Leadership Comprehensive

*3. Conflict is a natural and inevitable outcome in any group or organization. Select the correct statement from the following statements.* *A.* A defensive framework for conflict resolution includes winning some resources and losing others. *B.* To build effective interdisciplinary teams, conflict must be present, and managers must not interfere with conflict resolution. *C.* Conflict can be a positive force in a group, but conflict should be avoided most of the time in a group to get work done. *D.* Conflict arises when job descriptions are clear, policies and procedures are written, and uniform behaviors are fostered in an organization.

*A. A defensive framework for conflict resolution includes winning some resources and losing others.* To build effective interdisciplinary teams, conflict must be present, and managers have a role with conflict resolution to achieve a win-win solution rather than a win-lose or lose-lose solution. Conflict can be a positive force in a group, and some conflict is absolutely necessary for a group to get work done. Conflict arises when differences in professional judgment challenge the uniform behaviors within the role and responsibilities of a job description or policies and procedures written as guidelines.

*4. Chief nursing officers (CNOs) are accountable for establishing systems to assess, monitor, verify, and communicate ongoing competence requirements related to delegation, for both RNs and delegates. Which statements are correct (select all that apply)?* *A.* A key element in delegation is to assess the competency level of the staff. *B.* When an RN delegates a task, he or she is responsible for supervision and is accountable for the outcome. *C.* A state's nurse practice act consists of rules that govern how RNs delegate to competent staff. *D.* The National Council of State Boards of Nursing is opposed to delegation to unlicensed assistive personnel (UAP).

*A. A key element in delegation is to assess the competency level of the staff.* *C. A state's nurse practice act consists of rules that govern how RNs delegate to competent staff.* *B when an RN delegates a task, he or she is responsible for supervision and is accountable for the outcome.* The National Council of State Boards of Nursing is not opposed to delegation to UAP.

*3. The decision to delegate is not an easy one. There were five factors identified by the critical care nurses specialty organization that should be considered to make the best decisions. Which of the following identifies all five factors?* *A.* Care is complex and requires adaptation in approach, with some risk that the activity may cause potential harm, and the level of patient interaction and the patient's response to the activity are unpredictable. *B.* The complexity of the intervention or task, the skill of the registered nurse's (RN's) delegation, the competencies of unskilled assistive caregivers, the risk of harm to patients, and the criticality of the outcome *C.* The care requires special attention, adaptation, or an innovative approach, the skill of the RN's delegation, and the competencies of unskilled assistive caregivers. *D.* A patient's risk for potential harm, the skill of the RN's delegation, the competencies of assistive caregivers, the difficulty of the intervention, and the fact that a patient's response to the activity is unknown or unpredictable

*A. Care is complex and requires adaptation in approach, with some risk that the activity may cause potential harm, and the level of patient interaction and the patient's response to the activity are unpredictable.* The first answer is the best because it covers the five factors of when not to delegate: 1) When the potential for harm or risks for the activity are high for an individual patient; 2) when the complexity of the task makes it less desirable to delegate; 3) when the amount of problem solving and innovation requires special attention, adaptation, or an innovative approach for a particular patient; 4) when the outcome is unpredictable, which depends on how stable the patient is; and 5) when the level of patient interaction with delegated activity increases or decreases the amount of time the RN can spend with the patient and patient's family. Every time a nursing activity is delegated or one or more additional caregivers become involved, a patient's stress level may increase, and the nurse's opportunity to develop a trusting relationship is diminished. The other three answers provide one or more of the above five factors, but not all five are included in them.

*5. Resolving conflict requires interventions. One intervention is to initiate a timely private discussion to respect individual differences and be empathetic to both sides, yet have an assertive dialogue about facts and feelings to frame the main issue on some common principles in order to agree on a solution that satisfies all. Which of the following is this type of conflict management?* *A.* Creative problem solving *B.* Smooth or finesse the issue through an organizational change *C.* Restrict or isolate the conflict *D.* Compromise

*A. Creative problem solving* Produces feelings of gain and no feelings of loss for all conflict participants. This technique is the most effective but often not the first approach. The second answer involves smoothing or finessing the issue through an organizational change by restructuring around the issue. The third answer refers to restricting or isolating the conflict so the parties can agree to disagree about the conflict and move on to only items that they do agree about. Compromise is incorrect because this technique has the parties achieve some wins and losses, where each side gives up a part of its demands.

*5. Managers will need to manage a performance achieving or surpassing organizational and social objectives and responsibilities. The opportunity is to mere the performance appraisal process with the quality improvement process, which makes both a continuous process. Which statements would be correct about both (select all that apply)?* *A.* Performance appraisals and quality improvement share many of the same process steps, including data collection, standards comparison, needs assessment, and mutual goal setting. *B.* A team evaluation should be done based on team strengths, accomplishments, and motivation, and team cohesion should mean that all members accept the same ratings. *C.* Both processes are concerned with outcomes management and monitoring actions that affect the quality of care. *D.* Both should reflect the measurement of key performance indicators and require disciplinary actions for not meeting performance indicators.

*A. Performance appraisals and quality improvement share many of the same process steps, including data collection, standards comparison, needs assessment, and mutual goal setting.* *C. Both processes are concerned with outcomes management and monitoring actions that affect the quality of care.* Performance appraisals and quality improvement share many of the same process steps, including data collection, standards comparison, needs assessment, and mutual goal setting, and both processes are concerned with outcomes management and monitoring actions that affect the quality of care. A team evaluation should not be done to rate individuals. Though some criteria may be evaluated the same, each person should have individual criteria measured. The process of disciplinary action is a separate process from evaluation of performance. The performance appraisal process is often a process to provide constructive growth and development and to point out areas for improvement, which does mirror the quality improvement process.

*5. New policies, programs, projects, and services are developed to meet the needs of patients. Which statements are a description of when nurses take steps to use these items (select all that apply)?* *A.* Strategic management is the processing of an organization's vision or mission. *B.* Strategic planning is a process of developing an action plan for actualizing the mission. *C.* Strategic management is nurses making decisions about the delivery of care. *D.* Nurses use strategic planning to help them meet personal and professional goals.

*A. Strategic management is the processing of an organization's vision or mission.* *C. Strategic management is nurses making decisions about the delivery of care.* Strategic planning is a process of developing an action plan for actualizing the mission, but it is not a step to manage the strategy. Nurses use strategic management principles existing in the above items to help them meet personal and professional goals.

*2. What is the administrative, systematic, environment-related, future-oriented, and sensitive to the correct positioning of the organization known as?* *A.* Strategic management *B.* Tactics *C.* Strategy *D.* Operational effectiveness

*A. Strategic management* Tactics are operational choices for action that are made to implement strategy. Strategy is a competitive move or business approach designed to produce a successful outcome. Operational effectiveness is performing similar activities better than rivals.

*2. Which of the following are efforts to measure nursing workload?* *A.* The number of client days and the intensity and hours of nursing care required per client day. *B.* Acuity is the severity of a client illness and is an automated patient assessment. Information is entered into the patient electronic health record (EHR) by nurses to generate an accurate measurement of patient acuity. *C.* Components in determining the severity of illness include a client's perceived dependency, complexity, task determination, and number of workers available. *D.* Segregating patients into acuity classifications allows the staffing pattern to be developed based on the resource requirements of the specific mix of patients forecasted for the unit.

*A. The number of client days and the intensity and hours of nursing care required per client day.* The number of client days and the intensity and hours of nursing care required per client day is correct, because the volume of nurses with a certain skill level are needed for a given volume of patients, and the given intensity of nursing care required is related to reduced length of stay, higher patient turnover that requires intensive periods of higher resources for patient admissions, transfer, discharge, and other 1:1 activities for expected unstable patient cases. The second statement is incorrect and relates to severity of a client illness, which can be best determined by automated patient assessment information entered into the patient EHR by nurses to generate accurate measurements of patient acuity. The components in determining the severity of illness are related to the patient and his or her disease and treatment services, not a client's perceived dependency, the complexity of the condition, or the workers available. The fourth statement is incorrect because it is related to segregating patients into acuity classifications, which allows the staffing pattern to be developed based on the resource requirements of the specific mix of patients forecasted for the unit. That is not workload and nursing intensity.

*4. High performance can be rewarded with incentive payments for achieving high quality on national quality indicators specific to hospitals and ambulatory care environments. Pay, promotions, and other rewards can be tied to performance and its evaluation. Which of the following statements best captures the manager being a leader?* *A.* Transformational leaders will emphasize organizational learning and see knowledge, skill, and professional development and the individual's accomplishments toward goals rewarded. *B.* Data should be collected, quantified, and documented throughout the evaluation period for objectives tied to the individual's performance and should be based on outcomes that include errors and system issues. *C.* Leaders who reward positive behavior and punish individuals who behave negatively in the workplace practice a transformational style of leadership. *D.* Leaders with a transactional style of leadership empower staff to work toward the innovations needed in the health care system.

*A. Transformational leaders will emphasize organizational learning and see knowledge, skill, and professional development and the individual's accomplishments toward goals rewarded.* Transformational leaders emphasize organizational learning to prevent errors and system issues by advancing the knowledge, skill, and professional development of each individual, who in turn will see accomplishments toward their own goals and that of the organization. Often the organization is rewarded, which will impact the individual. Though data should be collected, quantified, and documented throughout the evaluation period for objectives tied to the individual's performance and should be based on outcomes, there should be no fault of employees for organization errors and system issues. The leaders who reward positive behavior and punish individuals who behave negatively in the workplace practice a transactional style of leadership, whereas the leaders with a transformational style of leadership empower staff to work toward the innovations needed in the health care system.

*2. Desires that are satisfied by specific products or services that are influenced by external cues are:* *A.* wants. *B.* market. *C.* needs. *D.* products.

*A. wants.* Wants are desires satisfied by specific products or services that are influenced by external cues. Market is actual or potential buyers and users of goods, services, and ideas. Needs are a basic biological, psychological, and social needs. Products are goods, services, or ideas that satisfy the wants and needs of individuals.

*5. Healthier work environments are associated with better staffing, lower burnout, lower turnover, and improved nurse-physician collaboration. Nurse managers likely should support which of the following statements (select all that apply)?* *A.* Unlicensed assistive personnel (UAP) assist nurses to perform client care tasks, including vital signs and assessments. *B.* An astute nurse manager can match the skill sets and experience with the patient care needs to deliver the best possible care for clients. *C.* There is no correlation between the number of registered nurses (RNs) per client and positive client outcomes. *D.* Health care agencies that obtain Magnet status often have improved nurse satisfaction, decreased nurse burnout, and better client outcomes.

*B. An astute nurse manager can match the skill sets and experience with the patient care needs to deliver the best possible care for clients.* *D. Health care agencies that obtain Magnet status often have improved nurse satisfaction, decreased nurse burnout, and better client outcomes.* An astute nurse manager who knows the staff characteristics in terms of education, licensure, skills, competencies, and experience level can match the skill sets and experience with the patient care needs when making assignments, which will deliver the best possible care for clients. Health care agencies that obtain Magnet status achieve healthier work environments that often have improved nurse satisfaction, decreased nurse burnout, and better client outcomes. UAP assist nurses to perform client care tasks, including vital signs, but they are not competent to complete patient assessments about functional health patterns. There is a correlation between the number of RNs per client and positive client outcomes.

*3. Marketing is a social and managerial process where individuals or groups obtain what they need and want by a process of exchange with others. For most nurses, the primary markets are clients, the employing organization, and physicians. Identify the correct statement for nurses and nurse managers to take advantage of marketing.* *A.* Marketing is only used in for-profit businesses as a strategy to increase market share. *B.* Gathering and analyzing information will lay the foundation for proactive capitalization on change opportunities. *C.* Marketing is a plan that relates to transactions in the exchange of goods and services in a market. *D.* Marketing occurs within a framework of forced or unintentional exchange for clients.

*B. Gathering and analyzing information will lay the foundation for proactive capitalization on change opportunities.* Gathering and analyzing information will lay the foundation for proactive capitalization on change opportunities. Marketing is used in charitable, non-profit, and for-profit businesses as a strategy to increase market share. Marketing is a process that relates to transactions in the exchange of goods and services in a market. Marketing does occur within a framework of voluntary exchange. Clients have the option to choose, for the most part, who they have for services.

*2. When managers address problem performance, such as substandard work like missed deadlines, absence or tardiness, and more, the manager should engage in:* *A.* coaching. *B.* counseling. *C.* mentoring. *D.* performance management.

*B. counseling.* Counseling is taking action to address problem performers whose work or behaviors are consistently substandard. Coaching is used to improve employee performance and ability to do a job. Mentoring is for an employee who shows promise. It is motivational process with collaborative goal setting for performance enhancement, used to shorten learning curves and increase productivity. Performance management is an interactive process among manager and employee including work motivation, performance appraisal, and performance rewards and development.

*1. The type of power exhibited when providing the opportunity for others to take responsibility and accountability for their work is:* *A.* referent power. *B.* empowerment. *C.* expert power. *D.* legitimate power.

*B. empowerment.* Referent power is a power based on charisma and interpersonal appeal, which is used to inspire others. Expert power is power within individuals who possess special skills, talents, and knowledge. Legitimate power is the authority to act based on position.

*1. A blend of marketing strategies and models used to achieve established goals is known as:* *A.* exchange. *B.* marketing mix. *C.* marketing orientation. *D.* market share.

*B. marketing mix.* Marketing mix is a blend of marketing strategies used to achieve established goals. The mix offers options for a broad number of stakeholders. Exchange is the act of obtaining a valued product from someone by giving something in return. Marketing orientation is focusing energy on identifying needs and on the delivery of services that create satisfied customers. Market share is the percentage of the total market for the product or service that is captured by the organization.

*1. A part of performance appraisal whereby the employee performs a self-assessment of his or her performance compared with pre-established criteria is known as:* *A.* formal performance appraisal. *B.* self-evaluation. *C.* peer review. *D.* informal performance appraisal.

*B. self-evaluation.* Self-evaluation is a part of performance appraisal whereby the employee performs a self-assessment of his or her performance compared with pre-established criteria. Formal performance appraisal is a summative performance appraisal with written documentation, interview, and follow-up. Peer review is assessing the level of work by an associate and is a process often used by medical staff departments. Informal performance appraisal is daily coaching to improve or refine components of performance.

*5. Criteria can be used to assess co-workers' competency for delegation. Which of the following methods can be used to assess the competency of nursing assistive personnel (select all that apply)?* *A.* Micro-managing and being able to step in and take over tasks *B.* Educating and training for the required role function *C.* Supervising with periodic review and performance feedback *D.* Orienting to the job description and evaluating tasks within a designated time frame

*C. Supervising with periodic review and performance feedback* *D. Orienting to the job description and evaluating tasks within a designated time frame* Micro-managing and being able to step in and take over tasks are incorrect because these will result in mistrust within the delegator-delegate relationship. Educating and training for the required role function is not an assessment process.

*6. Marshall discussed several approaches to prevent and manage conflict. One such approach was to adopt the AVID approach. What are nurses engaged in with this approach?* *A.* Avoid conflict; verify the information associated with the conflict; investigate what others think; decide how to prevent future situations *B.* Advocate the views for both sides; values to each side disclosed, information obtained; decide *C.* Assume the positive about others; validate the situation; ignore it and let it go; do something *D.* Assist others who are difficult to deal with; view the ideas as having potential; identify outside resources; discuss options

*C. Assume the positive about others; validate the situation; ignore it and let it go; do something* The correct answer is A: assume the positive about others and their behavior; V: validate the situation; I: ignore it and let it go; D: do something, such as debrief the situation with a trusted friend and get advice, discuss the situation and your response with an advisor, introduce relaxing activities and techniques into your lifestyle, or consider meditation as a way to become more self-aware and positively focused.

