Ch 14,15,16,17, 18

Nursing care and client outcomes may be evaluated by use of a retrospective evaluation process. Which of the following is an example of a retrospective evaluation process? A) Postdischarge questionnaire. B) Direct observation of nursing care. C) Client interview during hospitalization. D) Review of client's chart during hospitalization.

Ans: A Feedback: Retrospective evaluation may use postdischarge questionnaires and client interviews, or chart reviews after the client has been discharged. Concurrent evaluation occurs while the client is receiving care and may include the following: direct observation of nursing care and client interviews; and direct observation of chart reviews during hospitalization.

19. Which of the following actions would generally take place in the settling down stage of Daniel Levinson's Individual Life Structure theory? Select all that apply. A) Breaking away from the family B) Making initial career choices C) Trying new lifestyles D) Striving to gain respect E) Investing in family

Ans: D, E Feedback: In the settling-down phase (age 30-40), the adult invests energy into the areas of life that are most personally important. The areas of investment are primarily family, work, and community. The individual strives to gain respect, status, and a sense of authority. Breaking away from family occurs in the early adult transition. Making initial career choices and trying new lifestyles occurs in the entering-the-adult-world stage. Maximizing self-approval occurs in the pay-off years.

31. The client reports participating in water aerobics for 60 minutes three times each week. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

Ans: A Feedback: An affective outcome involves changes in the client's values, beliefs, and attitude, such as participating in water aerobics. Cognitive outcomes demonstrate increases in client knowledge. Physiologic outcomes are physical changes in the client. Psychomotor outcomes describe the client's achievement of new skills.

25. A woman is visiting the office and is in her third trimester of pregnancy. She asks the nurse about the development that is occurring at this stage of pregnancy. Which is accurate to tell her about the fetus? A) The lungs are mature. B) The fetus is 11 to 14 inches. C) The arms and legs are reflexive. D) The head circumference is 34 cm.

Ans: A Feedback: In the third trimester, the lungs are mature.

26. The nursing student is assessing a neonate who has been brought to the clinic for a well-baby visit. Which of the following would the nursing student expect as normal development for a neonate? A) Reaching for objects B) Staring at objects C) Kicking at objects D) Selecting specific objects

Ans: B Feedback: Neonates stare at objects, but are not capable of reaching, kicking or selecting objects at this phase of development.

4. A nurse documents the following data upon assessment of a neonate: heart rate 89 BPM, slow respiratory effort, flaccid muscle tone, weak cry, and pale skin tone. What would be the Apgar score for this neonate? A) 2 B) 3 C) 4 D) 5

Ans: B Feedback: The neonate is assessed immediately after birth. Of several existing measurement scales, the Apgar rating scale is the most commonly used. This scale is used to assess neonates 1 minute and 5 minutes after birth. This baby would receive 1 point for slow heartbeat, 1 point for slow respiratory effort, and 1 point for weak cry. Flaccid muscle tone and pale skin tone are both 0 points.

32. In which of the following cases should a progress note be written? Select all that apply. A) For any nurse-client interaction B) When admitting a client C) When receiving a client postoperatively D) When assisting a client with ADLs E) When a procedure is performed

Ans: B, C, E Feedback: A progress note should be written in the following instances: upon admission, transfer to another unit, and discharge; when a procedure is performed; upon receiving a client postoperatively or postprocedure; upon communicating with physicians regarding critical client information (e.g., abnormal lab value result); or for any change in client status.

15. A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next? A) Date it and put it in the client's record. B) Sign it and put it in the Kardex. C) Individualize it to the specific client. D) Use it as printed, based on common needs.

Ans: C Feedback: Standardized care plans that identify common problems and needs with relation to select client cohorts may be used. Unless such care plans are individualized to a specific client, however, they may not address individual client needs.

A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse? A) The UAP is responsible and accountable for his or her own actions. B) Nurses do not have authority to delegate interventions. C) The nurse transfers responsibility but is accountable for the outcome. D) The UAP can function in an independent role for all interventions.

Ans: C Feedback: UAPs are trained to function in an assistive role to the RN in client activities as delegated and supervised by the RN. Delegation is the transfer of responsibility of an activity to another individual while retaining accountability for the outcome.

8. Which of the following nurses is most likely to care for clients who are trying to resolve identity versus role confusion? A) A nurse who provides care in a large junior high school B) A pediatric nurse C) A nurse who works in a long-term care facility D) An occupation health nurse based at a lumber mill

Ans: A Feedback: According to Erikson, the crisis of identity versus role confusion is characteristic of adolescence. Consequently, a nurse who provides care in a junior high school is likely to see frequent manifestations of this crisis. Early childhood, middle adulthood, and late adulthood are not typical life stages for the resolution of this crisis.

34. A school nurse often observes adolescents challenging the decision making of their parents and teachers. Which of these developmental theorists relates this as an expected occurrence? A) Piaget B) Freud C) Havighurst D) Erikson

Ans: A Feedback: According to Piaget, challenging the decision making of adults is common in adolescence.

A nurse in a community health center has been having regular meetings with a woman who wants to stop smoking. Which of the following outcome decision options would the nurse document if the woman has not smoked for three months? A) Outcome met B) Outcome partially met C) Outcome not met D) Outcome inappropriate

Ans: A Feedback: After data have been collected and interpreted to determine client outcome achievement, the nurse makes and documents a judgment summarizing the findings. The three decision options are met, partially met, and not met. In this case, the nurse's judgment is that the client has met the expected outcome of smoking cessation.

23. A mother brings her toddler, age 20 months, to the clinic today for immunizations. She talks about trying to initiate toilet training a few weeks ago, but her son wasn't interested. She decided to put it off for awhile. She told her son he was a good boy and they would try again another time. According to Erik Erikson's theory, what is the likely outcome for Matt's developmental stage? A) Autonomy B) Identity C) Intimacy D) Initiative

Ans: A Feedback: Autonomy versus shame and doubt implies that if the caregivers are overprotective or have expectations that are too high, shame and doubt, as well as feelings of inadequacy, might develop in the child. The mother has a good attitude towards toilet training and from that, her son will develop his autonomy. Initiative has to do with Erikson's theory about preschool-aged children. Identify is related to adolescence, and intimacy is about young adulthood.

7. A nurse provides care in a women's health clinic that is located in an inner city neighborhood. Which of the following theorists' work applies most directly to this nurse's client population? A) Gilligan B) Kohlberg C) Gould D) Fowler

Ans: A Feedback: Carol Gilligan's work specifically addresses the moral development of women, proposing an ethic of care that develops through three levels during women's lives. Kohlberg, Gould, and Fowler do not differentiate between the developmental considerations of males and females.

32. The nurse is caring for a an infant age 11 months. The infant's mother tells states that when she asked the doctor about starting to toilet train her child, the doctor talked about cephalocaudal development. The mother then asks for an explanation of this term. Which of the following about cephalocaudal development is the nurse's best reply? A) Proceeds from brain down to feet B) Both sides of the body develop equally C) Brain must fully develop before toilet training D) Gross control to fine control

Ans: A Feedback: Cephalocaudal (proceeding from head to tail) development is the first trend, with the head and brain developing first, followed by the trunk, legs, and feet. The second trend is proximodistal development, which means that growth progresses from gross motor movements (such as learning to lift one's head) to fine motor movements (such as learning to pick up a toy with the fingers). The last trend is symmetric development of the body, with both sides of the body developing equally.

The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88, an increase from 134/78 at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care? A) My husband has been ill and I don't have anyone to help me care for him. B) I have learned to prepare foods differently so they are low in fat. C) My neighbor walks with me around the neighborhood every morning. D) I have been taking my hydrochlorothiazide (HydroDIURIL) every day.

Ans: A Feedback: Common factors that contribute to a client not following the plan of care include lack of family support, inability to afford treatment, limited access to treatment, and adverse physical or emotional effects of treatment. The burden of caring for her husband may be placing stress on the client, and causing her blood pressure to be elevated despite engaging in health promotion and blood pressure-lowering activities.

10. All humans learn from both formal and informal experiences. What orderly pattern of changes results in part from learning? A) Development B) Growth C) Maturity D) Aging

Ans: A Feedback: Development is an orderly pattern of changes in structure, thoughts, feelings, or behaviors resulting from maturation, experiences, and learning. It is a dynamic and continuous process as one proceeds through life, characterized by a series of ascents, plateaus, and declines. Growth is an increase in body size or changes in body cell structure, function, and complexity.

