N266 Final exam ch 1-23, 27-32

7. Match the intervention for promoting child safety on the left with the correct developmental stage on the right. ch 27 1. Teach children proper bicycle and skate board safety. 2. Teach children how to cross streets and walk in parking lot. 3. Teach children proper techniques for specific sports. 4. Teach children not to operate electric toothbrushes while unsupervised. 5. Teach children not to talk to or go with a stranger. 6. Teach children not to eat items found in the grass. A. School-age child B. Preschooler

Answer A: 1, 2, 3 ; B: 4, 5, 6.

7. The nurse is teaching a patient how to perform a testicular self-examination. Which statement made by the patient indicates a need for further teaching? ch 30 1. "I'll recognize abnormal lumps because they are very painful." 2. "I'll start performing testicular self-examination monthly after I turn 15." 3. "I'll perform the self-examination in front of a mirror." 4. "I'll gently roll the testicle between my fingers."

Answer: 1 The examination should be performed monthly in all men 15 years of age and older. Feel for small, pea-size lumps on the front and side of the testicle. Abnormal lumps are usually painless.

9. Using Maslow's hierarchy of needs, identify the priority for a patient who is experiencing chest pain and difficulty breathing. ch4 1. Self-actualization 2. Air, water, and nutrition 3. Safety 4. Esteem and self-esteem needs

Answer: 2. According to Maslow's theory, basic physiological needs are the patient's first priority, especially when a patient is severely dependent physically. In this example, the patient's need for adequate oxygenation (air) is the priority.

2. Which number corresponds to the area of the chest where you would auscultate for the tricuspid valve?

Answer: 4. The tricuspid area is located at the fourth or fifth intercostal space along the sternum.

1. Match the components of PICO using the question "Does the use of guided imagery compared with standard care decrease the postoperative pain in hospitalized adolescents?" ch 5 _____ (P) Patient/population A. Adolescents receiving standard care _____ (I) Intervention B. Decreased postoperative pain _____ (C) Comparison C. Hospitalized adolescents _____ (O) Outcome D. Guided imagery

Answer: C, D, A, B. This question includes the four PICO elements of patient/population (hospitalized adolescents who had surgery), intervention (guided imagery), comparison group (adolescents receiving standard care), and outcome (decreased postoperative pain).

5. Many older homes in a neighborhood are undergoing a lot of restoration. Lead paint was used to paint the homes when they were built. The community clinic in the neighborhood is initiating a lead screening program. This activity is based on which social determinant of health? CH3

Answer: Physical environment. This social determinant of health describes where a person lives and how that environment affects the person's health.

2. Match the elements for correct identification of outcome statements with the SMART acronym terms below. 1. Specific 2. Measurable 3. Attainable 4. Realistic 5. Timed a. Mutually set an outcome that a patient agrees to meet. b. Set an outcome that a patient can meet based upon his or her physiological, emotional, economic, and sociocultural resources. c. Be sure an outcome addresses only one patient behavior or response. d. Include when an outcome is to be met. e. Use a term in an outcome statement that allows for observation as to whether a change takes place in a patient's status.

2. Answer: 1c; 2e; 3a; 4b; 5d

7. A mother is concerned about her child's flulike symptoms. You learn from the health assessment that the mother practices use of "hot" and "cold" foods to treat ailments. Which of the following foods do you expect the mother to use to treat her child? ch 9 1. Chicken 2. Yogurt 3. Fresh fruits 4. Eggs

7. Answer: 4. Certain cultures believe in the importance of balance and harmony in health. Natural or holistic balance is believed to be achieved by using "hot" and "cold" foods as remedies to treat illness.

4. The nurse must take a verbal order during an emergency on the unit. Which of the following guidelines can be used for taking verbal or telephone orders? (Select all that apply). ch 31 1. Only authorized staff may receive and record verbal or telephone orders. The health care agency identifies in writing the staff who are authorized. 2. Clearly identify patient's name, room number, and diagnosis. 3. Read back all orders to health care provider. 4. Use clarification questions to avoid misunderstandings. 5. Write "VO" (verbal order) or "TO" (telephone order), including date and time, name of patient, and complete order; sign the name of the health care provider and nurse.

Answer: 1, 2, 3, 4, 5. These are all acceptable guidelines for taking verbal and telephone orders in a health care setting. All of the stated guidelines should be used by the nurse.

8. The nurse manager from the surgical unit was awarded the nursing leadership award for practice of transformational leadership. Which of the following are characteristics or traits of transformational leadership displayed by the award winner? (Select all that apply.) ch 21 1. The nurse manager regularly rounds on staff to gather input on unit decisions. 2. The nurse manager sends thank-you notes to staff in recognition of a job well done. 3. The nurse manager sends memos to staff about decisions that the manager has made regarding unit policies. 4. The nurse manager has an "innovation idea box" to which staff are encouraged to submit ideas for unit improvements. 5. The nurse manager develops a philosophy of care for the staff.

. Answer: 1, 2, 4. Nurse managers who practice transformational leadership are focused on change and innovation. They motivate and empower their staff with the focus on team development. The manager will spend time on the unit with the staff sharing ideas and listening to staff input. The manager is enthusiastic about opportunities to enhance the team and shows appreciation and recognizes team members for good work. The manager holds the team accountable and provides support for the team members in the stressful health care environment. The manager shares the philosophy of care developed by the nurse executive of the organization

10. A nurse is completing an assessment on a male patient, age 24. Following the assessment, the nurse notes that his family history is not significant for chronic illnesses, and his physical and laboratory findings are within normal limits. Because of these findings, nursing interventions are directed toward activities related to: (Select all that apply.) ch 13 1. Instructing him to return in 2 years. 2. Instructing him in secondary prevention. 3. Instructing him in health promotion activities. 4. Instructing him about routine screenings. 5. Instructing him about proper vaccinations.

10. Answer: 3, 4, 5. While young adults generally have a minimum of major health problems, lifestyles such as tobacco or alcohol abuse, risky sexual activity, obesity, and lack of physical activity put them at risk for health problems. Instructing young adults in health promotion activities can decrease the risk for lifestyle-related health issues in the young adult. Proper vaccinations (e.g., flu vaccines and boosters to routine childhood vaccinations, such as tetanus) and regular health screenings are also important to maintain health.

5. Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples of these roles and responsibilities? (Select all that apply.) CH 1 1. Caregiver 2. Autonomy 3. Patient advocate 4. Health promotion 5. Genetic counselor

5. Answer: 1, 2, 3, 4. Each of these roles or skills includes activities for the professional nurse. Each of these is used in direct care or is part of the professionalism that guides nursing practice.

6. Match the advanced practice nurse specialty with the statement about the role. CH1 1. Clinical nurse specialist 2. Nurse anesthetist 3. Nurse practitioner 4. Nurse-midwife a. Provides independent care, including pregnancy and gynecological services b. Expert clinician in a specialized area of practice such as adult diabetes care c. Provides comprehensive care, usually in a primary care setting, directly managing the medical care of patients who are healthy or have chronic conditions d. Provides care and services under the supervision of an anesthesiologist

6. Answer: 1b, 2d, 3c, 4a. The role statements describe the activities performed and the role of the advanced practice nurse specialty. Nurse midwives care for women who are pregnant or have women's health needs. Clinical nurse specialists typically see hospitalized patients with a specific type of illness or health problem. Nurse practitioners usually practice in a primary care setting and care for patients who are healthy or have minor acute or stable chronic conditions. Certified nurse anesthetists care for patients during the surgical experience and administer anesthesia during surgery.

8. The nurse is using the QSEN competency of EBP when working with the unit council to initiate a change related to pain management. Which behaviors demonstrate the nurse practicing behaviors associated with EBP? (Select all that apply.) ch 5 1. Initiating plan for self-development as a team member 2. Reading original research related to pain management 3. Demonstrating effective use of strategies to reduce risk of harm to self or others 4. Valuing EBP as critical to the development of pain management guidelines for the unit 5. Describing to the unit council reliable sources for locating clinical guidelines 6. Applying technology and information management tools to support safe processes of care

8. The nurse is using the QSEN competency of EBP when working with the unit council to initiate a change related to pain management. Which behaviors demonstrate the nurse practicing behaviors associated with EBP? (Select all that apply.) 1. Initiating plan for self-development as a team member 2. Reading original research related to pain management 3. Demonstrating effective use of strategies to reduce risk of harm to self or others 4. Valuing EBP as critical to the development of pain management guidelines for the unit 5. Describing to the unit council reliable sources for locating clinical guidelines 6. Applying technology and information management tools to support safe processes of care

9. A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. ch 16 1. "You say you've lost weight. Tell me how much weight you've lost in the past month." 2. "My name is Terry. I'll be the nurse taking care of you today." 3. "I have no further questions. Is there anything else you wish to ask me?" 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the past month, and your appetite has been poor—correct?"

9. Answer: 2, 4, 1, 5, 3. A patient-centered interview begins with a nurse's self-introduction. It then proceeds to an open ended question that allows a patient to tell his or her story about any health concerns. Listening and acknowledging a patient's concerns then allows you to probe for further information. Summarization lets the patient confirm accuracy of your interpretation of data. Finally, you end an interview by telling the patient you are finished, and letting him or her ask any final questions.

9. A 15-year-old patient tells the nurse that she is sexually active. What is the best action by the nurse? ch 12 1. Contact her parents to alert them of her need for birth control. 2. Explain that having sex is not appropriate for her age-group. 3. Counsel her on safe sex practices and on minimizing health risks. 4. Ask her to have her partner come to the clinic for STI testing.

9. Answer: 3. Nurses need to be sensitive to the emotional cues from adolescents before initiating health teaching to know when the teen is ready to discuss concerns. In addition, discussions with adolescents need to be private and confidential. Adolescents define health in much the same way as adults and look for opportunities to reach their physical, mental, and emotional potential.

4. A nurse is assigned to care for six patients at the beginning of the night shift. The nurse learns that the floor will be short by one registered nurse (RN) as a result of a call-in. A patient care technician from another area is coming to the nursing unit to assist. Because the unit requires hourly rounds on all patients, the nurse begins to make rounds on a patient who recently asked for a pain medication. The nurse is interrupted by another registered nurse who asks about another patient. Which factors in this nurse's unit environment will affect the ability to set priorities? (Select all that apply.) ch 18 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. Type of hospital unit 5. Competency of patient care technician

Answer 2, 3, 5. Many factors within the health care environment affect a nurse's ability to set priorities, including availability of resources (staffing), interruptions from care providers, and RN experience and technician competency. The type of hospital unit is not a factor, but the way a unit is organized and its model of care can be factors. A policy for conducting rounds in itself does not affect ongoing priority setting

3. A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority? ch 19 1. Patient in pain 2. Patient newly admitted 3. Patient who returned from surgery 4. Patient requesting assistance with meal tray

Answer 3. The patient returning from surgery is likely the most physiologically unstable, requiring the nurse to perform an assessment and ensure the patient is managed appropriately. The patient in pain is likely to be the next priority, depending on the severity of the patient's reported pain. The newly admitted patient will require a nursing history, which takes time. The nurse can have the assistive personnel assist with the meal tray.

5. A nurse working on a surgery floor is assigned four patients. The nurse assesses each patient, noting behaviors and physical signs and symptoms. Which of the following patients is more likely to be violent toward the nurse? ch 27 1. The first patient maintains eye contact with the nurse, is calm during the nurse's assessment, and asks questions frequently. 2. The second patient is very drowsy, loses attention span when the nurse asks questions, and mumbles when speaking. 3. The third patient moves nervously in bed, swears and grimaces when trying to cough, and speaks in a low volume. 4. The fourth patient speaks in a loud voice and becomes irritable when the nurse arrives to help walk the patient.

Answer 4. Patients who are most likely to enact violence include those who have an increased volume of speech, are irritable, demonstrate prolonged or intense glaring, mumble, use abusive language toward the nurse, and pace around the waiting area or bed.

8. Match the category of direct care on the left with the specific direct care activity on the right. ch 19 1. Counseling ___ 2. Lifesaving measure ____ 3. Physical care technique ___ 4. Activity of daily living ____ a. Assisting patient with oral care b. Discussing a patient's options in choosing palliative care c. Protecting a violent patient from injury d. Using safe patient handling during positioning of a patient

Answer: 1 b, 2 c, 3 d, 4 a

1. A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) ch 28 1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in Contact Precautions, he cannot leave the room. 5. C. difficile dies quickly once outside the body

Answer: 1, 2, 3 Clostridium difficile is transmitted through the oral-fecal route and spread through contact with contaminated feces or surfaces touched by hands not appropriately cleaned after providing care to a patient infected with C. difficile. The organism develops a hard spore and can live for long periods of time on surfaces, making it very hard to eradicate. As long as patient is continent of stool and first cleans hands and changes gown, a patient with C. difficile may leave the room.

5. The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) ch 28 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient on antibiotics who has been having loose stool for 24 hours 5. Decreasing a patient's environmental stimuli to decrease nausea

Answer: 1, 2, 3 Nausea is not typically associated with transmission of infection, and loose stools are a common side effect with antimicrobials. All the other interventions break the cycle of infection transmission.

10. Which of the following statements correctly describe the evaluation process? (Select all that apply.) ch 20 1. Evaluation is an ongoing process. 2. Evaluation involves the gathering of data for recognizing errors or omissions in care. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is done only when a patient's condition changes.

Answer: 1, 2, 3, 4. Evaluation is ongoing and reveals whether outcomes are achieved, which includes examining in what way a patient's condition changes. Because evaluation is ongoing, never use evaluation only when a patient condition changes.

1. A 52-year-old woman is admitted with pneumonia, dyspnea, and discomfort in her left chest when taking deep breaths. She has smoked for 35 years and recently lost over 10 lb. She is started on intravenous antibiotics, high-protein shakes, and 2 L O2 via nasal cannula. Her most recent vital signs are HR 112, BP 138/82, RR 22, tympanic temperature 37.9°C (100.2° F), and oxygen saturation 94%. Which vital signs reflect a positive outcome of the treatment interventions? (Select all that apply.) ch 29 1. Temperature: 37° C (98.6° F) 2. Radial pulse: 98 3. Respiratory rate: 18 4. Oxygen saturation: 96% 5. Blood pressure: 134/78

Answer: 1, 2, 3, 4. Radial pulse has dropped as temperature has become within expected range. Respiratory rate has decreased with lower temperature, and oxygen saturation has improved with improved respiratory rate

3. A nurse asks an AP to help the patient in Room 418 walk to the bathroom right now. The nurse tells the AP that the patient needs the assistance of one person and the use of a walker. The nurse also tells the AP that the patient's oxygen can be removed while he goes to the bathroom but to make sure that when it is put back on the flowmeter is still at 2 L. The nurse also instructs the AP to make sure the side rails are up and the bed alarm is reset after the patient gets back in bed. Which of the following components of the "Five Rights of Delegation" were used by the nurse? (Select all that apply.) ch 21 1. Right task 2. Right circumstance 3. Right person 4. Right directions and communication 5. Right supervision and evaluation

Answer: 1, 2, 3, 4. The nurse provided 4 of the 5 components but did not provide the right supervision and evaluation. The nurse delegated the task of a patient to the bathroom to the AP, which is in the scope of an AP's duties and responsibilities and matched to the AP skill level. The nurse did provide clear directions by describing the task and the time period to complete the task. The nurse did not use "please" and "thank you" in the request. The nurse did not ask whether there were any questions, which would provide the AP an opportunity to get clarification if needed. The nurse did not ask the AP to follow up on how the patient did or whether there were any problems. The nurse did not provide appropriate monitoring, evaluation, intervention as needed, or feedback.

9. Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) ch 19 1. Checks scientific literature or policy and procedure 2. Determines whether additional assistance is needed 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure

Answer: 1, 2, 3, 5. A more experienced nurse can assist, but unless there is an emergency and there is no time to prepare, you would not delegate. Instead you would learn how to perform the procedure. When performing an unfamiliar procedure, check policy and procedure, determine whether assistance is needed, prepare supplies and equipment, and consider all possible consequences of the procedure

4. Chronic illness (e.g., diabetes mellitus, hypertension, rheumatoid arthritis) may affect a person's roles and responsibilities during middle adulthood. When assessing the health-related knowledge base of both the middle-age patient with a chronic illness and his or her family, the assessment should include which of the following? (Select all that apply.) ch 13 1. Medical course of the illness 2. Prognosis for the patient 3. Coping mechanisms of the patient and family 4. Socioeconomic status 5. Need for community and social services

Answer: 1, 2, 3, 5. When assessing the patient with a chronic illness, it is important that the nurse know how much the patient and his family know about how the illness has progressed and the long-term prognosis for the patient. This includes understanding the patient and families' ability and readiness to accept the illness and the outlook for the patient. Understanding the coping mechanisms used by the patient and family will assist the nurse in determining how to proceed to teach and counsel the patient and family regarding the patient's treatment regimen and whether there is a need and acceptance for community or social services to assist the patient and family

5. A nurse is caring for a patient with chronic arthritis pain. The patient wants to add some complementary therapies to help with pain management. Which therapies might be most effective for controlling pain (Select all that apply): ch 32 1. Biofeedback 2. Acupuncture 3. Therapeutic touch 4. Chiropractic therapy 5. Herbal medicines

Answer: 1, 2, 3. Biofeedback is a mind-body technique that promotes relaxation and muscle tension and, in turn, reduces pain. Acupuncture modifies the body's response to pain and over time can reduce pain. Therapeutic touch is effective in reducing the pain response in patients with chronic illnesses. Chiropractic therapy realigns structure and reduces pain when the pain is the result of structural abnormality, not inflammation. Meditation assists in relaxing the body and stilling the mind. It allow a person to cope with stress, reduce anxiety, and feel at one with God and the universe. Herbal therapies are often used to prevent disease and promote health

9. Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.) ch 23 1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." 4. "Nurses do not have very much voice in legislation in Washington, DC, because of the nursing shortage." 5. "I will go back to school as soon as I finish orientation."

Answer: 1, 2, 3. Nurses need to be actively involved in their communities and be aware of current issues in health care. Staying abreast of current news and public opinion through the media is essential. Nurses need to join nursing committees to be involved in decision making. Nurses have a powerful voice in the legislature.

10. The public health nurse is working with the county health department on a task force to fully integrate the goals of Healthy People 2020. Most of the immigrant population do not have a primary care provider, nor do they participate in health promotion activities; the unemployment rate in the community is 25%. How does the nurse determine which goals need to be included or updated? (Select all that apply.) CH 3 1. Assess the health care resources within the community. 2. Assess the existing health care programs offered by the county health department. 3. Compare existing resources and programs with Healthy People 2020 goals. 4. Initiate new programs to meet Healthy People 2020 goals. 5. Implement educational sessions in the schools to focus on nutritional needs of the children.

Answer: 1, 2, 3. The nurse must first assess for existing health care resources and educational programs. Then the nurse must compare these resources and programs with Healthy People 2020 goals. These processes determine whether any goals need to be added or updated.

9. Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) ch 28 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures

Answer: 1, 2, 4 Proper cleaning and disinfection are processes that occur prior to sterilization, with cleaning always done from dirty to clean to decrease the risk of further infection and contamination.

1. Which of the following should be included in health teaching for a pregnant patient? (Select all that apply.) ch 12 1. Exposure of the fetus to alcohol, drugs, or tobacco can cause abnormal development. 2. Nutritional needs increase during pregnancy, and eating healthy foods is important. 3. Complementary and alternative therapies should always be avoided during pregnancy. 4. Provide education on self-care to reduce common discomforts of pregnancy, such as nausea. 5. Recommend birthing classes to prepare the mother for the birthing process

Answer: 1, 2, 4, 5. A woman's diet and exposure to alcohol, drugs, and tobacco can have a significant effect on fetal development. Providing anticipatory guidance and education regarding nutritional needs, self-care needs, and preparation for birth is critical for a pregnant patient. Complementary and alternative therapies should be evaluated for safety during pregnancy but do not always have to be avoided.

3. A 36-year-old patient newly diagnosed with type 1 diabetes shares with you that he is frustrated with the time it takes to prepare meals and monitor his exercise and blood sugar. He also is having trouble understanding his insulin schedule. Which of the following suggestions would be most appropriate? (Select all that apply.) ch 13 1. Provide patient education materials that are easy to read. 2. Refer this patient to a diabetes support group. 3. Refer the patient to his endocrinologist. 4. Suggest that the patient make an appointment with a registered dietitian. 5. Suggest ways to modify his schedule

Answer: 1, 2, 4, 5. Adults are often impatient with the time and energy requirements that a chronic health problem requires for proper management. Patient-centered educational materials and support groups often help patients deal with these challenges. Working with a dietitian will help the patient identify ways to modify his eating habits. Helping the patient incorporate nutritional and exercise health behaviors into his schedule is also important.

10. The nurse manager of a community clinic arranges for staff in-services about various complementary therapies available in the community. What is the purpose of this training? (Select all that apply.) CH 32 1. Nurses play an essential role in the safe use of complementary therapies. 2. Nurses are often asked for recommendations and strategies that promote well-being and quality of life. 3. Nurses learn how to provide all of the complementary modalities during their basic education. 4. Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. 5. Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life.

Answer: 1, 2, 4, 5. All of the statements are true except that nurses do not learn how to provide all of the complementary modalities during their basic education. Nurses play an essential role in the safe use of complementary therapies in our emerging health care system. They have an appreciation for many types of interventions and can understand the patient's need to become more involved in his or her health care decisions and choices. They also understand the patient's desire to take a more active role in his or her healing and health promotion processes. Culturally relevant care that uses a full complement of intervention strategies that are supported with evidence is a central tenet of contemporary nursing practice.