*5. An increasing number of nurses are being recognized for their knowledge, expertise, and contributions to the health care system. As nurses assume expanded roles, such as advanced practice and case management, the image of nurses is being elevated from a subservient one to one that reflects an autonomous, credible health care provider. The mix of tools for marketing these nursing services should focus first on:* *A.* Administrators play a role in designing the marketing mix by lowering costs through the judicious use of resources and delivering a quality nursing service within the health care unit. *B.* A nurse's strategy is for value, cost, convenience, and communication. *C.* Customer's view of the costs, the convenience, communication and their needs and wants regarding their psychosocial and emotional concerns with health. *D.* A public relation strategy should include price, product, place, and promotion.

*C. Customer's view of the costs, the convenience, communication and their needs and wants regarding their psychosocial and emotional concerns with health.* First, the customers who see the four C's which are costs, convenience, communication and customer needs and wants as important considerations. The customers' psychosocial and emotional concerns related to treatment, the family impact and their trusting relationship with caregivers are domains of nursing's knowledge and expertise to market. Most nurses play a role in designing the marketing mix by lowering costs through the judicious use of resources and delivering a quality nursing service within the health care unit. The administrators have very little interest or control of the unit activities with clients. The customer is interested in value, cost, convenience, and communication as a best solution with health care. The sellers of services are the board of directors and senior team. Nurses are the agents of delivery.

*4. Which is a perceived antagonistic process at the individual-organization level of interaction that affects productivity, morale, and teamwork in organizations?* *A.* Interpersonal conflict *B.* Organizational conflict *C.* Job conflict *D.* Social conflict

*C. Job conflict* Interpersonal conflict is a dynamic between interdependent parties who experience reactions to perceived disagreements and interference with attaining their goals. Organizational conflict is defined as the struggle for scarce organizational resources with those opposing this being opposed and preventing cooperation. The two parties (i.e., nurses and physicians) have perceived differences in goals for patient care and the human or material resources needed for those goals. Social conflict is a struggle between opponents over what is valued most in hopes to claim scarce status, power, and resources. In politics the allocation of funds to respective parties is often influenced by power.

*1. Staffing management is one of the most critical, highly complex, and time-consuming activities for nurse leaders at every level of the health care organization today. Which of the following statements is correct?* *A.* Staffing is the implementation of a staffing pattern that indicates the number and type of workers to be scheduled per shift. *B.* Variable staffing is based on a set maximum workload requirement. *C.* The staffing management plan is a structured approach to the process of identifying and allocating unit-based personnel resources in the most effective and efficient way. *D.* Staffing decisions are based solely on an individual's philosophy.

*C. The staffing management plan is a structured approach to the process of identifying and allocating unit-based personnel resources in the most effective and efficient way.* The major goal of staffing management is to provide the right number of nursing staff with the right qualifications to deliver safe, high-quality, and cost-effective nursing care to a group of patients and their families, as evidenced by positive clinical outcomes, satisfaction with care, and progression across the care continuum. A staffing management plan is a structured approach to the process of identifying and allocating unit-based personnel resources in the most effective and efficient way. A staffing pattern does not indicate the number and type of workers to be scheduled per shift but rather the number of paid hours per full-time equivalent and the percent of productive hours to total paid hours. Variable staffing is not based on a set maximum workload requirements but rather below maximum workload conditions, and staff is then supplemented when needed. Staffing decisions are not based solely on an individual's philosophy but more often the average forecasted care levels and more recently the near future (2 to 4 days), with an assessment and analysis of staffing needs to ensure competent staff are more available for clients.

*4. Similarities between the nursing process and the strategic planning process allow nurses to shortcut the learning curve and begin to move forward with the implementation phase. Strategic management involves:* *A.* assessing the nursing mission, diagnosing outcomes for needed services, developing a plan to achieve the outcomes, implementing the strategies, and evaluating the changes toward the outcome. *B.* identifying the organization's needs, establishing the purpose for new services, planning the action steps, and evaluating the outcomes for the new services. *C.* developing a strategic mission or vision, setting objectives, developing strategies to achieve the objectives, implementing the strategies, and evaluating the results. *D.* assessing the service needs, planning goals and objectives, implementing the action plan, and evaluating the goals and objectives.

*C. developing a strategic mission or vision, setting objectives, developing strategies to achieve the objectives, implementing the strategies, and evaluating the results.* The first answer is not the best answer because it uses the nursing process terms to align with the strategic management process. The second answer is incorrect because it is lacking implementation steps. The fourth answer is incorrect because it is lacking the development of an action plan before implementation.

*4. Scheduling by predictive modeling forecasts unplanned patient and staff events, such as admissions by day of week and unplanned sick calls. Principles supporting such a scheduling process for demand management would include:* *A.* scheduling and daily staffing by a patient classification system, with available staff within the EHR for each clinical unit or department, allowing staffing for procedures and tests. *B.* supporting administration, human resources, and finance to determine the quantity and skill of staff. *C.* embedding a decision support system that receives continuously measured progress on patient outcomes in real time, throughout a patient's stay, with which actual progress may be compared on individual patient changes in the outcomes-driven acuity system. *D.* projecting near future optimal staffing decisions while leaving choices open for available caregivers.

*C. embedding a decision support system that receives continuously measured progress on patient outcomes in real time, throughout a patient's stay, with which actual progress may be compared on individual patient changes in the outcomes-driven acuity system.* Embedding a decision support system that receives continuously measured progress on patient outcomes in real time, throughout a patient's stay, with which actual progress may be compared on individual patient changes in the outcomes-driven acuity system to make decisions. Scheduling and daily staffing by a patient classification system, with available staff within the EHR for each clinical unit or department, allowing staffing for procedures and tests, are possible through available technologies, but they do not support demand management principles. Supporting administration, human resources, and finance to determine quantity and skill of staff, while important, does not address the principle of capturing real-time data to support scheduling and staffing. Projecting near future optimal staffing decisions while leaving choices open for available caregivers would be possible using demand management, but the answer does not include any of the principles for an outcomes-driven acuity system based on established well-defined taxonomy documenting patient care and outcomes from assessments. The principle of demand management is to incorporate all present and planned electronic available data to reduce time in data gathering while using real-time valid data on clients.

*3. Implementation of a strategic plan can be accomplished when a priority order for achieving the strategic objectives or outcomes exists, responsibility for achieving these objectives has been determined, and some available financial support is provided within an expected timetable. The role of nurses would include:* *A.* finding out who is responsible for the implementation. *B.* waiting to implement until administration develops an action plan that breaks the plan into manageable parts. *C.* integrating the strategy into daily activities and keeping the strategy a major agenda item for their nursing department or service. *D.* waiting until the workable action plan is presented by nurse leaders.

*C. integrating the strategy into daily activities and keeping the strategy a major agenda item for their nursing department or service.* Nurses should integrate the strategy locally into daily activities and keep the strategy a major agenda item for their nursing department or service through education and self-learning steps. When empowered nurses take steps or low-cost steps they can begin to implement them before waiting for the formal action plan. The first answer, just finding out who is responsible for the implementation, is a passive step. The second answer is a passive step to wait for others to present the manageable parts of the plan before implementing, when education and learning can take place. The fourth answer, waiting until the workable action plan is presented by nurse leaders, is another passive step.

*3. The evaluation process used to quantify a performance may be influenced by perceptions, biases, and values of the employee and manager. Standards are criteria with a designation of levels. The manager can avoid differences by utilizing alternative appraisals for the diverse group, where the advance practice nurse is evaluated using which evaluation process?* *A.* Expectations regarding job criteria and performance that are set when the employee begins employment *B.* Performance goals and objectives that are established for the upcoming appraisal year *C.* Evaluation by peer group to assess employee on common criteria in order to validate by many people *D.* 360-degree evaluation to obtain reflections from related stakeholders

*D. 360-degree evaluation to obtain reflections from related stakeholders* The manager should evaluate the advance practice nurse using the 360-degree evaluation to obtain feedback from stakeholders including staff nurses, pharmacists, and physicians whom the employee directly works with. This tool is not recommended for other types of employees. The first answer describes a process the manager would use with new employees to set expectations regarding job criteria and performance when employees begin employment, which involves setting. The second answer describes a process the manager would use with very experienced employees who must accomplish specific objectives during the year because they are involved in project work or program work with timelines. The third answer describes a process the manager would use with experienced staff who work with a group of peers accomplishing similar work on an ongoing basis.

*1. A business approach that ensures a competitive advantage over similar enterprises involves conducting an environmental scan, knowing the competition, establishing goals, setting targets, developing an action plan, implementing the plan, and evaluating success. Which of the following statements is correct?* *A.* The best strategic planning is from the top down. *B.* The strategic planning process is threatening to employees and creates decreased job satisfaction. *C.* A basic form of strategic planning is a detailed written business plan with a comprehensive market analysis. *D.* Strategic management involves strategic planning and implementation.

*D. Strategic management involves strategic planning and implementation.* The best strategic planning is not from the top down but involves an opportunity for nurses to be recognized for their ideas and contributions. The strategic planning process is an opportunity for employees and should increase employee engagement and job satisfaction. The basic form of strategic planning may involve an adjunct business plan or action plan that provides general statements on who, what, by when, and where, with costs associated and, at times, some market research.

*2. Personal conflict can arise when trying to ingratiate another person because there is the use of:* *A.* influencing an individual or group to gain a scarce resource. *B.* providing a pay raise, promotion, or advancement. *C.* threats, discipline, or negative consequences. *D.* lavishing praise on another to make him or her feel important to gain favor.

*D. lavishing praise on another to make him or her feel important to gain favor.* Thus initiating personal conflicts with others. The first answer is incorrect because power is used to influence an individual or group to gain a scarce resource, so others are not involved. Reward power is used to provide a pay raise, promotion, or advancement and often does not lead to conflict with others. Coercive power is the use of threats, discipline, or negative consequences, but this is not ingratiating behavior.

*3. Demand management focuses on:* *A.* automating staffing plans in order to staff according to average forecasted care levels. *B.* creating predictable and cost-effective staffing according to real-time patient information based on individual patients moving through their stay as quickly as possible. *C.* supplying adequacy of product and services to meet client demands. *D.* measuring, predicting, and understanding demand for services, and deploying resources and management to meet consumers' wants and needs.

*D. measuring, predicting, and understanding demand for services, and deploying resources and management to meet consumers' wants and needs.* Demand management is measuring, predicting, and understanding demand for services, and deploying resources and management to meet consumers' wants and needs. Automating staffing plans in order to staff according to average forecasted care levels is how most staffing processes are set up, but this leads to stress when there is a rapid increase in client admission. It also leads to clinical stress due to the variability of severity of clients among the average or when other responsibilities are competing with the staff's time, such as discharges, admissions, transfers, or meetings. Creating predictable and cost-effective staffing according to real-time patient information based on individual patients moving through would be supported, though the dependency exists to measure, which is not stated in this answer. Supplying adequate product and services to meet client demands is a very broad description to explain the measurement necessary for staffing. Overall, demand management finds ways to control for the variability to address the increases and decreases by better planning, using data about scheduled events such as elective procedures, integration to patient flow and bed management systems, better control over bed assignments based on current unit workload, and improved planning for discharges using shorter shifts.

*4. Customer relationships concentrate energy on the identification of the needs and wants of customers and on the delivery of services that create satisfaction. A daily example of this is when* *A.* health records generated by health care professionals' practices comprise primarily problem list identification and treatments for clients. *B.* administrators and public relations use their knowledge, expertise, and skill to identify problems, implement strategies, and coordinate services to enhance client outcomes. *C.* organizational leaders ensure that all physicians are informed and thoughtful about what it takes to meet customer needs. *D.* nurses provide care by using the nursing process to diagnose and intervene on needs for health promotion or problems and risks.

*D. nurses provide care by using the nursing process to diagnose and intervene on needs for health promotion or problems and risks.* Nurses provide care through customer orientation every day by using the nursing process to identify problems, risks, and needs for health promotion and plan for resolution and care. It is imperative that organizations realize the impact nursing practice has on marketing orientation to the most important customer, the client. The health records as a product of many professionals is limited to short visits to diagnose and plan, whereas the product of professional nursing practice is comprised of risk surveillance and problem resolution with quality care provision for clients. The direct contact with patients is critical. Surgeons often resolve problems with quality care but rarely is the customer aware of the impact. Nurses use their knowledge, expertise, and skill to identify problems, implement strategies, and coordinate services to enhance client outcomes. Organizations can ensure that all caregivers and support staff are informed and thoughtful about what it takes to meet customer needs.

*6. A nurse manager and a nurse are liable for which of the following (select all that apply)?* *A.* Delegating to unlicensed assistive personal *B.* Supervising completion of appropriate tasks and functions *C.* Decisions and actions *D.* Skills of licensed and unlicensed personal

*A. Delegating to unlicensed assistive personal* *B. Supervising completion of appropriate tasks and functions* *C. Decisions and actions* *D. Skills of licensed and unlicensed personal* Nurses and nurse managers are accountable for their own acts and decisions, their competencies and other team members' competencies, and delegated actions and the completion of the tasks and functions appropriately. Nurses and nurse managers are subject to malpractice lawsuits.

*2. Levels of job stress that are either too low or too high have which consequence?* *A.* They manifest in emotional and physical exhaustion. *B.* They decrease individual productivity. *C.* They increase tension related to the person-in-environment demands. *D.* They intensify acute and chronic health problems.

*B. They decrease individual productivity.* The first answer is not seen with low job stress but is a consequence of when job stress is high. It is also known as burnout, and this will lower job productivity. The third answer is an aspect related to job stress from tension between a person's environments within the job; home, family, and professional responsibilities; and health and social status. The fourth answer is a consequence that may occur with prolonged chronic stress over time.

*Nursing data are used to evaluate client care, provider staffing, administration of care and the organization, and knowledge-based research for evidence-based practice. The analysis of large data warehouses using epidemiological methods would best support which function?* *A* Effectiveness research *B* Management information system dashboard *C* Quality improvement studies *D* Practice-based evidence

*A* Effectiveness research is the analysis of large databases or data warehouses using epidemiological methods. A management information system dashboard is an integrated system to collect and manipulate data for the purposes of directing and controlling resources. Quality improvement studies are analyses to identify common causes of variation and visual display of data trends. Practice-based evidence is informing practice from the analysis of patient data collected during the delivery of care.