29. The nurse is providing education on child growth and development to a group of parents at a public health clinic. In answer to a question about childhood enuresis, the nurse verifies that this can be a significant issue to the child and the parents. The nurse should be sure to inform the group that this condition is which of the following? A) A benign and self-limiting disorder B) Increasing in incidence in the United States C) Of significant concern to pediatricians D) Due to a lack of physical activity

Ans: A Feedback: Enuresis is diagnosed when a child is at least 5 years of age and is still having involuntary urination, usually at night. Although this problem is significant to the child and his or her parents, it is defined as a benign and self-limiting disorder, usually ending between 6 and 8 years of age. There is no research indicating that the incidence is increasing in the United States or that it is caused by lack of physical activity.

5. A boy age 4 years is constantly seeking out and exploring new experiences, and repeatedly asking his parents why-type questions. The boy's behavior suggests that he is successfully navigating an important developmental task within the developmental theory of: A) Erikson B) Freud C) Kohlberg D) Fowler

Ans: A Feedback: Erikson characterized development as a series of crises. The preschooler typically must choose between initiative (seeking new experiences and learning) and guilt. Freud focuses on psychosexuality while Kohlberg prioritizes moral development. Fowler explains development through the lens of faith.

33. Then nurse is caring for single, professional woman age 29 years, who was admitted with a severe gall bladder attack. The nurse visits with her and performs an assessment. The client is not married and fears a committed relationship because of a bad experience some years ago. The nurse knows that, according to Erikson's developmental theory, Judith is in danger of which of the following? A) Isolation B) Inferiority C) Role confusion D) Stagnation

Ans: A Feedback: Erikson's theory of young adulthood relates to finding one's life partner and sharing intimacy. The tasks for the young adult are to unite self-identity with identities of friends and to make commitments to others. Fear of such commitments results in isolation and loneliness. Role confusion, inferiority, and stagnation are related to Erikson's other age groups.

28. A nursing student is observing in a pediatric clinic. A grandmother brings an infant age 2 months to be seen. The infant has failed to gain the expected amount of weight and looks unwell. The nursing student wonders if this may be a failure to thrive baby. Which one of the following has been linked to failure to thrive babies? A) Nutritional deprivation B) Working mothers C) Use of day care centers D) Premature births

Ans: A Feedback: Failure to thrive, a condition of early infancy, has been linked to both nutritional and emotional deprivation. This list is not all inclusive. Use of day care centers by working mothers has not been noted as a factor contributing to failure to thrive, nor have premature births.

15. In contrast to Kohlberg, Gilligan developed a theory of moral development specifically for women. What is the central theme of Gilligan's theory? A) Response and care B) Rights and justice C) Adult transformation D) Individual life structure

Ans: A Feedback: Gilligan's theory, developed to explain the female viewpoint of morality as different from that of Kohlberg, views females as developing a morality of response and care and males as developing a morality of justice, rights, and obligation.

6. Which of the following developmental tasks is an important component of middle adulthood within Havighurst's theory of psychosocial development? A) Accepting and adjusting to physical changes B) Adjusting to reduced income C) Adjusting to decreasing health D) Learning to live with a marriage partner

Ans: A Feedback: Havighurst identifies the acceptance and adjustment to physical changes as a task associated with middle adulthood. Adjusting to declining health and reduced income are associated with later maturity, while learning to live with a marriage partner is a developmental task of young adulthood.

36. The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations? A) When communicating a client's change in condition to the client's physician B) When providing a change-of-shift report to a colleague C) When documenting the care that was provided to a client whose condition recently deteriorated D) When reporting to a client's family member or significant other

Ans: A Feedback: ISBARR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. ISBARR is considered a framework for communication rather than a format for documentation.

What is the unique focus of nursing implementation? A) Client response to health and illness B) Client response to nursing diagnosis C) Client compliance with treatment regimen D) Client interview and physical assessment

Ans: A Feedback: In all nurse-client interactions, the nurse is concerned with the client's response to health and illness and the nurse's ability to meet basic human needs. Whereas other health care professionals focus on selected aspects of the client's treatment regimen, nurses are concerned with how the client is responding to the plan of care in general.

2. A female client age 35 years explains to the community health nurse that her primary focus daily is the care of her family, her job, and her volunteer activities at her church. The client verbalizes contentment with her various roles and the balancing of these roles. According to the theory on "individual life structure" developed by Daniel Levinson and associates, this client is demonstrating characteristics associated with what phase of adulthood? A) Settling down B) Early adult transition C) Entering the adult world D) Midlife transition

Ans: A Feedback: In the settling-down phase (age 30-40), the adult invests energy into the areas of life that are most important, such as family, work, and community. The years of the middle to late 20s (age 22-28) are a time to build on previous decisions and choices, and to try different careers and lifestyles. It is defined as the phase of "entering the adult world." During early adult transition, the major concerns of the young adult (age 18-22) are to break away from the parents, to make initial career choices, and to establish intimate relationships. Midlife transition (age 40-45) involves a reappraisal of one's goals and values.

The manager of a medical unit regularly reviews the incident reports that result from errors and near misses that occur on the unit. How should the manager best respond to these incident reports? A) Use them to inform improvements and education on the unit. B) Use them to identify deficient workers for removal or demotion. C) Cross-reference them with client satisfaction reports from the unit. D) Use them to identify individuals who would benefit from probationary measures.

Ans: A Feedback: It is most beneficial for the manager to frame incident reports as sources of improvement, which can improve both client care and the work environment. Punitive follow-up by demotion, probation, or removal is likely to create reluctance among staff to complete incident reports. Cross-referencing incident reports with client satisfaction reports is unlikely to result in substantial improvements to the unit's care and culture.

The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice? A) The registered nurse B) The American Nurses Association C) The nurse manager D) The unit's medical director

Ans: A Feedback: It is the registered nurse who is responsible and accountable for nursing practice.

21. The nurse is seeing a pregnant woman 25 years of age. The woman's partner is very caring and loving, but has decided that he does not want to be a father, and so has left the relationship. The woman is determined to raise her child alone and says, "I will never let myself be hurt like that again." According to Gilligan's theory, on which level is this woman? A) Level 1: Selfishness B) Level 2: Undifferentiated Faith C) Level 3: Goodness D) Level 4: Nonviolence

Ans: A Feedback: Level 1 of Gilligan's theory says that relationships are often disappointing, and as a result, a woman might isolate herself to avoid getting hurt. Undifferentiated faith is part of Fowler's theory, not Gilligan's. Goodness is Level 2 of Gilligan's theory and says that acceptance by others is very important. Nonviolence is Gilligan's Level 3, and it says that nonviolence has to do with all judgments and decisions.

22. The nurse is caring for a woman 55 years of age who has been admitted for a hernia repair. The nurse is doing an initial nursing assessment and considers developmental theories. Where would the nurse place the client according to the theory of Daniel Levinson and associates? A) The pay-off years B) Later maturity C) Generativity versus stagnation D) Postconventional level

Ans: A Feedback: Levinson and associates describe the pay-off years as the years from 45 to 65. They are a time of maximum self-direction and self-approval. Physical and mental changes increase an awareness of one's aging and mortality. The postconventional level is a stage described by Lawrence Kohlberg. Later maturity is a stage described by Robert Havighurst. Generativity versus stagnation is appropriate for this client's age, but is a theory stage of Erik Erikson.

7. A nurse watches as a child continuously tells her mother "no!" to each comment the mother makes. The nurse knows that this behavior, termed negativism, is characteristic of which of the following developmental groups? A) Toddler B) Preschooler C) School-aged child D) Adolescent

Ans: A Feedback: Negativism (characteristically expressed by saying no) and outbursts of temper result from the toddler's efforts at control over the environment.

28. The nurse is visiting with the mother of a child age 20 months. The mother reports concern about the frequency of the toddler's loud outbursts of temper and saying no. The nurse recalls Erikson's theory about negativism and tells the mother which of the following? A) This is normal, and this is how your child tries to exert control over his environment. B) This is unacceptable and you must provide appropriate discipline. C) This has to do with regression and is a response to stress. D) This is normal and has to do with learning right from wrong.