1. A nurse completes the following steps during her shift of care. Which are the steps of nursing assessment? (Select all that apply.) ch 16 1. The review of patient data in the medical record 2. Confirming a patient's self-report of abdominal pain by inspecting the abdomen 3. Reporting results of an ongoing assessment to a nurse working the next scheduled shift 4. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration 5. Conducting an interview of a family caregiver

Answer: 1, 2, 4, 5. Assessment involves the step of collection of information from a primary source (a patient) and secondary sources (e.g., family caregiver, family members or friends, health professionals, medical record). The second step of assessment involves the interpretation and validation of data to determine whether more data are needed or the database is complete. Reporting results is important for continuity of care but is not an assessment step for the nurse reporting. The nurse receiving the report will use the data in the report for assessment information

7. A nurse asks how a patient's condition from a serious infection changed since yesterday while receiving a hand-off report. The nurse leaving the shift reports the patient has two priority nursing diagnoses—fluid imbalance and fever. The receiving nurse begins to provide care by measuring the patient's body temperature, inspecting the condition of the skin, reviewing the intake and output record, and checking the summary notes describing the patient's progress since the day before. The nurse asks a technician to measure intake and output during the shift. What critical thinking indicators reflect the nurse's ability to perform evaluation? (Select all that apply.) ch 20 1. Checking the summary notes 2. Asking the leaving RN about the patient's condition. 3. Assigning the technician to measure intake and output 4. Comparing current outcomes with those set for the patient's goals 5. Reflecting on patient's progress

Answer: 1, 2, 4, 5. Critical thinking indicators reflecting evaluation include examining the results of care according to clinical data collected, comparing achieved effects or outcomes with goals and expected outcomes, recognizing errors or omissions, and reflecting on the patient situation. Delegating a task such as intake and output measurement to a technician is appropriate but not a critical thinking indicator for evaluation.

1.Using Healthy People 2020 as a guide, which of the following would improve delivery of care to a community? (Select all that apply.) CH 3 1. Community assessment 2. Implementation of public health policies 3. Home safety assessment 4. Increased access to care 5. Determining rates of specific illnesses

Answer: 1, 2, 4, 5. Improved delivery of health care occurs through assessment of health care needs of individuals, families, and communities; development and implementation of public health policies; and improved access to care. For example, assessment includes systematic data collection on the population, monitoring of the population's health status, gathering information on rates of particular diseases or infections, and accessing available information about the health of the community. Although option 3, home assessment, might be valuable to an individual patient, it may not benefit the community as a whole.

2. Theory is essential to nursing practice because it: (Select all that apply.) ch 4 1. Contributes to nursing knowledge. 2. Predicts patient behaviors in situations. 3. Provides a means of assessing patient vital signs. 4. Guides nursing practice. 5. Formulates health care legislation. 6. Explains relationships between concepts

Answer: 1, 2, 4, 6. A theory contains a set of concepts, definitions, and assumptions that explain a phenomenon. The theory explains how these elements are uniquely related in the phenomenon. These components provide a foundation of knowledge from which nurses can direct and deliver caring nursing practices. A theory helps explain an event by defining ideas or concepts, explaining relationships between the concepts, and predicting outcomes of nursing care. A nursing theory conceptualizes an aspect of nursing to describe, explain, predict, or prescribe nursing care.

10. A nurse is conferring with another nurse about the care of a patient with a stage II pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following? (Select all that apply.) ch 19 1. Allows nurses to act more quickly and appropriately 2. Sets a level of clinical excellence for practice 3. Eliminates need to create an individualized care plan for the patient 4. Incorporates evidence-based interventions for stage II pressure injury 5. Provides for access to patient care information within the electronic health record

Answer: 1, 2, 4. A clinical practice guideline is a systematically developed set of statements about appropriate health care for specific health care problems or clinical situations. Evidence-based research provides the basis for sound clinical practice guidelines. A nurse individualizes how to apply nursing interventions for each unique patient. Standard interventions are developed for the more common health problems; thus standard interventions assist nurses to intervene more quickly and appropriately. An individualized plan of care is always necessary. The use of standard interventions aids in capturing sharable patient and care information within the electronic medical record.

2. A community health nurse is working in a clinic with a focus on asthma and allergies. What is the primary focus of the community health nurse in this clinic setting? (Select all that apply.) CH 3 1. Decrease the incidence of asthma attacks in the community 2. Increase patients' ability to self-manage their asthma 3. Treat acute asthma in the hospital 4. Provide asthma education programs for the teachers in the local schools 5. Provide scheduled immunizations to people who come to the clinic

Answer: 1, 2, 4. All of these activities improve the level of health and quality of life for patients in this community. Asthma self-management controls symptoms and improves a patient's quality of life. Assessing for and preventing risks, as well as educational programs, improve the level of health within a community. Managing chronic diseases in the community improves the overall level of health of that community.

8. A family consisting of a grandparent, two adults, and three schoolage children just immigrated to the United States. They come to a community wellness center to establish health care. Which of the following questions does the nurse ask to assess the family's function? (Select all that apply.) ch 10 1. "What does your family do to keep members healthy?" 2. "How does your family usually make decisions?" 3. "What health services are available in your neighborhood?" 4. "Which rituals or celebrations are important for your family?" 5. "Is there a lot of crime in your neighborhood?" 6. "How many parks are there in your community?"

Answer: 1, 2, 4. Cultural practices, decision making, and rituals and celebrations describe what is important to a family. This set of assessment data helps you gain insight into how the family functions and what they consider important to their health and family functioning.

4. A family is facing job loss of the father, who is the major wage earner, and relocation to a new city where there is a new job. The children will have to switch schools, and his wife will have to resign from the job she enjoys. Which of the following contribute to this family's hardiness? (Select all that apply.) ch 10 1. Family meetings 2. Established family roles 3. New neighborhood 4. Willingness to change in time of stress 5. Passive orientation to life

Answer: 1, 2, 4. Family hardiness refers to the internal strengths and durability of the family unit. A sense of control over the outcome of life, a view of change as beneficial and growth producing, communication with family members (as in family meetings), well-established family roles among family members, and an active rather than passive orientation in adapting to stressful events all contribute to family hardiness.

3. The nurse caring for a refugee community identifies that the children are undervaccinated and the community is unaware of resources. The nurse assesses the community and determines that there is a health clinic within a 5-mile radius. The nurse meets with the community leaders and explains the need for immunizations, the location of the clinic, and the process of accessing health care resources. Which of the following practices is the nurse providing? (Select all that apply.) CH 3 1. Raising awareness about community resources for the children 2. Teaching the community about health promotion and illness prevention 3. Promoting autonomy in decision making about health practices 4. Improving the health care of the community's children 5. Participating in professional development activities to maintain nursing competency

Answer: 1, 2, 4. Raising awareness about community resources for the children will help the community identify potential clinics for vaccination and well-baby and child examinations. By teaching the community about relevant illnesses, the nurse increases the level of awareness not only about the disease but also about methods of treatment. As the community becomes more informed about the illness, prevention, and treatment methods, the health of the community will increase

2. A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient in pain has two analgesics ordered prn for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during intervention? (Select all that apply.) ch 19 1. The nurse reviews the options for pain relief for the patient. 2. The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed. 3. The nurse reviews the policy and procedure for the cold application. 4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy. 5. The nurse delegates vital sign assessment of the patient returning from surgery to the assistive personnel.

Answer: 1, 2, 4. The nurse exercises critical judgment in decision making by reviewing the set of all possible nursing interventions for a patient's problem, reviewing possible consequences associated with each possible nursing action, determining the probability of all possible consequences, and judging the value of the consequence to the patient. Clinical decision making is not in play simply by accessing a resource. Decision making would be applied if the nurse revises or adapts how to perform the cold application. Delegation of vital signs in a potentially unstable patient is not good clinical decision making

4. Which type of personal protective equipment should the nurse wear when caring for a pediatric patient who is placed on Airborne Precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) ch 28 1. Disposable gown 2. N95 respirator mask 3. Face shield or goggles 4. Disposable mask 5. Gloves

Answer: 1, 2, 5 Chicken pox is an airborne organism that can travel great distances, so it is important that the air breathed by the nurse is filtered, and hands and clothes are covered, as required for airborne precautions.

3. An older adult states that she cannot see her medication bottles clearly to determine when to take her prescription. What should the nurse do? (Select all that apply.) ch 31 1. Provide a dispensing system for each day of the week. 2. Provide larger, easier-to-read labels. 3. Tell the patient what is in each container. 4. Have a family caregiver administer the medication. 5. Use teach-back to ensure that the patient knows what medication to take and when.

Answer: 1, 2, 5. Larger print and a dispensing system can ensure safe medication administration in older adults. Medication pamphlets in larger print are also available. The use of teach-back ensures that the patient understands his or her medications and increases safety.

2. Which of the following are examples of a nurse participating in primary care activities? (Select all that apply.) CH2 1. Providing prenatal teaching on nutrition to a pregnant woman during the first trimester 2. Assessing the nutritional status of older adults who come to the community center for lunch 3. Working with patients in a cardiac rehabilitation program 4. Providing home wound care to a patient 5. Teaching a class to parents at the local grade school about the importance of immunizations

Answer: 1, 2, 5. Primary care activities are focused on health promotion. Health promotion programs contribute to quality health care by helping patients acquire healthier lifestyles. Health promotion activities help keep people healthy through exercise, good nutrition, rest, and adopting positive health attitudes and practices.

5. Which of the following patients are at most risk for tachypnea? (Select all that apply.) ch 29 1. Patient just admitted with four rib fractures 2. Woman who is 9 months' pregnant 3. A patient admitted with hypothermia 4. Postoperative patient waking from general anesthesia 5. Three-pack-per-day smoker with pneumonia

Answer: 1, 2, 5. The patient with rib fractures is unlikely to breathe deeply, and a large fetus restricts diaphragmatic movement; both result in decreased ventilatory volume and increased respiratory rate. Pneumonia decreases gas exchange surface area; thus tachypnea occurs to increase minute ventilation. Hypothermia and general anesthesia depress respiratory rates.

6. A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude? ch 15 1. Responsibility 2. Humility 3. Accurate 4. Fairness

Answer: 1. Responsibility involves performing procedures correctly by following standards of care. Accurate, broad, and fair are intellectual standards. Humility is the recognition of when you need more information to make a decision.

9. During a home visit, a patient states, "I am really upset about my heart failure. I can't go out to eat anymore with my friends, I have no energy, and I don't even want to talk on the phone. All I do is focus on how this disease has changed my life and how much time I have left to live." How should the nurse respond? (Select all that apply.) ch 8 1. "Let's talk about going out to lunch. What is making you hesitant about eating with your friends?" 2. "Tell me about what types of activities you were doing before you knew you had heart failure." 3. "Eventually you will get used to all of the changes. You are doing OK." 4. "My mother has heart failure, and she has adjusted to diet, activity, and medication changes." 5. "How has your heart failure affected your energy level?"

Answer: 1, 2, 5. The patient's responses to these statements and questions will help the nurse better understand how heart failure is affecting the patient's ability to cope with the diagnosis and will guide topics for patient education. Option 3 provides false reassurance that is not supportive, and option 4 changes the focus of conversation away from the patient's concerns..

5. A nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started to notice a glare in the lights at home. Her vision is blurred, and she is unable to play cards with her friends, read, or do her needlework. Which of the following nursing interventions are appropriate? (Select all that apply.) ch 14 1. Refer her to an ophthalmologist. 2. Suggest large-print books and playing cards. 3. Reassure her that this is part of normal aging. 4. Suggest lower-wattage light bulbs to decrease glare. 5. Assess her home environment for safety

Answer: 1, 2, 5. This patient most likely has cataracts and should be referred to an ophthalmologist. While common, cataracts are not considered to be part of normal aging. In the meantime, using large-print books or playing cards and reducing home safety hazards would be beneficial. Lower-wattage light bulbs would not be helpful.

9. Which statements properly apply an ethical principle to justify access to health care? (Select all that apply.) ch 22 1. Access to health care reflects the commitment of society to principles of beneficence and justice. 2. If low income compromises access to care, respect for autonomy is compromised. 3. Access to health care is a privilege in the United States, not a right. 4. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. 5. If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.

Answer: 1, 2, and 4. Access to health care services can be justified through the application of the principles of justice, beneficence, respect for autonomy, and nonmaleficence. While option 3 is an opinion that can be justified with ethical analysis, no justification is offered in this statement, so this option is not correct. Option 5 again describes a point of view, but no ethical principles are described that support this view. Option 6 is incorrect because justice refers to fairness in the distribution of resources and basing access to medication only on income may not be fair.

8. Which statements reflect the difficulty that can occur for agreement on a common definition of the word quality when it comes to quality of life? (Select all that apply.) ch 22 1. Community values influence definitions of quality, and they are subject to change over time. 2. Individual experiences influence perceptions of quality in different ways, making consensus difficult. 3. The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. 4. Statistical analysis is difficult to apply when the outcome cannot be quantified. 5. Whether a person has a job is an objective measure, but it does not play a role in understanding quality of life.

Answer: 1, 2, and 4. These statements describe why a single definition for the term quality of life is challenging. Options 3 and 5 are true statements, but they do not explain why the definition of quality of life is difficult to agree on, which is what the question asks for.

10. Which of the following describes a nurse's application of a specific knowledge base during critical thinking? (Select all that apply.) ch 15 1. Initiative in reading current evidence from the literature 2. Application of nursing theory 3. Reviewing a policy and procedure manual 4. Considering a colleague's view of a patient's needs 5. Previous time caring for a specific group of patients

Answer: 1, 2. A nurse's specific knowledge base varies according to educational experience that includes basic nursing education, continuing education courses, and additional college degrees. A nurse also builds knowledge by reading the nursing literature (especially research-based literature) to maintain current knowledge of nursing science and theory

9. Which of the following are examples of the conventional reasoning form of cognitive development? (Select all that apply.) ch 11 1. A 35-year-old woman is speaking with you about her recent diagnosis of a chronic illness. She is concerned about her treatment options in relation to her ability to continue to care for her family. As she considers the options and alternatives, she incorporates information, her values, and emotions to decide which plan will be the best fit for her. 2. A young father is considering whether or not to return to school for a graduate degree. He considers the impact the time commitment may have on the needs of his wife and infant son. 3. A teenage girl is encouraged by her peers to engage in shoplifting. She decides not to join her peers in this activity because she is afraid of getting caught in the act. 4. A single mother of two children is unhappy with her employer. She has been unable to secure alternate employment but decides to quit her current job. 5. A young man drives over the speed limit regularly because he thinks he is an excellent driver and will not get into a car accident.

Answer: 1, 2. A person using conventional reasoning sees moral reasoning based on his or her own personal internalization of societal and others' expectations. A person wants to fulfill the expectations of the family, group, or nation and also to develop a loyalty to and actively maintain, support, and justify the order.

9. Which of the following are common barriers to effective discharge planning? (Select all that apply.) CH 2 1. Ineffective communication among providers 2. Lack of role clarity among health care team members 3. Sufficient number of hospital beds to manage patient volume 4. Patients' long-term disabilities 5. The patient's cultural background

Answer: 1, 2. Barriers to effective discharge planning include ineffective communication, lack of role clarity among health care team members, and lack of resources. The presence of long-term disability is not a barrier but a characteristic of some patients who need greater discharge planning. A patient's cultural background is not a barrier unless you do not consider cultural factors in planning for discharge.

8. A 45-year-old woman who is obese tells a nurse that she wants to lose weight. Which assessment findings may be contributing factors to the woman's obesity? (Select all that apply.) ch 13 1. The woman works in an executive position that is very demanding. 2. The woman says that she has little time to prepare meals at home and eats out at least four nights a week. 3. The woman works out at the corporate gym at 5 am three mornings per week. 4. The woman says that she tries to eat "low-cholesterol" foods to help lose weight. 5. The woman says that she vacations annually to reduce stress

Answer: 1, 2. Demanding and stressful work environments can lead to frequent "stress" eating of non-nutritious foods. Frequently eating away from home and eating fast food have been identified as contributing factors to obesity.

6. A nurse has been caring for a patient over 2 consecutive days. During that time the patient had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks whether the patient feels tenderness when the site is palpated. The nurse reviews the medical record from 24 hours ago and finds the catheter site was without redness or tenderness. Which of the activities below reflect the nurse's ability to perform patient evaluation? (Select all that apply.) ch 20 1. Comparing patient response with previous response 2. Examining results of clinical data 3. Recognizing error 4. Self-reflection 5. Checking medical record for when IV was inserted.

Answer: 1, 2. In this situation the nurse performs evaluation by initially examining the patient and gathering subjective and objective data to compare with previous findings. The data give information about the status of the IV site. At this time no error has been identified and no self-reflection has thus occurred. Checking the medical record for IV insertion is not an evaluation of the effect the IV has on the patient

9. A new nurse graduate is in orientation on a surgical unit and is being mentored by an experienced nurse. Which action completed by the new nurse graduate requires intervention by the experienced nurse? (Select all that apply.) ch 21 1. The new nurse stops documenting about a dressing change to take a patient some water. 2. The new nurse gathered the medications for two different patients at the same time. 3. The new nurse asked an AP to help transfer a patient from the bed to a wheelchair before discharge. 4. The new nurse educates a patient about pain management when administering a pain medication to a patient. 5. The new nurse gathers all equipment necessary to start a new IV site before entering a patient's room.

Answer: 1, 2. Organizational skills help a nurse deliver care safely and effectively. In answer choice 1, the nurse interrupts documentation to attend to a basic patient need. In this situation, the nurse could have asked an AP to get the water or completed documentation and then gotten the water for the patient. Limiting interruptions is important in preventing errors. In answer choice 2, the nurse gathers medications for two patients at one time. Nurses should prepare medications for only one patient at a time to prevent medication errors.

9. The nurse in a new community-based clinic is requested to complete a community assessment. Order the steps for completing this assessment. CH 3 1. Structure or locale 2. Social systems 3. Population

Answer: 1, 3, 2. To begin a community assessment, the structure and geographic boundaries of the community are identified. Look at the structures in the community (e.g., schools, churches, types of residences). Next, obtain data about the population and the demographics of the community. Who are the residents of the community, what is the age range, and which types of ethnicity are represented? Last, review the social systems in the community

6. Intimate partner violence (IPV) is linked to which of the following factors? (Select all that apply.) ch 13 1. Alcohol abuse 2. Marriage 3. Pregnancy 4. Unemployment 5. Drug use

Answer: 1, 3, 4, 5. IPV is linked to harmful health behaviors such as alcohol abuse and drug use. Other risk factors include unemployment and pregnancy

5. One element of clinical decision making is knowing the patient. Which of the following activities affect a nurse's ability to know patients better? (Select all that apply.) ch 15 1. Caring for similar groups of patients over time 2. Reading the evidence-based practices appropriate to patients 3. Learning how patients typically respond to their clinical situations 4. Observing patients 5. Engaging with patients experiencing illness

Answer: 1, 3, 4, 5. Knowing the patient includes a nurse's understanding of a specific patient and his or her subsequent selection of interventions. Knowing the patient relates to a nurse's experience with caring for patients, time spent in a specific clinical area, and having a sense of closeness with patients. Reading evidence-based practices builds your knowledge about nursing science but does not provide the knowledge needed through engaging with and observing patients.

6. Which of the following factors should be considered when choosing an intervention for a patient's plan of care? (Select all that apply.) ch 18 1. The specific patient outcome against which to judge effectiveness of interventions 2. The timing of care activities routinely conducted on the care unit 3. The scientific evidence available in support of an intervention 4. The amount of time required for implementation in consideration of patient's condition 5. The patient's values and beliefs regarding the intervention

Answer: 1, 3, 4, 5. When choosing interventions, consider six important factors: (1) desired patient outcomes, (2) characteristics of the nursing diagnosis, (3) research base knowledge for the intervention, (4) feasibility for doing the intervention, (5) acceptability to the patient, and (6) your own competency

7. Which of the following statements related to theory-based nursing practice are correct? (Select all that apply.) ch 4 1. Nursing theory differentiates nursing from other disciplines. 2. Nursing theories are standardized and do not change over time. 3. Integrating theory into practice promotes coordinated care delivery. 4. Nursing knowledge is generated by theory. 5. The theory of nursing process is used in planning patient care. 6. Evidence-based practice results from theory-testing research.

Answer: 1, 3, 4, 6. The overall goal of nursing knowledge is to explain the practice of nursing as different and distinct from the practice of medicine, psychology, and other health care disciplines. Theory generates nursing knowledge for use in practice, thus supporting evidence-based practice. The integration of theory into practice leads to coordinated care delivery and therefore serves as the basis for nursing. Although the nursing process is central to nursing, it is not a theory. Nursing theories are not stagnant and continue to evolve over time.

10. After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply.) ch 31 1. Assess the injection site. 2. Administer an oral medication for pain. 3. Notify the patient's health care provider of assessment findings. 4. Document assessment findings and related interventions in the patient's medical record. 5. This is a normal finding, so nothing needs to be done. 6. Apply ice to the site for relief of burning pain.

Answer: 1, 3, 4. Assessing the injection site may reveal a site reaction or induration from the injection. The health care provider needs to be notified in case there is an adverse effect from the injection. The nurse must always document adverse effects so that the site and patient can be monitored.

3. Which of the following statements correctly describes the evaluation process? (Select all that apply.) ch 20 1. Evaluation involves reflection on the approach to care. 2. Evaluation involves determination of the completion of a nursing intervention. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is performed only when a patient's condition changes.

Answer: 1, 3, 4. Evaluation is an ongoing process that involves reflection, clinical decision making, and the use of assessment skills to determine patient progress. It is not a determination of whether a nursing intervention was completed, but rather the effect of the intervention. An ongoing evaluation allows a nurse to determine whether a patient's condition has changed.