*Nurse leaders and their teams need to understand the guidelines and plan processes at local and regional levels. Clearly defined roles can prevent duplication of efforts and enhance coordination and orchestration of the all-hazards plan during an actual disaster. This will help allocate scarce resources and implement triage criteria for care in disaster events. Which of the following reflect what is expected during disaster management (select all that apply)?* *A* Having procedures to provide easy-to-follow, step-by-step action plans, fact sheets, and algorithms to identify the type of disaster, how to intervene, and what authorities to notify *B* Having the hospital administrator make the final decisions about ventilator allocation and other scarce resource distribution *C* Utilizing the expertise of each department with outlines of detailed step-by-step processes to actualize who is needed for a disaster *D* Determining prophylactic pharmaceutical dissemination plans to activate for protecting staff and their families

*A, D* Having procedures to provide easy-to-follow, step-by-step action plans, fact sheets, and algorithms to identify the type of disaster, how to intervene, and which authorities to notify; and determining prophylactic pharmaceutical dissemination plans to activate for protecting staff and their families to ensure there are health care workers to care for the victims are both expected during disaster management. The medical director or chief medical officer is likely to make the final decisions about ventilator allocation and other medical treatments, not the business administrator. Each department's expertise will be needed in a disaster, and detailed steps should guide these departments' efforts. Planning is essential before the disaster. Nursing leadership needs to lead efforts to ensure that all facility departments have an understanding of their role in a disaster situation. The role of the staff nurse in a disaster must be clearly defined and contain performance standards, including policies that speak to expected hours or refusal to work in these situations.

*A collaborative process of assessment to use a system of health service delivery, coordination, and monitoring to meet multiple service needs of clients is known as:* *A* case management. *B* total client care. *C* private duty nursing. *D* managed care.

*A* Case management is correct because the collaborative process involves assessment to use a system of health service delivery, coordination, and monitoring to meet multiple service needs of clients. Total client care is when nurses provide care to one or more clients for one shift. Private duty nursing is when one nurse provides care to one client. Managed care is coordinating the financing of care to achieve specific client outcomes given fiscal and resource constraints.

*A budget is a composed document used to forecast revenues and expenditures to control costs and to allocate resources. The development of the budget and the evaluation of its effectiveness are managerial responsibilities. A form of budgeting in which baseline data for the budget are determined from previous costs plus an inflation factor is called a:* *A* traditional budget. *B* zero-based budget. *C* operating budget. *D* capital budget.

*A* A traditional budget is a form of budgeting in which baseline data for the budget are determined from previous costs plus an inflation factor. A zero-based budget is a form of budgeting in which the entire budget is developed from scratch. An operating budget is an annual plan for the unit's or organization's daily functioning revenue and expenses for a single year. Responsibility reports are often generated monthly to evaluate operations to determine current balance. A capital budget indicates major purchases of $500 or more.

*Community stakeholders, including local government, fire and rescue workers, and hospitals, have been focused on gathering information from a variety of resources, developing collaborative response plans, and preparing for a probable disaster. As nurse managers and leaders, what steps are essential first?* *A* Establishing an all-hazards preparedness plan to create an all-hazards preparedness task force (AHPTF) that includes knowledge of the national response plan and state and local disaster response plans *B* Engaging acute care facilities to be prepared and have a plan in place only for external disasters *C* The Health Insurance Portability and Accountability Act (HIPAA) and The Joint Commission (TJC) require all health care facilities to have detailed all-hazard preparedness plans and to conduct drills internally. *D* Designing an all-hazards preparedness plan that includes only those in the internal organization

*A* Establishing an all-hazards preparedness plan to create an AHPTF and local, state, and national response plans is the first step. When engaging acute care facilities to be prepared and have a plan in place, external and internal disasters such as fires and any loss of critical resources (phones, electricity, etc.) should be included. HIPAA and TJC require all health care facilities to have detailed all-hazard preparedness plans and to conduct drills with community agencies as well as internally. When designing an all-hazards preparedness plan, membership should include both those in the internal organization and those within the surrounding communities.

*When nurses actively engage in making decisions regarding nursing practice, quality of patient care, education, nursing peer issues, and issues in the work environment, what model is likely being used?* *A* Shared governance model *B* Administrative model *C* Councilor model *D* Congressional model

*A* In the shared governance model, nurses actively engage in making decisions regarding nursing practice, quality of patient care, education, nursing peer issues, and issues in the work environment. The administrative model is not a professional practice model. The councilor model structures staff and manages governance for certain functions through the use of committees or councils of elected representatives and is a type of shared governance model. The congressional model is not a professional practice model but rather a legislative model with committee responsibilities.

*A model of population care management would include:* *A* population needs assessment, identification of health services, targeted health planning, wellness and prevention, care management, and case management. *B* population needs assessment, prioritization of needs, community wellness resources, provider prevention services, and health education services. *C* population needs surveys, community funding, emergency medical services, medical home clinic services, school health programs, and occupational health for workers. *D* population needs surveys, community engagement, community planning, emergency medical services, medical home clinic services, school health programs, and occupational health education services.

*A* Population care management includes six levels of activities: population needs assessment, identification of health services, targeted health planning, wellness and prevention, care management, and case management.

*Shared governance requires slow, gradual development, role-modeling, and mentoring by nurse leaders, and continual coaching, nurturing, and education for nursing staff and management. Select the statement that is an accurate statement about shared governance.* *A* Shared governance models empower nurses to provide quality care. *B* All clinical nurses are in favor of a shared governance system in which accountability and decision making are encouraged. *C* Implementation of shared governance systems is costly and requires considerable time and effort. *D* Shared governance remains out of reach to some and a simple process to others.

*A* Shared governance models empower nurses to provide quality care. Not all clinical nurses are in favor of a shared governance system in which accountability and decision making are encouraged. The implementation of shared governance systems is not necessarily costly and does not always require considerable time and effort. The implementation has been accomplished with very little resources. Shared governance does remain out of reach to some organizations and is an endless process to others because it requires gradual development, role-modeling, and mentoring by nurse leaders and continual coaching, nurturing, and education for nursing staff and management.

*Identify the elements of organizational structure that address patient safety. What structural changes do you recommend for further improving safety in this organization using organizational design principles?* *A* Empowering employees to report problems or potential problems, encouraging innovations and improvements in processes, and rewarding continual learning and exploration *B* Keeping administrators out of the way of staff and allowing staff to improve the environment in their organization *C* Safety teams, who evaluate near-misses and report errors to know who risk managers should discipline, direct educational offerings *D* Root cause analysis when a problem is reported so that all aspects of an error situation can be avoided

*A* The correct answer is empowering employees to report problems or potential problems, encouraging innovations and improvements in processes, and rewarding continual learning and exploration. Risk managers are involved in the safety work of organizations and work closely with interdisciplinary safety teams. Administrators are important in support, providing resources, and fostering a learning environment. Many interdisciplinary safety teams evaluate near-misses and reported errors, examine structures and processes to assess faulty systems, and make recommendations for improvements to prevent errors. Root cause analysis is used by organizations when a problem is reported so that all aspects of an error situation can be explored to prevent and improve future care.

*Multiple unique goals are achieved with case management services that are different from the goals of managed care. Nurses as case managers contribute to which of these goals (select all that apply)?* *A* Coordinating client-focused care by planning and arranging access to appropriate services and interventions *B* Providing nursing interventions to meet diagnosed client needs in the most cost-effective manner *C* Seeking to reduce costs, conserve resources, and maximize the value of services *D* Tracking outcomes and guiding services across time and settings through ongoing evaluation of assessments

*A, B, D* Case management goals focus on client advocacy, coordination of health care delivery, and facilitation of specific cost and quality outcomes by direct interventions that include 1) coordinating client-focused care by planning and arranging access to appropriate services and interventions; 2) providing nursing interventions to meet diagnosed client needs in the most cost-effective manner; and 3) tracking outcomes and guiding services across time and settings through ongoing evaluation of assessments. The third answer is incorrect because it describes managed care, which differs from case management in that managed care goals are broader and provide a structure to limit the use and cost while achieving the same effectiveness of health services for all clients.

*Health information exchange (HIE) is defined as the electronic movement of health-related information among organizations according to nationally recognized standards. Health information exchange organizations are responsible for which of the following?* *A* Establishing a provider directory and secure provider-provider messaging, exchanging the continuity of care document, and e-prescribing for ambulatory medications *B* Providing oversight to authorize the locations for immunization registries and public health surveillance of contagious diseases *C* Expanding services to include provider health records to exchange vital signs and lab tests and to coordinate care information *D* Organizing major urban information networks or a regional health information organization (RHIO), often for a geographic area, to make the nationwide health information network

*A* The correct answer is establishing a statewide provider directory and secure provider-provider messaging, exchanging the continuity of care document, and e-prescribing for ambulatory medications. These are a few of the initial requirements for statewide health information networks that will connect to the nationwide health information network. States are to provide oversight to authorize the locations of health information from EHRs and the process for secure access and use of the information and to align with the immunization registry and public health surveillance of contagious diseases. The expanding services are to include personal health records and exchanging of other vital diagnostic, outcome, and coordinated care information. The federal government partially funded the startup for the HIE process within either a state information network or an RHIO, often for a geographic area. Many border states are linking efforts for hospitals and clinics on the boards, so many efforts for the nationwide health information network are gradually designed by joint state efforts or when multiple RHIOs join within geographic areas such as New York City or Chicago.

*The organization and individuals engaged in scientific investigation using methods and variables that influence the rate and extent of adoption of practices to improve clinical services is known as:* *A* translation research. *B* evidence-based practice. *C* research utilization. *D* best practice.

*A* The correct answer is translation research or implementation science, where the organization and individuals invest in scientific investigation using methods and variables to determine the influence rate and extent of adoption of evidence-based practices to improve clinical services. Evidence-based practice involves steps to integrate research and other best evidence with clinical expertise and client values in daily health care decision making. Research utilization is a process of using research findings as a basis for practice. Best practice is applying the most recent, relevant nursing interventions in clinical practice which describe innovative practices that are recognized by peer organizations and contribute to meeting quality or fiscal goals.

*Health care quality and safety principles and practices form the foundation of any accessible, reliable care services. In establishing this foundation, which of the following statements helps guide it?* *A* The importance is on outcomes rather than process and structure. *B* Risk management programs are designed to ensure a high level of quality. *C* Three areas in which quality can be measured are structure, process, and cost. *D* When an incident report is filled out, it absolves the person from responsibility for the occurrence.

*A* The importance is on outcomes rather than process and structure today. Risk management programs are designed to mitigate risks or prevent errors or events from ever happening; these steps do not ensure a high level of quality. The three areas in which quality can be measured are structure, process, and outcomes, not cost, though cost is important in the measure of cost-effective outcomes and processes. When an incident report is filled out, it does not absolve the person from responsibility for the occurrence.

*The analysts who design, plan, change, or train individuals to do the work of the organization are known as holding the:* *A* technostructure position. *B* line position. *C* staff position. *D* support staff position

*A* The technostructure position is held by the analyst who designs, plans, changes, or trains individuals to do the work of the organization. The line position is described as the direct line of hierarchical authority. The staff position is the position that provides expertise and knowledge for accomplishing organizational goals. Support staff are individuals who perform activities that enable individuals to do the direct work of the organization.

*Nurse leaders who encourage transformation through their commitment to the journey will find roles changing. Which of the following statements best describe the role of nurse managers (select all that apply)?* *A* Staff members in decentralized organizations are more accountable because fewer people provide functional supervision, quality monitoring, or unit-specific responsibilities. *B* Nurse managers are accountable for transactional processes such as budgets, productivity, and quality monitoring, on top of their roles as coaches, mentors, and leaders to staff nurses. *C* Nurses have an opportunity to take leader roles in integrated care networks with shared governance, and the nurse manager's role shifts to one of facilitating, enabling, and supporting the staff personnel. *D* Nurses have depth of experience in attending and conducting committee meetings, setting agendas, developing consensus, and dealing with conflict.

*A, B, C* The statement that staff members in decentralized organizations are more accountable because fewer people provide functional supervision, quality monitoring, or unit-specific responsibilities is correct because these accountabilities were previously part of the role of the nurse manager. Nurse managers are accountable for transactional processes such as budgets, productivity, and quality monitoring, on top of their roles as coaches, mentors, and leaders to staff nurses. Nurses have an opportunity to take leader roles in integrated care networks with shared governance, and the nurse manager's role shifts to one of facilitating, enabling, and supporting the staff personnel. The last statement is incorrect because nurses do not have the depth of experience in attending and conducting committee meetings, setting agendas, developing consensus, and dealing with conflict.

*Nurses involved in the selection or development of a nursing care delivery system should consider which of the following important (select all that apply)?* *A* Fiscal accountability, client characteristics, staffing composition, case mix severity, and clinical service intensity *B* Practice guidelines and new medication information and technology *C* Role of the RN, practice expectations, accountability of nurses, decision making about care, and provider competencies and experience *D* Direct and indirect client nursing care interventions, end of shift reporting, physician-prescribed care, and communication

*A, B, C, D* The selection of a nursing care delivery system requires the consideration of several specific issues related to the organization, practice, and role of the RN and interaction with the client, physician, and others.

*Organizational and leadership factors that are important to the recruitment and retention of nurses in the workplace are described by which of the following statements (select all that apply)?* *A* Nurses want to have control over their practice and collaborative relationships with physicians relative to care management. *B* Nurses want to work in an institution that has a clearly defined professional practice model that uses the skills and knowledge of the professional nurse. *C* Nurses want a work setting with few vacancies. When the positions have been identified and the shift/holiday schedules determined good flexibility for the selection of staffing hours and shifts. *D* Nurses specifically want a leadership and organizational structure that supports participatory involvement.

*A, B, D* Three of the statements are correct in describing the characteristics desired by professional nurses who are recruited within the evidence-based Magnet Recognition Program®. The nurses want to have control over their practice and collaborative relationships with physicians relative to care management. Nurses want to work in an institution that has a clearly defined professional practice model that uses the skills and knowledge of the professional nurse. Nurses specifically want a leadership and organizational structure that supports participatory involvement. The incorrect statement was that nurses want a work setting with few vacancies when the positions have identified shift/holiday schedules determined good flexibility for selection of staffing hours and shifts.

*According to Laschinger et al., structural empowerment and creation of a culture of civility are important managerial and organizational behaviors related to staff satisfaction and intention to stay. This approach is consistent with the report In Our Hands (2002) and the Institute of Medicine (IOM) report Crossing the Quality Chasm (2001). This approach is consistent with the Magnet Recognition Program® of the American Nurses Association (ANA), the AHA is best described by which two of the following statements (select all that apply)?* *A* Authentic respect for others requires time, presence, engagement, and intention to seek common ground. *B* People, for the most part, want to be able to go to work each day with a sense of getting paid for time spent in the work area and not be required to participate on committees and do maintenance work. *C* People expect to be treated with respect and have a sense of security within the job and work environment, which managers will need to establish a community/culture of caring and safety/security for nurses and other health care providers. *D* It involves low-intensity deviant behavior with ambiguous intent to harm the target, being characteristically rude and discourteous, and displaying a lack of respect for others.

*A, C* The correct answers are related to civility, which is the authentic respect for others requiring time, presence, engagement, and intention to seek common ground. People expect to be treated with respect and have a sense of security within the job and work environment, which managers will need to establish a community/culture of caring and safety/security for nurses and other health care providers. Both are consistent with the Magnet Recognition Program® of ANA, the AHA report In Our Hands (2002), and the IOM report Crossing the Quality Chasm (2001). People, for the most part, want to be able to go to work each day with a sense of getting paid for time spent in the work area and not be required to participate on committees and do maintenance work, which is less professional. The fourth answer describes incivility, which is low-intensity deviant behavior with ambiguous intent to harm the target, being characteristically rude and discourteous, and displaying a lack of respect for others.