Ans: A Feedback: Negativism (characteristically expressed by saying no) and outbursts of temper result from the toddler's efforts at control over the environment. Because this is normal, severe discipline is not warranted. Regression, or behavior that is more characteristic of a younger age, can occur at any time in response to stressful circumstances. Learning right from wrong is one of the tasks in Havighurst's theory.

31. The nurse provides prenatal education to a group of pregnant teenagers. One of the group members asks the nurse to talk about the possible complications for a newborn. An accurate statement about neonatal complications would be which of the following? A) Respiratory difficulties B) Physiologic jaundice C) Caput succedaneum D) Subconjunctival hemorrhage

Ans: A Feedback: Respiratory difficulties can occur and be life-threatening to the neonate. Birth traumas that cause temporary symptoms are of concern because the parents need to be reassured that the symptoms will disappear. Examples include caput succedaneum (localized edema of the scalp), molding (elongation of the skull as the baby passes through the birth canal), and subconjunctival hemorrhage. The nonthreatening nature of physiologic jaundice, which commonly occurs in the neonate's first days, should also be explained to the parents.

3. A child who attends church with his parents imitates religious gesture but does not have an understanding of these religious behaviors. The child also asks his parents, "How do you know God exists? Have you ever seen him?" This child is described as having characteristics associated with which stage of faith development as defined by Fowler? A) Intuitive-Projective Faith B) Mystical-Literal Faith C) Synthetic-Conventional Faith D) Individuative-Reflective Faith

Ans: A Feedback: The child is demonstrating characteristics of the stage of Intuitive-Projective Faith. During this stage, the child takes on parental attitudes toward religious or moral beliefs without an understanding of them. During the Mystical-Literal Faith stage, the child accepts the existence of a deity. Synthetic-Conventional Faith is the characteristic stage for many adolescents when they begin to question life-guiding values or religious practices in an attempt to stabilize their own identity. The Individuative-Reflective Faith stage often occurs during the older adolescent and young adult years, as individuals become responsible for their own commitments, beliefs, and attitudes.

25. The emergency department nurse is caring for an infant age 2 months who was brought in by a hired caregiver. The infant is underweight and looks uncared for. The caregiver reports that the mother of the infant is unreliable and may be using drugs; the infant is often unclean and hungry when dropped off at the caregiver's home. The infant has diaper rash and a weak cry. If this situation is not remedied, what will this infant have difficulty achieving, according to Erikson's developmental theory? A) Trust B) Autonomy C) Initiative D) Identity

Ans: A Feedback: The infant learns to rely on caregivers to meet basic needs of warmth, food, and comfort. This is how the infant learns to form trust in others. Mistrust is the result of inconsistent, inadequate, or unsafe care. The other choices are later stages of Erikson's developmental theory.

14. What is the primary risk to the developing fetus during pregnancy if there is cocaine use by the mother? A) Decreased fetal circulation and oxygenation B) Increased maternal weight gain and edema C) Neural tube defects and low birth weight D) Respiratory difficulties and excess mucus

Ans: A Feedback: The maternal use of cocaine during pregnancy brings about abrupt changes in the mother's blood pressure, resulting in decreased fetal blood flow and oxygenation.

35. The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following? A) The physician's assessment and treatment B) Results of laboratory and diagnostic studies C) Nursing documentation and plan of care D) Information from other members of the health care team

Ans: A Feedback: The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment.

34. The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider? A) ISBAR B) EMAR C) SOAP D) CBE

Ans: A Feedback: The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.

Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will do what? A) Terminate the plan of care. B) Modify the plan of care. C) Continue the plan of care. D) Re-evaluate the plan of care.

Ans: A Feedback: The nurse will terminate the plan of care when each expected outcome has been achieved. Modifying the plan of care is necessary if there are difficulties in achieving the outcomes. Re-evaluating each step of the nursing process is a step in the modification of a plan of care. Continuing the plan of care occurs if more time is needed to achieve the outcomes.

4. After a child plays in the yard, his mother asks him to pick up his toys and put them in the toy bin in the garage. Knowing that he does not want to spend time in his room as a punishment, the child follows his mother's directions. What stage of moral development, according to Kohlberg, is this child demonstrating? A) Preconventional level: stage 1 B) Preconventional level: stage 2 C) Conventional level: stage 1 D) Conventional level: stage 2

Ans: A Feedback: The preconventional level is based on external control as the child learns to conform to rules imposed by authority figures. At stage 1 (punishment and obedience orientation), the motivation for choices of action is fear of physical consequences of authority's disapproval. At stage 2 (instrumental relativist orientation), the thought of receiving a reward overcomes fear of punishment, so actions that satisfy this desire are selected. The conventional level involves identifying with significant others and conforming to their expectations.

A child demonstrates increasing language skills and an understanding of symbols. Creative play and the use of imagination is an important activity in the child's life. Based upon these characteristics and according to Jean Piaget's theory, what stage of cognitive development is the child demonstrating? A) Preoperational stage B) Sensorimotor stage C) Concrete operational stage D) Formal operational stage

Ans: A Feedback: The preoperational stage (ages 2 to 7 years) is characterized by the beginning use of symbols, through increased language skills and pictures. Play activities during this time help the child understand life events and relationships. The sensorimotor stage (birth to 24 months) is marked by stages that begin with the demonstration of basic reflexes through beginning development in reasoning skills. The concrete operational stage (ages 7 to 11 years) is characterized by the development of logical thinking, an understanding of reversibility, relations to numbers, and the loss of egocentricity. The formal operational stage (age 11 years and older) is characterized by the use of abstract thinking and deductive reasoning.

31. A nursing student is visiting a third-grade class to observe growth and development in action and does assessments on the children. They are learning to think logically and to classify and relate objects and ideas. According to Erikson, in what developmental stage are they? A) Industry versus inferiority B) Latency C) Acceptance of deity D) Concrete operational

Ans: A Feedback: Third graders are in Erikson's industry versus inferiority stage. Focusing on the end result of achievements, the school-aged child gains pleasure from finishing projects and receiving recognition for accomplishments. Concrete operational is Piaget's theory for school-aged children. Latency is Freud's theory. Acceptance of a deity is a developmental theory belonging to Fowler.

18. A mother of three children under the age of 4 tells the nurse, "I don't understand why my children are so hard to toilet train before they are 2." How should the nurse respond? A) "Bladder control during the day usually occurs by ages 2.5 to 3 years." B) "Do you think you are doing something wrong? They should be trained." C) "I don't know. I will have to talk to your doctor, and I will let you know." D) "I had that same problem. You just have to try harder."

Ans: A Feedback: Toddlers between the ages of 2.5 and 3 years usually have bladder control during the day and sometimes at night.

30. The nursing student is visiting a middle school with an assignment to observe and visit with students while walking around with the school nurse. Then nursing student is interested to learn that some students seem to be rebelling against authority figures like teachers and parents. The nursing student recalls that, according to Erikson's theory, this is not abnormal behavior. To which stage of Erikson's theory does this behavior belong? A) Identity versus role confusion B) Industry versus inferiority C) Initiative versus guilt D) Autonomy versus shame

Ans: A Feedback: Trying on roles and even rebellion are considered normal behaviors as the adolescent acquires a sense of self and decides what direction will be taken in life. Role confusion occurs when the adolescent is unable to establish identity and a sense of direction. The other choices are different stages of Erikson's theory.

26. The nurse is working in the newborn nursery and observes neonates in various states of health and wellness. The nurse is aware that which of the following factors can affect fetal development? Choose all that apply. A) Age of mother B) Prenatal nutrition C) Substance abuse by mother D) Congenital vision deficit E) Poor neonatal nutrition

Ans: A, B, C Feedback: Fetal development can be altered by maternal age (with risk greater in those under age 15 or over age 35), substance abuse, inadequate prenatal care, inadequate maternal nutrition, and maternal substance abuse. Congenital abnormalities and poor neonatal nutrition do not affect fetal development.

21. Which client outcome is a physiologic outcome? Select all that apply. A) The client's HA1c is 7.4%. B) The client's blood pressure is 118/74. C) The client rates his or her pain rating as 6. D) The client self-administers insulin subcutaneously. E) The client describes manifestations of wound infection.