3. A nurse working on a medicine unit in the hospital hears the fire alarm go off. As the nurse walks down the hallway, there is smoke coming from the family waiting area. Which of the following steps should the nurse take? (Select all that apply.) ch 27 1. Immediately phone in to the hospital alert system the exact location of the fire. 2. Direct the nurse technician to place empty stretchers behind the fire doors. 3. Go to each patient room, and direct ambulatory patients to walk themselves to a safe area. 4. Work with the nurse technician to help move patients requiring wheelchairs from their rooms. 5. Close the room doors of patients who cannot get out of bed, and keep them in their rooms

Answer: 1, 3, 4. If a fire occurs in a health care agency, protect patients from immediate injury, report the exact location of the fire, contain it, and extinguish it if possible. The nurse should alert the hospital about the fire immediately. The nurse technician should not place stretchers behind fire doors; the fire doors need to be able to close when a fire alarm sounds. It is important to keep equipment from blocking these doors. Patients who are close to a fire, regardless of its size, are at risk of injury and need to be moved to another area. Direct all ambulatory patients to walk by themselves to a safe area. In some cases, they can help move patients in wheelchairs. Move patients who cannot get out of bed from the scene of a fire by a stretcher, their bed, or a wheelchair. Do not leave them in their rooms.

3. A nurse is caring for a 66-year-old patient who lives alone and is receiving chemotherapy and radiation for a new cancer diagnosis. He is unable to care for himself because of severe pain and fatigue. He moves into his 68-year-old brother's home so his brother can help care for him. Which assessment findings indicate that this family caregiving situation will be successful? (Select all that apply.) ch 10 1. Both the patient and his brother attend church together regularly. 2. The brothers are living together and enjoy eating the same foods. 3. Other siblings live in the same city and are willing to help. 4. The patient and his brother have a close network of friends. 5. The patient has obsessive-compulsive disorder and has difficulty throwing away possessions.

Answer: 1, 3, 4. Many older adults use their faith and spirituality to cope with life changes. Having a close social network and other family members who are willing to assist with caregiving helps to alleviate the stress experienced by caregivers. Potential risk factors for caregiver distress and burden in this relationship include that the brothers are living together and that one of the brothers has a mental illness.

6. Which of the following are outcomes measurements? (Select all that apply.) ch 5 1. A nurse teaches a patient how to administer an injection and then observes the patient do a return demonstration. 2. A nurse implements a new pain-management protocol and checks patients' charts to confirm whether interventions are being provided. 3. A nursing unit adopts a set of strategies for reducing pressure injuries, and the UPC members use direct observation of the skin to measure incidence of pressure injuries. 4. A nursing unit implements a new fall-prevention protocol and checks the monthly performance data for incidence of falls on the unit. 5. A nursing unit implements a patient rounding program, and the charge nurse watches the assistive personnel to see whether hourly rounding is being done on patients.

Answer: 1, 3, 4. Outcomes measurements are the observable or measurable effects of health care interventions. A nurse observing a patient's return demonstration, direct observation of patients' skin to measure incidence of pressure injuries, and checking the monthly performance data for incidence of falls are all outcome measures. The other options are examples of process measurements.

4. A nurse in a community health clinic has been caring for a young female teenager with diabetes for several months. The nurse's goal of care for this patient is to achieve self-management of insulin medication. Identify appropriate evaluative measures for self-management for this patient. (Select all that apply.) ch 20 1. Quality of life 2. Patient satisfaction 3. Clinic follow-up visits 4. Adherence to self-administration of insulin 5. Description of side effects of medications

Answer: 1, 3, 4. Quality of life is a standard measure for patients with a chronic disease such as diabetes. Adherence to medication administration, demonstrated psychomotor skill (e.g., self-injection), and adherence to medical follow-up visits are common measures of health behavior. Patient satisfaction is not a measure as to whether the patient is managing her diabetes. Description of side effects measures knowledge, not self-management, although knowledge may assist a patient to better self-manage a problem.

7. Which are examples of positive health habits that may prevent the development of chronic illness later in life? (Select all that apply.) ch 13 1. Routine screening and diagnostic tests 2. Unprotected sexual activity 3. Regular exercise 4. Consistent seat belt use 5. Excess alcohol consumption

Answer: 1, 3, 4. Routine screening and diagnostic tests (i.e., laboratory screening for serum cholesterol or serum glucose levels, mammography or colonoscopy) will provide early detection of health issues. Regular exercise helps maintain weight and improve musculoskeletal functioning. Seat belt use saves lives and reduces the extent of injury in motor vehicle accidents

2. Which complementary therapies are most easily learned and applied by a nurse? (Select all that apply.) ch 32 1. Therapeutic massage therapy 2. Traditional Chinese medicine 3. Progressive relaxation 4. Breathwork and guided imagery 5. Therapeutic touch

Answer: 1, 3, 4. These are nurse-accessible complementary therapies. A simple back rub can be administered by nurses. Therapeutic massage therapists are licensed by local governmental agencies, and additional educational preparation is required to practice. Traditional Chinese medicine practitioners also attend training/educational programs, typically accredited by the Accreditation Commission for Acupuncture and Oriental Medicine

10. Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.) ch 16 1. Recognize normal changes associated with aging. 2. Avoid direct eye contact. 3. Lean forward and smile as you pose questions. 4. Allow for pauses as patient tells his story. 5. Use the list of questions from the clinic assessment form to complete all data

Answer: 1, 3, 4. When assessing older adults, listen patiently and allow for pauses and time for patients to tell their story. Do not just focus on the list of questions on an assessment form. The questions might not be relevant to the patient's problems. Recognize normal changes associated with aging. Older-adult symptoms are often muted or less obvious, vague, or nonspecific compared with younger adults. Maintain a patient-directed gaze. Eye contact shows interest in what the patient is saying.

7. Put the following steps for removal of protective barriers after leaving an isolation room in order. ch 28 1. Remove and dispose of gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side

Answer: 1, 3, 5, 4, 2 Removing isolation PPE correctly decreases the risk of self-contamination. The gloves are considered the most contaminated pieces of PPE and are therefore removed first. The face shield or goggles are next because they interfere with removal of other PPE. The gown is third, followed by the mask or respirator

6. Which of the following describe characteristics of an integrated health care system? (Select all that apply.) CH 2 1. The focus is holistic. 2. Participating hospitals follow the same model of health care delivery. 3. The system coordinates a continuum of services. 4. The focus of health care providers is finding a cure for patients. 5. Members of the health care team link electronically to use the EMR to share the patient's health care record

Answer: 1, 3, 5. Integrated health care systems are shifting to more holistic approaches to health care. At the core of this shift is provision of a coordinated continuum of services for enhancing the health status of defined populations. There is no single model for an integrated health care system. Two types of integrated health care delivery systems are common: an organizational structure that follows economic imperatives and a system that supports an organized care delivery approach. Patient-centered medical home care is an example; members of the care team are linked by information technology, electronic health records, and system-best practices to ensure that patients receive care when and where they need it, and how they want it

1. A nurse is completing an assessment on a 27-year-old female patient. Which questions best assess the psychosocial aspects of this young woman's health? (Select all that apply.) ch 13 1. Do you feel safe in your home and at work? 2. How many fruits and vegetables do you typically eat every day? 3. Describe your relationship with your family. 4. Have you had the vaccine to prevent HPV? 5. What are your long-term career goals?

Answer: 1, 3, 5. Young adults need physical and emotional resources and support systems to meet the many challenges, tasks, and responsibilities they face. Asking assessment questions such as feeling safe at home and at work, satisfaction with family relationships, and identifying long-term career goals provides information about the young adult's psychosocial health that supports successful maturation in this developmental stage. Assessment questions about the intake of fruits and vegetables and the HPV vaccine do not assess the patient's psychosocial health.

4. The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other approaches to ethical problems? (Select all that apply.) ch 22 1. Ethics of care pays attention to the context in which caring occurs. 2. Ethics of care is used only by nurses because it is part of the Nursing Code of Ethics. 3. Ethics of care requires understanding the relationships between involved parties. 4. Ethics of care considers the decision maker's relationships with other involved parties. 5. Ethics of care is an approach that suggests a greater commitment to patient care. 6. Ethic of care considers the decision maker to be in a detached position outside the ethical problem.

Answer: 1, 3, and 4. The ethics of care emphasizes attention to the context in which an ethical problem occurs and the relationships between involved parties, including relationships with the decision maker. No approach to ethical problems is exclusive to a single discipline, and no approach is superior to the others nor does any approach demonstrate a higher level of commitment to the patient, so options 2 and 5 are incorrect. Option 6 is true of principle-based approaches such as deontology but not true of the ethics of care.

1. Setting priorities for a patient's nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care? (Select all that apply.) ch 18 1. Priority setting establishes a preferential order for nursing interventions. 2. In most cases wellness problems take priority over problem-focused problems. 3. Recognition of symptom patterns helps in understanding when to plan interventions. 4. Longer-term chronic needs require priority over short-term problems. 5. Priority setting involves creating a list of care tasks.

Answer: 1, 3. Priority setting is the ordering of nursing diagnoses or patient problems to establish a preferential order for nursing interventions. Generally, actual needs and problems take priority over wellness, possible risk, and health promotion problems. Short-term acute patient care needs and problems typically take priority over longer-term chronic needs. Priority setting is not the ordering of a list of care tasks, but an organization of the desired outcomes for a patient. Symptom pattern recognition from your patient assessment and certain knowledge triggers help you understand which diagnoses require intervention and the associated time frame to intervene effectively

2. Before implementing touch, what does a nurse need to know about touch? (Select all that apply.) ch 7 1. Some cultures may have specific restrictions about non-skillbased touch. 2. Touch is a type of verbal communication. 3. Touch can successfully influence a patient's level of comfort. 4. There is never a problem with using touch at any time. 5. Touch only reduces physical pain.

Answer: 1, 3. Some cultures have restrictions as to who can touch and when to touch. Assess your patient to determine whether there are any restrictions. Touch is a method of nonverbal communication. Touch can help improve a patient's sense of comfort and leads to a connection between nurse and patient. Not all patients perceive touch to be therapeutic. Know and understand whether your patients accept touch and how they interpret your intentions. Touching a patient can reduce physical pain and discomfort and decrease anxiety and fear.

7. A nurse in a community health clinic reviews screening results from students in a local high school during the most recent academic year. The nurse discovers a 10% increase in the number of positive tuberculosis (TB) skin tests when comparing these numbers to the previous year. The nurse contacts the school nurse and the director of the health department. Together they begin to expand their assessment to all students and employees of the school district. The community nurse was acting in which nursing role(s)? (Select all that apply.) CH 3 1. Epidemiologist 2. Counselor 3. Collaborator 4. Case manager 5. Caregiver

Answer: 1, 3. When the community health nurse initially noticed an increase in the number of positive TB skin tests, the nurse was comparing current data with previous data to track positive skin test rates. Once the increase was noted, the community health nurse collaborated with the school nurse and other members of the health department to determine the impact of the increased positive TB skin tests.

8. A nurse demonstrates caring by helping family members to: (Select all that apply.) ch 7 1. Become active participants in care. 2. Remove themselves from personal care. 3. Make health care decisions for the patient. 4. Plan uninterrupted time for family and patient to be together. 5. Discuss their concerns.

Answer: 1, 4, 5. Caring for the family takes into consideration the context of the patient's illness and the stress that it imposes on all members. Encouraging family members to provide some care and discuss concerns helps the family to feel involved. Last, providing time for the family to just be together without any "care tasks" or interruptions encourages "presence" for the patient and family.

10. A 71-year-old patient enters the emergency department after falling down stairs at church. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.) ch 14 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness 5. Exercise history

Answer: 1, 4, 5. Risk factors for falling include sensory changes such as visual loss, musculoskeletal conditions affecting mobility (in this case weakness), and deconditioning (from lack of exercise). The mere presence of a chronic disease is not a risk factor unless it is a condition such as a neurological disorder that alters mobility or cognitive function. The patient's blood pressure is stable, and there is no report of orthostatic hypotension. A one-floor residence should not pose risks.

8. Two nurses are revising a self-management education program to help patients better manage their asthma. What strategies are most important for them to include in the program? ch 8 1. Have patients list the medications they are prescribed to take and describe any problems they are having with their medications. 2. Create a common set of patient goals that the patients will work toward as a group. 3. Look for group leaders who are health care providers that are respected by the community. 4. Provide information on how to balance activities during the day. 5. Ask patients to discuss how other people in their family react to them now that they have asthma.

Answer: 1, 4, 5. Self-management education (SME) programs provide evidence-based interventions to help patients with chronic diseases manage their illness and its related symptoms. Current evidence shows that patients need to identify and work on their individual goals. Also offering small, highly interactive group workshops that are facilitated by highly trained leaders who have health challenges of their own is very effective; respected health care providers may not have the personal experience with asthma needed to effectively lead group discussions. Providing strategies, such as how to deal with fatigue, isolation, medication management, and effective communication with family, friends, and health care professionals, helps engage patients in making healthy lifestyle changes

8. At a well-child examination, the mother comments that her toddler eats little at mealtime, will sit only briefly at the table, and wants snacks all the time. Which of the following should the nurse recommend? (Select all the apply.) ch 12 1. Provide nutritious snacks for a healthy diet. 2. Offer rewards for eating at mealtimes. 3. Avoid snacks so she is hungry at mealtime. 4. Offer finger foods so she can eat as she walks. 5. Explain to her why eating at mealtime is important.

Answer: 1, 4. Mealtime has psychosocial and physical significance. If the parents struggle to control toddlers' dietary intake, problem behavior and conflicts can result. Toddlers often develop "food jags," or the desire to eat one food repeatedly. Rather than becoming disturbed by this behavior, encourage parents to offer a variety of nutritious foods at meals and to provide only nutritious snacks between meals. Toddlers are unlikely to sit down at the table for extended meals, so finger foods are recommended.

4. Which of the following best describe a collaborative health problem? (Select all that apply.) ch 17 1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status 2. The language medical practitioners use to communicate a patient's health problem and associated treatments and response 3. A diagnostic label that classifies a patient's response to illness so that all nurses can be familiar with a specific patient's health care needs 4. A language used by health care providers to communicate and consider each other's unique perspective, so they can better manage the multiple factors that influence the health of individuals 5. A diagnosis that provides clear direction as to the type of nursing interventions nurses are licensed to provide independently

Answer: 1, 4. Option 2 describes a medical diagnosis, and options 3 and 5 describe a nursing diagnosis. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status. Nurses intervene in collaboration with personnel from other health care disciplines to manage collaborative problems.

2. A 9-year-old child has a difficult time making friends at school and being chosen to play on the team. He also has trouble completing his homework and, as a result, receives little positive feedback from his parents or teacher. According to Erikson's theory, failure at this stage of development results in: (Select all that apply.) ch 11 1. Feelings of inadequacy. 2. A sense of guilt. 3. A poor sense of self. 4. Feelings of inferiority. 5. Mistrust.

Answer: 1, 4. School-age children need to feel real accomplishment and be accepted by peers to develop a sense of industry. Without proper support for learning new skills, or if skills are too difficult, they develop a sense of inadequacy and inferiority

6. A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) ch 14

Answer: 1, 4. The psychosocial stresses of retirement are usually related to role changes with a spouse or within the family and to loss of the work role. Often there are new expectations of the retired person. This patient is not likely to become socially isolated because of the size of the family. Whether the wife will have to work is not a major concern at this time, nor is the age of the patient.

4. Which of the following actions, if performed by a registered nurse, could result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) ch 23 1. Reviewing the electronic health record of a family member who is a patient in the same hospital on a different unit 2. Refusing to provide health care information to a patient's child 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written order 5. Completing an occurrence report on the unit

Answer: 1, 4. Viewing a family member's electronic health record violates the patient's rights provided by HIPAA. A physical restraint can be applied only on the written order of a health care provider based on The Joint Commission and Medicare guidelines

4. Sequence the skills in the expected order of gross-motor development in an infant, beginning with the earliest skill. ch 12 1. Can lift head 45 degrees off table, when prone 2. Pulls self to standing position 3. Sits upright without support 4. Rolls from back to abdomen 5. Rolls from abdomen to back

Answer: 1, 5, 4, 3, 2. Although the pace of growth and development varies for each individual, it usually follows the same pattern. Lifting of head while prone occurs first, followed by turning and rolling, and then sitting, followed by standing.

4. A patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been praying daily to help him through this difficult time. He does not have a primary health care provider because he has never really been sick, and his parents never took him to a physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) ch 6 1. Difficulty paying his bills 2. Praying daily 3. Age of patient (46 years) 4. Stress from the divorce and the loss of a job 5. Family practice of not routinely seeing a health care provider

Answer: 1, 5. External factors impacting health practices include family beliefs and economic impact. The way that patients' families use health care services generally affects their health practices. Their perceptions of the seriousness of diseases and their history of preventive care behaviors (or lack of them) influence how patients think about health. Economic variables may affect a patient's level of health by increasing the risk for disease and influencing how or at what point the patient enters the health care system

6. A patient is in skeletal traction and has a plaster cast due to a fractured femur. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.) ch 23 1. Failure to document a change in assessment data 2. Failure to provide discharge instructions 3. Failure to provide patient education about cast care. 4. Failure to use proper medical equipment ordered for patient monitoring 5. Failure to notify a health care provider about a change in the patient's condition

Answer: 1, 5. The failure to document a change in assessment data and the failure to notify a health care provider about a change in patient status reflect a breach of duty to the patient.

9. A healthy adult patient tells the nurse that he obtained his blood pressure in "one of those quick machines in the mall" and was alarmed that it was 152/72 when his normal value ranges from 114/72 to 118/78. The nurse obtains a blood pressure of 116/76. What would account for the blood pressure of 152/92? (Select all that apply.) ch 29 1. Cuff too small 2. Arm positioned above heart level 3. Slow inflation of the cuff by the machine 4. Patient did not remove his long-sleeved shirt 5. Insufficient time between measurements

Answer: 1, 5. Using too small of a cuff and not allowing for insufficient time between measurements will result in false-high readings. Arm above heart level and slow inflation result in false low readings.

5. From the following list of indicators, determine which indicators are goals (G) and which indicators are outcomes (O). ch 20 1. _____ Will achieve pain relief 2. _____ Ambulates 10 feet down hallway 3. _____ Will remain free of infection 4. _____ Will be afebrile 5. _____ Reports pain severity reduced from 6 to a 4 on scale of 0 to 10 6. _____ Will gain improved mobility

Answer: 1-goal, 2-outcome, 3-goal, 4-goal, 5-outcome, 6-goal. A nursing plan of care includes mutually established goals and nurse-sensitive outcomes relevant to a patient's health status. Goals are broad statements that describe a desired change in a patient's condition, perceptions, or behavior. A nurse-sensitive outcome is a state, behavior, or perception that is measured along a continuum in response to a nursing intervention

4. The nurse asks a patient the following series of questions: "Describe for me how much you exercise each day." "How do you tolerate the exercise?" "Is the amount of exercise you get each day the same, less, or more than what you did a year ago?" This series of questions would likely occur during which phase of a patient-centered interview? ch 16 1. Orientation 2. Working phase 3. Data interpretation 4. Termination

Answer: 2. The working phase of a relationship involves gathering accurate, relevant, and complete information about a patient's condition. It usually begins with open-ended questions.

5. Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need? ch 17 1. Patient obtains social support care related to caregiver stress 2. Fear related to open-heart surgery 3. Acute Pain related to splinting of incision 4. Impaired Family Coping related to insufficient caregiver support

Answer: 1. A nursing diagnosis must identify a patient response to a health care problem and not the goal of care. Achieving social support would be a goal of care in a plan of care for relieving caregiver stress. Answers 2, and 3 are diagnostic errors: 2 makes the related factor a surgical procedure, 3 uses a symptom as a related factor. 4 is a correctly worded nursing diagnosis.

2. Match the assessment activity on the left with the type of assessment on the right. ch 16 1. Assessment conducted at beginning of a nurse's shift 2. Review of a patient's chief complaint 3. Completion of admitting history at time of patient admission to a hospital 4. Completion of the Long Term Care Minimum Data Set during an elderly patient admission to a nursing home A. Problem focused B. Comprehensive

Answer: 1. A, 2. A, 3. B, 4. B. Assessments can be either comprehensive or problem focused. A periodic assessment is a problem-focused approach that begins with a patient's presenting situation and specific problematic areas. A comprehensive assessment about a patient includes a detailed assessment of a patient's physical, psychosocial, cultural, spiritual, and lifestyle needs.

10. You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first? ch 23 1. Call the nursing supervisor to discuss the situation. 2. Discuss the problem with a colleague. 3. Leave the nursing unit and go home. 4. Say nothing and begin your work.

Answer: 1. Alerting the nursing supervisor as a representative of the hospital administration is the first step in providing notice that a problem may exist related to insufficient staffing. This notice serves to share the burden of knowledge of the staffing inequity issues that may create an unsafe patient situation for the hospital and nursing staff.

3. During a nursing assessment a patient displayed several behaviors. Which behavior suggests the patient may have a health literacy problem? ch 9 1. Patient has difficulty completing a registration form at a medical office 2. Patient asks for written information about a health topic 3. Patient speaks Spanish as primary language 4. Patient states unfamiliarity with a newly ordered medicine

Answer: 1. Behaviors that might reflect a health literacy deficit include having difficulty completing registration forms or health histories, failing to make follow-up appointments, and asking few questions during a nursing history or physical examination.

9. A hospice nurse sits at the bedside of a male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch? ch 7 1. Caring touch 2. Protective touch 3. Task-oriented touch 4. Interpersonal touch

Answer: 1. Caring touch is a form of nonverbal communication. You express this in the way that you hold a patient's hand, give a back massage, gently position a patient, or participate in a conversation. When using a caring touch, you connect with the patient physically and emotionally.

5. A patient who is newly diagnosed with breast cancer states, "Although I am really scared about what is going to happen to me, I know my family will learn from this experience, and we will be stronger in the end." What term does the nurse use in the patient's medical record to describe the characteristic displayed in this statement? ch 10 1. Resiliency 2. End-of-life care 3. Family functioning 4. Family's culture

Answer: 1. Family resiliency helps families maintain a healthy response even when they are experiencing stressful events.

4. When Ryan was 3 months old, he had a toy train; when his view of the train was blocked, he did not search for it. Now that he is 9 months old, he looks for it, reflecting the presence of: ch 11 1. Object permanence. 2. Sensorimotor play. 3. Schemata. 4. Magical thinking.