*Quality can be defined in which of the following ways (select all that apply)?* *A* When outcomes compare favorably with standards *B* When activities and interventions are examined *C* The measurement of effectiveness, efficiency, benefits, and appropriateness of care services *D* The existence of a program or actions to show effort in the pursuit of excellence

*A, C* When outcomes compare favorably with standards, the minimum expectation has been achieved. The measurement of effectiveness, efficiency, benefits or harms, and the appropriateness of care services is also a way to define quality. When activities and interventions are examined, this is a measure of process. The program and actions themselves do not necessary invoke the pursuit of excellence; rather, the lifelong structural characteristics, processes, and ongoing analysis of quality indicators are the many characteristics which must exist for clinical excellence to manifest.

*Nurses have not yet clearly defined their contributions to health care services nor readily know the costs and outcomes associated with their care when asked. Nurse managers can find this knowledge when making use of which of the following items described in statements below (select all that apply)?* *A* The use of technology and computerization improves productivity and increases accuracy. *B* The cost-effectiveness model is a budgetary model that determines costs and assists managers with determining the proper skill mix for a unit. *C* Techniques for measuring productivity include time and motion studies, patient care requirements, and standards of care. *D* Budget spreadsheets can be sent electronically with embedded formulas that compute the summary statistics.

*A, C, D* Managers can use technology and computerization to evaluate productivity, with increased accuracy of capturing nursing documentation in a standard method using defined concepts, which is necessary in data analysis. Managers can use techniques for measuring productivity which include time and motion studies, patient care requirements, and standards of care to gain knowledge. Electronic spreadsheets provide an opportunity to apply different scenarios for the budget and often provide last year's projected actual information to make projections. There is no cost-effectiveness budgetary model that determines costs and assists managers with determining the proper skill mix for a unit; rather a staffing plan specifies the skill mix of direct care staff and the nursing hours per patient day appropriate for the patient population on the unit, which assists managers with personnel budget.

*Which of the following describe the four tenets embraced by members of the IOM Committee on Quality of Health Care in America and how these tenets incorporate into nursing practice (select all that apply)?* *A* Nurses use standardization of processes when using nursing diagnoses to identify issues with clients and using nursing interventions to identify best practice to improve client's status. *B* Nurses are members of multidisciplinary teams, and people are the problem, not the processes and systems. *C* Nurses use assessments to collect patient data to diagnose problems and risk and to assess the state of optimal health care across the continuum. *D* Using the methodology of PDCA (plan-do-check-act) is like the nursing process.

*A, C, D* The use of nursing diagnoses and interventions aligns with the tenet of standardization of processes as the key to managing work and people. The tenet is that processes and systems are the problems, not people. The use of assessments and data collection aligns with the tenet that quality measurement and monitoring is everyone's job. The use of PDCA and the nursing process aligns with the tenet that the impetus for quality monitoring is a planned part of the organizational culture to enhance and improve services continuously, based on continuous feedback from employees and customers. This practice of continuous feedback is the ongoing practice of the nursing process, which provides nurses feedback to improve the plan of care after evaluation of assessment findings. Another tenet is that quality can be enhanced only in safe, nonpunitive work cultures, which relates to the culture of the organization, where nurses are empowered to speak up about unsafe conditions in the workplace. Another tenet is that consumers and stakeholders must be included in all phases of quality improvement planning, which relates to a nurse's intervention for mutual goal setting with clients. Another tenet is that consensus among all stakeholders must be obtained to have an impact on quality, which relates to a nurse's role as part of the multidisciplinary team working together.

*8. Complexity and chaos theory has application to leadership and management decision making. Which of the following statements apply to this theory (select all that apply)?* *A.* A web of interdependence and mutual interconnection among nurses, physicians, and support staff results in an adaptive system with open boundaries, multiple levels of organization, and rule sets that serve as the organization's operating procedures. *B.* Organizational behaviors emerge from personal changes creating ever-changing feedback loops and new ways for health care delivery. *C.* Changes in external and internal environments from manager changes result in system changes over time. *D.* The behavior of nurses is governed by the rules (formal and informal), information flow, diversity, and interconnectedness of the organization.

*A. A web of interdependence and mutual interconnection among nurses, physicians, and support staff results in an adaptive system with open boundaries, multiple levels of organization, and rule sets that serve as the organization's operating procedures.* *D. The behavior of nurses is governed by the rules (formal and informal), information flow, diversity, and interconnectedness of the organization.* It is incorrect to state that organizational behaviors emerge from personal changes creating ever-changing feedback loops and new ways for health care delivery, because multiple feedback loops exist and new ways of organizational behavior will emerge. "Changes in external and internal environments from manager changes result in system changes over time" is incorrect because the system changes over time as it adapts to changes in the environments.

*4. Nurses and nurse managers are guided by both legal and ethical considerations in making decisions. Which of the following is the correct statement regarding this fact?* *A.* Administrative rules include those regulations promulgated and adopted by federal or state agencies to implement statutory law adopted by Congress or state legislatures. *B.* Physicians govern the legal practice of nurses. *C.* As professional autonomy and responsibility increase, the level of accountability and liability decreases. *D.* When conflict exists between federal and state statutes, the state statute will usually, but not always, take precedence.

*A. Administrative rules include those regulations promulgated and adopted by federal or state agencies to implement statutory law adopted by Congress or state legislatures.* The Centers for Medicare & Medicaid Services would be an example of a federal agency that uses administrative rules to implement the acts legislated by Congress and signed by the President. The second statement is incorrect because each country or, in the United States, each state legislates the practice act for nursing, and a board of nursing in most states administers the act. The third statement is incorrect because the level of accountability and liability increases when professional autonomy and responsibility increase. The fourth statement is incorrect because when federal and state statutes conflict, the federal statute will usually, but not always, take precedence.

*7. Research has shown which two of these statements are correct (select all that apply)?* *A.* Nurses need to be responsible for beliefs, values, meanings, goals, and relationships. *B.* Experienced leaders feel comfortable with the star pattern communication style. *C.* In crisis situations, members work in a team that capitalizes on the skills and strengths of each team member. *D.* Less experienced leaders feel most comfortable with the circle pattern communication style.

*A. Nurses need to be responsible for beliefs, values, meanings, goals, and relationships.* *C. In crisis situations, members work in a team that capitalizes on the skills and strengths of each team member.* The second answer should state that experienced leaders feel comfortable with the circle pattern communication style or interaction among the group equally. The statement about less experienced leaders is incorrect as well, because they feel more comfortable with the star pattern communication style or having nurses direct everything to the manager.

*9. What habits are characteristic of critical thinking by nurses? (select all that apply)* *A.* Questioning, reflection, contextual perspective *B.* Confidence, creativity, flexibility *C.* Open-mindedness, perseverance *D.* Purposeful, systematic, within a frame of reference, grounded in information

*A. Questioning, reflection, contextual perspective* *B. Confidence, creativity, flexibility* *C. Open-mindedness, perseverance* Scheffer and Rubenfeld (2000) have stated that habits of the mind that are characteristic of critical thinking by nurses include confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, open-mindedness, perseverance, and reflection. The Critical Thinking Community (2008) characterized for a broader population that critical thinking has a purpose, is systematic, considers alternative viewpoints, occurs within a frame of reference, and is grounded in information.

*1. Effective delegation skills are important for leaders and managers whose function is to get work done through the efforts of others. The individual who accepts this work is called:* *A.* delegate. *B.* adaptor. *C.* supervisor. *D.* delegator.

*A. delegate.* Delegates accept the service, work, activities, or projects that need to get done. In nursing, a team of delegates from an organization may gather together to do service projects locally in communities or in third world countries. An adaptor is an individual who generates new solutions to problems. A supervisor is an individual who guides others to accomplish a specific task or activity. A delegator is an individual who assigns a task to another.

*3. Ethical dilemmas encountered as a result of the clash between clinical and organizational ethics differ from those encountered in clinical practice. Budget cuts, the inability to replace equipment that is failing, and lost time to complete services would be examples. Proactive strategies by managers would include:* *A.* developing an organizational culture of respecting each other's ethical standards and not asking nurses to compromise their ethics. *B.* communicating what is inappropriate ethical behavior. *C.* listening to staff and others' concerns about unresolved dilemmas arising from the ongoing conflict between clinical and organizational ethics. *D.* assessing situations in which a client's needs are beyond a nurse's qualifications and competencies.

*A. developing an organizational culture of respecting each other's ethical standards and not asking nurses to compromise their ethics.* Is the best strategy listed. The steps to develop such a culture would be educational opportunities; processes that include communication plans and networking plans; evaluation of risks; and early intervention techniques, such as rapid responses by skilled teams to reduce the impact of a dilemma which can cause distress to some. The second strategy is not adequate with communication only about the inappropriate; a leader will have strategies to model and communicate the positive approach to understanding dilemmas and finding resolution between the conflicting sides. Communication and understanding the sides to a dilemma is a starting point. The third strategy is not adequate, although listening to staff and others may help to determine the core issues and guide in selecting another more useful strategy to improve the culture and avoid unresolved dilemmas. The fourth strategy is not an adequate response because the situations in which a client's needs are beyond a nurse's qualifications and competencies must be handled promptly and not just assessed.

*3. People are often unaware of exactly how they are spending their time. The best strategy is to:* *A.* take control of your calendar using a time journal to see precisely where all one's time is spent in 30-minute increments. *B.* use every minute possible in the day to accomplish work-related activities. *C.* simply analyze the workday and prioritize the workload around routine habits to reduce stress. *D.* use checklists, delegate, plan ahead, and divide large projects or tasks into smaller, more manageable undertakings.

*A. take control of your calendar using a time journal to see precisely where all one's time is spent in 30-minute increments.* The best strategy is to take control of your calendar using a journal to record how time is used in increments, which makes the abstract idea of time a concrete reality and allows for finding opportunities to eliminate time wasters. Using a checklist, part of the fourth answer, is another good strategy, but it is additional to the strategy of keeping track of all completed tasks and starting a daily planner to log all tasks that need to be completed, which focuses on individual personal time management. The fourth answer only partially suggests some of these items, as well as other methods used. The second answer is incorrect because the goal of time management is not to use every minute possible in the day to accomplish work-related activities but rather to accomplish specific activities during the time available. The third answer is incorrect because analyzing the workday and prioritizing the workload is difficult when comfortable habits that consume time need to change.

*A complex combination of a hierarchical structure with project teams is the definition of which type of organization structure?* *A* Decentralized *B* Matrix *C* Centralized *D* Divisionalized

*B* A matrix organization is a complex combination of a hierarchical structure with project teams. Decentralized organization is when the power to make decisions is filtered down toward the individual worker. Centralized organization is when the power to make decisions is concentrated at the top of an organization. The divisionalized organization is a collection of semiautonomous units linked by a central administrative structure.

*Valid, reliable, and operationally defined measures that are important, feasible, and have clinical logic and measurement properties are known as:* *A* end results. *B* indicators. *C* outcomes. *D* findings.

*B* Indicators are valid, reliable, and operationally defined measures. End results are the end product from formal tests or outcomes research to explain what the condition or level is for a client. Outcomes are dependent on measured and quantified observed or described indicators. Findings are dependent on what was collected, how it was collected, when it was collected, where it was collected, and who collected it, all of which relies on defined indicators that are valid, reliable, and collected in a systematic way.

*Expenses related to overhead, administration, or building are known as:* *A* budgets. *B* indirect costs. *C* expenses. *D* revenues.

*B* Indirect costs are expenses related to overhead, administration, or building. Other fixed staff members, such as unit clerks, need to be included. A budget is a financial plan that guides resource use. Expenses are the costs incurred for services provided. Revenues are the income for the provision of services.

*Nursing must have standardized, uniformly collected, retrievable, and comparable service-related management data elements. A Nursing Management Minimum Data Set (NMDS) provides nurses which of the following options?* *A* Repository sets providing classifications, workflows, information, and evidence-based knowledge to support clinical decision making and delivery of safe patient care *B* An integrated management information system for collecting, storing, retrieving, and processing a collective set of data to evaluate nursing interventions on client outcomes *C* A set of standards and recommended practices used by perioperative managers, staff nurses, educators, student nurses, and nursing programs to manage regulatory changes, changes in practice, and the advancement of the EHR *D* A set of standards that assists nurses with vendor evaluation of automated information systems or EHR systems

*B* NMDS needs to provide the option of an integrated management information system for collecting, storing, retrieving, and processing a collective set of data to evaluate nursing interventions on client outcomes. The data set may obtain data from multiple sources. A knowledge repository is for providing a collection of classifications, workflows, information, and evidence-based knowledge to support clinical decision making and delivery of safe patient care. The Perioperative Nursing Data Set is a set of standards and recommended practices used by perioperative managers, staff nurses, educators, student nurses, and nursing programs to manage regulatory changes, changes in practice, and the advancement of the EHR. The Nursing Information Data Set Evaluation Center is a set of standards that assists nurses with vendor evaluation of automated information systems or EHR systems.

*Which of the following describes ways in which nurse managers can create an environment devoted to health care safety?* *A* Developing a punitive work environment to remove staff who lack behaviors for safety *B* Establishing a culture of safe, effective, patient-centered, timely, efficient, and equitable care *C* Examining processes and systems issues regarding people, providing feedback, and rewarding achievement of safety goals *D* Mentoring others toward the goals of excellence and finding external data for comparison

*B* Nurse managers should establish a culture of safe, effective, patient-centered, timely, efficient, and equitable care that is consistent with the Institute of Medicine (IOM) Committee on Quality of Health Care in America. The nurse manager should develop a nonpunitive work culture. The nurse manager should examine processes and systems issues for problems, not people; provide positive feedback; and reward achievement of safety goals. The nurse manager should mentor others toward the goals of excellence in health care and evaluate internal data.

*The process of integrating nursing and health sciences with computer and information sciences to manage and communicate data, information, knowledge, and wisdom in practice is known as:* *A* clinical information system (CIS). *B* nursing informatics. *C* data repository. *D* technology with informatics.

*B* Nursing informatics is the process of integrating nursing and health sciences with computer and information sciences to manage and communicate data, information, knowledge, and wisdom in practice. CIS is the capture of clinical data to support more efficient and effective decision making and clinical care delivery. Data repository is a process of storing specific data longitudinally over multiple episodes of care, making it accessible to provide continuity of care to the individual patient. Technology with informatics combines the sciences of engineering, computers, and information with the cognitive health sciences.

*Variables that influence nursing practice and client care delivery include:* *A* client-centered versus task-focused versus provider-focused perspective. *B* skill mix for client condition severity, nurse-to-client ratio, use of temporary staff, workload, nursing education and experience, and technology level. *C* medical home structure for more integrated or coordinated between acute and primary care. *D* RN preparation, critical thinking, and delegation skills.

*B* The best answer is measureable skill mix for client condition severity, nurse-to-client ratio, use of temporary staff, workload, nursing education and experience, and technology are influencing nursing practice within a variety of service settings and locations. This answer provides a list of measurable items. The first answer is incorrect because client-centered perspective, provider-centered models, and task-focused perspective are not measureable variables. The third answer is not specific to nursing care delivery and is more focused on physician clinic practice. Though RN preparation with skills can be a variable, it has been quite difficult to measure and lacks formal impact on client care delivery due to the intermix of skilled nurses with client care. Other process variables would include availability of supplies, coordination of care planning, professional client assessment and monitoring, and effective staff communication, which are documented care elements.

