale: Telemedicine and mobile health technology facilitate client engagement, while helping providers deliver more cost-effective care. Telemedicine embraces applications and services that include two-way video communications, e-mail, and wireless phones. Mobile health features multiple technologies integrated into the increasingly wireless and mobile health care delivery system. Client engagement technology would include the concept of client portals (where clients can access an electronic medical record system and personal health information); online appointments scheduling; and personalized, condition-focused alerts/reminders in the form of e-mails, automated telephone calls, or text messages. Data aggregation is a process that involves data collection, analysis, use, reporting, and delivery of feedback throughout the organization. Organizations will use process and outcomes data to measure what they achieve for clients and population-based communities. Population health management technology performs data mining, risk stratification, and analysis. Searches can be conducted for disease trends, diagnoses, procedures, and missed appointments.

The following statement is documented in a client's health record: "Patient c/o severe H/A upon arising this morning." Which interpretation of this statement is most accurate?

The client reports waking up this morning with a severe headache. Rationale: The statement uses approved abbreviations for complains of (c/o) and headache (H/A). Therefore the statement indicates that the client is complaining of a severe headache this morning. The abbreviation c/o stands for complains of, not coughing. The abbreviation H/A stands for headache, not heart attack or heartburn.

A client is seeking care at the local clinic. The nurse is completing a cultural assessment. Which scenario would demonstrate cultural assimilation?

The client's child learned the dominant language as a second language Rationale: The child is demonstrating an example of cultural assimilation by taking on the language of the dominant culture. When a minority group lives within a dominant group, its members may adapt some of their cultural practices that once made them different. This process is referred to as cultural assimilation. Watching television from the home country, cooking traditional foods, and speaking only the original language demonstrate the original culture and an attempt to bring the minority culture into the dominant culture.

The nurse is using an interpreter to communicate with a client who speaks a different language. What would be the best way to choose an interpreter for this client?

The interpreter should understand the health care system. Rationale: Obviously, nurses cannot become fluent in all languages, but certain strategies for fostering effective cross-cultural communication are necessary when providing care for clients who are not fluent in the dominant language. Cultural needs should be considered when choosing an interpreter; however, it is also important to use an interpreter who understands the health care system. In choosing an interpreter, the nurse should not select one who speaks in a loud voice, conducts the conversation quickly, or always makes direct eye contact. Direct eye contact is regarded differently among cultures.

Which finding from a nursing audit reflects high standards for client safety and institutional health care?

The nurse documents clients' responses to nursing interventions Rationale: Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by The Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health histories and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

A client has requested a translator to help understand the questions that the nurse is asking during the client interview. The nurse knows that what is important when working with a client translator?

Translators may need additional explanations of medical terms. Rationale: When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when talking about an emotional topic. Talking loudly not only does not help with better understanding, but it can also come across as hostile and rude. Even professional translators don't understand all medical terms and may need some clarification at times.