Answer: 1. He is now in Piaget's later stage of sensorimotor thought and has learned that objects exist even though he cannot see or touch them.

7. Health care reform will bring changes in the emphasis of care. Which of these models is expected from health care reform? CH1 1. Moving from an acute illness to a health promotion, illness prevention model 2. Moving from an illness prevention to a health promotion model 3. Moving from hospital-based to community-based care 4. Moving from an acute illness to a disease management model

Answer: 1. Health care reform also affects how health care is delivered. There is greater emphasis on health promotion, disease prevention, and management of illness.

6. A nurse is caring for a patient newly diagnosed with testicular cancer. He asked the nurse to help him find the meaning of cancer by supporting beliefs about life. This is an example of: ch 7 1. Instilling hope and faith. 2. Forming a human-altruistic value system. 3. Cultural caring. 4. Being with.

Answer: 1. Instilling hope and faith helps increase an individual's capacity to get through an event or transition and face a future with meaning.

10. During an EBP committee meeting, a nurse discussed two systematic integrative reviews related to the use of prepackaged bath kits versus the standard use of bath basins. What level of evidence is the nurse presenting? ch5 1. Level I 2. Level II 3. Level IV 4. Level VI

Answer: 1. Level 1 evidence is the strongest level of evidence. It is comprised of systematic integrative reviews or metaanalyses of randomized and unrandomized clinical trials.

1. A patient discharged a week ago following a stroke is currently participating in rehabilitation sessions provided by nurses, physical therapists, and registered dietitians in an outpatient setting. In what level of prevention is the patient participating? ch 6 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Transtheoretical prevention

Answer: 1. Level 1 evidence is the strongest level of evidence. It is comprised of systematic integrative reviews or metaanalyses of randomized and unrandomized clinical trials. ch 6

5. A nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the following is an appropriate goal for restorative care? CH2 1. Patient will be able to walk 200 feet without shortness of breath. 2. Wound will heal without signs of infection. 3. Patient will express concerns related to return to home. 4. Patient will identify strategies to improve sleep habits.

Answer: 1. Restorative interventions focus on returning patients to their previous level of function or on reaching a new level of function limited by their illness or disability. The goal of restorative care is to help individuals regain maximal functional status and to enhance quality of life through promotion of independence.

2. The licensed practical nurse (LPN) provides you with the changeof-shift vital signs on four of your patients. Which patient does the nurse need to assess first? ch 29 1. 84-year-old man recently admitted with pneumonia, RR 28, SpO2 89% 2. 54-year-old woman admitted after surgery for repair of a fractured arm, BP 160/86 mm Hg, HR 72 3. 63-year-old man with venous ulcers from diabetes, temperature 37.3° C (99.1° F), HR 84 4. 77-year-old woman with left mastectomy 2 days ago, RR 22, BP 148/62

Answer: 1. SpO2 89% is a critical value and requires immediate attention. Other values require attention but are not life threatening

8. Which of the following statements best explains therapeutic touch (TT)? CH 32 1. Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield 2. Intentionally heals tissue damage or corrects certain disease symptoms 3. Is overwhelmingly effective in many conditions 4. Is completely safe and does not warrant any special precautions

Answer: 1. TT is focused on healing the whole person and providing energy to the body that supports innate healing responses. The research literature is questionable; systematic analyses claim that the research designs are too weak for any conclusive evidence to be identified with confidence. Although TT is relatively safe and there have been very few negative events associated with its use, all therapies (complementary or conventional) should be used with caution in certain populations.

9. Which statement made by a new graduate nurse about the teach back technique requires intervention and further instruction by the nurse's preceptor? ch 9 1. "After teaching a patient how to use an inhaler, I need to use the teach-back technique to test my patient's technique." 2. "The teach-back technique is an ongoing process of asking patients for feedback." 3. "Using teach-back will help me identify explanations and communication strategies that my patients will most commonly understand." 4. "Using pictures, drawings, and models can enhance the effectiveness of the teach-back technique."

Answer: 1. Teach-back is not a testing of patient knowledge or ability to use devices but is a confirmation of how well a nurse explains concepts to patients.

10. A nurse is taking care of a patient who has decided to stop smoking cigarettes. Which online resource would provide evidence-based information about smoking cessation? ch 8 1. The American Lung Association online toolkit for smoking cessation 2. An online blog led by a nurse for people discussing smoking cessation 3. A self-help website maintained by a hospital focusing on general wellness behaviors 4. A CDC website that discusses addictive behavior and risk factors

Answer: 1. The American Lung Association has an online toolkit that provides many resources for smoking cessation and would be the best online resource for patient referral. Online blogs may not be evidence-based. The resources in Options 3 and 4 do not provide specific information on how to stop smoking.

1. The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship? ch 30 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history

Answer: 1. The first part of the general survey is assessment of the appearance and behavior of the patient. As you are initiating the nurse-patient relationship, observe gender and race, age, signs of distress, body type, posture, gait, body movement, hygiene and grooming, dress, affect and mood, speech, and signs of patient abuse

7. Resolution of an ethical problem involves discussion with the patient, the patient's family, and participants from appropriate health care disciplines. Which statement best describes the role of the nurse in the resolution of ethical problems? ch 22 1. To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations 2. To study the literature on current research about the possible clinical interventions available for the patient in question 3. To hold a point of view but realize that respect for the authority of administrators and physicians takes precedence over personal views 4. To allow the patient and the physician private time to resolve the dilemma on the basis of ethical principles

Answer: 1. The ideal process for resolving ethical problems engages the perspectives of all involved, and nurses, as members of the health care team, have a valuable and unique point of view to share. Option 2 is a strategy that assists in answering a clinical question but does not address ethics. Options 3 and 4 are incorrect because both suggest that the nurse disengage from her own values and critical thinking and follow an action driven by the points of views of others.

3. The nurse spends time with a patient and family reviewing a dressing change procedure for the patient's wound. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role? CH 1 1. Educator 2. Advocate 3. Caregiver 4. Communicator

Answer: 1. The nurse is demonstrating the role of educator. An educator explains concepts and facts about health, describes the reason for routine care activities, demonstrates procedures such as home-care activities, reinforces learning or patient behavior, and evaluates the patient's progress in learning through return demonstration.

6. When taking care of patients, a nurse routinely asks whether they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? ch 6 1. Holistic 2. Health belief 3. Transtheoretical 4. Health promotion

Answer: 1. The nurse is using a holistic model of care that takes a more holistic view of health by considering emotional and spiritual well-being and other dimensions of an individual to be important aspects of physical wellness. The holistic health model of nursing attempts to create conditions that promote optimal health. Nurses using the holistic nursing model recognize the natural healing abilities of the body and incorporate complementary and alternative interventions such as music therapy, reminiscence, relaxation therapy, therapeutic touch, and guided imagery because they are effective, economical, noninvasive, nonpharmacological complements to traditional medical care.

5. A nurse is conducting a home visit with a new mom and her three children. While in the home the nurse weighs each family member and reviews their 3-day food diary. She checks the mom's blood pressure and encourages the mom to take the children for a 15- to 30-minute walk every day. The nurse is addressing which level of need, according to Maslow? ch 6 1. Physiological 2. Safety and security 3. Love and belonging 4. Self-actualization

Answer: 1. The nurse's actions address the basic physiological needs of nutrition, physical activity, and oxygen. According to Maslow, basic needs must be met before meeting higher level needs.

8. Which explanation provided by the nurse is the most accurate meaning for "providing culturally congruent care"? ch 9 1. It fits the patient's valued life patterns and set of meanings. 2. It is the same set of values as those of the health care team member providing daily care. 3. It holds one's own way of life as superior to those of others. 4. It redirects the patient to a more socially expected set of values.

Answer: 1. The ongoing process of cultural competence refers to the need of the health care professional to be culturally sensitive in providing culturally appropriate care specific to the needs of the patient, family, and community.

1. The nurse is caring for a patient who needs a liver transplant to survive. This patient has been out of work for several months, does not have health insurance, and cannot afford the procedure. Which of the following statements speaks to the ethical elements of this case? ch 22 1. The health care team should select a plan that considers the principle of justice as it pertains to the distribution of health care resources. 2. The patient should enroll in a clinical trial of a new technology that can do the work of the liver, similar to the way dialysis treats kidney disease. 3. The social worker should look into enrolling the patient in Medicaid, since many states offer expanded coverage. 4. A family meeting should take place in which the details of the patient's poor prognosis are made clear to his family so that they can adopt a palliative approach.

Answer: 1. The principle of justice as it pertains to the distribution of health care resources is the ethical element present in option 1. Options 2, 3, and 4 are all potential strategies for assisting this patient, but they do not address the ethical elements of the case

4. The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? ch 19 1. Physical care technique 2. Activity of daily living 3. Indirect care measure 4. Lifesaving measure

Answer: 1. This is an example of a physical care technique

8. A nurse is caring for a patient who recently lost a leg in a motor vehicle accident. The nurse best assists the patient to cope with this situation by applying which of the following theories? ch4 1. Roy 2. Watson 3. Johnson 4. Benner

Answer: 1. When applying Roy's adaptation model, the nurse helps the patient cope with/adapt to changes in physiological, self-concept, role function, and interdependence domains.

6. A nurse is caring for a man who is recently retired and who appears withdrawn. He says he is "bored with life." The nurse helps this individual find meaning in life by: ch 11 1. Encouraging him to reflect on his relationships with others. 2. Encouraging relocation to a new city. 3. Explaining the need to simplify life. 4. Encouraging him to adopt a new pet

Answer: 1. You can enhance feelings of integrity by encouraging older adults to reflect upon meaningful relationships, such as relationships with a higher power, family members, or the community.

7. A nurse on a hospital unit is preparing to hand off care of a patient being discharged to a home health nurse. Match the activities on the left with the hand-off report categories on the right. Activities Categories ch 18 1. Use a standard checklist for the report. 2. Encourage questions and clarification. 3. Offer specific information on how to reduce patient's risks. 4. Give report at time when shift has ended and other nurses are requesting information. 5. Explain how patient's discharge was delayed by insufficient numbers of staff. 6. Organize time by preparing in advance what to report. A. Strategy for Effective Hand-off B. Strategy for Ineffective Hand-of

Answer: 1A, 2A, 3A, 4B, 5B, 6A.

4. Match the threats to safety on the right to the category of risk factors on the left. ch 27 A. Individual Risks B. Developmental Risks 1. An older adult has limited finances. 2. A young toddler likes to explore objects by placing them in his mouth. 3. A 55-year-old patient has a residual gait change due to a stroke. 4. A school-age child chooses to play ice hockey. 5. A patient newly diagnosed with diabetes has low health literacy.

Answer: 1A, 2B, 3A, 4B, 5A. Individual safety risk factors include lifestyle, impaired mobility, sensory or communication impairment, limited economic resources, and a lack of safety awareness. Developmental risks include those unique to each developmental age group, such as a toddler's desire to explore orally

10. Match the fall prevention intervention on the left with the scientific rationale on the right. ch 27 1. Prioritize nurse call system responses to patients at high risk. 2. Place patient in a wheelchair with wedge cushion. 3. Establish elimination schedule with bedside commode. 4. Use a low bed for patient. 5. Provide a hip protector. 6. Place nonskid floor mat on floor next to bed. A. Maintains comfort and makes exit difficult B. Makes it difficult for patients with lower extremity weakness to stand C. Reduces slipping when walking D. Reduces fall impact E. Ensures rapid response for help F. Reduces chance of patient trying to get out of bed on own

Answer: 1E, 2A, 3F, 4B, 5D, 6C

10. Match the following caring behaviors with their definitions. ch 7 1. Knowing 2. Being with 3. Doing for 4. Maintaining belief a. Sustaining faith in the other's capacity to get through an event or transition and face a future with meaning b. Striving to understand an event as it has meaning in the life of the other c. Being emotionally present to the other d. Doing for the other as he or she would do for self if it were at all possible

Answer: 1b, 2c, 3d, 4a. These are from Swanson's theory (see Table 7.2). The theory describes caring as consisting of five categories or processes. Swanson defines caring as a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. This theory supports the claim that caring is a central nursing phenomenon but not necessarily unique to nursing practice.

2. Match the concepts for a critical thinker on the right with the application of the term on the left. Term Application Concepts for Critical Thinkers ch 15 a. Anticipate how a patient might respond to a treatment. ___ 1. Truth seeking b. Organize assessment on the basis of patient priorities. ___ 2. Open-mindedness c. Be objective in asking questions of a patient. ___ 3. Analyticity d. Be tolerant of the patient's views and beliefs.

Answer: 1c, 2d, 3a, 4b.

10. An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. ch 18 Goals Outcomes 1. _____ Patient will ambulate independently in 3 days. 2. _____ Patient will be injury free for 1 month. 3. _____ Patient will achieve 5-pound weight gain in 1 month. 4. _____ Patient will achieve pain relief by discharge. a. Patient expresses fewer nonverbal signs of discomfort within 24 hours. b. Patient increases caloric intake to 2500 calories daily. c. Patient walks 20 feet using a walker in 24 hours. d. Patient identifies barriers to remove in the home within 1 week.

Answer: 1c, 2d, 3b, 4a.

5. Match the following types of theory with the appropriate description. ch 4 1. Middle-range theory 2. Shared theory 3. Grand theory 4. Practice theory a. Very abstract; attempts to describe nursing in a global context b. Specific to a particular situation; brings theory to the bedside c. Applies theory from other disciplines to nursing practice d. Addresses a specific phenomenon and reflects practice

Answer: 1d, 2c, 3a, 4b.

10. Match the following actions (1 through 4) with the terms (a through d) listed below: ch 22 a. Advocacy b. Responsibility c. Accountability d. Confidentiality 1. You see an open medical record on the computer and close it so that no one else can read the record without proper access. 2. You administer a once-a-day cardiac medication at the wrong time, but nobody sees it. However, you contact the provider and your head nurse and follow agency procedure. 3. A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patient's request. 4. You tell your patient that you will return in 30 minutes to give him his next pain medication.

Answer: 1d, 2c, 3a, 4b. Action 1 corresponds with option d. Preventing unnecessary access to a patient's health care information protects the patient's right to confidentiality. Action 2 corresponds to option c, accountability. Accountability refers to taking ownership of one's actions, which includes acknowledging errors. Action 3 corresponds to option a, advocacy. Sharing the patient's stated wish with other members of the health care team is an example of using your voice to benefit another person, in this case the patient. Action 4 corresponds with option b, responsibility. By following through on an established plan in caring for the patient, the nurse demonstrates responsibility.

6. Match the following descriptions to the appropriate grand theorist ch 4 1. King 2. Henderson 3. Orem 4. Neuman a. Based on the theory that focuses on wellness and prevention of disease b. Based on the belief that people who participate in self-care activities are more likely to improve their health outcomes c. Based on 14 activities, the belief that the nurse should assist patients with meeting needs until they are able to do so independently d. Based on the belief that nurses should work with patients to develop goals for care

Answer: 1d, 2c, 3b, 4a

6. The nurse is assessing the cranial nerves. Match the cranial nerve with its related function. ch 30 Cranial Nerves Cranial Nerve Function 1. XII Hypoglossal 2. V Trigeminal 3. VI Adducens 4. IV Trochlear 5. X Vagus a. Motor innervation to the muscles of the jaw b. Lateral movement of the eyeballs c. Sensation of the pharynx d. Downward, inward eye movements e. Position of the tongue

Answer: 1e, 2a, 3b, 4d, 5c

10. Patient-to-patient transmission of infection cannot occur if gloves are routinely used. ch 28 1. True 2. False

Answer: 2 Although gloves are an additional tool to decrease the spread of infection from patient to patient, touching gloves with unclean hands as you put them on contaminates the gloves so that they are no longer clean

2. A patient is diagnosed with meningitis. Which type of isolation precaution is most appropriate for this patient? ch 28 1. Reverse isolation 2. Droplet Precautions 3. Standard Precautions 4. Contact Precautions

Answer: 2 Because the patient is diagnosed with meningitis, which can be spread when the patient coughs or sneezes, droplet precautions are most appropriate.

8. A nurse is assigned to care for a woman who is expecting her first child. The nurse organizes herself and plans to gather data about the patient by applying Pender's health promotion model, including the patient's characteristics and experiences and situational influences. She plans to observe patient behavior and consider the patient's psychosocial issues. Such data will offer a clear understanding to help the nurse identify the patient's needs. This is an example of which of the following concepts? (Select all that apply.) ch 15 1. Diagnostic reasoning 2. Deductive reasoning 3. Inductive reasoning 4. Assessment 5. Problem solving

Answer: 2 and 4. Assessment involves data gathering to improve knowledge about patients and to recognize patterns of data that reveal problems. Deductive reasoning moves from the general to the specific. A nurse will start analysis of the facts and observations about a patient from a conceptual viewpoint, such as Nola Pender's health promotion model. Then the nurse forms an inference and eventually interprets the patient's condition with respect to the conceptual view

4. A patient presents in the clinic with dizziness and fatigue. The assistive personnel (AP) reports a slow but regular radial pulse of 44. Place the following care activities in priority order. ch 29 1. Direct the AP to obtain a blood pressure. 2. Request that the patient lie on the clinical stretcher. 3. Assess the patient's apical pulse for a full minute. 4. Prepare to administer cardiac-stimulating medications

Answer: 2, 1, 3, 5, 4. The first priority is patient safety. Getting the patient to lie on a stretcher prevents falls. Directing the AP to obtain BP relates to the patient's symptom of dizziness while the nurse assesses apical pulse. If BP is abnormal, the nurse should recheck value. Oxygen saturation can be obtained quickly. The patient may require medications to increase heart rate

5. A nurse is administering ophthalmic ointment to a patient. Place the following steps in correct order for the administration of the ointment. ch 31 1. Clean eye, washing from inner to outer canthus. 2. Assess patient's level of consciousness and ability to follow instructions. 3. Apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva. 4. Have patient close eye and rub lightly in a circular motion with a cotton ball. 5. Ask patient to look at ceiling, and explain the steps to patient.

Answer: 2, 1, 5, 3, 4. This is the correct order for safe administration of ophthalmic ointment.

6. Which of the following actions by the nurse demonstrate the practice of core principles of surgical asepsis? (Select all that apply.) ch 28 1. The front and sides of the sterile gown are considered sterile from the waist up. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. After cleansing the hands with antiseptic rub, apply clean disposable gloves

Answer: 2, 3 Maintaining sterility throughout the procedure requires constant vigilance and strict rules to ensure sterility, such as keeping the sterile field in sight at all times, making sure everyone in the room is in protective clothing like gowns, masks, eyewear and gloves, and considering anything beyond the front or below the waist of the gown to be contaminated. To make sure the sides of the sterile field are not contaminated, there is an outer one-inch border not considered sterile

8. A nurse reviews data gathered regarding a patient's response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in? (Select all that apply.) ch 17 1. Data collection 2. Data clustering 3. Data interpretation 4. Making a diagnostic statement 5. Goal setting

Answer: 2, 3 and 4. Data interpretation involves analyzing assessment findings and then involves placing a label on a data pattern or cluster to clearly identify the patient's response to health problems. Critical thinking is necessary. The interpretation of data clusters or patterns leads to the selection of various nursing diagnoses that may apply to a patient. It is important to compare the data in a cluster with the data standards for a diagnosis to come to a reasoned conclusion in making an accurate nursing diagnosis. In this case the nurse did not gather additional data, so avoidance of an error in data collection is not a correct response. Goal setting is not part of the nursing diagnosis process.

10. A nurse is calling a patient's health care provider about a problem the patient is having following surgery. The health care organization uses the SBAR system in reporting patient problems. Put the statements in order according to the SBAR system. ch 21 1. Would it be possible to give the patient an antiemetic to help with the patient's nausea and comfort? 2. The patient is experiencing nausea right now. The nausea has worsened over the past hour. He states he feels as though he is going to get sick. 3. The patient had surgery earlier today to remove a tumor in the colon. He was admitted to the surgical unit 4 hours ago. He has a nasogastric (NG) tube in place. There is no postoperative order for an antiemetic. 4. The patient denies pain and vital signs are stable. B/P 114/68; pulse 76; respiratory rate 20; temperature 98.6° F. The surgical dressing is dry and intact. The NG tube is intact and draining light brown fluid. It flushes well, and placement was confirmed using pH testing of gastric contents. The patient does not want to roll onto his side because of the nausea.

Answer: 2, 3, 4, 1. SBAR provides a consistent way to communicate patient problems. In this example, the Situation (S) is that the patient is experiencing nausea. Next the nurse provides the Background (B) about the patient's surgery and current orders. Then the nurse provides Assessment (A) data about the patient's current status. Finally, the nurse provides a Recommendation (R) to administer an antiemetic medication

8. Which of the following are symptoms of secondary traumatic stress and burnout that commonly affect nurses? (Select all that apply.) ch 6 1. Regular participation in a book club 2. Lack of interest in exercise 3. Difficulty falling asleep 4. Lack of desire to go to work 5. Anxiety while working

Answer: 2, 3, 4, 5. Nurses are particularly susceptible to the development of secondary traumatic stress and burnout—the components of compassion fatigue. Symptoms include decline in health, emotional exhaustion, irritability, restlessness, impaired ability to focus and engage with patients, feelings of hopelessness, inability to take pleasure from activities, and anxiety

5. The nurse is teaching a patient to prevent heart disease. Which information should the nurse include? (Select all that apply.) ch 30 1. Add salt to every meal. 2. Talk with your health care provider about taking a daily low dose of aspirin. 3. Work with your health care provider to develop a regular exercise program. 4. Limit daily intake of fats to less than 25% to 35% of total calories. 5. Review strategies to encourage the patient to quit smoking.