*The accountable care organization (ACO) will need to measure progress toward optimized population health. The measures for the ACO would include:* *A* benchmarks that provide frames of reference against which an organization can compare itself relative to others. *B* population health measures on clinical process and outcome indicators, patient satisfaction, functional status, quality of life, economic and utilization indicators, and changes in health disparities. *C* structured care methodologies, such as critical pathways or streamlined interdisciplinary tools, identification of best practices, facilitated standardization of care, quality enhancement, and outcomes measurement. *D* variances identifying positive and negative differences between what was expected from a standard and what actually occurred with client- and family-related, systems-related, or provider-related factors.

*B* The correct answer is ACOs will need population health measures on clinical process and outcome indicators, patient satisfaction, functional status, quality of life, economic and utilization indicators, and changes in health disparities. The first answer is incorrect because benchmarking—which is established by professional societies, health systems, national databases, or texts and manuals—is a useful strategy to understand internal processes and performance levels and can be used for evaluating evidence-based practices to construct better critical pathways and to have a frame of reference to compare itself relative to others. The third answer is incorrect, because the standardized care methods focus on patients within settings and not across settings that work together. The fourth answer is incorrect, because standards and processes would need to exist to document, collect, analyze, and determine differences for all of the client, family, systems, and provider factors.

*A number of industry-based models for quality management and measurement have been adopted by the health care industry over the past two decades. The model that provides a holistic approach to enterprise transformation and focuses on stakeholders' value propositions and interdependencies to determine effective processes before achieving efficiency in workflow across the enterprise would be:* *A* Six Sigma. *B* Lean Enterprise. *C* International Organization for Standardization (ISO) 9000. *D* Baldrige National Quality Award (BNQA).

*B* The correct answer is Lean Enterprise, which is a model of quality measurement that was originally associated with Deming but reintroduced to the United States in the mid-1990s to eliminate operational waste in an organization. Six Sigma is a strategy to reduce variation and error rates. This approach measures defects, and, though a historical approach used by business for many decades, the approach has been deployed in health care for over two decades. ISO 9000 is a series of standards to address quality management to manage its systems and processes. The achievement of an ISO 9000 registration means there is compliance with the development, manufacturing, and supply of products and services to facilitate trade between countries; share technological advances and good management practice; disseminate innovation; safeguard consumers of products and services; and make life simpler by providing solutions to common problems. BNQA establishes a set of performance standards in seven areas of excellence: 1) leadership, 2) strategic planning, 3) customer and market focus (focus on patients, other customers, and markets), 4) information and analysis, 5) human resource focus, 6) process management, and 7) business results (organizational performance results).

*The degree to which a client or population with common personal or environmental characteristics continues a negotiated treatment is a parameter. To measure this indicator in a community or interdependent organizations, such as ACOs, would be:* *A* compliance. *B* adherence. *C* maintenance. *D* noncompliance.

*B* The correct answer is adherence, which is the degree to which a client or population with common characteristics continues a negotiated treatment within the community or interdependent formal organization that functions to meet a variety of collective needs. Compliance is the degree to which a client initially assents to a treatment plan. Maintenance is the degree to which a client continues positive health behaviors without supervision. Noncompliance is behavior that fails to coincide with a health-promoting or therapeutic plan between client and provider. This type of behavior is based on several defining characteristics found during assessments.

*A manager's role in an organization is important and influences the retention of nurses. The following statements offer correct and incorrect ways to improve retention. Identify the correct statement.* *A* A large span of control is conducive to a supportive work environment and autonomous practice. *B* Nursing leaders can initiate a mentoring program in which each nurse new to an institution has a nurturing mentor. *C* One factor that negatively affects nursing recruitment and retention is autonomy in practice. *D* In the future, most nursing employment openings will be in primary care.

*B* The correct answer is for nursing leaders to initiate a mentoring program in which each nurse new to an institution has a nurturing mentor. Adjusting the span of control for nurse managers will impact the supportive work environment and autonomous practice for nurses. The one factor that positively affects nursing recruitment and retention is autonomy in practice. In the future, most nursing employment openings will not be in primary care.

*Managers and executives in practice will struggle to make decisions regarding staffing and practice to achieve best outcomes. Staffing levels have often but not always been associated with a number of unfavorable outcomes, including increased surgical mortality, failure to rescue, and rates of complications due to errors in care such as urinary tract infections, intravenous line infections, decubitus ulcers, and patient falls. Managers and executives can take steps to:* *A* review the literature in nursing outcomes research to find a valuable point of reference for managers that lowering staffing levels and skill mix in hospitals associates with decreased risk of negative outcomes. *B* identify data systems that are comprehensive for outcomes management in order to support the monitoring of nursing-sensitive outcomes and establish continuous monitoring of outcomes against internal and external benchmarks using a national database of quality indicators. *C* use a wealth of information available to them and hire data analysts and others to determine what data indicate a need for action. *D* contribute unit-specific data on nursing-sensitive indicators to a national nursing database registry and use balanced scorecard for administrative discharge data evaluation.

*B* The correct answer is to identify data systems that are comprehensive for outcomes management in order to support the monitoring of nursing-sensitive outcomes and establish continuous monitoring of outcomes against internal and external benchmarks using a national database of quality indicators. The Centers for Medicare & Medicaid Services, The Joint Commission, and the Magnet Recognition Program® of the American Nurses Credentialing Center incorporate outcome-based reporting requirements into their processes. In reviewing the literature regarding nursing outcomes research to find a valuable point of reference, managers will find that they need to increase staffing levels and ensure an educated skill mix in hospitals in order to decrease the risk of negative outcomes. Managers and executives will be able to use a wealth of information available to them at their desktops in the form of dashboards that allow drill down capacity to find factors related to the data findings. The business outcomes reporting tools allow structures for data use that eliminates the direct need for waiting to have data analysts run reports. Managers and executives are critical individuals along with staff to interpret the findings to determine what action to take or if there is a need to get more data to substantiate conclusions. Executives must contribute unit-specific data on nursing-sensitive indicators to a national nursing database registry and acquire useful balanced scorecard for data evaluation of internal business care processes and client, customer, population, provider, and financial indicators.

*During the start-up, the system-wide task force will need to meet frequently and begin with which steps?* *A* Equipping the hospital emergency incident command system for disasters with communication devices *B* Including the public health department, police, and other critical community organizations in all-hazards community preparedness plan meetings and conducting a hazard vulnerability analysis to create and emergency operations plan *C* Developing a command center, which is integral to an all-hazards plan, and determining who will staff the center *D* Conducting a gap analysis to identify areas in which there are gaps in the preparedness plan of a facility

*B* The first steps are to include the public health department, police, and other critical community organizations in all-hazards community preparedness plan meetings and to conduct a hazard vulnerability analysis. The hazard vulnerability analysis is important to determine unique vulnerabilities and subsequently determine the needs such as to equip the hospital emergency incident command system for disasters with communication devices or to equip other settings that are likely to withstand any vulnerability, as seen within the E5 tornado in Joplin, Missouri. Communities in rural areas must analyze and evaluate the threats and opportunities as well as the collective strengths and weaknesses in a gap analysis before upgrading or developing a command center, which is integral to an all-hazards plan, and determining who staffs the center. Before conducting a gap analysis in the all-hazards preparedness plan of a facility, the initial hazard vulnerability analysis needs to occur.

*Leaders and managers should know the many aspects of case management. Two statements are correct and two statements are incorrect. Identify the two correct statements (select all that apply).* *A* Case management focuses on continuity of the plan. *B* Case management entails providing holistic care, conservation of resources, and care across episodes and settings. *C* A current trend is the push for accountability and accreditation for case management organizations. *D* Case management frequently is associated with health maintenance organizations and preferred provider organizations.

*B, C* Case management entails providing holistic care, conservation of resources, and care across episodes and settings, and there is a current trend to push for accountability and accreditation for case management organizations. The first statement is incorrect because case management focuses on coordination of care across settings and providers, whereas continuity of the plan could exist while coordination is lacking. The fourth statement is also incorrect because case management is not associated with health maintenance organizations and preferred provider organizations, which frequently focus on providers and not the management of care.

*NIOSH recognizes that workplace violence happens in the health care industry and recommends which violence prevention strategies for employers (select all that apply)?* *A* Writing violence prevention plans that do not tolerate violence, reporting violence, and maintaining security in the workplace *B* Implementing environmental designs such as signaling systems, alarm systems, monitoring systems, security devices, security escorts, and lighting *C* Implementing behavior modifications such as worker training in recognizing and managing assaults and resolving conflicts *D* Implementing administrative controls such as adequate staffing patterns to prevent personnel from working alone, controlled access, and systems to alert security personnel

*B, C, D* NIOSH strategies include environmental designs, behavior modifications, and administrative controls. The overlap of agencies providing recommendations, guidelines, and/or strategies can create confusion for leaders, but often the agencies will attempt to coordinate their messages over time. The first answer is incorrect because this plan provides guidelines initiated by OSHA, the agency overseeing worker safety, while NIOSH, which is under the CDC, has provided mere recommendations for violence in the workplace. OSHA's plan sets forth guidelines and has components of a violence prevention program that should include a written plan, worksite analysis, hazard prevention and control, safety and health training, and record keeping and evaluation of the program. OSHA's plan is a guideline and much more prescriptive for the manager, whereas the NIOSH messages are recommendations to consider. Both have value for the managers but are coming from different agencies.

*What are two health care trends that can impact the use for measuring and managing outcomes would include (select all that apply)?* *A* The lack of documentation of effectiveness of client services and the variations in practice have triggered the demand for outcomes measurement *B* Management decision making should be evidence-based wherever possible in order to optimize quality of care *C* Pay-for-performance reimbursement systems provide for direct payment of services if within a medical home model *D* Cost-containment strategies often involve a focus on decreasing staff coverage or reducing the proportions of registered nurses in staff mixes without forethought to the potential consequences

*B, D* Management decision making should be evidence-based wherever possible in order to optimize quality of care. Cost-containment strategies often involve a focus on decreasing staff coverage or reducing the proportions of registered nurses in staff mixes without forethought to the potential consequences. The lack of documentation of effectiveness of client services and the variations in practice have triggered the demand for outcomes measurement and a demand to implement evidence-based practices when there is not a lack of documentation. Pay-for-performance reimbursement systems tie a portion of payment of services to achieving specific levels of measurable, targeted outcomes or attaining the highest scores for specific measures

*The turnover rate of a new graduate ranges from 22.6% to 60% in the first year while in a workforce. That produces averages in age of 45 years old, and nurses begin to phase into retirement beginning at age 55 years. In light of these facts, it became important to focus attention on expanding retention programs beyond promotion of job satisfaction, safety, respect, and financial security to strategies to develop infrastructure services that meet the diverse needs of new employees. The strategies include which of the following (select all that apply)?* *A* The strategy is for each generational group to have time to develop with managers *B* The strategy of social networking and social support to address concerns with incivility and cynicism associated with supervisor and co-worker incivility *C* The strategy for leadership to foster reward and management by exception *D* The strategy of a nurse residency program and preceptor to promote nurse autonomy and the nurse role on the interdisciplinary team

*B, D* The two strategies would include a residency program and preceptor to promote nurse autonomy and the nurse role on the interdisciplinary team, and social networking and support to address incivility and cynicism. The first statement would be a better strategy if each generational group would have representation or opportunity for input in planning and decision making. The third statement would be a better strategy for transformational leadership style, which influences, inspires confidence building, stimulates intellect, and offers individualized experiences.

*1. Effective communication can best be described by which one of the following statements?* *A.* The major part of any communication is the words that we say to others. *B.* Conversation that is clear, direct, straightforward, and offers frequent message transmission is most effective. *C.* To respond effectively to communication, place responsibility on others. *D.* Feedback should be used carefully and only when absolutely necessary, because it inhibits effective communication.

*B. Conversation that is clear, direct, straightforward, and offers frequent message transmission is most effective.* The major part of any communication is not just the words we say to others; the tone, voice, and expressions add content to the message. To respond effectively to communication, placing responsibility on both oneself and others is necessary. Feedback should be used because it provides a method of clarification of message for more effective communication.

*2. Any decision in a chaotic health care delivery environment may cause an unanticipated future problem. Identify the true statement about decision making.* *A.* Decision-making strategies are interchangeable and can be used effectively in any situation. *B.* Decision making is used to solve problems. *C.* Decision making must be even more deliberative when problems require urgent action. *D.* Decision making is not a behavior but rather a method in selecting and implementing a course of action from alternative courses of action for dealing with a situation or problem.

*B. Decision making is used to solve problems.* The statement "Decision-making strategies are interchangeable and can be used effectively in any situation" is incorrect because, for example, ethical decision making uses ethical principles and moral reasoning in its steps for specific situations and is not useful when clinical expert decision-making activities are necessary, which require creative and innovative ideas, adaptation to uncertainty, understanding of the context of the current problem, and learning obtained from prior experience. The statement "Decision making must be even more deliberative when problems require urgent action" is incorrect, because urgent action requires a rapid decision-making process. The last statement is incorrect, because decision making is a behavior exhibited in selecting and implementing a course of action from alternative courses of action for dealing with a situation or problem. It may or may not be the result of an immediate problem.

*5. A transformative leadership style influences the effectiveness of group decision making. The rational group decision-making model is based on which of the following?* *A.* Power, influence, negotiation, bargaining, and interest group influence *B.* Economic perspective of decision making and maximum utility *C.* Difficulty identifying and resolving problems due to ambiguity, complexity, and illogical step taking *D.* Use of standard operating procedures and guidelines

*B. Economic perspective of decision making and maximum utility* The first answer is incorrect because it is the political model that is based on power, influence, negotiation, bargaining, and interest group influence. The third answer is incorrect because it is the garbage model that involves difficult problem identification and problem resolution under circumstances of ambiguity, complexity, and illogical step taking. The fourth answer is incorrect because it is the process model that is based on using standard operating procedures and guidelines.

*5. Which time management strategies are the best strategies to re-energize people to handle the activities of the workplace and decrease the stress response?* *A.* Dividing up a project into manageable parts and setting deadlines for each part *B.* Having time to think *C.* Becoming skillful with technology to manage deadlines and tracking project progress online *D.* Utilizing the management team (assistants, charge nurses, clinical nurse specialists, educators) to strategize timing for all team members to schedule people time

*B. Having time to think* A key survival technique in health care services where timeliness is of the essence for many is having time to think. There is a need to create time, plan for it, and commit to it. An appointment for thinking time is self-energizing. It has been recommended to have at least 2 hours. The first answer, though a good strategy, does not re-energize the manager or other people involved. It reduces stress by not kicking the deadlines into the future, which results in sustaining the issue or problem. The third answer is also a good strategy, but one does not need technology to manage time. Some workers are in roles where human interaction is more essential than technology, and stress is lower. The fourth strategy is also good for managers working with their team. This is a form of role modeling or setting the expectations with team members to support the staff of caregivers who ultimately impact the outcome of care to clients.

*10. Important decisions are made by nurses. Which of the following are examples of collaborated decisions (select all that apply)?* *A.* Devise an array of plans to optimize client recovery, mobility, and self-care; maintain airway patency and hemodynamic stability; and prevent the development of decubitus ulcers *B.* Plan steps to achieve organizational goals, implement multisystem change processes, and improve service delivery and client outcomes *C.* Address complicated and difficult client care risks and problems regarding infection, injury, and contamination *D.* Diagnose and document client needs for health promotion, risks, and problems

*B. Plan steps to achieve organizational goals, implement multisystem change processes, and improve service delivery and client outcomes* *C. Address complicated and difficult client care risks and problems regarding infection, injury, and contamination* Nurses collaborate on complex client care issues that require the talents and perspectives of various health care professionals to maximize client outcomes. Nurses collaborate with colleagues from various disciplines, including medicine, social work, pharmacy, and pastoral services, to address complicated and difficult client care problems. Nurse managers and directors collaborate with those in other disciplines to achieve organizational goals, implement multisystem change processes, and improve service delivery and client outcomes. The first statement is specific to nursing practice in the provision of nursing care and care management to devise an array of strategies to optimize client recovery, mobility, and self-care; maintain airway patency and hemodynamic stability; and prevent the development of decubitus ulcers. The fourth statement is specific to nurses' role in assessing the client's functional health patterns to diagnose and document client needs for health promotion, risks, and problems.