Ans: A, B, C Feedback: Physiologic outcomes are physical changes in the client, such as pain ratings and blood pressure and HA1c measurements. Psychomotor outcomes describe the client's achievement of new skills, such as insulin administration. Cognitive outcomes demonstrate gains in client knowledge, such as manifestations of infection.

20. Which of the following statements accurately describes factors that may affect an individual's growth and development? Select all that apply. A) Physical characteristics such as height, bone size, eye color, and hair color are inherited from the family of origin. B) Fetal development can be altered by maternal age, inadequate maternal nutrition or substance abuse. C) Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships, low self-esteem, and poor social skills. D) Infants who are malnourished in utero develop fewer brain cells than infants who have had adequate prenatal nutrition. E) Environmental factors such as poverty and violence do not have a direct effect on growth and development.

Ans: A, B, C, D Feedback: Physical characteristics, such as height, bone size, eye color and hair color, are inherited from our family of origin. Fetal development can be altered by maternal age (with risk greater in those under age 15 and over age 35), substance abuse, inadequate prenatal care, inadequate maternal nutrition, and maternal substance abuse. Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships, low self-esteem, and poor social skills. Infants who are malnourished in utero develop fewer brain cells than infants who have had adequate prenatal nutrition. Environmental factors that might alter development include poverty and violence. The effect of each can occur independently, but they are more likely to be interrelated. Prenatal, individual, and caregiver factors influence development in many ways.

33. The nurse is educating a Young Childcare class and one of the parents asks what kinds of actions on his part may increase safety for his 14-month-old daughter during the next 2 years. Which of the following responses would be appropriate? Choose all that apply. A) Keep medications locked away B) Keep plastic bags out of reach C) Use approved car seats D) Teach to chew small food well E) Do not swing by arms or legs

Ans: A, B, C, E Feedback: Accidents are a leading cause of injuries and death in toddlers. Toddlers are curious about medications and may swallow them if allowed. They may asphyxiate themselves if allowed to play with plastic bags. Approved car seats will keep them safe in case of a motor vehicle accident. Swinging by extremities may cause dislocation of joints. Toddlers should not be allowed access to small-sized foods, such as grapes, olives, or carrot rounds. Small, hard foods should never be allowed.

27. The nurse is educating a high school health and fitness class about substance abuse. One of the group members asks what happens if a pregnant woman is using drugs. The nurse's best replies include which of the following? Choose all that apply. A) Low birth weight B) Premature births C) Regular prenatal care D) Congenital anomalies E) Risk of poor nutrition

Ans: A, B, D, E Feedback: Substance abuse by a pregnant woman increases the risk for congenital anomalies, low birth weight, and prematurity in her developing fetus. Someone who is using drugs is less likely to eat a nutritious diet and have regular prenatal care.

32. The nurse is providing prenatal education for a group of young pregnant women. One woman asks about the advantages of breastfeeding her infant. Which of the following would the nurse include in answer to this question? Choose all that apply. A) Has high lactose and low protein content B) Permanent immunity from certain infections C) Acidic environment which inhibits bacterial growth D) Contains antibodies, immunoglobulins, and leukocytes E) Alkaline environment which inhibits microbe growth

Ans: A, C, D Feedback: The neonate inherits a transient immunity from infections as a result of immunoglobulins that cross the placenta. Breastfeeding provides further protection against bacterial and viral infections through antibodies, immunoglobulins, and leukocytes in breast milk. The high lactose content in breast milk, combined with limited protein, promotes an acid environment that is unsuitable for bacterial growth.

12. A college student 20 years of age is preparing for a career as a teacher. What need initially influences the decision to establish a career? A) Overcoming low self-esteem B) Becoming independent of one's family C) Establishing one's own moral philosophy D) Demonstrating industry and spirituality

Ans: B Feedback: A major psychosocial developmental requirement for the young adult is choosing a vocation. The decision to enter the world of work is strongly influenced initially by the need to become independent of one's family and to be self-sufficient.

16. A nurse is explaining ADHD to a community parents group. What characteristics of this disorder are exhibited by an affected child? A) Daydreams, math difficulties, speech problems B) Inattention, impulsiveness, hyperactivity C) Enuresis, shyness, scoliosis D) Separation anxiety, reading difficulties, boredom

Ans: B Feedback: ADHD is a developmentally inappropriate degree of inattention, impulsiveness, and hyperactivity. To be diagnosed, the child must have manifested symptoms before the age of 7 years, and the symptoms must be present in at least two settings.

13. According to Erikson, normal adolescent behavior includes trying on new roles and possibly even rebelling. What is the purpose of this behavior in adolescents? A) To establish a sense of security B) To establish a sense of identity C) To gain autonomy D) To avoid inferiority

Ans: B Feedback: According to Erikson, the developmental task for adolescents is identity versus role confusion. Trying on new roles and even rebelling are normal behaviors as the adolescent acquires a sense of self and decides what direction to take in life. The other choices are not appropriate for adolescents.

29. A nurse is caring for a child age 13 months who was admitted to the pediatric unit with a new diagnosis of asthma. The mother tells mentions how frustrated she gets because the baby puts everything in her mouth, even things that are not clean. The nurse knows that according to Freud's theory of growth and development, which of the following explains this behavior? A) Lessens teething pain B) Major source of gratification C) Sucking is a basic reflex D) Assists in gaining confidence

Ans: B Feedback: According to Freud, during the oral stage, the infant uses his or her mouth as the major source of gratification and exploration. Pleasure is experienced from eating, biting, chewing, and sucking. This provides the infant with security. Chewing on things probably does lessen teething pain and sucking is a basic reflex, but neither of these things are part of Freud's theory. Putting things in the mouth is not connected with gaining confidence.

22. A young adult tells the nurse that he has been sexually active with his girlfriend. What teaching is most important for this individual? A) Proper hygiene B) Condom use C) Relationships D) Stress

Ans: B Feedback: Adolescents and young adults who engage in unprotected sexual intercourse are at a higher risk for contracting sexually transmitted diseases (and their complications) than are adults. All STDs, especially AIDS, pose serious health threats.

Ans: C Feedback: Cephalocaudal (proceeding from the head to the tail) development is the first trend, followed by proximodistal (progressing from gross motor to fine motor movements), and finally by symmetric (both sides of the body developing equally). 12. Many different factors affect growth and development. For example, why does one child have blonde hair and blue eyes while another child has brown hair and green eyes? A) Childhood illnesses B) Genetic inheritance C) Prenatal influences D) Maternal nutrition

Ans: B Feedback: At conception, every human receives an equal number of chromosomes from each parent. Physical characteristics, such as height, bone size, and eye and hair color, are inherited from our family of origin.

16. A child 7 years of age attending a Roman Catholic Mass with his parents stands and holds his hymnal to sing the opening song. According to Fowler, what stage of development is this child experiencing? A) Undifferentiated faith B) intuitive-projective faith C) mythical-literal faith D) synthetic-conventional faith

Ans: B Feedback: Intuitive-projective faith is most typical of the 3- to 7-year-old child. Children imitate religious gestures and behaviors of others, primarily their parents. They take on their parents' attitudes toward religious or moral beliefs without a thorough understanding of them. Imagination in this stage leads to long-lived images and feelings that they must question and reintegrate in later stages.

10. What social group prepares the school-aged child to get along in the larger world and teaches appropriate sex role behavior? A) Parents B) Peers C) Siblings D) Grandparents

Ans: B Feedback: Peer groups in middle childhood help prepare the child for getting along in the larger world and teach appropriate sex role behavior. They also act as transition models for the child in leaving the caregiver influence and moving toward adult independence.

20. A student nurse is assigned to care for a preschool child who is scheduled for surgery. How can the student decrease the child's fears about the surgery? A) Explain that nothing is going to hurt and that it will soon be over. B) Be honest about pain and use words the child can understand. C) Ask the child's parents to pretend that nothing is going to be done. D) Ignore the child's fears and focus on teaching the parents.

Ans: B Feedback: Preschool-aged children who are scheduled for surgery or hospitalization have many fears. The nurse can help decrease fears by explaining procedures in language the child can understand and by being honest about how much pain a procedure will cause. The other choices would not be honest nor help the child.