Answer: 2, 3, 4, 5. Teaching about prevention of heart disease focuses on risk factor reduction. Smoking, lack of regular aerobic exercise, and a diet high in sodium and fats are three major risk factors that can be modified. Quitting smoking, regular exercise, and a diet with lower sodium and fat intake are preventive measures. Low-dose aspirin has been shown to be beneficial in reducing the risk of heart disease.

1. At 1200 the registered nurse (RN) says to the assistive personnel (AP), "You did a good job walking Mrs. Taylor by 0930. I saw that you recorded her pulse before and after the walk. I saw that Mrs. Taylor walked in the hallway barefoot. For safety, the next time you walk a patient, you need to make sure that the patient wears slippers or shoes. Please walk Mrs. Taylor again by 1500." Which characteristics of positive feedback did the RN use when talking to the AP? (Select all that apply.) ch 21 1. Feedback is given immediately. 2. Feedback focuses on one issue. 3. Feedback offers concrete details. 4. Feedback identifies ways to improve. 5. Feedback focuses on changeable things. 6. Feedback is specific about what is done incorrectly only.

Answer: 2, 3, 4, 5. These are characteristics of good feedback. The nurse gives feedback on the process of the AP monitoring and ambulating a patient. The other options are not appropriate because the RN did not provide feedback immediately (the AP performed the task in the morning, but the feedback was not given until the afternoon), and you should give both positive feedback as well as feedback to improve the incorrectly done tasks

3. A nurse is teaching the mother of a young infant about prevention of sudden infant death syndrome (SIDS). Which of the following statements indicates that the teaching has been effective? (Select all that apply.) ch 12 1. "I'll let the baby sleep in bed with me so I can watch her." 2. "I'll remove stuffed animals and pillows from the crib." 3. "I'll place my baby on her back for sleep." 4. "I'll be sure to keep my baby's room cool." 5. "I'll keep a crib bumper in the bed to prevent drafts."

Answer: 2, 3, 4. Safeguards that reduce the risk of SIDS include proper positioning on the back; removing stuffed animals, soft bedding, and pillows; and avoiding overheating the infant.

5. Which of the following are strategies for creating work environments that support nurse caring interventions? (Select all that apply.) ch 7 1. Increasing technological support 2. Improving flexibility for scheduling 3. Providing opportunities to discuss care 4. Promoting autonomy of practice 5. Encouraging increased input concerning nursing functions from health care providers

Answer: 2, 3, 4. These factors all affect nursing satisfaction. When nurses' job satisfaction is high, nurses are more connected with their patients and view their caring practices as part of the nursing culture. Increasing technology frequently removes the nurse from patient care and can have a negative impact on job satisfaction.

6. A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order ch 17 1. Consider the context of patient's health problem and select a related factor. 2. Review assessment data, noting objective and subjective clinical information. 3. Cluster clinical data elements that form a pattern. 4. Identify appropriate assessment findings for diagnosis. 5. Identify a nursing diagnosis.

Answer: 2, 3, 5, 1, 4.

6. A nurse working the night shift is assigned a patient who has a history of having fallen in the hospital during a previous admission. The nurse wants to review the admission assessment completed by the nurse on the day shift. Which of the following sections in the assessment are most likely to provide information about the patient's current fall risks? (Select all that apply.) ch 27 1. Allergy history 2. Medication history 3. Patient age 4. Patient's occupation 5. Physical exam of neuromuscular function

Answer: 2, 3, 5. A patient's age will reveal his or her developmental status. The medication history is important to determine whether the patient is taking medications that typically predispose patients to falling. The examination of neuromuscular function will reveal whether the patient has any problems with cognitive status, muscle strength and coordination, balance, and gait—all of which can predispose to falls. The allergy history and occupational history will not reveal risk factors for patients to fall.

8. A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse asks about his ability to complete activities of daily living (ADLs). ADLs include independence with: (Select all that apply.) ch 14 1. Driving. 2. Toileting. 3. Bathing. 4. Daily exercise. 5. Eating.

Answer: 2, 3, 5. Activities of daily living are self-care tasks that measure function and are markers for the ability to live independently. Although driving and daily exercise are important to quality of life and health maintenance, they would not necessarily impact a person's ability to live independently

1. A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) ch 14 1. The center needs to be clean, and rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides three meals daily with a set menu and serving schedule. 5. Staff encourage family involvement in care planning and assisting with physical care

Answer: 2, 3, 5. Adequate staffing, provision of social activities, and active family involvement are essential. Meals should be high quality with options for what to eat and when it is served. A nursing center should be clean, but it should look like a person's home rather than a hospital.

10. The nurse assesses the risk factors for coronary artery disease (CAD) in a female patient. Which of these factors are classified as genetic and physiological? (Select all that apply.) ch 6 1. Sedentary lifestyle 2. Mother died from CAD at age 48 3. History of hypertension 4. Eats diet high in sodium 5. Elevated cholesterol level

Answer: 2, 3, 5. Genetic and physiological risk factors include those related to heredity, genetic predisposition to an illness, or those that involve the physical functioning of the body. This patient's genetic and physiological risk factors include her family history of CAD as well as her history of hypertension and elevated serum cholesterol level. A sedentary lifestyle and dietary choices are behavioral factors that increase the risk for developing CAD.

10. A nurse newly hired at a community hospital learns about intentional hourly rounding during orientation. Which of the following are known evidence-based outcomes from intentional rounding? (Select all that apply.) CH 2 1. Reduction in nurse staffing requirements 2. Improved patient satisfaction 3. Reduction in patient falls 4. Increased costs 5. Reduction in patient call light use

Answer: 2, 3, 5. Intentional rounding is an evidence-based practice used in an increasing number of hospitals today. Studies have shown that intentional rounding can reduce patient falls and call light use and improve patient satisfaction scores. Proactive problem solving can occur when using intentional rounding. Education for patients helps them understand the importance of this practice.

1. A nurse admits a 32-year-old patient for treatment of acute asthma. The patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds with bilateral wheezing. The nurse makes the patient comfortable and starts an ordered intravenous infusion to administer medication that will relax the patient's airways. The patient tells the nurse after the first medication infusion, "I feel as if I can breathe better." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following is an evaluative measure? (Select all that apply.) ch 20 1. Asking patient to breathe deeply during auscultation 2. Counting respirations per minute 3. Asking the patient to describe how his breathing feels 4. Starting the intravenous infusion 5. Auscultating lung sounds

Answer: 2, 3, 5. Measuring respirations by counting, asking the patient for self-report of breathing, and listening to lung sounds after medication is delivered are all evaluative measures. Asking a patient to breathe deeply is a technique used in an assessment skill. Starting the intravenous infusion is an intervention

7. According to Piaget's cognitive theory, a 12-year-old child is most likely to engage in which of the following activities? (Select all that apply.) ch 11 1. Using building blocks to determine how houses are constructed 2. Writing a story about a clown who wants to leave the circus 3. Drawing pictures of a family using stick figures 4. Writing an essay about patriotism 5. Hanging out with a best friend

Answer: 2, 5. As adolescents mature, their thinking moves to abstract and theoretical subjects. They have the capacity to reason with respect to possibilities. They typically have a close friend and enjoy spending time with friends.

7. The school nurse has been following a 9-year-old student who has shown behavioral problems in class. The student acts out and does not follow teacher instructions. The nurse plans to meet with the student's family to learn more about social determinants of health that might be affecting the student. Which of the following factors would be appropriate for this type of assessment? (Select all that apply.) 1. The student's seating placement in the classroom 2. The level of support parents offer when the student completes homework 3. The level of violence in the family's neighborhood 4. The age at which the child first began having behavioral problems 5. The cultural values about education held by family

Answer: 2, 3, 5. Social determinants include social support, exposure to crime and violence, and culture. The nurse should learn the child's age at which behavioral problems appeared, but this is not a social determinant. Seating placement is not a social determinant but could be a factor if the child has visual or other physical problems.

1. A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.) ch 19 1. The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure. 2. The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient. 3. The nurse directs the patient care technician to set up meal trays for patients. 4. The nurse directs the patient care technician to gather a history from the newly admitted patient about his medications. 5. The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal.

Answer: 2, 3, 5. The nurse can delegate repetitive, noninvasive tasks such as vital signs on a stable patient, assisting a mobile patient with ambulation, and setting up meal trays. It is inappropriate for the nurse to delegate aspects of the nursing process, such as collecting a medication history. The nurse also should not delegate vital signs if a patient might be unstable from returning from a diagnostic test.

8. A patient diagnosed with colon cancer has been receiving chemotherapy for 6 weeks. The patient visits the outpatient infusion center twice a week for infusions. The nurse assigned to the patient is having difficulty accessing the patient's intravenous (IV) port used to administer the chemotherapy. Despite attempts to flush the port, it is obstructed. This also occurred 2 weeks earlier. What steps should the nurse follow to make a consultation with a member of the IV infusion team? (Select all that apply.) ch 18 1. Ask the IV nurse to come to the infusion center at a time when the nurse starts care for a second patient. 2. Specifically identify the problem of port obstruction, and attempt to flush the port to resolve the problem. 3. Explain to the IV nurse the frequency in which this port has obstructed in the past. 4. Tell the IV nurse the problem is probably related to the physician who inserted the port. 5. Describe to the IV nurse the type and condition of the port currently in use.

Answer: 2, 3, 5. When making a consult, identify the general problem area (obstructed port). Provide a consultant with relevant information about the problem area (type and condition of port). Provide a summary of the problem, the methods used to resolve the problem so far, and outcomes of these methods (port flushing, port remains obstructed). Do not prejudice or influence consultants (physician to blame). Be available to discuss a consultant's findings and recommendations. The consultant is not there to take over the problem but to help you resolve it

7. A nurse is administering a metered-dose inhaler (MDI) with a spacer to a patient with chronic obstructive pulmonary disease. Place the steps of the procedure in the correct order. ch 31 1. Insert MDI into end of spacer. 2. Perform a respiratory assessment. 3. Remove mouthpiece from MDI and spacer device. 4. Place the spacer mouthpiece into patient's mouth, and instruct patient to close lips around the mouthpiece. 5. Depress medication canister, spraying 1 puff into spacer device. 6. Shake inhaler for 2-5 seconds. 7. Instruct patient to hold breath for 10 seconds. 8. Instruct patient to breathe in slowly through mouth for 3 to 5 seconds.

Answer: 2, 3, 6, 1, 4, 5, 8, 7. Obtains baseline respiratory assessment before medication. Ensures optimal delivery of medication using a metered-dose inhaler.

4. A school nurse is planning a health fair for children in first, second, and third grade to promote healthy behaviors. The most appropriate health screening for this age-group would be: (Select all that apply.) ch 8 1. Providing information about eating fruits and vegetables 2. Taking the children's blood pressure 3. Recording the children's height and weight on a growth chart 4. Asking the students about their family history of cancer 5. Teaching the students about the risks of secondhand smoke

Answer: 2, 3. Age-appropriate screening for this group is assessing the children's blood pressure and height and weight. The children may not know about their family history of cancer as they are too young. Providing information about healthy nutrition and secondhand smoke are health promotion interventions and do not provide screening information.

7. The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) ch 19 1. The application of the skin barrier is a dependent care measure. 2. The call to the ostomy and wound care specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure. 4. The application of the skin barrier is an instrumental activity of daily living. 5. Inspecting the skin is a direct care activity.

Answer: 2, 3. Application of the skin barrier is a direct, independent care measure. It is not an instrumental activity of daily living. Inspecting the skin is an assessment step. The other two interventions are described correctly.

9. A critical care nurse is using a new research-based intervention to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? CH 1 1. Patient-centered care 2. Evidence-based practice 3. Teamwork and collaboration 4. Quality improvement 10. The nurses on an acute care

Answer: 2. The use of a research intervention to improve patient care brings the evidence-based practice gained from the research to the bedside.

3. A nurse sends a text message to the oncoming nurse to report that a patient refuses to take medication as ordered. What should the oncoming nurse do? (Select all that apply). ch 23 1. Add this information to the board hanging at the patient's bedside. 2. Tell the nurse who sent the text that the text is a HIPAA violation. 3. Inform the nursing supervisor. 4. Forward the text to the charge nurse. 5. Thank the nurse for sending the information.

Answer: 2, 3. The Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology Act provide rules about how and with whom nurses can share patient health information. Sending a text message to another nurse about a patient is a violation of these acts. Report violations of the privacy of patient health information to your supervisor or manager

8. A patient is diagnosed with a multidrug-resistant organism (MDRO) in his surgical wound and asks the nurse what this means. What is the nurse's best response? (Select all that apply.) ch 28 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any antibiotic options available to treat the patient's infection.

Answer: 2, 4 An MDRO is a single organism that is resistant to one or more classes of antibiotics, which makes it harder to treat, but there is treatment available

1. A nurse enters a patient's room at the beginning of a shift to conduct an assessment of his condition following a blood transfusion. The nurse cared for the patient on the previous day as well. The patient has a number of issues he wishes to share with the nurse, who takes time to explore each issue. The nurse also assesses the patient and finds no signs or symptoms of a reaction to the blood product. The nurse observed the patient the prior day and sees a change in his behavior, a reluctance to get out of bed and ambulate. Which of the following actions improve the nurse's ability to make clinical decisions about this patient? (Select all that apply.) ch 15 1. Working the same shift each day 2. Spending time during the patient assessment 3. Knowing the early mobility protocol guidelines 4. Caring for the patient on consecutive days. 5. Knowing the pattern of patient behavior about ambulation

Answer: 2, 4, 5. Clinical decision making is enhanced by spending enough time during patient assessments and knowing a patient's typical behaviors (which is reinforced when a nurse is assigned to a patient on consecutive days). Working the same shift does not mean the nurse will care for the same patient. Knowledge about the mobility protocol is helpful, but clinical decisions center on the needs of an individual patient (e.g., whether a patient meets the criteria for a mobility protocol and how well he or she has advanced so far).

2. A mother and her two children are homeless and enter a free health care clinic. Which statements most likely describe the effects of homelessness on this family? (Select all that apply.) ch 10 1. The children have stability in their education. 2. The family members may have symptoms of malnutrition, such as anemia. 3. The family is at a low risk for experiencing violence. 4. The children are at higher risk for developing ear infections. 5. All family members may have mental health issues.

Answer: 2, 4, 5. Families who are homeless often experience difficulty in accessing food and have a poor nutritional status. Children are at a higher risk for developing ear infections. Homelessness puts all family members at risk for developing mental health issues. Children have difficulty proving residency for school enrollment, so they are more likely not to be in school or to drop out. Families that are homeless are also at a higher risk for experiencing physical and emotional violence.

10. A patient is admitted for dehydration caused by pneumonia and shortness of breath. He has a history of heart disease and cardiac dysrhythmias. The assistive personnel reports his admitting vital signs to the nurse. Which measurements should the nurse reassess? (Select all that apply.) ch 29 1. Right arm BP: 118/72 2. Radial pulse rate: 72 and irregular 3. Temporal temperature: 37.4°C (99.3°F) 4. Respiratory rate: 28 5. Oxygen saturation: 99%

Answer: 2, 4, 5. Irregular pulse and elevated respiratory rate are outside expected values and require further assessment by the nurse. Pneumonia and shortness of breath can cause low oxygen saturation; an assessment of 99% may be a false-high value. Blood pressure and temperature are within expected values for the patient history

5. A nurse is providing health promotion information at a health fair for female patients who are diagnosed with cancer. What information should the nurse include? (Select all that apply.) ch 8 1. Recommending that they avoid drinking alcohol to prevent alcohol misuse 2. Information from the local health department about smoking-cessation classes 3. The need to avoid physical activity while receiving cancer treatment to lessen fatigue 4. Strategies to talk with family and friends about the cancer diagnosis and the side effects from their treatment 5. How nutritional needs may change based on the diagnosis of cancer and its treatment

Answer: 2, 4, 5. Providing education about the benefits of smoking cessation and resources available to stop smoking promotes health. Friends and family may become tired of hearing about a patient's chronic illness experience. Helping the attendees learn effective ways to communicate with friends and family about their cancer and its treatment effects will promote understanding. Patients need information on how to make healthy dietary choices to promote their health. Diet choices often need to be modified when a patient is diagnosed with a chronic illness. Alcohol misuse occurs when a woman drinks more than 3 drinks a day or 7 drinks a week. People with chronic diseases need to participate in the same amount of activity and muscle-strengthening as healthy people whenever possible after consulting with their health care provider regarding the types and amounts of activity that are appropriate.

1. Which of the following are safe practices to follow in the safe preparation and storage of food? (Select all that apply.) ch 27 1. Always use a single cutting board to prepare foods for cooking. 2. Refrigerate leftovers as soon as possible. 3. Always buy vegetables in packages marked "prewashed." 4. Cook meats to the proper temperature. 5. Wash hands thoroughly before food preparation.

Answer: 2, 4, 5. The Centers for Disease Control and Prevention (CDC) recommends washing hands thoroughly before food preparation and to wash cooking surfaces often. Keep raw meat, poultry, seafood, and their juices away from other foods, and use separate cutting boards for each. Rinse fruits and vegetables thoroughly, and always cook food to the proper temperature. Refrigerate leftovers promptly. A single cutting board can cause cross contamination. Even if packages show that vegetables have been prewashed, thoroughly wash when opening a package.

3. A nurse working on a medical patient care unit states, "I am having trouble sleeping, and I eat nonstop when I get home. All I can think of when I get to work is how I can't wait for my shift to be over. I wish I felt happy again." What are the best responses from the nurse manager? (Select all that apply.) ch 6 1. "I'm sure this is just a phase you are going through. Hang in there. You'll feel better soon." 2. "I know several nurses who feel this way every now and then. Tell me about the patients you have cared for recently. Did you find it difficult to care for them?" 3. "You can take diphenhydramine over the counter to help you sleep at night." 4. "Describe for me what you do with your time when you are not working." 5. "The hospital just started a group where nurses get together to talk about their feelings. Would you like for me to e-mail the schedule to you?"

Answer: 2, 4, 5. This nurse is experiencing symptoms of compassion fatigue. The nurse manager needs to establish a therapeutic relationship with the nurse. Acknowledging personal thoughts and feelings and talking with other nurses to identify coping strategies can help this nurse work through the feelings associated with compassion fatigue. Engaging in healthy behaviors and establishing a good work-life balance may also help.

6. A nurse is visiting a patient who lives alone at home. The nurse is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.) c 19 1. Reviewing the family caregiver's availability during medication administration times 2. Determining the value the patient places on taking medications 3. Reviewing the number of medications and time each is to be taken 4. Determining all consequences associated with the patient missing specific medicines 5. Reviewing the therapeutic actions of the medications

Answer: 2, 4. Adherence is related to how a patient values a particular treatment and whether negative consequences are perceived if the treatment is not followed. Reviewing the family caregiver availability will be useful if the nurse cannot help the patient adhere better. Reviewing the number of medications will not change adherence unless the nurse consults with the physician about simplifying the regimen. Reviewing therapeutic actions of medication ensures safer administration but not better adherence

6. A nurse is caring for a patient experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner? (Select all that apply.) ch 32 1. Always fail and cause illness and disease 2. Cause negative responses over time 3. React the same way for all individuals 4. Protect an individual from harm in the short term 5. Tolerate the stress response indefinitely

Answer: 2, 4. In the beginning stress responses serve as a warning and physiological "alarm" of sorts, preparing the person to respond to harm. In this way they can be a protective mechanism. However, stress that continues unmitigated for long periods of time creates states of "exhaustion" that translate ultimately into negative physiological and psychological events.

3. Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) ch 17 1. Offer frequent skin care because of Impaired Skin Integrity 2. Risk of Infection 3. Chronic Pain related to osteoarthritis 4. Activity Intolerance related to physical deconditioning 5. Lack of Knowledge related to laser surgery

Answer: 2, 4. Option 2 is a "risk for" diagnosis and does not have related factors. Option 4 has related factors that a nurse can manage with etiology-specific interventions. Option 1 identifies a nursing intervention instead of a problem. Option 3 has a related factor of a medical diagnosis, which a nurse cannot treat directly. Option 5 describes a treatment procedure and not the patient's response to the procedure.

2. A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes, usually twice or more." The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.) ch 17 1. Age 42 2. Dysuria 3. Difficulty performing perineal hygiene 4. Nocturia 5. Episode of diarrhea

Answer: 2, 4. The assessment findings are individual data elements that form a pattern revealing a nursing diagnosis. The assessment findings include dysuria and nocturia. The patient's age is a descriptive characteristic of the patient. The episode of diarrhea is a historical finding that predisposed the patient to having perineal hygiene needs, but is not an assessment finding for the diagnosis.

9. During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.) ch 14 1. Taking two medications for hypertension 2. Taking a total of eight different medications during the day 3. Having one physician who reviews all medications 4. Patient's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

Answer: 2, 4. The patient is at risk for an adverse drug event (ADE) because of polypharmacy and his history of renal disease, which affects drug excretion. Taking two medications for hypertension is common. Having one physician review all medications and involving a family caregiver are desirable and are safety factors for preventing ADEs.

6. The nurse is administering an IV push medication to a patient who has a compatible IV fluid running through intravenous tubing. Place the following steps in the appropriate order. ch 31 1. Release tubing and inject medication within amount of time recommended by agency policy, pharmacist, or medication reference manual. Use watch to time administration. 2. Select injection port of IV tubing closest to patient. Whenever possible, injection port should accept a needleless syringe. Use IV filter if required by medication reference or agency policy. 3. After injecting medication, release tubing, withdraw syringe, and recheck fluid infusion rate. 4. Connect syringe to port of IV line. Insert needleless tip or small-gauge needle of syringe containing prepared drug through center of injection port 5. Clean injection port with antiseptic swab. Allow to dry. 6. Occlude IV line by pinching tubing just above injection port. Pull back gently on syringe plunger to aspirate blood return.