*6. Critical thinking is central to decision making. Which of the following is a true statement?* *A.* Critical thinking and creative problem solving are the same. *B.* Two cognitive processes, intuition and analysis, are used in critical thinking for nursing judgments. *C.* A critical thinker sustains the norm or status quo. *D.* Clinical decision making is the same thing as diagnostic reasoning.

*B. Two cognitive processes, intuition and analysis, are used in critical thinking for nursing judgments.* The first statement is incorrect because critical thinking is a set of cognitive skills that include interpretation, analysis, evaluation, inference, explanation, and self-regulation. The third statement is incorrect because a critical thinker challenges and questions the norm and considers potential unintended consequences in the context of decision making. The fourth statement, "Clinical decision making is the same thing as diagnostic reasoning," is incorrect because reasoning is based on aspects of thinking skills, such as inductive or deductive reasoning for diagnosing.

*2. The determinant for the decision to delegate is the legal scope of delegation rules described within:* *A.* an institutional policy. *B.* a nurse practice act. *C.* the American Nurses Association (ANA) Code of Ethics. *D.* The Joint Commission (TJC) Patient Care Standards.

*B. a nurse practice act.* The state's nurse practice act contains language that allows registered nurses to delegate. Institutional policies do not set rules but rather provide further interpretation of the procedural steps to guide nurses in the intervention of delegation. The ANA Code of Ethics is incorrect because the code guides the conduct of the profession but is not a set of rules. TJC is a standards-setting organization for institutional settings and defers to the state practice acts and local policies to evaluate the quality and safety of care within the organization.

*Several ways to attract nurses include efforts within an organization in which individuals continually expand their talents and work collectively. This strategy is known as:* *A* instituting a greater registered nurse (RN) staffing mix. *B* formative evaluation. *C* learning organization. *D* summative evaluation.

*C* A learning organization is an organization in which individuals continually expand their talents and work collectively. Instituting a greater RN mix for staffing has demonstrated fewer care outcomes that are negative in research studies. Formative evaluation is the developmental assessment of an employee's progress. Summative evaluation is assessing the fit and work of an employee at the end of orientation and annually. All are strategies for nurse managers to consider for retention of better staffing for demand.

*An overarching organizational strategy to ensure accountability of all employees, to incorporate evidence-based health care quality indicators, and to improve care delivered to various populations is best known as:* *A* the accreditation and certification process. *B* continuous quality improvement. *C* a performance improvement program. *D* meaningful use final rules.

*C* A performance improvement program is an overarching organizational strategy to ensure accountability of all employees to incorporate evidence-based health care quality indicators and to continuously improve care delivered to various populations. The accreditation and certification process has been a voluntary method to incentivize and encourage organizations to develop quality improvement systems and processes and to report the quality indicators publicly. Continuous quality improvement is a program that aims to develop long-term processes to first analyze business processes and capabilities to improve them and be responsive to customer needs, suppliers, or other agents within the workflow. Meaningful use final rule is a program associated with the Affordable Care Act and administered by CMS that is a strategy to measure the quality indicators, though its emphasis is to incentivize providers, that is, hospitals and clinic practices, to use health information technologies.

*Although all clients need coordinated care, disease management best serves the needs of targeted, high-risk populations for:* *A* coordinating the care of the individual client in relation to one or more diseases or health conditions after hospitalization. *B* coordinating rehabilitative services, financial assistance, and teaching regarding rehabilitative expectations. *C* a specific disease or health condition of a population group, with subsequent application to individuals over time. *D* managing services for patients using beyond what is typically expected in order to reduce cost and focus on only necessary medical services.

*C* Disease management best serves the needs of targeted, high-risk populations for a specific disease or health condition of a population group, with subsequent application to individuals over time, such as with diabetes mellitus. The first answer is about case management and is coordinating the care of the individual client in relation to one or more diseases or health conditions, which does not need to relate to a hospitalization. Coordinating rehabilitative services, financial assistance, and teaching regarding rehabilitative expectations is related to a unique client situation, not to a disease. It is more often associated with the impact of injury or results from a debilitating disease or surgical outcome. The fourth answer is about managed care for all patients and does not specifically focus on individual client case management but rather on limiting care to reduce cost by focusing on only necessary medical services.

*Implementation of a shared governance model is best accomplished when which of the following steps are considered within the organization?* *A* Administrators must justify the initial cost in terms of personnel time, effort, and financial commitment. *B* The cost of shared governance is not operationalized into the budget, because the philosophy of accountability must be implemented by someone. *C* Organizational executives, managers, and point-of-care staff receive education and support. *D* The organizational purpose is to share the work through developing the culture that supports, encourages, and maintains it.

*C* Education about shared governance at all levels is necessary to disseminate the accountability and support the innovation. Administrators will need to justify a startup budget and eventually operational costs in terms of personnel time, effort, and financial commitment for the initial development phase and sustainability to support a nurse's role in councils and other accountable roles. The chief nursing officer needs to build the cost of maintaining shared governance into the operational budget for it to become successful, and the philosophy of accountability must be implemented. The shared organizational purpose will be to become innovative and efficient when developing the culture that supports, encourages, and maintains it, not just the existing workload being shared.

*Continuous change in the health care delivery and reimbursement systems has created a challenge to controlling or avoiding costs, while continually improving the quality of care. Nurses should use the resources of the client to maximize health benefits, while simultaneously utilizing the resources of the institution or agency. This effort to maximize cost-effectiveness is known as:* *A* cost-benefit. *B* fiscal responsibility. *C* social accountability. *D* cost avoidance.

*C* Fiscal responsibility is explained by examples where the nurse may use the most expensive tape (institution costs) on a client with poor skin integrity to ensure the tape sticks and offers some waterproof (to avoid adverse events such as skin tears, which lengthen stay). The lower-cost item may or may not be substituted with equal results, and therefore nurses can help reduce costs when they know the per-item cost of the supplies they use and then use this information to evaluate substitutions with evidence-based practices. Cost-benefit is when a treatment can provide a better outcome over another treatment, though the costs are exceedingly high. Social accountability is a broad view of being mindful of social concerns and priorities, including internal and external stakeholders. Cost avoidance is taking action to reduce future costs, such as taking early steps to prevent adverse events or reducing risks that could cause damage.

*When clients are grouped together and cared for by one nurse, this is known as:* *A* functional nursing. *B* team nursing. *C* group nursing. *D* primary nursing.

*C* Group nursing is when clients are grouped together and cared for by one nurse. It is a model used in the past but is how physicians have organized their care around a group or panel of patients for whom they are responsible. Functional nursing is the assignment of tasks to registered nurses (RNs), licensed practical/vocation nurses (LPN/LVNs), or aides. Team nursing is coordination of care with RN, LPN/LVN, and aide assignments by an RN to a group of clients. Primary nursing is the assignment of clients to one nurse who has 24-hour accountability.

*Violence in hospitals is caused by a combination of internal and external factors. A systematic review of the literature on the effects of violence toward nurses reported the predominant responses to be anger, fear, anxiety, posttraumatic stress disorder symptoms, guilt, self-blame, and shame. Which of the following is correct regarding violence in the workplace?* *A* Most researchers agree that violence against nurses is significantly over-reported. *B* Education and restaurant workers have the highest incidence of injuries from workplace assaults. *C* Horizontal violence is common in nursing and is a form of bullying. *D* Intimidation can be a form of violence but is not an implied threat when objects are thrown or stares are given.

*C* Horizontal violence is common in nursing and is a form of bullying. Most researchers agree that violence against nurses is significantly under-reported. Health care workers and social workers have the highest incidence of injuries from workplace assaults. Intimidation can be and is a form of violence and is an implied threat requiring handling, whether it is a push, glare, or thrown object.

*Managers of health care organizations have an ethical obligation to protect the safety of workers. What information, approaches, or practices would help managers with this ultimate responsibility?* *A* The National Institute for Occupational Safety and Health (NIOSH) works with the Centers for Disease Control and Prevention (CDC) and reported that homicide has become the second leading cause of occupational injury death. *B* Total quality management is a program to protect the financial assets of an organization from loss by focusing on prevention. *C* The Occupational Safety and Health Administration (OSHA) is a regulatory agency that oversees the safety and health of health care workers and issues fines for workplace safety violations. *D* The CDC provides the expertise, information, and tools that people and communities need to protect their health.

*C* OSHA will identify common risk factors and include policy recommendations and practical corrective methods to help prevent and mitigate the effects of workplace violence. The first answer is information about one of the leading causes of occupational injury death from NIOSH, but NIOSH works within the CDC and its mission. Risk management plans and programs, not total quality management, protect the financial assets of an organization from loss by focusing on prevention. Managers have a fiscal responsibility to prevent workplace violence because of the economic costs of workplace violence and the potential legal liability; therefore, they will collaborate with risk managers, who manage the risk management program, and occupational health professionals, who manage the employee health programs. The CDC has a much larger mission and is not focused solely on worker safety, as are NIOSH and the work of OSHA.

*Professional nurses develop performance and quality improvement programs and conduct evidence-based improvement studies and research. Which statement is true about standards?* *A* Structure standards measure whether the services provided by the organization make any difference. *B* A standard of care is outcome-oriented and focuses on the nurse as a provider. *C* Standards can be set only by professional organizations. *D* Standards essentially define quality, against which performance and outcomes are measured.

*D* Standards essentially define quality, against which performance and outcomes are measured. Structure standards measure the internal characteristics of the organization and its personnel. A standard of care is describing the scope of professional standards in which a nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. Standards can be set beyond professional organizations; examples would include The Joint Commission and the Centers for Medicare & Medicaid Services (CMS), which are not professional.

*Outcomes management is a process that can be described accurately by which of these statements?* *A* Outcomes management provides relatively little data for internal use in health care organizations. *B* Effects of outcome management are used as measures of all three of Donabedian's aspects of quality: structure, process, and outcomes. *C* Outcomes management is an interdisciplinary process designed to provide quality care, decrease fragmentation, and constrain costs. *D* Variances with outcome management are complex, interactive, and only occur at a single level, such as that of organization level.

*C* Outcomes management is an interdisciplinary process designed to provide quality care, decrease fragmentation, and constrain costs. Outcomes management collects data for internal use in health care organizations, and the information derived from measuring client outcomes is used to identify trends, examine variances, and determine appropriate care needs to improve care to an individual, group, or population. The indicators are used as measures of all three of Donabedian's aspects of quality: structure, process, and outcomes. Outcomes management is a process used to assist managers and others to make rational patient care-oriented decisions based on what is known about the positive or negative variance in care and its impact on patient outcomes.

*A strategy of demonstrating an opportunity for improvement at baseline, outlining current practice related to specific care process indicators is:* *A* outreach or academic detailing. *B* change champions. *C* performance gap assessment. *D* audit and feedback.

*C* Performance gap assessment is a strategy of demonstrating an opportunity for improvement at baseline, outlining current practice related to specific care process indicators. Outreach or academic detailing is a marketing strategy in which a trained individual meets one on one with practitioners in their setting to provide information about the evidence-based algorithms, workflows, or practices and indicators to improve practice. Change champions are practitioners from the local peer group who continually promote the practice change by using new technologies, interventions, and workflows that include evidence-based practices. Audit and feedback is the ongoing monitoring of critical indicators of practice and providing periodic reporting of data and information back to the clinicians responsible for client care.

*The condition in which the delicate balance of nurse supply and nurse demand is not at equilibrium is described within the following statements. Identify which statement is correct regarding shortages.* *A* A nursing shortage is the understaffing of nursing units caused by tight budgets or poor working conditions. *B* Using foreign nurses to fill U.S. vacancies is a useful strategy to improve the nursing shortage and is not problematic because there is a surplus of nurses in many countries. *C* Strategies are important to enhance the image of nursing and nurses to attract individuals into the profession of nursing. *D* The future projected demand for nurses is related to the increases in preventive services related to chronic conditions and a decline in population.

*C* Strategies are important to enhance the image of nursing and nurses to attract individuals into the profession of nursing. The nursing shortage is not the result of understaffing of nursing units caused by tight budgets or poor working conditions. Using foreign nurses to fill U.S. vacancies is not a useful strategy to improve the nursing shortage and is problematic because there is not a surplus of nurses in many countries. A future projected demand for nurses is related to the increases related to chronic conditions and an aging population.

*The electronic health record (EHR) implementation of computerized provider order entry (CPOE), clinical decision support (CDS), barcode scanning, and electronic medication administration records (eMAR) applications is dependent on design and use. The best statement about clinical documentation to support these EHR applications is:* *A* standards of care may be programmed into the system to assist in prompting optimal care and offer guides for data collection. *B* data can be gathered easily from the clinical and business processes to record the client's medical problems. *C* the EHR design and clinical documentation with evidence-based definable terms must support nursing care models and the nursing process workflow for patient-centered care. *D* good data can reduce errors in medication administration and order entry when the client's health data are accessed across the continuum of care

*C* The EHR design and clinical documentation with evidence-based definable terms must support nursing care models and the nursing process workflow for patient-centered care. Patients who receive nursing plans will be able to search definitions of terms used within the documentation. The first statement could be improved to state that standards of care can be programmed into the system to assist in prompting optimal care and offer guides for data collection, which is seen with clinical decision support tools. Data collection and reuse of that data within clinical and business processes are important within the design to avoid duplication. The EHR data contains the client's medical problems, medical care, collaborative problems, nursing care, and the risks and needs to promote functional health patterns that are shared among the team and clients. Validated, updated data can reduce errors in medication administration and order entry when the client's health data are accessed across the continuum of care.

*A health care organization plans to integrate an electronic health record (EHR) into all clinical areas. Using the five theories of organization as a social system would put forward to manage the challenge, which approach is best for nursing?* *A* Scientific management school where leaders choose a single best technology and implementation process for the organization with EHR implementation in all units and settings *B* Classic management theory where a top-down approach is used, and administration selects the system and determines the implementation process *C* Open systems theory where the leaders emphasize the dynamic interaction and interdependence of the organization with its external environment and internal subsystem *D* Bureaucratic theory where leaders aim toward mass production and technical efficiency in implementing an EHR system

*C* The correct answer is open systems theory, where the leaders emphasize the dynamic interaction and interdependence of the organization, and key individuals, nursing staff, and support staff provide input based on their role, expertise, and experience. The best information is then used to select and implement the EHR system in the organization. The scientific management school is incorrect because the nurse's role is to learn the EHR system and adapt and implement it to work in settings or units where it was not intended, thus creating gaps in functions for different services, such as obstetrics, oncology, or home care services. The classic management theory is incorrect because nurses are expected to learn the system and implement it without providing input into selection, build of content, or implementation process. The bureaucratic theory is incorrect because the mass production and technical efficiency in implementing the EHR would have decisions made by top-level executives and pushed down based on both technical and staffing issues. The nurse's role is to implement the system and design workarounds for any missing technical functions, information, or knowledge context in the design, thus using paper documents to fulfill missing functions.