35. The nurse is working on the pediatric unit today and caring for an infant age 3 months who is admitted with a respiratory infection. As the nurse assesses her, the mother tells states that she thinks the baby is ready to feed herself. The nurse explains proximodistal development to the mother and why self-feeding may take a little longer to happen. The nurse provides some information about appropriate expectations. Place the following developmental abilities in order according to proximodistal progression. 1. Waving arms 2. Lifting head 3. Holding a spoon 4. Picking up a grain of rice A) 1, 2, 3, 4 B) 2, 1, 3, 4 C) 3, 1, 2, 4 D) 2, 3, 1, 4

Ans: B Feedback: Proximodistal development means that growth progresses from gross motor movements (such as learning to lift one's head) to fine motor movements (such as learning to pick up a toy with the fingers).

6. A nurse is observing a group of toddlers at play. What behavior illustrates normal physiologic development in children of this age? A) Attempting to feed self B) Using fingers to pick up small objects C) Throwing and catching a ball D) Understanding the feelings of others

Ans: B Feedback: Toddlers, aged 1 to 3, can pick up small objects with their fingers. The other responses are characteristic of other stages of physiologic development: Infants attempt to feed themselves; preschoolers can throw and catch balls; school-aged children understand the feelings of others (cognitive, not physiologic, development).

24. An girl age 18 years has chosen not to attend a party in which alcohol will be consumed. Which value system is she most likely adhering to? A) Role modeling B) Intimacy versus isolation C) Law-and-order orientation D) Autonomy versus shame and doubt

Ans: C Feedback: Adolescents have a high level of moral judgment, with a law-and-order orientation.

17. A child 2 years of age is hospitalized for a surgical procedure. Although previously all fluids were taken from a cup, the toddler wants a bottle to suck on. The nurse recognizes this behavior as what? A) Totally unacceptable B) Proof that the child is sick C) Normal regression D) Abnormal behavior

Ans: C Feedback: Based on the principles and theories of growth and development, the nurse recognizes possible regression during difficult periods or times of crisis, accepting and supporting a return to a forward progression in development. It is acceptable, normal behavior for the hospitalized toddler.

11. As the fetus develops, certain growth and development trends are regular and predictable. The first trend is cephalocaudal growth. What does this mean? A) Legs and feet develop first. B) Both sides of the body develop equally. C) Head and brain develop first. D) Gross motor skills are learned last.

Ans: C Feedback: Cephalocaudal (proceeding from the head to the tail) development is the first trend, followed by proximodistal (progressing from gross motor to fine motor movements), and finally by symmetric (both sides of the body developing equally).

What activity is carried out during the implementing step of the nursing process? A) Assessments are made to identify human responses to health problems. B) Mutual goals are established and desired client outcomes are determined. C) Planned nursing actions (interventions) are carried out. D) Desired outcomes are evaluated and, if necessary, the plan is modified.

Ans: C Feedback: During the implementing step of the nursing process, nursing actions (interventions) planned during the planning step are carried out.

34. The nurse is working on the pediatric unit today and caring for a girl age 8 months who is admitted with a respiratory infection. As the nurse assesses her, the mother notes that she thinks her daughter is ready to walk. The nurse explains cephalocaudal development to her and why walking may take a little longer to happen. The nurse also provides some information about appropriate expectations. Place the following developmental abilities in order according to cephalocaudal progression. 1. Roll over 2. Sit up alone 3. Crawl 4. Walk 5. Run 6. Skip A) 1, 2, 4, 6, 3, 5 B) 1, 3, 2, 4, 5, 6 C) 1, 2, 3, 4, 5, 6 D) 1, 2, 4, 3, 6, 5 E) 2, 1, 3, 4, 5, 6

Ans: C Feedback: Growth and development follow regular and predictable trends. Cephalocaudal (proceeding from head to tail) development is the first trend, with the head and brain developing first, followed by the trunk, legs, and feet.

18. Which developmental theory suggests success in achieving developmental tasks during later stages of life? A) Kohlberg's theory B) Piaget's theory C) Havighurst's theory D) Kubler-Ross' theory

Ans: C Feedback: Havighurst's theory of development suggests that success in achieving developmental tasks leads to success with tasks in later stages of life.

14. A school-aged child always follows the rules and obeys traffic lights when crossing the street. Based on Kohlberg's theory, what type of development is being demonstrated? A) Cognitive B) Intellectual C) Moral D) Psychosocial

Ans: C Feedback: Kohlberg's theory of moral development includes the stages through which individuals move. School-aged children obey rules and regulations established by society and enforced by authority figures.

24. A nursing student is assisting the school nurse with a middle school health fair. The student does height and weight assessments on the students. As the nursing student assess them, the student observes that the students are able to use deductive reasoning and think in abstract ways. According to Piaget, in what development stage are they? A) Genital B) Identity versus role confusion C) Formal operational D) Gender role acceptance

Ans: C Feedback: Piaget owns the formal operational theory stage that is characterized by the use of abstract thinking and deductive reasoning. Freud's theory of the genital stage indicates sexual interest can be expressed in overt sexual relationships. Sexual pressures and conflicts typically cause turmoil as the adolescent makes adjustments in relationships. Identity versus role confusion is Erikson's stage for adolescents. The stage of gender role acceptance belongs to Havighurst.

A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean? A) The nurse is using critical thinking to implement the dressing change. B) The client has specified how the dressing should be changed. C) Written plans are developed that specify nursing activities for this skill. D) The physician verbally requested specific steps of the dressing change.

Ans: C Feedback: Protocols (written plans that detail the nursing activities to be executed in specific situations) are nurse-initiated interventions. They expand the scope of nursing practice in certain clearly defined situations.

11. A student nurse reading a client's chart notes that the physician has documented an adolescent as prepubescent. What does the term prepubescent mean? A) Adult secondary sex characteristics are present B) Ova and sperm are produced by the reproductive organs C) Reproductive organs do not yet produce ova and sperm D) Active sexual behavior has been initiated

Ans: C Feedback: Puberty can be divided into three stages. In the first stage—prepubescence—secondary sex characteristics begin to develop but the reproductive organs do not yet function.

17. An adolescent client tells the nurse, "I just don't want to live anymore." What should the nurse do next? A) Document the adolescent's statement in the client record. B) Sit down and discuss all the reasons there are for living. C) Make an immediate referral to a suicide-prevention professional. D) Laughingly, teach the adolescent about making scary statements.

Ans: C Feedback: Suicide is the third leading cause of death in adolescents and young adults. Verbal or nonverbal indicators of suicide should not be ignored; rather, an immediate referral should be made to a professional trained in suicide prevention.

1. A nurse is teaching a young woman about healthy behaviors during the embryonic stage of pregnancy. Which of the following should the nurse emphasize to prevent congenital anomalies? A) Adequate intake of food and fluids B) Importance of rest and sleep C) Avoid alcohol and nicotine D) Progression of stages during delivery

Ans: C Feedback: The embryonic stage of prenatal development occurs from the fourth to the eighth week of pregnancy. Because this is a period of rapid growth and change, the fetus is especially vulnerable to any factor that might cause congenital anomalies, such as maternal use of alcohol and nicotine. Although the other choices are appropriate in educating the pregnant woman, they do not prevent congenital anomalies.

8. A preschooler is in Kohlberg's preconventional phase of moral reasoning. What is the focus of the phase? A) To learn sex differences and modesty B) A sexual desire for the opposite sex C) Obeying rules to avoid punishment D) Literal concept of God as a male human

Ans: C Feedback: The focus of the preschooler, based on Kohlberg's theory, is on obeying rules to avoid punishment and receive a reward. Although the other responses are characteristic developments of the preschooler, they are not components of moral development.

35. A nurse is teaching the care of the newborn class and one of the members makes a comment about keeping the baby too warm. She says, My mother always said to go by how I feel; if I'm cold, the baby needs more clothing and if I'm too warm, so is the baby." Which of the following is the nurse's best response? A) That is correct; you should go by how warm you are feeling. B) Always keep the baby bundled up to keep warm. C) The baby's temperature responds quickly to the environmental temperature. D) If the baby shivers, add more layers of clothing.

Ans: C Feedback: The newborn is unable to regulate its body temperature, so it takes on the temperature of the environment. The mother cannot go by how she feels because hormonal changes after childbirth may affect her temperature. Always keeping the baby bundled will probably cause overheating in some cases. The newborn is unable to produce heat by shivering.