Answer: 2, 5, 4, 6, 1, 3. These are the correct steps to administer an IV push medication in an existing line with compatible fluid running

7. During admission of an obese patient with heart failure the assistive personnel (AP) reports to the nurse that the blood pressure (BP) is 140/76 on the left arm and 128/72 on the right arm. What actions do you take on the basis of this information? (Select all that apply.) ch 29 1. Notify the health care provider immediately. 2. Repeat the measurements on both arms using a stethoscope. 3. Ask the patient if she has taken her blood pressure medications recently. 4. Obtain blood pressure measurements on lower extremities. 5. Verify that the correct cuff size was used during the measurements. 6. Review the patient's record for her baseline vital signs. 7. Compare right and left radial pulses for strength.

Answer: 2, 6. The systolic BP measurements are significantly different and may reflect some vascular abnormalities. However, unexpected findings require reassessment by the nurse with a comparison to previous values. It is premature to notify the provider without further assessment. The differences are not caused by medications. An inappropriate cuff size would reflect similar systolic pressures; pulse strength would be similar for these BP measurements.

1. A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? ch 17 1. Incorrect clustering of data 2. Wrong diagnosis 3. Condition is a collaborative problem 4. Premature ending assessment

Answer: 2. A standard for the nursing diagnosis of Impaired Skin Integrity is the actual alteration in skin integrity, not the skin being clean and intact. The student needs to review data and compare more closely with the standard assessment findings for a correct diagnosis

2. A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the surgery to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: CH 1 1. Educator. 2. Advocate. 3. Caregiver. 4. Communicator

Answer: 2. An advocate protects the patient's human and legal right to make choices about his or her care. An advocate may also provide additional information to help a patient decide whether to accept a treatment or may find an interpreter to help family members communicate their concerns.

2. When designing a plan for pain management for a patient following surgery, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. If the nurse's actions are driven by respect for autonomy, what aspect of this scenario best demonstrates that? ch 22 1. Assessing the patient's pain on a numeric scale every 2 hours 2. Asking the patient to establish the goal for pain control 3. Using alternative measures such as distraction or repositioning to relieve the pain 4. Monitoring the patient for oversedation as a side effect of his pain medication

Answer: 2. Asking the patient to establish the goal for pain control is a demonstration of respect for autonomy. Assessing, monitoring, and using alternative measures are interventions that address pain but that are not necessarily grounded in the principle of autonomy.

6. When nurses are communicating with adolescents, they should: ch 12 1. Ask closed-ended questions to get straight answers. 2. Ask the adolescent to collaborate on plan of care. 3. Avoid looking for meaning behind adolescents' words or actions. 4. Avoid discussing sensitive issues such as sex and drugs

Answer: 2. Do not avoid discussing sensitive issues. Asking questions about sex, drugs, and school opens the channels for further discussion. Ask open-ended questions. Look for the meaning behind their words or actions. Be alert to clues to their emotional state. Adolescents should be involved in their plan of care.

2. A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: ch 14 1. Dementia. 2. Depression. 3. Delirium. 4. Anxiety

Answer: 2. Factors that often lead to depression include presence of a chronic disease or a recent change or life event (such as loss). Patients are alert but easily distracted in conversation.

3. A nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: ch 14 1. Normal aging. 2. Delirium. 3. Depression. 4. Worsening dementia.

Answer: 2. Hallmark characteristics of delirium are acute confusion, hallucinations, and agitation. These symptoms are not part of the normal aging process. As dementia worsens, there is a gradual rather than sudden change in memory, usually not accompanied by hallucinations. Depression does not present with acute confusion and agitation.

10. During a visit to a family clinic, a nurse teaches a mother about immunizations, the use of car seats, and home safety for an infant and toddler. Which type of nursing interventions are these? ch 10 1. Restorative 2. Health promotion 3. Acute care 4. Growth and development

Answer: 2. Health promotion activities focus on interventions designed to maintain the physical, social, emotional, and spiritual health of the family unit, including information about specific health behaviors and family coping techniques.

7. You are caring for a 4-year-old child who is hospitalized for an infection. He tells you that he is sick because he was "bad." Which is the most correct interpretation of his comment? ch 12 1. Indicative of maladaptive stress response 2. Representative of his cognitive development 3. Suggestive of excessive discipline at home 4. Indicative of his developing sense of inferiority

Answer: 2. If two events are related in time or space, preschool children link them in a causal fashion. For example, the hospitalized child reasons, "I cried last night, and that's why the nurse gave me the shot.

4. In addition to a thorough patient assessment, when a nurse uses one of the nursing-accessible complementary therapies, he or she must ensure that which of the following has occurred? ch 32 1. The family has provided permission. 2. The patient has provided permission and consent. 3. The health care provider has given approval or provided orders for the therapy. 4. The nurse has received specialized training in the therapeutic technique.

Answer: 2. Nurse-accessible therapies are independent nursing interventions. As long as the scope of practice identified by the nurse's State Board of Nursing permits this activity, you do not need to obtain permission from the patient's primary provider or his or her family members unless the patient is underage. An adult can provide consent. Specialized training is not required for nursing-accessible therapies.

9. As part of a faith community nursing program in her church, a nurse is developing a health promotion program on breast selfexamination for the women's group. Which statement made by one of the participants is related to the individual's accurate perception of susceptibility to an illness? ch 6 1. "I have a door hanging tag in my bathroom to remind me to do my breast self-examination monthly." 2. "Since my mother had breast cancer, I know that I am at increased risk for developing breast cancer." 3. "Since I am only 25 years of age, the risk of breast cancer for me is very low." 4. "I participate every year in our local walk/run to raise money for breast cancer research."

Answer: 2. On the basis of health belief model, this statement indicates that the patient is concerned about developing breast cancer and feels that there is a risk or susceptibility based on recognition of a familial link for the disease. Once this link is recognized, the patient may perceive the personal risk.

2. A patient has labored breathing, a respiratory rate of 28 per minute, and lung sounds that reveal wheezing bilaterally. The nurse starts an ordered intravenous infusion to administer medication that will relax the patient's airways. When the nurse asks how the patient feels, he responds by saying, "I feel as if I can breathe better." The nurse auscultates the patient's lungs and notes decreased wheezing with a respiratory rate of 22 per minute. Which of the following evaluative measures may not reflect change in a patient's condition? ch 20 1. Counting respirations per minute 2. Asking the patient to describe how his breathing feels 3. Observing breathing pattern 4. Auscultating lung sounds

Answer: 2. Self-report may not truly reflect whether a patient's behavior or perception has changed.

9. Traditional Chinese medicine (TCM) is used by many patients. Which statement most accurately describes intervention(s) offered by TCM providers? CH 32 1. Uses acupuncture as its primary intervention modality 2. Uses many modalities based on the individual's needs 3. Uses primarily herbal remedies and exercise 4. Is the equivalent of medical acupuncture

Answer: 2. TCM practitioners use a variety of interventions that are based on individual patient assessment findings and needs. Modalities include herbal therapies, acupuncture, moxibustion, cupping, prescribed exercise such as tai chi or qi gong, and lifestyle changes. Although acupuncture is often confused with TCM, when it is used alone, acupuncture is not a whole system of medicine. Rather the National Institutes of Health/National Center for Complementary and Alternative Medicine considers it to be a mind-body technique that is often referred to as medical acupuncture. Although herbal therapies and exercise are considered to be part of the treatment repertoire of the TCM provider, these modalities are not considered to be primary interventions.

7. A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. The patient is very thin and unkempt, has a stage 3 pressure injury on her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son, who accompanied her to the hospital. What is the nurse's next step? ch 14 1. Call social services to begin nursing home placement. 2. Ask the son to step out of the room so that she can complete her assessment. 3. Call adult protective services because you suspect elder mistreatment. 4. Assess the patient's cognitive status.

Answer: 2. The assessment leads you to suspect elder mistreatment, but the nurse needs more information directly from the patient before calling social services or the adult protective services or telling the patient she cannot return home. The nurse will best get this information by asking the son to leave so that she can privately ask the patient direct questions. If the son refuses to leave, this will be another indication that elder mistreatment may be occurring. Cognitive testing will be important but is not the priority.

8. A nurse is assigned to care for an 82-year-old patient who will be transferred from the hospital to a rehabilitation center. The patient and her husband have selected the rehabilitation center closest to their home. The nurse learns that the patient will be discharged in 3 days and decides to make the referral on the day of discharge. The nurse reviews the recommendations for physical therapy and applies the information to fall prevention strategies in the hospital. What discharge planning action by the nurse has not been addressed correctly? CH 2 1. Patient and family involvement in referral 2. Timing of referral 3. Incorporation of referral discipline recommendations into plan of care 4. Determination of discharge date

Answer: 2. The nurse must make the referral as soon as possible. The other elements of discharge planning, including knowing the discharge date, involving the patient and family in decision-making, and incorporating the referral discipline's recommendations for the patient's care are part of discharge planning.

1. A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? ch 23 1. Family member 2. Surgeon 3. Nurse 4. Nurse manager

Answer: 2. The person performing the procedure is responsible for informing the patient about the procedure and its risks, benefits, and possible complications.

5. A patient in the intensive care unit experiences a sentinel event related to central-line catheter care that resulted in serious injury. What performance improvement model should the unit use to identify errors that led to the sentinel event? ch 5 1. Six Sigma 2. Root cause analysis 3. PDSA 4. Balanced scorecard

Answer: 2. The unit should conduct a root cause analysis. The purpose of the root cause analysis is to gather data and information to identify active and latent errors that occurred leading to the sentinel event. The other options are quality improvement models that focus on process and performance measures leading to practice change. They may be used to improve processes or practice after the root cause analysis has identified the underlying errors that led to the sentinel event.

3. Which of the family caregivers listed below will the nurse expect to be most at risk for experiencing poor health outcomes? ch 8 1. A 20-year-old daughter caring for a mother who needs help setting up her medications weekly 2. The 68-year-old spouse of a patient who is experiencing worsening dementia 3. A 32-year-old parent of a child who has an ear infection 4. A married couple who is sharing the caregiving responsibilities for a parent who was recently diagnosed with hypertension and coronary artery disease

Answer: 2. This family caregiver is elderly, has most likely cared for the patient who has significant needs for more than a year, lives with the patient, and is married to the patient. Factors that put the caregiver at greatest risk for poor health outcomes include providing care for more than a year, being 65 years of age or older, providing care for a family member who has significant needs, caring for someone with Alzheimer's disease or dementia, and living with the care recipient. Spouses report the largest impact on their health.

1. It is important to take precautions to prevent medication errors. A nurse is administering an oral tablet to a patient. Which of the following steps is the second check for accuracy in determining the patient is receiving the right medication? ch 31 1. Logging on to automated dispensing system (ADS) or unlocking medicine drawer or cart. 2. Before going to patient's room, comparing patient's name and name of medication on label of prepared drugs with MAR. 3. Selecting correct medication from ADS, unit-dose drawer, or stock supply and comparing name of medication on label with MAR or computer printout. 4. Comparing MAR or computer printout with names of medications on medication labels and patient name at patient's bedside.

Answer: 2. This is the second check for accuracy.

6. The nurse is caring for a family where there is a strong family history of breast cancer. One of the family members says, "I am afraid of having genetic testing. If it is positive, I know I have cancer." What is the nurse's best response? ch 8 1. "It will help diagnose the cancer early if you have it." 2. "If the results are positive, it means you have a higher risk for breast cancer, not that you have cancer." 3. "If it is going to cause you to worry, don't have the screening done." 4. "I am sure you will be fine. You are a healthy woman."

Answer: 2. This patient does not understand genetic testing and needs further information. A positive genetic screen for breast cancer indicates the genetic mutation exists in a woman's DNA, placing her at an increased risk for developing one of these cancers. It does not mean that the woman will develop one of these cancers

2. A nurse received change-of-shift report on these four patients and starts rounding. Which patient does the nurse need to focus on as a priority? ch 21 1. The patient who had abdominal surgery 2 days ago who is requesting pain medication 2. A patient admitted yesterday with atrial fibrillation who now has a decreased level of consciousness 3. A patient with a wound drain who needs teaching before discharge in the early afternoon 4. A patient going to surgery for a mastectomy in 3 hours who has a question about the surgery

Answer: 2. This patient is of high priority. The patient is experiencing the physiological problem of decreased level of consciousness that is an immediate threat to the patient's survival and safety. The nurse must intervene promptly and notify the health care provider of the life-threatening problem.

6. A community health nurse conducts a community assessment focused on adolescent health behaviors. The nurse determines that a large number of adolescents smoke. Designing a smoking cessation program at the youth community center is an example of which nursing role? CH 3 1. Educator 2. Counselor 3. Collaborator 4. Case manager

Answer: 2. To engage a patient to participate in a smoking-cessation program or any program that requires changing a behavior requires the nurse to act as a counselor to support the patient in changing that behavior (e.g., in this case a smoking habit). The nurse does not educate the patient about the dangers of smoking but first must actively counsel him or her to decide to change the behavior. Without support and counseling, the smoking-cessation education may not be used effectively by the patient.

3. The nurse teaches parents how to have their children learn impulse control and cooperative behaviors. This would be during which of Erikson's stages of development? ch 11 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Autonomy versus sense of shame and doubt

Answer: 2. Toddlers are learning that parents and society have expectations about behaviors and that they must learn to control their behavior.

4. The nurse is caring for a patient admitted to the neurological unit with the diagnosis of a stroke and right-sided weakness. The nurse assumes responsibility for bathing and feeding the patient until the patient can begin performing these activities. The nurse in this situation is applying the theory developed by: ch4 1. Johnson. 2. Orem. 3. Roy. 4. Peplau

Answer: 2. When applying Orem's self-care deficit theory, the nurse continually assesses the patient's ability to perform selfcare and intervenes as needed to ensure that physical, psychological, sociological, and developmental needs are being met. As the patient's condition improves, the nurse encourages the patient to begin doing these activities independently.

6. A hospice nurse is caring for a family that is providing end-of-life care for their grandmother, who has terminal breast cancer. The nurse focuses on symptom management for the grandmother and on helping the family with developing coping skills. This approach is an example of which of the following? ch 10 1. Family as context 2. Family as patient 3. Family as a system 4. Family as structure

Answer: 2. When the family as patient is the approach, the family's needs, processes, and relationships (e.g., parenting or family caregiving) are the primary focuses of nursing care.

6. A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: ch 16 1. Reflection. 2. Clinical inference. 3. Cue. 4. Validation.

Answer: 2. You begin to cluster cues that seem to relate together, make inferences, and identify emerging patterns. Clinical inference is part of the clinical decision-making process and precedes any judgment or decision about what are a patient's problems. It is the interpretation of the cues.

3. A patient is placed on Airborne Precautions for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? ch 28 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

Answer: 3 By providing a rationale for the isolation, the patient is able to better understand the safety risks and cooperate with care. Providing reading material or other distractions for the patient will also help with times when alone in the room.

3. A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient's lungs and hears crackles in the left lower lobe. The patient's respiratory rate is 20 per minute compared with an average of 16 per minute during previous clinic visits. The patient tells the nurse, "It is hard for me to get a breath." Which of the following data sets are examples of subjective data? (Select all that apply.) ch 16 1. Heart rate of 20 per minute and chest congestion 2. Lung sounds revealing crackles and use of intercostal muscles to breathe 3. Patient statement, "It's hard for me to get a breath" 4. Slumped posture and previous respiratory rate of 16 per minute 5. Patient report of sore throat and hoarseness

Answer: 3 and 5. Subjective data are your patients' verbal descriptions of their health problems, in this case hoarseness, sore throat, and the statement, "It is hard for me to get a breath." All other data are objective data

9. Place the following steps for applying a wrist restraint in the correct order: ch 27 1. Pad the skin overlying the wrist. 2. Insert two fingers under the secured restraint to be sure that it is not too tight. 3. Be sure that the patient is comfortable and in correct anatomical alignment. 4. Secure restraint straps to bedframe with quick-release buckle. 5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly

Answer: 3, 1, 5, 2, 4.

7. Using the Transtheoretical Model of Change, order the steps that a patient goes through to make a lifestyle change related to physical activity. ch 6 1. The individual recognizes that he is out of shape when his daughter asks him to walk with her after school. 2. Eight months after beginning walking, the individual participates with his wife in a local 5K race. 3. The individual becomes angry when the physician tells him that he needs to increase his activity to lose 30 lb. 4. The individual walks 2 to 3 miles, 5 nights a week, with his wife. 5. The individual visits the local running store to purchase walking shoes and obtain advice on a walking plan.

Answer: 3, 1, 5, 4, 2. This sequence follows the order of the steps of transtheoretical model of change: precontemplation, contemplation, preparation, action, and maintenance.

4. The REFLECT model can improve learning after providing patient care. Place the steps of this model in the correct order: ch 15 1. Think about your thoughts and actions at the time of a situation. 2. Review the knowledge you gained from the experience. 3. Review the facts of the situation. 4. Set a schedule for completing your plan of action. 5. Consider options for handling a similar situation in the future. 6. Recall any feelings you had at the time of the situation. 7. Create a plan for future situations.

Answer: 3, 1, 6, 2, 5, 7, 4. This is the correct order following the REFLECT model.

6. A nurse performs the following four steps in delegating a task to an AP. Place the steps in the order of appropriate delegation. ch 21 1. Do you have any questions about walking Mr. Malone? 2. Before you take him for his walk to the end of the hallway and back, please take and record his pulse rate. 3. In the next 30 minutes please assist Mr. Malone in Room 418 with his afternoon walk. 4. I will make sure that I check with you in about 40 minutes to see how the patient did.

Answer: 3, 2, 4, 1. This is the sequence of effective delegation. The nurse delegated the task of walking a patient to the AP, which is in the scope of the AP's duties and responsibilities and matched to the AP's skill level. The nurse provided clear directions by describing the task (the walk, taking and recording the pulse), the desired outcome (walk to the end of the hallway and back), and the time period (within the next 30 minutes). The nurse explains the process of follow-up with the AP to check how the patient did. The nurse asks whether the AP has any questions to provide the AP the opportunity to ask questions for clarification.

8. A patient is to receive medications through a small-bore nasogastric feeding. Which nursing actions are appropriate? (Select all that apply.) ch 31 1. Verifying tube placement after medications are given 2. Mixing all medications together to give all at once 3. Using an enteral tube syringe to administer medications 4. Flushing tube with 30 to 60 mL of water after the last dose of medication 5. Checking for gastric residual before giving the medications 6. Keeping the head of the bed elevated 30 to 60 minutes after the medications are given

Answer: 3, 4, 5, 6. An enteral tube syringe is necessary to avoid dangerous misconnections and accidentally administering the medications through another tube. Flushing the tubing after medication administration clears the tubing of any residual medication and ensures that the tube remains patent. If gastric residuals are high, then the absorption of the enteral tube medication is reduced. Elevating the head of the bed helps to reduce the risk for aspiration. Verification of tube placement is essential before administering anything via a nasogastric tube. Medications are given separately to avoid any drug-to-drug interactions, which could clog the feeding tube.

10. The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include? (Select all that apply.) ch 30 1. First child at the age of 26 years 2. Menopause onset at the age of 49 years 3. Family history with BRCA1 inherited gene mutation 4. Age over 40 years 5. Onset of menses before the age of 12 6. Recent use of oral contraceptives

Answer: 3, 4, 5, 6. These are all risk factors for development of breast cancer. Onset of menopause after the age of 55, not at the age of 49, is a risk factor. First child after the age of 30, not birth of a child at 26, is a risk factor.

2. A nurse enters the hospital room of a patient who had a total knee replacement the day before. Which of the following pose potential safety risks? (Select all that apply.) ch 27 1. A current safety inspection sticker is on the IV fluids pump. 2. A walker is positioned near the patient's bedside. 3. The hospital bed is in the high position. 4. There is no gait belt at the bedside. 5. The overbed table with the patient's glasses is positioned against the wall opposite the end of the bed.

Answer: 3, 4, 5. All electrical equipment should be inspected routinely and have current safety inspection stickers. The patient has had knee surgery, so the presence of a walker is needed for him to ambulate. Safety risks include the absence of a gait belt; one should always be available for a patient who will need assistance in ambulation. The bed position is incorrect; it should be in low position. The position of the bedside table does not allow the patient to reach personal or care items easily.

7. A nurse has been caring for a patient with a chronic wound that has not been healing. The nurse talks with a nurse specialist in wound care to find alternative approaches from what the health care provider ordered for dressing the wound. The two decide that because of the patient's allergy to tape a nonallergenic dressing will be used. The nurse obtains an order from the health care provider for the new dressing. After two days there is improvement in the wound. This is an example of which critical thinking standards? (Select all that apply.) ch 15 1. Clear 2. Broad 3. Relevant 4. Risk taking 5. Creativity

Answer: 3, 4, 5. In this situation the nurse is seeking a different approach and being creative in pursuing the wound care specialist and asking for wound care options. The two nurses show relevance in selecting an option crucial to the patient's unique situation (an allergy). The nurse takes a risk by considering an option different from what the health care provider initially ordered.

9. A married couple has three children. The youngest child just graduated from college and is moving to a different city to take a job. The other two children left the home several years ago. Both of their parents are older and are beginning to need help to maintain their home. What assessment questions will help the nurse determine the family's functioning? (Select all that apply). ch 10 1. Which transitions or changes in your family are you currently experiencing? 2. Are your children having any problems that are affecting your family right now? 3. Describe a recent family conflict and how your family resolved it. 4. What coping strategies do you typically use as a family? 5. Who is involved in helping care for your parents?

Answer: 3, 4, 5. This family is recently without children and has older parents to assist. Assessment questions about family functioning address how individuals behave in relation to one another, which is reflected in questions that determine how the family completes routine activities (e.g., making meals, doing laundry), communicates, and solves problems.

8. The nurse finds a 68-year-old woman wandering in the hallway and exhibiting confusion. The patients says she is looking for the bathroom. Which interventions are appropriate for this patient? (Select all that apply.) ch 27 1. Ask the health care provider to order a restraint. 2. Recommend insertion of a urinary catheter. 3. Provide scheduled toileting rounds every 2 to 3 hours. 4. Institute a routine exercise program for the patient. 5. Keep the bed in high position with side rails down. 6. Keep the pathway from the bed to the bathroom clear.