*Antagonistic behaviors including gossip, verbal and nonverbal innuendo, scapegoating, passive-aggressiveness, disrespecting privacy, and bullying have a psychological impact on working relationships. They can impair work performance and impact health care delivery. Leaders and managers have a responsibility to act. Which of the following is a step with such antagonistic behaviors?* *A* Staff training in basic violent behavior prevention *B* Threat management after conducting a threat assessment to investigate the person making threats and admonish, reprimand, counsel, or terminate the employee *C* Post-incident response with an integrated system of services and procedures *D* Employee assistance programs (EAPs) with a range of services to help employees cope with stressors that occur at home and at work

*C* The correct answer is post-incident response counseling that could involve an integrated system of services and procedures to reduce the potential impact of a violent incident on employees. Incident debriefing should be offered to all employees when such an event occurs. OHSA recommends planning to provide staff training in basic violence behavior prevention, but it should not be the post-incident response. Threat management after conducting a threat assessment that investigates the person making threats and admonishes, reprimands, counsels, or terminates that employee is addressing the agent causing the threat but not the victims and all staff who are part of the post-incident response. EAPs are an option for employees to receive a range of services to help cope with stressors that occur at home and at work, but this is not considered a post-incident response that considers all employees.

*What are four building blocks nurses should use to develop the organizational structures to support an evidence-based practice environment?* *A* Incorporate evidence-based practice terminology into mission, vision, and strategic plan; integrate research findings and systematic review content into the health information technologies used by all; adopt evidence-based practice changes into patient care orders and policy and procedures; establish processes to identify topics for development to improve quality and performance and to conduct research *B* Develop a mission, vision, and strategic plan that includes context about evidence-based practice as a standard of care; develop a shared governance model that supports nurses to participate in evidence-based practice designs into practice; encourage nurse managers and leaders to promote evidence-based practices; expect all nurses to demonstrate evidence-based practices in daily role performance with clients *C* Incorporate evidence-based practice terminology into mission, vision, strategic plan, and performance appraisals; integrate evidence-based practice into the governance structure of nursing departments and the health care system; demonstrate the value of evidence-based practice through administrative behaviors of the chief nurse executive; establish explicit expectations about evidence-based practice for nursing leaders with a culture that values clinical inquiry *D* Develop a mission, vision, and strategic plan; integrate evidence-based practices into the governance structure of nursing departments and within all organizational departments, including policies, procedures, orientation, and job descriptions; educate nurse executives, nurse managers, nurses, physicians, and other health care professionals about the value of evidence-based practices; establish a reward and recognition process for nurses and others

*C* The correct answer is to (1) incorporate evidence-based practice terminology into the mission, vision, strategic plan, and performance appraisals of staff; (2) integrate the work of evidence-based practice into the governance structure of nursing departments and the health care system; (3) demonstrate the value of evidence-based practice through administrative behaviors of the chief nurse executive; and (4) establish explicit expectations about evidence-based practice for nursing leaders who create a culture that values clinical inquiry. The other answers provide components of these four building blocks but are missing the importance of having the chief nurse executive and nurse leaders committed to pursuing evidence-based practices and the culture of valuing clinical inquiry.

*Leadership is necessary across all organizational levels, and different roles can support implementing evidence-based changes. Which of the following roles are important to the success of this transformation of practice (select all that apply)?* *A* Senior leaders *B* Medical staff directors *C* Chief nurse executives *D* Opinion leaders

*C, D* There are many roles, such as the chief nurse executive through nurse managers, advanced practice registered nurses, and staff nurses. Everyone in evidence-based practice work has a role that builds upon their knowledge and skills. Nurse executives have organizational responsibility for creating a culture in which clinicians expect evidence-based practice, and they have the capacity to develop and sustain a vision inclusive of evidence-based practice. Opinion leaders are informal leaders from the local health care setting who are viewed as important and respected sources of influence by those in their peer group. The opinion leaders could be advanced practice registered nurses who can function as facilitators or staff nurses who are expert clinicians who have the skills to collaborate, problem solve, and find creative solutions. Other key individuals would be nurse managers who use participatory leadership to promote and create action plans to support evidence-based practice, set the expectations for the unit, discuss the importance of the work of evidence-based practice with the unit nurses and other disciplines, encourage and respond to new ideas, promote staff questioning practice, support the team with time to work on the project, act as project cheerleaders, track progress, facilitate moving the project through appropriate committees, and allocate resources as needed. Senior leaders may not be important but they are an involved group because they manage the resources and share the quality and financial reports with board and other entities to promote the investment of resources to achieve further benefits from evidence-based practices. The medical staff directors may not be important to the change but should be informed of what is happening, similar to the senior leaders, to be supporting agents.

*5. __________ is being loyal and faithful to commitments and accountable for responsibilities.* *A.* Autonomy *B.* Veracity *C.* Fidelity *D.* Values

*C. Fidelity* Autonomy is a client's right to self-determination and freedom of decision making. Veracity is a norm of telling the truth and not intentionally deceiving. Values are strongly held beliefs that are freely chosen.

*2. The roles of sender and receiver must be assumed in interpersonal communication. This is reflected within which description of communication?* *A.* Communicating with diagnosing and adapting is one of the basic competencies of influencing, effectiveness in engaging and motivating people, and in getting work done through others. *B.* When humanistic or democratic values are upheld in an organization, then trusting, authentic relationships become the norm in a nurturing, productive work environment. With humanistic values, intergroup cooperation, flexibility, and organizational effectiveness tend to improve. *C.* Interpersonal communication is a two-way level of communication involving face-to-face interactions between people who are consistently aware of each other. *D.* Skillful, positive questioning by a leader or manager can persuade people to willingly commit themselves to see personal benefits and accept change.

*C. Interpersonal communication is a two-way level of communication involving face-to-face interactions between people who are consistently aware of each other.* Is the best definition of interpersonal communication. The roles of sender and receiver evolve in the later work by others and may be seen when talking about leaders, managers, and followers. The first answer is from Hersey et al. (2013) regarding the interpersonal competence required for successful leadership where communicating with diagnosing and adapting are basic competencies of influencing and effectiveness in engaging and motivating people and in getting work done through others. The second answer is from Argyris, who emphasizes the humanistic values of intergroup cooperation and flexibility and the idea that when humanistic or democratic values exist within an organization, then trusting, authentic relationships become the norm in a nurturing, productive work environment. The fourth answer is from Harvey, who suggested skillful, positive questioning can persuade people to willingly commit themselves to see personal benefits and accept change. The positive questioning capitalizes on inviting agreement, commitment, and realization.

*1. What is a wrongful act committed against another person or organization or their property that causes harm and can be remedied by a civil lawsuit?* *A.* Malpractice *B.* Legal liability *C.* Tort *D.* Negligence

*C. Tort* Malpractice is the failure of a professional person to act as other prudent professionals with the same knowledge and education would act under similar circumstances. Legal liability is legal responsibility for harm caused to others. Nurses, nurse managers, and health care facilities are all subject to being found legally responsible for harm caused to others by wrong practice from expected practice or evidence-based practice. Negligence is the failure to exercise the proper degree of care required by the circumstances.

*4. Healthy work environments increase patient satisfaction, support patient outcomes, and avoid errors. Healthy work environment standards to adopt would include:* *A.* setting expectations and controlling behaviors within the workplace. *B.* establishing transparency of information and setting strict communication patterns. *C.* acknowledgement, awareness, and assessment of workplace stress. *D.* knowing what the executive boss wants as a priority.

*C. acknowledgement, awareness, and assessment of workplace stress.* Health care organizations that want to assure quality care for patients can begin with the acknowledgement, awareness, and assessment of workplace stress. The first answer should state setting positive behaviors for all in the workplace and recognizing the simple acts of kindness every day to decrease stress for everyone. An example of this strategy is shared and used by the Studer's Group. The second answer is incorrect, because even though establishing transparency of information is helpful, the expectation is for communication patterns to exist through regular conversation, notes, or words of praise (workplace spirituality) that bring enjoyment, recognition and commitment to helping self, each other, and the organizational environment in simple ways (greetings, smiles, tone of voice, keeping environment tidy). The fourth answer is incorrect because nurses get caught up in priorities set by others. Knowing what is and what is not a priority is a first step. Asking the boss brings relief when true priorities are revealed. As managers, staff are the priority, when caring for staff means caring for patient.

*1. Role strain means:* *A.* expectations are incompatible with the professional values of the nurse. *B.* one cannot possibly complete all assigned activities in the scheduled time frame. *C.* expectations of the multiple responsibilities of the manager can produce stress. *D.* expectations are unclear to the nurse.

*C. expectations of the multiple responsibilities of the manager can produce stress.* Role incongruity means the role expectations are incompatible with the professional values. Role overload is when one cannot possibly complete all assigned activities in the scheduled time frame. Role ambiguity is when role expectations are unclear to the nurse.

*People are knowledgeable about natural disasters within their local regions; however, many have not had to consider the devastation that can be caused by terrorism such as radiological exposures, nuclear blasts, conventional bombings, or agricultural contamination. Identify the correct statement.* *A* A chemical disaster is an incident involving a natural or deliberate outbreak of a pathogen affecting large numbers of adults and children. *B* A biological disaster is a catastrophic event caused by the use of weapons such as guns, bombs, missiles, and grenades. *C* A disaster is a foreseen and often sudden event that causes great damage, destruction, and human suffering. *D* A cyber disaster is a catastrophic event affecting large numbers of people and lasting more than a few hours that impacts the ability to use information technology.

*D* A cyber disaster is a catastrophic event affecting large numbers of people and lasting more than a few hours that impacts the ability to use information technology. A chemical disaster is an incident involving an agent such as a deadly gas, but it is not a natural or deliberate outbreak of a pathogen affecting large numbers of adults and children. A biological disaster is the use of a pathogen affecting the population, not a catastrophic event caused by the use of weapons such as guns, bombs, missiles, and grenades. A disaster is an unforeseen and often sudden event that causes great damage, destruction, and human suffering.

*Given the interdisciplinary nature of case management, who would be best in the case manager role?* *A* Associate degree nurses are skilled in the coordination of client care. *B* Geriatric advanced practice nurses are skilled in the coordination of client care for specialized services. *C* Registered nurses after five years possess expert knowledge, experience, and education and are qualified to be case managers. *D* Advanced practice nurses draw on a wealth of knowledge to lead and coordinate the health care team.

*D* Advanced practice nurses are best for the case manager role because they draw on a wealth of knowledge to lead and coordinate the health care team. Associate degree nurses are lacking some formal leadership knowledge, critical thinking, and clinical reasoning skills to be best suited for the coordination of client care and leading the interdisciplinary team. Geriatric advanced practice nurses are skilled in the coordination of geriatric client care for specialized services, but not for infant, pediatric, or other disability- or condition-specific cares. Not all RNs possess expert knowledge, experience, and education and are qualified to be case managers after 5 years; only those with advanced education and skills would be best suited for the role.

*Accurately determining the costs of providing patient care service is an important budgetary function. Nurses will need to plan better and negotiate for budgeted dollars. Nursing has historically been seen as a cost center and not a revenue generator, so which skill is most important for planning?* *A* Efficiency to do the right things to improve quality *B* Effectiveness to provide fast or inexpensive services *C* Productivity to calculate the cost of nursing care multiplied by the unit of output *D* Costing out nursing services to determine the actual costs associated with providing patient care interventions

*D* Costing out nursing service to know actual costs associated with providing patient care interventions within the cost center is the most important skill for planning. The interventions relate to activity-based costing that can reflect what it costs to provide services if volume is known. The first step in activity-based costing is to identify all the cost drivers associated with a specific service, many of which associate with time elements. Efficiency is the least cost combination of inputs required to produce an outcome. Effectiveness is doing the right things to improve quality or health benefit. Both are important in the improvement of services when defects or less-optimal quality is reported. Productivity is measured by the relationships between volume of service inputs and costs of those hours associated with those variable outputs or number of clients. which assumes clients are similar. Often productivity is used as a comparison with similar units of service.

*Centralization and decentralization are organizational philosophies about where decision-making authority resides in the institution. What is the best description of centralization and decentralization?* *A* Confident administrators will decentralize during crisis and centralize during stable times. *B* An organization may use selective decentralization for decision making in the functional areas of staffing and operations, while centralizing the decisions of purchasing at very low dollar limits. *C* Centralization is the concentration of decision-making authority at the service lines of the organization. *D* Decentralization is dispersing decision-making authority throughout the organization.

*D* Decentralization is dispersing decision-making authority throughout the organization. Confident administrators will centralize during crisis and decentralize during stable times. An organization may use selective decentralization for decision making in the functional areas of staffing, purchasing, and operations, while centralizing a few decisions of purchasing at very substantial dollar amounts, program additions, or elimination of services or programs. Centralization is the concentration of decision making at the top of the organization.

*Manager decisions and treatment of employees associate with workplace violence. Any toleration of hostile or threatening behavior can result in escalation that results in physical harm. Which type of behavior is often tolerated and not reported?* *A* Employees being fired *B* Acts of bullying, verbal threats, and harassment *C* Presence of weapons and/or the use of alcohol or drugs *D* Intimidation, pushing, and slapping

*D* Intimidation, pushing, and slapping behaviors are not often reported as workplace violence. Employees being fired; acts of bullying with verbal threats; presence of weapons; and the use of alcohol or drugs tend to get the attention of employees, and when employees are comfortable, they will report to managers.

*The process for determining the effect of different conditions to nurses and nursing practice on the health status of patients is:* *A* research using risk adjustment. *B* health services research. *C* outcomes research. *D* nursing effectiveness research.

*D* Nursing effectiveness research is determining the effect of different conditions to nurses and nursing care on the health status of patients and is also known as nursing outcomes research. Research using risk adjustment uses analysis to account for relevant individual differences in patient populations, thus improving the interpretation of results. Health services research is a broad area that examines the extent to which services achieve the goals of health care. Outcomes research is a field of health services research that examines the extent to which services change functional status and quality of life for clients or mortality rates.

*Case managers were deployed to decrease fragmentation; reduce expense by streamlining care; and control costs by linking, advocating, coordinating, negotiating, educating, and monitoring. Today the model that guides hospitals and clinics to case manage is best described in which of the following statements?* *A* Social services, rehabilitation, and public health have addressed coordination of care for the ill and the poor to manage catastrophic injury or illness. *B* Traditional public health nursing has addressed the coordination of client-centered care within the community setting. *C* Tertiary care has addressed the treatment of acute, episodic health care conditions. *D* Public health guides the health care organization to coordinate and integrate services across the continuum from hospital to community to reduce costs and eliminate redundancy of services.

*D* Public health guides the health care organization to coordinate and integrate services across the continuum from hospital to community to reduce costs and eliminate redundancy of services. The continuum includes health promotion/illness prevention, public health, primary care, diagnostics/drugs, ambulatory care, acute inpatient, rehabilitative/chronic, long-term care, home services, and palliative care segments. The first answer was an older model used to manage clients that needed services in order to even leave the institution and relied on social services, rehabilitation, and public health to address coordination of care for the ill and the poor to manage catastrophic injury or illness. The second answer was traditional public health nursing after hospitalization. It addressed the coordination of client-centered care within the community setting and was also part of the visiting nurses association model for care outside of the hospital setting. The third answer was a tertiary care model that addressed the treatment of acute, episodic health care conditions to eliminate the costs of hospitalizations and was less concerned with the situation for care at home.