33. A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do? A) Completely erase or delete the erroneous entry if possible. B) Use a highlighter to mark the incorrect entry and place initials next to it. C) Strike out the entry with a single line, place initials next to it, and write the correct entry. D) Black out the erroneous entry with a dark pen or marker.

Ans: C Feedback: The nurse should strike out the erroneous entry with a single line and place initials over it. When an error occurs, erasure or use of correction fluid is not permissible. Use of highlighters is not allowed and can draw attention to the erroneous documentation.

30. The nurse is providing education on childhood safety to a group of parents. In response to a question, the nurse relates that the major causes of death in toddlers include which of the following? Choose all that apply. A) Infections B) Childhood diseases C) Drowning D) Motor vehicle crashes E) Accidents

Ans: C, D, E Feedback: Accidents, such as motor vehicle crashes, poisonings, burns, drowning, choking and aspirations, and falls are the major cause of death in toddlers. Childhood diseases are not a factor due to current immunization protection. Most infections are treatable with antibiotics.

Nursing students need to learn to nurse themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of nursing care? A) Time management, communication, and establishing a support system. B) Establishing a support system, a sense of humor, and self-awareness. C) Self-awareness, preparation for crisis, and stress management. D) A sense of humor, anticipation of loss, and developing negative body image.

Ans: D Feedback: Activities that would prepare nursing students for the delivery of nursing care include time management, communication, establishing a support system, self-awareness, stress management, a sense of humor, and preparation for crisis and loss. Negative body image is not desired.

3. At birth, the neonate must adapt to extrauterine life through several significant physiologic adjustments. Which of the following is the most important adjustment that occurs? A) Body temperature responds to the environment B) Reflexes develop C) Stool and urine are eliminated D) Breathing begins

Ans: D Feedback: At birth, the neonate must adapt to extrauterine life through several significant physiologic adjustments. The most important occur in the respiratory and circulatory systems as the neonate begins breathing and becomes independent of the umbilical cord.

5. A nurse is teaching a group of parents about the dangers of Sudden Infant Death Syndrome (SIDS). The nurse recommends that parents place their children on a firm surface laying on their: A) left side. B) right side. C) abdomen. D) back.

Ans: D Feedback: Because sleep habits have been implicated with SIDS, it is recommended that healthy infants up to the age of 6 months sleep on their back (rather than the stomach) on a firm surface in a safety-approved crib. Placing infants in a side-lying position is not recommended because babies who sleep on their sides are more likely to roll onto their abdomen.

Ans: B Feedback: Neonates stare at objects, but are not capable of reaching, kicking or selecting objects at this phase of development. 27. The nurse is educating the mother of an infant age 4 months on safety concepts in child rearing. Which of the following statements by the mother suggests that she may require some repetition and reinforcement of the information? A) I must keep small objects out of the baby's reach. B) The baby will sleep in her crib, not with me and my husband." C) I must keep appointments for the baby's immunizations. D) The baby can sleep on her stomach during naps.

Ans: D Feedback: Because sleep habits have been implicated with SIDS, it is recommended that healthy infants up to the age of 6 months sleep on their back (rather than the stomach) on a firm surface in a safety-approved crib. There is a schedule that includes recommendations for infant immunizations from the Advisory Committee on Immunization Practices. Because infants put small objects in their mouths, choking is a risk. Accidental deaths occur most commonly when infants share a bed with parents (cosleeping) and are inadvertently wedged beneath another person, trapped in a dangerous position, such as between the bed and the wall, or suffocated by bedding.

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this? A) Psychomotor B) Affective C) Physiologic D) Cognitive

Ans: D Feedback: Cognitive goals involve increasing client knowledge. These goals may be evaluated by asking clients to repeat information or to apply new knowledge in their everyday lives.

27. What activity in charting will assist most in the avoidance of errors? A) Objectivity B) Organization C) Legibility D) Timeliness

Ans: D Feedback: Documentation in a timely manner can help avoid errors.

2. A nurse is teaching a pregnant woman about nutritional needs. Which of the following nutritional deficiencies during pregnancy might result in neural tube defects in the developing fetus? A) Vitamin D B) Iodine C) Calcium D) Folic acid

Ans: D Feedback: During pregnancy, maternal nutrition is essential for normal fetal growth and development. Folic acid deficiencies might result in neural tube defects in the infant.

13. A nurse is teaching a young couple about the normal changes during pregnancy. What should be included in the teaching sessions about the expectant father's role? A) Nothing, the mother's preparation is more important. B) In a traditional family, the mother is responsible for child care. C) The importance of feeling pride as a future parent. D) The provision of support in meeting maternal needs.

Ans: D Feedback: During pregnancy, the expectant father needs to learn the normal physiologic and psychological changes of pregnancy, explore his feelings about the developing infant and birth, and accept his supportive role in meeting maternal needs.

23. A school nurse is concerned about the almost skeletal appearance of one of the high school students. Although all of the following nutritional problems can occur in adolescents, which one is most often associated with a negative self-concept? A) Eating fast foods B) Obesity C) Fad dieting D) Anorexia nervosa

Ans: D Feedback: Fad diets, eating fast foods, and obesity are common nutritional problems in adolescents. However, the most common severe eating disorders are anorexia nervosa and bulimia, which almost always involve a negative self-concept.

What characteristic of a competent nurse practitioner enables nurses to be role models for clients? A) Sense of humor B) Writing ability C) Organizational skills D) Good personal health

Ans: D Feedback: Good personal health enables nurses not only to practice more efficiently, but also to be a health model for clients and their families. Nurses can help clients to imitate good health behaviors, and eventually integrate them into their daily life through the process of identification.

9. A child gains weight and becomes taller each year. What is this process called? A) Development B) Orderly change C) Progression D) Growth

Ans: D Feedback: Growth is an increase in body size or changes in body cell structure, function, and complexity. Development is an orderly pattern of changes in structure, thoughts, feelings, or behaviors resulting from maturation, experiences, and learning.

19. A nurse is teaching a group of expectant parents about infant safety. Which of the following is mandated by the law to promote infant safety? A) Lowering temperatures on hot water heaters B) Covering electrical outlets with safety prongs C) Removing all cords from mini-blinds and drapes D) Using special car safety seats and restraints

Ans: D Feedback: Preventive measures against safety hazards must be taught to new parents. The law mandates the use of special car safety seats and restraints for infants. The other choices are important safety considerations, but they are not mandated by law.

15. A nurse is educating the parents of an infant about possible health problems during infancy. Which of the following health problems during infancy is most serious? A) Colic B) Seborrheic dermatitis C) Failure to thrive D) SIDS

Ans: D Feedback: SIDS (sudden infant death syndrome) is the sudden death of an infant under the age of 1 year, unexpected in light of the infant's history, in which a postmortem examination fails to reveal a cause of death. It is the leading cause of death in infants aged 1 week to 1 year.

Ans: C Feedback: Standardized care plans that identify common problems and needs with relation to select client cohorts may be used. Unless such care plans are individualized to a specific client, however, they may not address individual client needs. 16. What part of the client's record is commonly used to document specific client variables, such as vital signs? A) Progress notes B) Nursing notes C) Critical paths D) Graphic record

Ans: D Feedback: The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements.

9. Which of the following sets of terms best characterizes the school-aged child? A) Reflexes, alert state, temperament B) Negativism, regression, anal stage C) Preoperational, asking "why," fears D) Doing, succeeding, accomplishing

Ans: D Feedback: The school-aged child is in the industry-versus-inferiority stage of Erikson's theory, with a focus on learning useful skills and developing positive self-esteem. The emphasis is on doing, succeeding, and accomplishing.

21. Which of the following would be an appropriate topic for a nurse to present at an elementary school PTA meeting? A) Prevention of congenital anomalies B) Dangers of smoking and drinking during pregnancy C) Importance of bonding and attachment D) Commonality of communicable diseases

Ans: D Feedback: With increased interactions with other children in school, communicable conditions, such as scabies, impetigo, and head lice, are more prevalent. The other choices are not appropriate educational topics for parents of elementary school children.