Answer: 3, 4, 6. There are no appropriate conditions for this patient to be restrained. A patient who repeatedly wanders may require the temporary use of restraints to keep him or her safe. However, the use of alternatives to restraints is preferred, and if a restraint is required, use the least restrictive. A urinary catheter is not inserted to avoid having a patient use the bathroom. The patient should have a low bed so that if the patient falls, the risk of injury may be lessened

5. A nursing student is providing a hand-off report to a registered nurse (RN) who is assuming her patient's care at the end of the clinical day. The student states, "The patient had a good day. His intravenous (IV) fluid is infusing at 124 mL/hr with D5½NS infusing in left forearm. The IV site is intact, and no complaints of tenderness I ambulated him twice during the shift; he tolerated walking to the visitors lounge and back with no shortness of breath, respirations 14, heart rate 88 after exercise. He uses his walker without difficulty, gait normal. The patient ate ¾ of his dinner with no gastrointestinal complaints. For the goal of improving the patient's activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) ch 18 1. IV site not tender 2. Uses walker to walk 3. Walked to visitors lounge 4. No shortness of breath 5. Tolerated dinner meal

Answer: 3, 4. In this case, outcomes to determine whether a patient is tolerating activity include measures of exercise tolerance, including respiratory status and distance walked. Using a walker is an intervention; the fact that the walker is used without difficulty is a measure of mobility, not activity tolerance. The IV site being nontender is an outcome for Risk of Infection. Tolerating a dinner meal could be an outcome for appetite problem or nausea

7. Place the following steps of the assessment process in the correct order. ch 16 1. Compare data with another source to determine data accuracy. 2. As a pattern forms, probe and frame further questions. 3. Interview a patient, observe behavior, and gather physical assessment findings. 4. Cluster cues that relate together, make inferences, and identify emerging patterns. 5. Differentiate important data from the total data you collect.

Answer: 3, 5, 4, 2, 1. The assessment process begins with thorough and appropriate data collection, gained through patient interview, observation, and physical examination. Once all data are collected, you then differentiate important data from the total data you collect; emerging signs of a problem are important to focus on compared with normal findings for a body function. Cluster the cues that relate together and begin to identify a pattern for a problem area. Once a pattern forms, probe further with the interview or observations. Finally, during validation compare data with other sources to determine accuracy

7. Meditation may intensify the effects of which of these medications? (Select all that apply.) ch 32 1. Steroid medications 2. Insulin 3. Thyroid-regulating medications 4. Cough syrups 5. Antihypertensive medications

Answer: 3, 5. Mind-body techniques, including meditation, create physiological responses in the cardiovascular and respiratory systems. These responses may include decreased blood pressure, reduced heart rate, and slowed respirations. They decrease the need for antihypertensive and other cardiac regulators and thyroid-regulating medications.

10. Fill in the Blank: A(n) __________________________ diagnosis is one that applies when there is an increased potential or vulnerability for a patient to develop a problem. ch 17

Answer: Risk

9. A patient has undergone surgery for a femoral artery bypass. The surgeon's orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? (Select all that apply.) ch 30 1. Place the fingers behind and below the medial malleolus. 2. Have the patient slightly flex the knee with the foot resting on the bed. 3. Have the patient relax the foot while lying supine. 4. Palpate the groove lateral to the flexor tendon of the wrist. 5. Palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes.

Answer: 3, 5. To palpate the dorsalis pedis pulses (located in the feet), ask the patient to relax the foot, and then palpate along the top of the foot in a line with the groove between the extensor tendons of the great and first toes. Placing fingers behind the medial malleolus is a technique for assessing the posterior tibial pulse. Having a patient slightly flex the knee is a technique for assessing the popliteal artery behind the knee. Palpation of the groove lateral to the flexor tendon of the wrist is the technique to assess the radial artery.

4. While administering medications, a nurse realizes that a prescribed dose of a medication was not given. The nurse acts by completing an incident report and notifying the patient's health care provider. Which of the following is the nurse exercising? ch 21 1. Authority 2. Responsibility 3. Accountability 4. Decision making

Answer: 3. Accountability is nurses being answerable for their actions. It means nurses accept the commitment to provide excellent patient care and the responsibility for the outcomes of the actions in providing that. Following institutional policy for reporting medication errors demonstrates the nurse's commitment to safe patient care

8. The nurse is observing as the student nurse performs a respiratory assessment on a patient. Which action by the student nurse requires the nurse to intervene? ch 30 1. The student stands at a midline position behind the patient, observing for position of the spine and scapula. 2. The student palpates the thoracic muscles for masses, pulsations, or abnormal movements. 3. The student places the bell of the stethoscope on the anterior chest wall to auscultate breath sounds. 4. The student places the palm of the hand over the intercostal spaces and asks the patient to say "ninety-nine.

Answer: 3. Breath sounds should be auscultated using the diaphragm of the stethoscope. Auscultate in a systematic pattern over the posterior and anterior chest wall.

1. A health system upgraded its electronic health record across all its practice settings to enhance patient care and communication among health care providers. This is an example of which component of the Chronic Care Model? ch 8 1. Health systems 2. Decision support 3. Clinical information systems 4. Community

Answer: 3. Clinical information systems maintain and share patient health information among providers and patients to ensure effective communication and quality patient care

3. The application of deontology does not always resolve an ethical problem. Which of the following statements best explains one of the limitations of deontology? ch 22 1. The emphasis on relationships feels uncomfortable to decision makers who want more structure in deciding the best action. 2. The single focus on power imbalances does not apply to all situations in which ethical problems occur. 3. In a diverse community it can be difficult to find agreement on which principles or rules are most important. 4. The focus on consequences rather than on the "goodness" of an action makes decision makers uncomfortable

Answer: 3. Deontology is an approach to ethics that identifies the correct action as that which is supported by fundamental principles and duties. The disadvantage of this approach is that its application relies on consensus around what the primary duties and principles are. Option 1 describes a limitation of the ethics of care. Option 2 describes a limitation of feminist ethics, while option 4 describes a limitation of utilitarianism.

7. Which example demonstrates a nurse performing the skill of evaluation? ch 21 1. The nurse explains the side effects of the new blood pressure medication ordered for the patient. 2. The nurse asks a patient to rate pain on a scale of 0 to 10 before administering a pain medication. 3. After completing a teaching session, the nurse observes a patient drawing up and administering an insulin injection. 4. The nurse changes a patient's leg ulcer dressing using aseptic technique.

Answer: 3. Evaluation is one of the most important aspects of clinical care coordination, involving the determination of patient outcomes. Observing a patient do a return demonstration of teaching is evaluation to ensure that patient has understood teaching. Option 2 is not evaluation because it occurs before administering a pain medication. The other options are interventions.

5. A 50-year-old woman has elevated serum cholesterol levels that increase her risk for cardiovascular disease. One method to control this risk factor is to identify the patient's current diet trends and describe dietary changes to reduce the risk. This nursing activity is a form of: ch 13 1. Referral. 2. Counseling. 3. Health education. 4. Stress-management techniques.

Answer: 3. Health teaching offers dietary information to the woman to enable her to make decisions about her dietary health practices in an attempt to lower her cholesterol.

3. The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? ch 30 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2

Answer: 3. In healthy adults the normal respiratory rate varies from 12 to 20 respirations per minute. A rate of 8 breaths/min is too low and could be caused by anesthesia or opioid sedation effects.

4. Which of the following nursing activities is provided in a secondary health care environment? CH2 1. Conducting blood pressure screenings for older adults at the Senior Center 2. Teaching a patient with chronic obstructive pulmonary disease purse-lipped breathing techniques at an outpatient clinic 3. Changing the postoperative dressing for a patient on a medical-surgical unit 4. Doing endotracheal suctioning for a patient on a ventilator in the medical intensive care unit

Answer: 3. In secondary care the diagnosis and treatment of illnesses are traditionally the most common services. Secondary services are usually provided in an acute care setting. Inpatient medical-surgical units provide secondary care. Critical care units provide tertiary care.

5. A young male patient enters the emergency department with fever and signs of a possible sexually transmitted infection. The nurse enters the patient's cubicle and begins to enter a history on the computer screen. Before beginning the nurse introduces himself and tells the patient all information will be held confidentially. The nurse starts data collection by establishing eye contact with the patient and then looks at the computer prompts to select a series of questions. As the nurse fills out questions on the computer, the patient asks a question about his treatment. The nurse states, "Let me get through these questions first." Which action interferes with the nurse's ability to use connection as a communication skill. ch 16 1. Introducing self to patient 2. Using the computer as a prompt for questions 3. Making the nurse's questions a priority 4. Assuring the patient all information is confidential

Answer: 3. Introducing self is a form of courtesy, as is informing the patient of the confidentiality of patient information. Using the computer as only a prompt and not solely focusing on the computer is appropriate. However, making your assessment questions more of a priority than those of the patient interferes with and prevents good connection.

9. A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which of the following is appropriate for evaluating a patient's expectations of care? ch 20 1. On a scale of 0 to 10 rate your level of nausea. 2. The nurse weighs the patient. 3. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" 4. The nurse states, "Tell me four different foods included in your diet."

Answer: 3. It is important to evaluate whether you have met a patient's expectations of care. This includes asking about the patient's perceptions of care. Evaluating patient expectations determines the patient's satisfaction with care and strengthens partnering between you and the patient.

8. A nursing student is giving a presentation to a group of other nursing students about the needs of patients with mental illnesses in the community. Which statement by the student indicates that the nursing professor needs to provide further teaching? CH3 1. "Many patients with mental illness do not have a permanent home." 2. "Unemployment is a common problem experienced by people with a mental illness." 3. "The majority of patients with mental illnesses live in longterm care settings." 4. "Patients with mental illnesses are often at a higher risk for abuse and assault.

Answer: 3. Many patients with severe mental illnesses are homeless, unemployed, and at a greater risk for abuse and assault. Patients with mental illnesses no longer routinely live in long-term psychiatric institutions but instead receive resources in the community.

6. A nurse working in a large occupational health clinic knows that many of the workers at her company are marginalized and at risk for poor health outcomes. Which of the following individuals are most likely to be marginalized? ch 9 1. Wives of the employees 2. The head supervisors of the company 3. Workers who have a high school education 4. Workers employed for less than a year at the company

Answer: 3. Marginalized groups are more likely to have poor health outcomes and die earlier because of a complex interaction among their individual behaviors, environment of the communities in which they live, the policies and practices of health care and governmental systems, and the clinical care they receive. Examples of marginalized groups include people who are gay, lesbian, bisexual, or transgender; people of color; people who are physically and/ or mentally challenged; and people who are not college educated.

3. While planning care for a patient, a nurse understands that providing integrative care includes treating which of the following? ch 32 1. Disease, spirit, and family interactions 2. Desires and emotions of the patient 3. Mind-body-spirit of patients and their families 4. Muscles, nerves, and spine disorders

Answer: 3. Mind-body spirit is the focus of holistic nursing

2. Which factor affects a middle-age adult's adherence to a treatment plan? ch 13 1. Gender 2. Lifestyle 3. Motivation 4. Family history

Answer: 3. Motivation plays a key role in adherence with a prescribed course of therapy. Motivation can be influenced by a variety of factors, including age, experience, family history, social support, and pressure by health care providers.

8. A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? ch 23 1. Document her findings and treat the patient. 2. Instruct the mother on safe handling of a 2-year-old child. 3. Contact a child abuse hotline. 4. Discuss this story with a colleague.

Answer: 3. Nurses are mandated reporters of suspected child abuse. These assessment findings possibly indicate child abuse

5. A nurse received bedside report at the change of shift with the night-shift nurse and the patient. The nursing student assigned to the patient asks to review the patient's medical record. The nurse lists patients' medical diagnoses on the message boards in the patients' rooms. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? ch 23 1. Discussing patient conditions at the bedside at the change of shift 2. Allowing the nursing student to review the assigned patient's chart before providing care during the clinical experience 3. Posting medical information about the patient on a message board in the patient's room 4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

Answer: 3. Posting the medical condition of a patient on a message board in the patient's room is not necessary for the patient's treatment. Doing so can result in this information being accessed by persons who are not involved in the patient's treatment

4. The examination for registered nurse (RN) licensure is the same in every state in the United States. This examination: CH 1 1. Guarantees safe nursing care for all patients. 2. Ensures standard nursing care for all patients. 3. Provides a minimal standard of knowledge for an RN in practice. 4. Guarantees standardized education across all prelicensure programs.

Answer: 3. RN candidates must pass the NCLEX-RN® to attain licensure. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in the United States.

10. Which of the following categories of shared theories would be most appropriate for a patient who is grieving the loss of a spouse? ch4 1. Biomedical 2. Leadership 3. Psychosocial 4. Developmental

Answer: 3. Rationale: You can use various psychosocial theories to help patients with loss, death, and grief.

1. A family includes a mother, a stepfather, two teenage biological daughters of the mother, and a biological daughter of the father. The father's daughter just moved home following the loss of her job in another city. The family is converting a study into a bedroom and is in the process of distributing household chores. Nursing assessment reveals all members of the family think that their family can adjust to lifestyle changes. This is an example of family: ch 10 1. Diversity. 2. Durability. 3. Resiliency. 4. Configuration

Answer: 3. Resiliency is the ability of the family to cope with the unexpected. This family used resources to provide some short-term solutions for the return home of an adult child.

3. A patient has been hospitalized for the past 48 hours with a fever of unknown origin. His medical record indicates tympanic temperatures of 38.7°C (101.6°F) at 0400, 36.6°C (97.9°F) at 0800, 36.9°C (98.4°F) at 1200, 37.6°C (99.6°F) at 1600, and 38.3°C (100.9°F) at 2000. How would the nurse describe this pattern of temperature measurements? ch 29 1. Usual range of circadian rhythm measurements 2. Sustained fever pattern 3. Intermittent fever pattern 4. Resolving fever pattern

Answer: 3. Temperature was elevated above acceptable range, returned to normal, and then elevated.

10. A 4-month-old infant has not been feeling well for 2 days. Which number on the image identifies the area of the infant's head where the nurse can assess for dehydration? ch 12 1. 1 2. 2 3. 3 4. 4 5. 5

Answer: 3. The anterior fontanel closes at 12 to 18 months, whereas the posterior fontanel closes by the end of the second or third month.

3. A nurse is reading a research article discussing a new practice to decrease the incidence of catheter-associated urinary tract infections. One section of the article describes who was studied and how the data were collected to answer the research questions and hypotheses. What section of the research article is currently being read? ch5 1. The literature review 2. The data analysis 3. The methods 4. The implications for practice

Answer: 3. The methods section of a study describes the study design, subjects being studied, and how the researcher collects and organizes the data to answer the research question and hypotheses. The methods section also tells you where the study was conducted, how many subjects participated in the study, and what instruments were used to collect the data.

3. A nursing student is providing a hand-off report to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated walking to end of hall each time and back with no shortness of breath. Heart rate was 88 and regular after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I changed the dressing over his intravenous (IV) site and started a new bag of D5½NS. Which intervention is a dependent intervention? ch 18 1. Providing hand-off report at change of shift 2. Enhancing the patient's sleep hygiene 3. Administering IV fluids 4. Taking vital signs

Answer: 3. The only intervention that requires a physician or health care provider order is IV fluid administration. All other interventions are independent.

2. Based on the Transtheoretical Model of Change, what is the most appropriate response to a patient who states: "Me, stop smoking? I've been smoking since I was 16!" ch 6 1. "That's fine. Some people who smoke live a long life." 2. "OK. I want you to decrease the number of cigarettes you smoke by one each day, and I'll see you in 1 month." 3. "What do you think is the greatest reason why stopping smoking would be challenging for you?" 4. "I'd like you to attend a smoking-cessation class this week and use nicotine replacement patches as directed.

Answer: 3. The patient's response indicates that he is in the precontemplation stage and not intending to make a change in behavior in the next 6 months. In this stage the patient is not interested in information about the behavior and may be defensive when confronted with the information. Asking an open-ended question about smoking may stimulate the patient to identify a reason to begin a behavioral change. Nurses are challenged to motivate and facilitate health behavior change in working with individuals.

9. Nurses in a community clinic are conducting an EBP project focused on improving the outcomes of children with asthma. The PICO question asked by the nurses is "In school-aged children, does the use of an electronic gaming education module versus educational book improve the usage of inhalers?" In the question, what is the "O"? ch 5 1. School-aged children 2. Educational book 3. Use of inhalers 4. Electronic gaming education

Answer: 3. The question is "In school-aged children, does the use of an electronic gaming education module versus educational book improve the usage of inhalers?" The population of interest is school-aged children. The "I" would be an electronic gaming education, the "C" would be educational book, and the "O" would be use of inhalers.

2. A parent has brought her 6-month-old infant in for a well-child check. Which of her statements indicates a need for further teaching? ch 12 1. "I can start giving her whole milk at about 12 months." 2. "I can continue to breastfeed for another 6 months." 3. "I can give her plenty of fruit juice to increase her vitamin intake." 4. "I can start giving her solid food now, introducing one food at a time."

Answer: 3. The use of fruit juices and nonnutritive drinks such as fruit-flavored drinks or soda should be avoided since these do not provide sufficient and appropriate calories during this period.

8. A nurse meets with the registered dietitian and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? CH1 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Quality improvement

Answer: 3. This is an example of the competency of teamwork and collaboration. This competency focuses on the nurse functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care

7. A patient tells the nurse, "My doctor told me to lose weight, exercise, stop smoking, and eat better. I am not sick at all. Why would he tell me that?" The nurse's best response would be: ch 8 1. "Since I was not there to hear the conversation, I am not exactly sure." 2. "All of these things are behaviors that are good for you and your family. Why not just give it a try?" 3. "I believe he is trying to get you to think about ways that you can be healthier. All these things help to prevent future health problems." 4. "Eating a balanced, healthy diet and exercising regularly will help you lose weight. I know stopping smoking is really hard to do."

Answer: 3. This response is based on therapeutic communication and provides basic rationale for recommendations improving general health and preventing chronic disease. It is appropriate for a nurse to provide clarification in this situation.

3. A young woman comes to a clinic for the first time for a gynecological examination. Which nursing behavior applies Swanson's caring process of "knowing" the patient? ch 7 1. Sharing feelings about the importance of having regular gynecological examinations 2. Explaining risk factors for cervical cancer 3. Recognizing that the patient is modest and maintaining her privacy during the examination 4. Asking the patient what it means to have a vaginal examination

Answer: 3. Understanding a patient's beliefs, values, and culture enables the nurse to know the context of a patient's illness, treatments, or screening. As a result, the nurse individualizes interventions to help the patient. Knowing the patient is essential when providing patient-centered care

5. Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? ch 19 1. Knowing the source of the guideline 2. Reviewing the evidence used to develop the guideline 3. Individualizing how to apply the clinical guideline for a patient 4. Explaining to a patient the purpose of the guideline

Answer: 3. Whenever a nurse applies a practice guideline, it is essential to consider the patient's unique needs and how to adapt and deliver the guideline. Knowing the source and reviewing the evidence are helpful in knowing the strength of any guideline. Explaining the purpose keeps a patient informed but is not the most important principle.

8. The assistive personnel (AP) informs the nurse that the electronic blood pressure machine on the patient who has recently returned from surgery after removal of her gallbladder is flashing a blood pressure of 65/46 and alarming. Place the care activities in priority order. ch 29 1. Press the start button of the electronic blood pressure machine to obtain a new reading. 2. Obtain a manual blood pressure with a stethoscope. 3. Check the patient's pulse distal to the blood pressure cuff. 4. Assess the patient's mental status. 5. Remind the patient not to bend her arm with the blood pressure cuff.

Answer: 4, 1, 3, 2, 5. First priority is to verify that the patient's blood pressure is providing adequate blood flow to the brain and critical organs. Movement interferes with electronic blood pressure measurement; recycling the machine will obtain a blood pressure while you are assessing the patient. Check the distal pulse to verify circulation to the extremity and then obtain manual blood pressure if needed. Patient education can prevent false values and decrease patient anxiety with alarms

7. A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of: ch 17 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster

Answer: 4. A data cluster is the data elements about a patient that form a meaningful pattern, in this case a pattern of impaired mobility.

8. Elizabeth, who is having unprotected sex with her boyfriend, comments to her friends, "Did you hear about Kathy? You know, she fools around so much; I heard she was pregnant. That would never happen to me!" This is an example of adolescent: ch 11 1. Imaginary audience. 2. False-belief syndrome. 3. Personal fable. 4. Sense of invulnerability

Answer: 4. Adolescents can be risk takers and believe that they are immune to the negative consequences of behaviors; they are just beginning to be future oriented in their thought process and see everything as black or white.

2. A woman has severe life-threatening injuries, is unresponsive, and is hemorrhaging following a car accident. The health care provider ordered two units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? ch 23 1. Obtain a court order to give the blood. 2. Convince the husband to allow the nurse to give the blood. 3. Call security and have the husband removed from the hospital. 4. Gather more information about the wife's preferences and determine whether the husband is her power of attorney for health care.

Answer: 4. Adult patients such as those with specific religious objections are able to refuse treatment for personal religious reasons. Because this patient is unresponsive, it is important for the nurse to better understand the patient's preferences and know if the woman has a power of attorney for health care before following the husband's wishes. However, there needs to be clear directions on who can make the decision

4. Which statement made by a patient who is at average risk for colorectal cancer indicates an understanding about teaching related to early detection of colorectal cancer? ch 30 1. "I'll make sure to schedule my colonoscopy annually after the age of 60." 2. "I'll make sure to have a colonoscopy every 2 years." 3. "I'll make sure to have a flexible sigmoidoscopy every year once I turn 55." 4. "I'll make sure to have a fecal occult blood test annually once I turn 45.