*Changing the operational process of an organization is often necessary when adding or updating patient care and health information technologies. The process to engage in making this change is called:* *A* scalar process. *B* job redesign. *C* workflow. *D* reengineering.

*D* Reengineering is changing the operational processes of an organization by radical redesign of business processes. A scalar process is the creation of levels of authority in a hierarchy, where the increased layers of management help the organization cope with increasing work complexity and extended time lines. Job redesign focuses on who does which tasks and on maximizing flexibility, cross-training, and productivity. Workflow is a structure to engage staff nurses and others in decisions impacting their work when inter-professional staff work together to articulate workflow.

*A manager who experiences the failure to retain an employee who is performing satisfactorily or better is dealing with a:* *A* turnover. *B* transfer. *C* termination. *D* resignation.

*D* Resignation is the failure to retain an employee who is performing satisfactorily or better. Turnover is the loss of an employee because of transfer, termination, or resignation. A transfer is movement of an employee from one area in the organization to another. Termination is discharge of an employee who is performing less than satisfactorily.

*Nurse managers play a role in staffing a nursing area, and they need to explore all opportunities to sustain staffing at appropriate levels. Nurse managers who determine the most qualified applicant for a posted job are in the process of:* *A* identifying staff vacancy. *B* recruitment. *C* retention. *D* selection.

*D* Selection is determining the most qualified applicant with skills, knowledge, and experience for a posted job. Identifying staff vacancy is determining the part- or full-time equivalent employee positions needed. Recruitment is seeking out and identifying individuals for potential employment. Retention is continuing the strategies to support employment of qualified staff.

*A rigorous scientific process used to combine findings from research into a powerful and clinically useful report to guide practice is:* *A* performance appraisal. *B* practice guideline. *C* implementation science. *D* systematic review.

*D* Systematic review is a rigorous scientific process used to combine findings from research into a powerful and clinically useful report to guide practice. Performance appraisal is an evaluation process based on job descriptions, with inclusion of evidence-based practice components across to promote positive reinforcement and expectations in the work environment. A practice guideline is a statement designed to assist the provider and client in making decisions about appropriate health care for specific clinical circumstances. Implementation science is a type of scientific investigation that supports movement of evidence-based, effective health care approaches from clinical knowledge into routine use, testing strategies to promote uptake, and use of innovations such as building the database of knowledge into the electronic health record, redesign of a clinical workflow, or electronic forms associated with patient care technologies.

*The resources for nurse executives, nurse leaders, or other nurse representatives would include some of the following references to conduct a gap analysis to determine needs, but where should the managers begin to access knowledge about planning for disasters?* *A* Agency for Healthcare Research and Quality (AHRQ) *B* American Hospital Association (AHA) *C* Centers for Disease Control and Prevention (CDC) *D* Federal Emergency Management Association (FEMA)

*D* The correct answer for community response and conducting an effective gap analysis would be to use FEMA (www.emforum.org/vforum/FEMA/Gap Analysis Program Guidance 03-13-2009.pdf) to determine necessary planning tools for the response plans. AHRQ (wwwahrq.gov/research/epri) has worked with health care entities doing project research to provide textbooks and training materials on coordination of a community plan for emergency preparedness for all types of major disasters. The AHA focuses on the hospitals as major contributors to disaster preparedness. The CDC provides many training materials and works directly with the Office of National Preparedness under the Health and Human Services Department, which provides many public resources for citizens. The nurse leaders should start with FEMA resources to collaborate with the community needs, but there are many more resources available to train local staff on conducting annual reviews and disaster drills to establish a program for preparedness and practice for the events.

*The integration and coordination of health services to a specified population of patients or to individual patients has been described as case management. Select the best statement to describe this approach.* *A* A comprehensive, integrated approach to care and reimbursement based on the natural course of a disease *B* A systematic integration and organized way to finance and deliver health care to achieve specific client outcomes, given fiscal and other resource constraints *C* A documented plan that identifies a predictable process of diagnoses and/or treatment for a condition based on practice guidelines *D* A comprehensive collaborative process of assessment, planning, facilitation, and communication to organize and evaluate patient care activities and advocate for services and available resources that will promote quality, cost-effective outcomes

*D* The correct answer is that it includes the steps of care coordination, which is a comprehensive collaborative process of assessment, planning, facilitation, and communication to organize and evaluate patient care activities and advocate for services and available resources that will promote quality, cost-effective outcomes. The first answer is incorrect because a comprehensive, integrated approach to care and reimbursement based on the natural course of a disease is considered disease management. The second answer is incorrect because managed care is considered a systematic integration and coordination to finance and deliver health care to achieve specific client outcomes, given fiscal and other resource constraints. Managed care is a broader view of financing services that would rely on case management. The third answer is incorrect because the document plan that identifies a predictable process of diagnoses and/or treatment for a condition based on practice guidelines is a critical pathway.

*Nurse managers, in collaboration with nursing leadership, design nursing systems for the provision of client care and the betterment of the organization. Nurse managers should consider which of the following important?* *A* Two factors that nurse managers must consider when designing a care delivery system are the type of nursing skilled staff and turnover. *B* Mixed model approaches offer a confusing type of nursing care delivery system, with trying to balance nurses' needs with those of clients, physicians, and organizations. *C* Models that promote professional practice have implications for job satisfaction, the character of professional practice, and the amount of control staffing leading to turnover. *D* They should include staff nurses in the development and selection process of the professional practice model.

*D* The correct answer is to include staff nurses in the development and selection process of the professional model. The two factors that nurses and managers must consider when designing a care delivery system are cost and quality. Mixed model approaches offer new, evolving types of nursing care delivery systems that nurse managers should balance nurses' needs with those of clients, physicians, and organizations. Models that promote professional practice have implications for job satisfaction, the character of professional practice, and the amount of control over nursing decision making without relationship to turnover.

*1. Which of the following statements is true about problem solving?* *A.* Problem solving is a high-level skill used only by health care professionals. *B.* Critical thinking and problem solving are the foundation of effective decision making. *C.* The team problem-solving method is a slow process and is a poor method for making decisions. *D.* Problem solving is a rational and logical thought process.

*D. Problem solving is a rational and logical thought process.* The statement that problem solving is a high-level skill used only by health care professionals is incorrect, because the high-level skill nurses and others use is critical thinking, a cognitive skill. The second statement is incorrect and should state that critical thinking and effective decision making are the foundation of effective problem solving. Health professionals improve the effectiveness by using the skill of critical thinking. The third statement is incorrect because team problem solving is a faster process for making decisions, because the use of interdisciplinary members of the team enhances the timeliness of a decision that is made in a silo.

*Which of the following statements correctly describes case management?* *A* Primary therapists have therapeutic relationships with the clients and provide primary case management functions. *B* Physicians must document the effects of interventions on client outcomes to demonstrate that they can provide cost-effective services. *C* Social workers can coordinate care for all patients and provide case manager functions to coordinate health care services for high-risk populations across community, acute, and long-term care settings. *D* Registered nurses (RNs) have emerged as the large majority of case managers, especially in hospitals, because of their specialized expertise for the function of determining medical necessity for health care payment and because of care coordination for complex medical discharge planning needs.

*D* The correct statement is that RNs have emerged as the large majority of case managers, especially in hospitals, because of their specialized expertise for the function of determining medical necessity for health care payment and because of care coordination for complex medical discharge planning needs. The first statement is incorrect because this model exists for primary therapists to do case management, but they view their primary relationship to the clients as being to provide therapeutic intervention. Case management functions are undertaken as a part of their role, but they do not provide primary case management functions. The second statement is incorrect because more often the nurse must document the effects of interventions or medications on client outcomes to demonstrate that they can provide cost-effective services. The third statement is incorrect because nurses, not social workers, can coordinate care for all patients and provide case manager functions to coordinate health care services for high-risk populations across community, acute, and long-term care settings.

*3. Select the statement that describes how clinical decision making differs from managerial decision making.* *A.* Professional nurses in clinical practice are making clinical decisions about client diagnoses and care plan orders, but the technical nurses are making managerial decisions about containment of costs and maximizing health care delivery. *B.* Clinical decision making involves the collection of information, selection, and evaluation of an action, whereas managerial decision making involves the processing of existing information to select an action. *C.* Clinical decision making by nurses is far less sophisticated than managerial decision making by nursing executives, nurse managers, and directors. *D.* Clinical decision making focuses on diagnosing client health issues, risks, or problems and planning or coordinating nursing interventions, but managerial decision making focuses on resolution of organizational problems and the plans to achieve organizational goals.

*D. Clinical decision making focuses on diagnosing client health issues, risks, or problems and planning or coordinating nursing interventions, but managerial decision making focuses on resolution of organizational problems and the plans to achieve organizational goals.* The first statement is incorrect: Professional nurses in clinical practice are making clinical decisions about client diagnoses and care plan orders, and the nurse executives and nurse managers are making managerial decisions about containment of costs and maximizing health care delivery. Technical nurses more often lack the formal management and/or leadership education for managerial decisions. The second statement is incorrect because both forms of clinical and managerial decision making involve the collection and processing of information and the selection and evaluation of an action; the focus of the decisions differs. The third statement is incorrect, because the sophistication of clinical decision making differentiates the professional nurse from the technical nurse and can be more challenging than managerial decisions, though the scope of coverage will vary between the two decisions.

*4. Decision-making tools and strategies support the process for decisions. Select the one statement that is true.* *A.* Group decision making tends to be more ineffective for system problems. *B.* All decision tree questions have a yes or no answer. *C.* Managers who use trial and error as the usual strategy for decision making often are effective. *D.* Critical pathways are a type of decision tree.

*D. Critical pathways are a type of decision tree.* They are used for clinical care and other industry decisions. The first statement is incorrect because group decision making tends to be more reflective and include more information and experts to effectively solve system problems with fewer consequences. The second statement is incorrect because only simple decision trees use questions that must be answered yes or no to direct the flow of thinking for making a decision. Algorithms for emergent care scenarios are an example of yes/no trees. The third statement is incorrect because managers using evidence-based strategies for decision making will be effective, and those using trial and error are ineffective more often.

*5. Select the best statement for why communication processes are important to organizations.* *A.* Horizontally decentralized organizations are more efficient than centralized organizations. *B.* Positive communication techniques include agreeing uncritically and reassuringly. *C.* Individual communication is more complex than group communication because it is so intensive. *D.* Human interaction issues are the general area in which leaders and managers spend most of their time.

*D. Human interaction issues are the general area in which leaders and managers spend most of their time.* The first statement is not correct because the horizontally decentralized organization takes much more effort in communication and is not necessarily more efficient than a centralized organization at communication processes. The second statement is incorrect because positive communication techniques include encouragement, optimistic words and expressions, and seeking constructive responses through questioning. The third statement is not correct because group communication is more complex than individual communication because it is so intensive.

*6. Leaders who give and take exchanges aimed at resolving issues are doing which of the following?* *A.* Bargaining *B.* Effective communication *C.* Persuasion *D.* Negotiation

*D. Negotiation* Bargaining is the exchange of a series of offers and counteroffers about what each party will do, give, and/or receive, until an agreement is reached to the satisfaction of all. Effective communication is a skilled process necessary in negotiation, persuasion, and bargaining and is the trust, respect, and empathy created with the interaction. Persuasion is influencing another to modify thoughts and behaviors of others.

*3. When the leader engages in dialogue with the nurse to share ideas and help in making decisions, what style of Situational Leadership® communication is being used?* *A.* Selling *B.* Delegating *C.* Telling *D.* Participating

*D. Participating* The leader engages in dialogue with the nurse to share ideas and help in making decisions; this includes supervision with coaching and mentoring. Selling is when the leader motivates the nurse by explaining the rationale for the task and answers the nurse's questions for clarification about a procedure that the nurse had not completed before. Delegating is when the leader trusts the nurse and turns over the responsibility for the decisions and performance to complete the task. Telling is when the leader clearly describes what to do, when to do it, where to do it, and how to do it, with clear directions and guidance.

*4. Nurses may communicate using humanizing and dehumanizing attitudes which impact the outcome of communication: Select the most humanizing option below.* *A.* In a small group session, there were varying opinions, with two individuals quite vocal about their viewpoints on how to proceed with a project. *B.* The manager handles the nurses on the unit with tolerance, judgment, and role playing. *C.* In a unit-based group session, there was disregard for conversation offered by 10 group members with steps to change the agenda item to another topic. *D.* The manager engaged nurses to share their concerns and ideas openly and their fears about the developing project.

*D. The manager engaged nurses to share their concerns and ideas openly and their fears about the developing project.* The fourth situation provides a humanizing attitude as conceptualized within the Humanizing Nursing Communication Theory. The first statement is a dehumanizing example of a group with two individuals taking over the conversation; this could be humanized if the individuals were to have positive regards and acceptance of other viewpoints in the group or equally give voice to all who are present. The second statement is a dehumanizing example of a manager who interacts with nurses on the unit using tolerance, judgment, and role playing responses when empathy, caring, and authenticity would be more welcoming to invite the interaction of all nurses. The third statement is a dehumanizing example where the group disregards those sharing thoughts and views, whereas the humanizing attribute would be dialogue, holistic with power to include those points expressed in the group discussion. Humanizing attributes include dialogue, individual, holistic, choice, equality, positive regard, acceptance, empathy, authenticity, caring, irreplaceability, intimacy, coping, and power. Dehumanizing attributes include monologue, categories, parts, directives degradation, disregard, judgment, tolerance, role playing, carelessness, expendability, isolation, helplessness, and powerlessness.

*7. A number of decision-making strategies have been identified for clinical and managerial decision making. An effective strategy for nurse managers to select in examining possible causes related to production would be:* *A.* pilot projects. *B.* cost-benefit analysis. *C.* scenario planning. *D.* fish bone charts.

*D. fish bone charts.* Pilot projects are limited experimental trials used to develop an optimal and alternative solution to a problem. Cost-benefit analysis is an appropriate strategy to use when deciding budgetary issues and may include listing the positive and negative aspects of a given outcome to assist with decision making. Scenario planning is used in a group setting to brainstorm about the future and is a beneficial strategy to use in a constantly changing environment.

*2. Duty of care owed by the nursing professional to the client is the minimum requirements that define an acceptable level of care. The minimum requirements are best located in:* *A.* the Social Policy Statement and Washington Manual. *B.* published standards by the American Nurses Association, nursing textbooks, and databases. *C.* federal agency guidelines and regulations and the Care Standards Act 2000. *D.* state nurse practice acts, standards published by nursing professional organizations and specialty practice groups, and/or a facility's policy and procedure manuals.

*D. state nurse practice acts, standards published by nursing professional organizations and specialty practice groups, and/or a facility's policy and procedure manuals.* In malpractice cases, the standard of care owed to the injured client is commonly introduced into evidence by expert witnesses, and the impact of that evidence is ultimately determined by the jury after receiving instructions from the judge on the law applicable to its use. The Nursing's Social Policy Statement does refer to where the standards may be found, and the Washington Manual is for medical therapeutics and is a source for medicine but not nursing. In the second answer, the published standards of practice would be appropriate but not the databases or textbooks. Federal agency guidelines and regulations would be appropriate, but not the Care Standards Act 2000, which applies to the United Kingdom and not the United States.