28. The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client's breathing is easier. The nurse is engaging in which phase of the nursing process? A) Assessment B) Diagnosing C) Planning D) Implementing E) Evaluating

Ans: E Feedback: The nurse is collecting evaluative data to determine whether or not the client is achieving the therapeutic response to the bronchodilator.

34. The correct sequence of steps for performance improvement is: 1. Discover a problem. 2. Plan a strategy using indicators. 3. Implement a change. 4. Assess the change. A) 1, 2, 3, 4 B) 1, 4, 2, 3 C) 4, 1, 2, 3 D) 1, 2, 4, 3 E) 1, 3, 2, 4

Ans: A Feedback: The correct sequence of steps for performance improvement is (1) discover a problem; (2) plan a strategy using indicators; (3) implement a change; and (4) assess the change; if the change is not met, plan a new strategy.

Educating clients on their diabetic regimen of administering insulin is the implementation of which skill? A) Intrinsic B) Technical C) Interpersonal D) Visual

Ans: B Feedback: The administration of insulin is a technical skill. Technical competence means being able to use equipment, machines, and supplies in a particular specialty.

3. The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? A) Narrative notes B) SOAP notes C) Focus charting D) Charting by exception

Ans: A Feedback: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client's discharge needs. This interaction is an example of which professional nursing relationship? A) Nurse-health care team B) Nurse-patient C) Nurse-patient-family D) Nurse-nurse

Ans: A Feedback: A nurse-health care team professional relationship occurs when the nurse coordinates the input of the multidisciplinary team into a comprehensive plan of care. The nurse may also serve as a liaison between the client and family and the health care team, as necessary.

22. Which activity is a possible solution for inadequate nursing staffing? A) Identify the kind and amount of nursing services required. B) Learn to give quality care during designated work period. C) Use a team conference to develop a consistent plan of care. D) Educate the client to become an assertive health care consumer.

Ans: A Feedback: A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who refused to cooperate with the therapeutic regimen. Educating the client to become an assertive health care consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period.

29. The nurse is preparing to mail a client satisfaction questionnaire to a client who was discharged from the hospital four days ago. Which type of evaluation is the nurse conducting? A) Retrospective evaluation B) Peer review C) Nursing audit D) Concurrent evaluation

Ans: A Feedback: A retrospective audit uses post-discharge questionnaires to collect data. A nursing audit is a method of evaluating nursing care that involves reviewing client records to assess the outcomes of nursing care (or the process by which these outcomes were achieved). Concurrent evaluation involves direct observations of nursing care, client interviews, and chart review to determine whether the specified evaluative criteria are met. Peer review involves the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is done for the purpose of professional performance improvement.

2. The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? A) Vulnerability to legal liability since nurse's safe, routine care is not recorded B) Increased workload for nurses in order to complete necessary documentation C) Failure to identify and record client problems and associated interventions D) Significant differences in the charting between nurses due to lack of standardization

Ans: A Feedback: A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

20. A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing? A) Data, information, knowledge B) Process, documentation, analysis C) Research, controls, variables D) Hypothesis, nursing, practice

Ans: A Feedback: According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support clients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology (ANA, 2001, p. vii).

The nurse witnessed a more senior nurse make six unsuccessful attempts at starting an intravenous (IV) line on a client. The senior nurse persisted, stating, "I refuse to admit defeat." This resulted in unnecessary pain for the client. How should the first nurse best respond to this colleague's incompetent practice? A) Report the nurse's practice and have the nurse manager address the matter. B) Encourage the nurse to attend an in-service on IV starts. C) Reassure the nurse that this is a difficult skill and give her feedback on her performance. D) Document an unmet outcome in the client's plan of care.

Ans: A Feedback: According to the study Silence Kills: The Seven Crucial Conversations for Healthcare (Maxfield, Grenny, Patterson, McMillan, & Switzler, 2005), an appropriate response to incompetence is to report the matter and enlist the manager to conduct follow-up. Reassuring the nurse and encouraging education are not sufficient responses to incompetence. This action does not constitute an unmet outcome on the part of the client.

1. A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as ... A) Avelox (moxifloxacin) 400 mg daily B) Avelox (moxifloxacin) 400 mg Q.D. C) Avelox (moxifloxacin) 400 mg qd D) Avelox (moxifloxacin) 400 mg OD

Ans: A Feedback: Among the JCAHO's list of "do not use" abbreviations are Q.D., qd, and OD when denoting a once-per-day drug administration. Because of the potential for misinterpretation and consequent drug errors, the JCAHO recommends writing "daily" in the order.

Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 feet without the use of mobility aids by 12/12/2011." Several nurses have evaluated the client's progression towards this outcome at various points during her care. Which of the following evaluative statements is most appropriate? A) "12/12/2011 - Outcome partially met. Patient ambulated 75 feet without the use of mobility aids" B) "12/12/2011 - Outcome unmet. Patient's ambulation remains inadequate." C) "12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation." D) "12/14/2011 Outcome met."

Ans: A Feedback: An evaluative statement should include both the decision about how well the outcome was met along with data that support this decision. Characterizing the client's ambulation as "inadequate" is not sufficiently precise. Stating that this outcome was met with the use of a cane contradicts the original terms of the outcome.

18. What is the primary purpose of an incident report? A) Means of identifying risks B) Basis for staff evaluation C) Basis for disciplinary action D) Format for audiotaped report

Ans: A Feedback: An incident report, also termed a variance or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. Incident reports should not be used for disciplinary action against staff members.

33. The nurse is giving a shift report to the oncoming nurse who will be caring for a client with a portacath access device. The oncoming nurse states, I have never taken care of a client with a portacath. Would you give me the basics, so I know what to do? Which standard for establishing and sustaining healthy work environments is the oncoming nurse breaching? A) Appropriate staffing B) Effective decision making C) True collaboration D) Skilled communication

Ans: A Feedback: Appropriate staffing ensures that client needs are effectively matched with nurse competencies. In this scenario, the nurse is ill-prepared to care for the client. The nurse needs structured training to learn about the nursing care of portacaths. Skilled communication requires health team members to communicate in a respectful, non-intimidating manner with colleagues. True collaboration involves skilled communication, mutual respect, shared responsibility, and decision making among nurses, and between nurses and other health team members. Effective decision making ensures nurses are valued and active partners in making policy, directing and evaluating clinical care, and leading organizational operations.

A nurse is interested in improving client care on the unit through performance improvement. What is the first step in this process? A) Discover the problem. B) Plan a strategy. C) Implement a change. D) Assess the change.

Ans: A Feedback: Each nurse must decide how to respond when he or she perceives that client care is being compromised. The four steps listed are all components of the process of performance improvement, with discovering the problem being the first step.

A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this client's care? A) Educate the client about the benefits of early mobilization and offer to assist him. B) Respect the client's wishes to remain in his bed and ask him when he would like to begin mobilizing. C) Show the client the expected outcomes on his clinical pathway that relate to mobilization. D) Document the client's noncompliance and reiterate the consequences of delaying mobilization.

Ans: A Feedback: Educating the client about the benefits of mobilizing, and offering to assist combines teaching with the promotion of self-care. It is likely premature to label the client as noncompliant, and showing him the expected outcomes on his clinical pathway is unlikely to motivate him if he is reluctant. It is appropriate for the nurse to educate and encourage the client rather than simply accepting his refusal and providing no other interventions.

A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care? A) Research findings B) Resources C) Current standards of care D) Ethical and legal guides to practice

Ans: A Feedback: Nurses concerned about improving the quality of nursing care use research findings to enhance their nursing practice. Reading professional journals and attending continuing education workshops and conferences are excellent ways to learn about new nursing strategies that have proved effective.

An older adult client is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration? A) Facilitate communication between the different professionals and attempt to coordinate care. B) Educate the client about the unique scope and focus of each member of the healthvcare team. C) Modify the client's plan of care to better reflect the commonalities between the different disciplines. D) Arrange for each professional to perform bedside assessments and interventions simultaneously rather than individually.

Ans: A Feedback: Nurses play a pivotal role in the coordination of care and often need to facilitate communication between members of different disciplines. Educating the client about the role of each professional may be useful, but it does not achieve coordination of care. Similarly, amending the client's plan of care will not create unity and collaboration. It is unrealistic to expect each member of the care team to always visit simultaneously.