Answer: 4. American Cancer Society guidelines state that for people of average risk, beginning at the age of 45, an annual fecal occult blood test is recommended. Flexible sigmoidoscopy is recommended every 5 years in this population. A colonoscopy is used every 10 years if recommended by the health care provider.

4. Older adults frequently experience a change in sexual activity. Which best explains this change? ch 14 1. The need to touch and be touched is decreased. 2. The sexual preferences of older adults are not as diverse. 3. Medication side effects often impact sexual functioning. 4. Frequency and opportunities for sexual activity may decline

Answer: 4. As a result of loss of a loved one or a chronic illness in themselves or their partner, opportunities for sexual activity may decline. Aging does not change the need for touch, and older adults are diverse. Only select medications impact sexual functioning

7. An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is: ch 7 1. Making health care decisions for patients. 2. Having family members provide a patient's total personal hygiene. 3. Injecting the nurse's perceptions about the level of care provided. 4. Asking permission before performing a procedure on a patient

Answer: 4. Asking permission demonstrates to the patient and family that the nurse respects the patient's rights. Respecting and protecting patient rights is part of "doing for" and "being with" the patient.

5. Which task is appropriate for a registered nurse (RN) to delegate to an AP? ch 21 1. Explaining to the patient the preoperative preparation before the surgery in the morning 2. Administering the ordered antibiotic to the patient before surgery 3. Obtaining the patient's signature on the surgical informed consent 4. Helping the patient to the bathroom before leaving for the operating room

Answer: 4. Assisting the patient with toileting activities is within the scope of an AP's duties. The other activities require the skill and knowledge of the RN.

7. A 7-year-old child was recently diagnosed with asthma. A nurse is providing education to the child and her parents about the treatment and management of asthma and changes they need to make in their home environment to promote her health. Which statement made by the parents requires follow-up by the nurse? ch 10 1. "We have made an appointment to talk with the school nurse about the change in our child's health." 2. "We forgot to give our daughter her medications before bedtime, so we made a list of her medications to help us remember." 3. "We have worked out a schedule to check on her before and after school." 4. "We have not been spending time with our parents because we are so busy taking care of our daughter."

Answer: 4. Changes in family relationships indicate possible family caregiver stress.

10. Dave reports being happy and satisfied with his life. What do we know about him? ch 11 1. He is in one of the later developmental periods, concerned with reviewing his life. 2. He is atypical, since most people in any of the developmental stages report significant dissatisfaction with their lives. 3. He is in one of the earlier developmental periods, concerned with establishing a career and satisfying long-term relationships. 4. It is difficult to determine Dave's developmental stage since most people report overall satisfaction with their lives in all stages.

Answer: 4. Each of the life stages can be achieved successfully and result in satisfaction, including old age.

1. When planning patient education, it is important to remember that patients with which of the following illnesses often find relief in complementary therapies? ch 32 1. Lupus and diabetes 2. Ulcers and hepatitis 3. Heart disease and pancreatitis 4. Chronic back pain and arthritis

Answer: 4. Evidence supports the use of many complementary therapies for chronic pain syndromes, particularly pain that is unremitting and unresponsive to conventional allopathic therapies

3. A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: ch 15 1. Creativity. 2. Fairness. 3. Clinical reasoning. 4. Applying ethical criteria

Answer: 4. Incorporating a patient's beliefs and values promotes patient autonomy and nurse advocacy, key ethical principles in clinical decision making.

4. What factor results in vulnerable populations being more likely to develop health problems? CH 3 1. The ability to use available resources to find housing 2. Adequate transportation to the grocery store and community clinics 3. Availability of others to help provide care 4. Limited access to health care services

Answer: 4. It is the excess of risks and combination of risk factors that make this population more vulnerable, thus limiting access to health care services. These vulnerabilities can be associated with the individual's/community's social determinants of health or individual health disparities

3. Which of the following statements is true regarding Magnet® status recognition for a hospital? CH2 1. Nursing is run by a Magnet manager who makes decisions for the nursing units. 2. Nurses in Magnet hospitals make all of the decisions on the clinical units. 3. Magnet is a term that is used to describe hospitals that are able to hire the nurses they need. 4. Magnet is a special designation for hospitals that achieve excellence in nursing practice.

Answer: 4. Magnet® status is a process and review that hospitals go through that shows achievement of excellence in nursing practice. The designation is given by the American Nurses Credentialing Center and focuses on demonstration of quality patient care, nursing excellence, and innovations in professional practice.

1. Which activity performed by a nurse is related to maintaining competency in nursing practice? CH2 1. Asking another nurse about how to change the settings on a medication pump 2. Regularly attending unit staff meetings 3. Participating as a member of the professional nursing council 4. Attending a review course in preparation for a certification examination

Answer: 4. Maintaining ongoing competency is a nurse's responsibility. Earning certification in a specialty area is one mechanism that demonstrates competency. Specialty certification has been shown to be positively related to patient safety.

7. The nurses on a medical unit have seen an increase in the number of pressure injuries developing in their patients. The nurses decide to initiate a performance improvement project using the PDSA model. Which of the following is an example of "Plan" from that model? ch 5 1. Orienting patients to the unit's practice of hourly rounding on patients 2. Reviewing the incidence of pressure injuries on patients cared for using the protocol 3. Based on findings from patients who developed injuries, implementing an evidence-based skin care protocol on all units 4. Meeting with all disciplines to develop a multidisciplinary approach for reducing pressure injuries

Answer: 4. Meeting with all disciplines to develop a multidisciplinary approach for reducing pressure injuries is developing a plan to test the change (Plan).The implementation of the new protocol is the "Do," or carrying out the test. Reviewing the incidence of pressure injuries on patients cared for using the protocol is observing and learning the outcomes (study). Orienting the patients on the unit to the practice of hourly rounding is part of the protocol being implemented.

3. A nurse ensures that each patient's room is clean; well ventilated; and free from clutter, excessive noise, and extremes in temperature. Which theorist's work is the nurse practicing in this example? ch 4 1. Henderson 2. Orem 3. King 4. Nightingale

Answer: 4. Nightingale's environmental theory directs the nurse to manipulate the environment to promote rest and healing.

5. Parents are concerned about their toddler's negativism. To avoid a negative response, which of the following is the best way for a nurse to demonstrate asking the toddler to eat lunch? ch 12 1. Would you like to eat your lunch now? 2. Would you like to sit at the big table to eat? 3. When would you like to eat your lunch with your friends? 4. Would you like apple slices or applesauce with your sandwich?

Answer: 4. Nurses and parents can deal with the negativism by limiting the opportunities for a "no" answer.

6. What is the best response for the nurse to give if a patient asks the nurse to send a photo of an x-ray to him via a messaging tool in a social media site? ch 22 1. Yes, if you remove all patient identifiers before sending 2. No, because the patient's x-ray results should be discussed with a provider 3. Yes, because respect for autonomy means honoring this patient's request 4. No, because health information of any kind should not be shared on social media

Answer: 4. Patient information should not be shared over social media. While the patient does have a right to obtain health records, this is not the best mechanism by which to share the information. Even without specific identifiers, the information could be seen by others and attributed to the patient.

1. The components of the nursing metaparadigm include: ch 4 1. Person, health, environment, and theory. 2. Health, theory, concepts, and environment. 3. Nurses, physicians, health, and patient needs. 4. Person, health, environment, and nursing.

Answer: 4. Person, health, environment, and nursing are the four components that comprise the nursing metaparadigm

5. When preparing a 4-year-old child for a procedure, which method is developmentally most appropriate for the nurse to use? ch 11 1. Allowing the child to watch another child undergoing the same procedure 2. Showing the child pictures of what he or she will experience 3. Talking to the child in simple terms about what will happen 4. Preparing the child through play with a doll and toy medical equipment

Answer: 4. Preschoolers are in the preoperational stage of cognitive development and learn more easily when play is used to teach.

9. A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the past 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? ch 18 1. Patient will be turned every 2 hours within 24 hours. 2. Patient will have normal formed stool within 48 hours. 3. Patient's ability to turn self in bed improves. 4. Erythema of skin will be mild to none within 48 hours

Answer: 4. Reduced erythema is the only outcome that measurably assesses condition of patient's skin and within a set time frame. It is realistic. The ability to turn self is an outcome measuring mobility status. Normal formed stools is an outcome focused on improving bowel incontinence. Turning a patient is an intervention and not an outcome.

8. A nurse in the recovery room is monitoring a patient who had a left knee replacement. The patient arrived in recovery 15 minutes ago. The nurse observes the patient to be restless, turning frequently, and groaning; the patient's heart rate is 92 compared with 76 preoperatively. Blood pressure is stable since admission to the recovery room. The nurse reviews the medical orders for analgesic therapy. The nurse notes that the postop dose of an ordered analgesic has not yet been given. What is most likely to cause the nurse to reflect on the patient's situation? ch 20 1. The patient is recovering normally. 2. The symptoms reflecting restlessness 3. The patient's blood pressure trend 4. The delay in administration of the analgesic

Answer: 4. Reflection is a nurse's conscious effort to think about nursing interventions and outcomes. It usually occurs in the presence of a trigger event, which involves a breakdown or perceived breakdown in practice such as the delay or omission of a treatment.

9. A 34-year-old female executive has a job with frequent deadlines. She notes that when the deadlines appear, she tends to eat highfat, high-carbohydrate foods. She also explains that she gets frequent headaches and stomach pain during these deadlines. After receiving health education from the nurse, the executive decides to try yoga. In this scenario yoga is used as a(n): ch 13 1. Outpatient referral. 2. Counseling technique. 3. Health promotion activity. 4. Stress-management technique.

Answer: 4. Relaxation techniques, such as imagery, biofeedback, and yoga, help recondition the patient's response to stress. Yoga is an ancient practice of controlling body and mind by which there is a physical and mental harmony. It is frequently used as an effective intervention for stress and stress-related physical symptoms.

4. A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discusses his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual caring. The patient's nurse replies: ch 7 1. "You're correct; spiritual care should be left to a pastoral care professional." 2. "You're correct; religion is a personal decision." 3. "Nurses should explain their own religious beliefs to patients." 4. "Spiritual, mind, and body connections can affect health."

Answer: 4. Spirituality offers a sense of connectedness: intrapersonally (connected with oneself), interpersonally (connected with others and the environment), and transpersonally (connected with the unseen, God, or a higher power).

7. A man who is homeless enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the city hospital for care before assessing the patient. This action is most likely a violation of which of the following laws? ch 23 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Americans with Disabilities Act (ADA) 3. Patient Self-Determination Act (PSDA) 4. Emergency Medical Treatment and Active Labor Act (EMTALA)

Answer: 4. The EMTALA requires that an emergency situation needs to be established and that the patient needs to be stabilized before a transfer is appropriate

4. A nurse implements an EBP change that teaches patients the importance of taking their diabetes medications correctly and regularly on time using videos streamed on the Internet. The nurse measures the patients' behavioral outcome from the practice change using which type of measurement? ch 5 1. Measuring the patient's weight 2. Chart auditing teaching sessions 3. Observing patients viewing the videos 4. Checking patients' blood sugars

Answer: 4. The desired behavioral outcome is the patients' blood sugars, which will show the patients' adherence to taking medications as prescribed. Measuring the patients' weight is a desirable physical outcome but not a measure of the effects of the teaching program. Charting auditing teaching sessions is a process measure to track teaching sessions. Observing the patients viewing the DVD is also a process measure.

10. The nurses on an acute care medical floor notice an increase in pressure injury formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure injury risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career? CH 1 1. Clinical nurse specialist 2. Nurse administrator 3. Nurse educator 4. Nurse researcher

Answer: 4. The nurse researcher investigates problems to improve nursing care and to further define and expand the scope of nursing practice. He or she often works in an academic setting, hospital, or independent professional or community service agency.

1. The nurse is aware that preschoolers often display a developmental characteristic that makes them treat dolls or stuffed animals as if they have thoughts and feelings. This is an example of: ch 11 1. Logical reasoning. 2. Egocentrism. 3. Concrete thinking. 4. Animism.

Answer: 4. This is the belief that inanimate objects have lifelike qualities; it is a component of magical thinking evident in preoperational thought.

9. A nurse is caring for a patient who has poor pain control. The patient has a history of opioid abuse. During the day the patient made frequent requests for a pain medication. In order to make an effective clinical decision about this patient, the nurse needs to ask questions about the data available on the patient to make a thorough and thoughtful decision. The nurse asks herself, "How does my view about the patient's pain tolerance compare with the patient's, and does that pose a problem?" This is an example of: ch 15 1. A question about assumptions. 2. A question about evidence. 3. A question about procedure. 4. A question about perspective.

Answer: 4. Thoughtful clinical decision making involves asking questions about your perspective, such as how does your own view compare with that of the patient.

1. An experienced nurse is explaining the use of touch from a caring perspective. What information does the nurse include in the discussion with the student about touch? ch 7 1. Nurses touch patients only while performing procedures or doing assessments. 2. Touch is a type of verbal communication. 3. Nurses use touch only when a patient is in pain. 4. Touch forms a connection between nurse and patient

Answer: 4. Touch is relational and leads to a connection between nurse and patient. It involves contact and noncontact touch. Contact touch involves obvious skin-to-skin contact, whereas noncontact touch refers to eye contact.

1. You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which statement best describes this code? CH 1 1. Improves self-health care 2. Protects the patient's confidentiality 3. Ensures identical care to all patients 4. Defines the principles of right and wrong to provide patient care

Answer: 4. When giving care, it is essential to provide a specified service according to standards of practice and to follow a code of ethics. The code of ethics is the philosophical ideals of right and wrong that define the principles you will use to provide care to your patients. It serves as a guide for carrying out nursing responsibilities to provide quality nursing care and as a guide to the ethical obligations of the profession

2. Place the steps of the EBP process in the appropriate order. ch 5 1. Critically appraise the evidence you gather. 2. Ask the clinical question in PICOT format. 3. Evaluate the outcomes of the practice decision or change. 4. Search for the most relevant and best evidence. 5. Cultivate a spirit of inquiry. 6. Integrate the evidence. 7. Communicate the outcomes of the EBP change

Answer: 5, 2, 4, 1, 6, 3, 7. The process starts with a spirit of inquiry and the final step is sustaining the EBP change.

8. In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history? ch 16 1. Current medications 2. Patient expectations of planned surgery 3. Review of patient's family support system 4. History of allergies 5. Patient's explanation for what might be the cause of symptoms that require surgery

Answer: 5. The nursing health history has several components. A review of present illness or health concerns includes a question asking the patient what provokes or precipitates symptoms. Gathering a patient's explanation for what might be the cause of symptoms is the appropriate approach. Past health history is the component that includes a medication history and history of allergies. Patient expectations of treatment is another component. A review of family interaction and support is part of the family history component

6. Which number marks the location where the nurse would auscultate the point of maximal impulse (PMI)? ch 29 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6

Answer: 5. This is the spot where you would auscultate the PMI.

5. The following are steps in the process to help resolve an ethical problem. What is the best order of these steps to achieve resolution? ch 22 1. List all the possible actions that could be taken to resolve the problem. 2. Articulate a statement of the problem or dilemma that you are trying to resolve. 3. Develop and implement a plan to address the problem. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the problem. 5. Take time to clarify values and identify the ethical elements, such as principles and key relationships involved. 6. Recognize that the problem requires ethics.

Answer: 6, 4, 5, 2, 1, 3. This order reflects a systematic approach to ethical problems, similar to the nursing process.

9. Place the steps of administering an intradermal injection in the correct order. ch 31 1. Inject medication slowly. 2. Note the presence of a bleb. 3. Advance needle through epidermis to 3 mm. 4. Using nondominant hand, stretch skin over site with forefinger. 5. Insert needle at a 5- to 15-degree angle into the skin until resistance is felt. 6. Cleanse site with antiseptic swab.

Answer: 6, 4, 5, 3, 1, 2. This is the correct sequence of steps to administer an intradermal injection

2. The health care provider has written the following orders. Which orders does the nurse need to clarify before administering the medication? Provide rationale for your answers, and rewrite the order so that it follows the ISMP current medication order safety guidelines. Timoptic .25% solution 1 drop OD BID Metoprolol 12.50 mg QD Insulin Glargine 6 u SC twice a day Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100

Answer: The nurse needs to clarify all the orders. Timoptic .25% solution 1 drop OD BID has a "naked" decimal point, and OD (right eye) could be mistaken for AD (right ear). Metoprolol 12.50 mg QD has a trailing zero, and the dosage could be mistaken for 1250 mg if the decimal point is not seen; it also has no route identified. Insulin Glargine 6 u SC twice a day includes the letter u, which means units but could be mistaken as the number 0 or 4, and SC could be mistaken as SL. Enalapril 2.5 mg. PO three times a day, hold for systolic blood pressure <100 has a period after mg, which could be mistaken as the number 1, and the < sign could be mistaken as greater than. The correctly written orders are "Timoptic 0.25% solution 1 drop right eye BID." Metoprolol 12.5 mg QD PO Insulin glargine 6 units subcutaneous twice a day Enalapril 2.5 mg PO three times a day, hold for systolic blood pressure less than 100

2. A nurse is providing education to a patient with type 2 diabetes. Which characteristics does the nurse include in her teaching to explain why type 2 diabetes is considered a chronic disease? (Select all that apply.) ch 8 1. Type 2 diabetes lasts throughout a person's life. 2. Genetic mutations drive the treatment for type 2 diabetes. 3. People with type 2 diabetes have to modify some of their daily activities. 4. Type 2 diabetes occurs in elderly people. 5. People with type 2 diabetes require ongoing medical care

Answer:1, 3, 5. A chronic disease is a pathophysiologic condition that lasts more than 1 year, requires ongoing medical care, and often limits a person's usual activities of daily living due to symptoms of the disease or self-care activities required to manage the disease.

5. Health care organizations must provide which of the following based on federal civil rights laws? (Select all that apply.) ch 9 1. Provide language assistance services at all points of contact free of charge. 2. Provide auxiliary aids and services, such as interpreters, note takers, and computer-aided transcription services. 3. Use patients' family members to interpret difficult topics. 4. Ensure that interpreters are competent in medical terminology. 5. Provide language assistance to all patients who speak limited English or are deaf.

Answers: 1, 2, 4, 5. The CLAS standards include standards for communication and language assistance, including providing language assistance free of charge, auxiliary aids and services, interpreters competent in medical terminology, and language assistance for patients with limited English or who are deaf.

2. A 35-year-old woman has Medicaid coverage for herself and two young children. She missed an appointment at the local health clinic to get an annual mammogram because she has no transportation. She gets the annual screening because her mother had breast cancer. Which of the following are social determinants of this woman's health? (Select all that apply.) ch 9 1. Medicaid insurance 2. Annual screening 3. Mother's history of breast cancer 4. Lack of transportation 5. Woman's age

Answers: 1, 4, 5. Social determinants of health are the conditions under which persons are born, grow, live, work, and age. The social determinants of health are mostly responsible for health disparities. Examples include age, race and ethnicity, socioeconomic status (as reflected by the woman's insurance), access to nutritious food, transportation resources, religion, sexual orientation, level of education, literacy level, disability (physical and cognitive), and geographic location (e.g., access to health care).

10. Match the cultural concepts on the left with the correct definitions on the right. ch 9 1. Etic world view __________ a. Factor that shapes how people perceive others and how they relate to reality 2. World view __________ b. Insider's perspective in an intercultural encounter 3. Cultural desire __________ c. A policy model that describes factors and power structures that shape and influence life 4. Intersectionality __________ d. An outsider's perspective in an intercultural encounter 5. Emic world view __________ e. The motivation of a health care professional to "want to" engage in cultural competency

Answers: 1d, 2a, 3e, 4c, 5b.

4. A nurse desires to communicate with a young woman who is Serbian and who has limited experience with being in a hospital. The nurse has 10 years of experience caring for Serbian women. The patient was admitted for a serious pregnancy complication. Apply the LEARN model and match the nurse's behaviors with each step of the model. ch 9 1. L ___________ a. The nurse notes that she has learned that fathers can visit mothers at any time in both Serbia and the United States. 2. E ___________ b. The nurse shares her perception of the woman's experiences as a patient. 3. A ___________ c. The nurse asks the patient how she can maintain bed rest when she returns home. 4. R __________ d. The nurse attends to the patient and listens to her story about hospitals in Serbia. 5. N __________ e. The nurse involves the patient in a discussion of the treatment options for her condition.

Answers: 1d, 2b, 3a, 4e, 5c. Listen with empathy and understanding to patient perception of the problem; Explain your perceptions of the problem (physiological, psychological, spiritual, and/or cultural; Acknowledge and discuss cultural differences and similarities between you and your patient; Recommend treatment (involving the patient); and Negotiate agreement (incorporate selected aspects of the patient's culture into patient-centered care).

1. Which of the following is an example of a patient with a health disparity? (Select all that apply.) ch 9 1. A patient who has a homosexual sexual preference 2. A patient unable to access primary care services 3. A patient living with a chronic disease 4. A family who relies on public transportation 5. A patient who has had a history of smoking for 10 years

Answers: 2, 3, 5. Poor health status (chronic disease), disease risk factors (smoking history), poor health outcomes, and limited access to health care (unable to access primary care) are types of health disparities.

9. A nursing assessment reveals a patient in the home setting who has reduced mobility following recovery from a stroke. The patient has weakness in the left leg and arm. The patient has a walker, which he has never used before, and his wife tells the nurse that he is unsteady in using the walker. The patient fell while in the hospital. The physical therapist came to the home, but the wife tells the nurse, "We are not sure how to get my husband upstairs. The therapist explained how to use the walker, but we have questions." The nurse developed the following concept map. Place the links between the nursing diagnoses in the correct direction. ch 17

ability to ambulate. Primary health problem: Stroke Impaired Mobility • Weakness of left leg and arm • Unsteady walking • Requires walker to ambulate Lack of Knowledge • Has questions about how to use walker • Unsure of how to ascend stairs • Patient new to use of walker Risk for Fall • Fell in hospital • Weakness of left lower extremity • Unsteady when ambulating