An older adult client has lost significant muscle mass during her recovery from a systemic infection. As a result, she has not yet met the outcomes for mobility and activities of daily living that are specified in her nursing plan of care. How should her nurses best respond to this situation? A) Continue the plan of care with the aim of helping the client achieve the outcomes. B) Terminate the plan of care since it does not accurately reflect the client's abilities. C) Modify the plan of care to better reflect the client's current functional ability. D) Replace the client's individualized plan of care with a clinical pathway.

Ans: A Feedback: Nurses regularly evaluate clients' progression toward the achievement of outcomes that are specified in plans of care. When clients need more time to achieve desired outcomes, it is appropriate to continue with the existing plan of care. It is not necessary to terminate the plan of care and modification may be premature. Abandoning the plan and replacing it with a clinical pathway is counterproductive to the continuity of care.

A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other clients can hear her. The nurse should respond by modifying which of the following resources? A) Environment B) Personnel C) Equipment D) Patient and visitors

Ans: A Feedback: Providing an environment for the client that is more conducive to privacy and, ultimately, to her elimination needs is necessary in this case. The equipment itself (i.e., the commode) is not the problem, but rather its proximity to others. The staff and the client herself are not central to the client's new problem.

Many of the homeless clients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the clients state that the clinic is difficult to find and in an intimidating environment. This demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed? A) Psychosocial background of clients B) Developmental stage of clients C) Ethical and legal considerations D) Resources

Ans: A Feedback: Requiring clients to attend a clinic that is difficult to access, and located in a daunting environment, shows a lack of consideration for clients' psychosocial backgrounds. Resources, development, and ethics are not central to this lapse in care.

24. A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation? A) Information is documented in separate forms by each health care personnel. B) It is a unified, cooperative approach for resolving the client's problems. C) It is organized at one location according to the client's health problems. D) It is compiled to facilitate communication among health care professionals.

Ans: A Feedback: Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client's care. The problem-oriented method of recording demonstrates a unified, cooperative approach to resolving the client's problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among health care professionals.

9. A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality? A) Writing the client's name on the student care plan B) Providing the instructor with plans for care C) Discussing the medications with a unit nurse D) Providing information to the physician about laboratory data

Ans: A Feedback: Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.

A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention? A) Sitting with the client to encourage her to talk B) Telling the laboratory technician to speed up the results C) Calling the physician for an order for an anxiolytic D) Educating the client about reducing risk factors

Ans: A Feedback: Supportive interventions include recognizing the need for encouragement, unconditional acceptance of behaviors, and the positive effects of being present for clients during stress or crisis. To support the anxious client, the nurse should sit with her and encourage her to talk. Telling the laboratory technician to speed up the results, or calling the physician and taking orders for anxiolytics are inappropriate supportive interventions. Educating the client about reducing risk factors is an educational intervention.

The nurse has responded to a client's request to view her medical chart by arranging a meeting between the client, the clinical nurse leader, and her primary care physician. The nurse is exemplifying which of the following characteristics of quality health care? A) Information B) Science C) Cooperation D) Individualization

Ans: A Feedback: The Institute of Medicine's Committee on Quality Health Care in America has identified aspects of care that clients can reasonably expect. One of these expectations is information, which is manifested by allowing clients access to their medical records. Other characteristics that clients can expect are knowledge-based care (science), coordination between professionals (cooperation), and respect for client choices and preferences (individualization).

12. Which one of the following methods of documentation is organized around client diagnoses rather than around patient information? A) Problem-oriented medical record (POMR) B) Source-oriented record C) PIE charting system D) focus charting

Ans: A Feedback: The POMR is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care.

13. A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym? A) Client complaints of pain B) Client history C) Client's chief complaint D) Client interventions

Ans: A Feedback: The SOAP format (subjective data, objective data, Assessment [the caregiver's judgment about the situation], plan) is used to organize data entries in the progress notes of the POMR. A client complaint of pain is subjective data (S).

4. A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? A) "Client complaining of abdominal pain rated at 8/10." B) "Client is guarding her abdomen and occasionally moaning." C) "Client has a history of recent abdominal pain." D) "2 mg Dilaudid PO administered with good effect"

Ans: A Feedback: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which of the following actions should the nurse perform before revising a plan of care? A) Discuss any lack of progress with the client. B) Collect information on abnormal functions. C) Identify the client's health-related problems. D) Select appropriate nursing interventions.

Ans: A Feedback: The nurse should discuss any lack of progress with the client so that both the client and the nurse can speculate on what activities need to be discontinued, added, or changed. Collecting information on abnormal functions and risk factors is done during the assessment. Identification of the client's health-related problems is done during diagnosis. Nurses select appropriate nursing interventions and document the plan of care in the planning stage of the nursing process, not during evaluation.

Each time a nurse administers an insulin injection to a client with diabetes, she tells the client what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting in the client? A) Self-care B) Dependence C) Competence D) Discipline

Ans: A Feedback: The plan of nursing care should include specific instructions for education/learning needs of the client to promote self-care and independence. Competency pertains to the nurse's ability (knowledge, skills, and attitudes) to provide safe and effective care. The nurse's role includes education, counseling, and advocating, but not providing discipline to clients.

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be kept comfortable and to not continue further treatment. The daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time? A) Explain to the daughter the wishes of the client. B) Arrange a meeting between the physician and daughter. C) Contact the imaging center to schedule the testing. D) Persuade the client to agree to the daughter's request.

Ans: A Feedback: The priority is for the nurse to explain to the daughter the wishes of the client and support the client's decision. As an advocate, the nurse implements actions to protect the rights of the client. The other options do not support the client's decision.

The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? A) Notify me right away if the client's systolic blood pressure is 170 or greater. B) Let me know if the client's blood pressure becomes elevated. C) If the client's blood pressure falls outside normal limits, come get me. D) I need to know if the client's blood pressure changes from his normal baseline.

Ans: A Feedback: When delegating tasks, it is essential for the nurse to give clear instructions to the person to whom the task is being delegated. The statement, which includes specific parameters for the systolic blood pressure, clearly identifies what the UAP should be alerted to and the subsequent action to take. The other three options are vague and do not provide adequate direction for the UAP.

20. Which activity does the nurse engage in during evaluation? Select all that apply. A) Collect data to determine whether desired outcomes are met. B) Assess the effectiveness of planned strategies. C) Adjust the time frame to achieve the desired outcomes. D) Involve the client and family in formulating desired outcomes. E) Initiate activities to achieve the desired outcomes.

Ans: A, B, C Feedback: The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage. During the evaluation stage, the nurse collects data to determine whether desired outcomes are met, assesses the effectiveness of planned strategies, and adjusts the time frame to achieve the desired outcomes.

31. Which of the following are examples of breaches of client confidentiality? Select all that apply. A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. C) A nurse checks the medical record of a client to see who should be called in an emergency. D) A nurse updates the employer of a client regarding the client's return to work. E) A nurse uses a computer to document a client's response to pain medication.

Ans: A, B, D Feedback: Nurses may use computers to document client data as long as they are not in a public area, and as long as the computer is shut down following the entries. A nurse can also check the medical record for a relative to call in case of an emergency. All the other examples are violations of client confidentiality.

30. Which of the following are examples of incidental disclosures of client health information that are permitted? Select all that apply. A) A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B) Two nurses are overheard talking about a client through the door of an empty client room. C) A nurse places a client chart in a holder on the examining room door with the name facing out. D) A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms. E) A nurse calls out the name of a client who is seated in the waiting room.

Ans: A, B, E Feedback: Permitted incidental disclosures of PHI include using sign-in sheets without the reason for visit; the possibility of a conversation being overheard if measures are taken to be private; placing a client chart on the door with the face pages facing inward; placing an x-ray on a light board as long as it is not unattended; calling the name of a waiting patient; and leaving appointment reminders on answering machines (provided only a minimal amount of information is given).

29. Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that apply. A) U (unit) B) QD (daily) C) NPO (nothing per os) D) mL (milliliters) E) > (greater than)

Ans: A, B, E Feedback: The words "unit", "daily", "greater than" and "less than" should be spelled out. NPO, mL, and mcg are acceptable abbreviations.

The nurse is trying to determine factors influencing a client who is not following the plan of care. Which client statement identifies a potential factor interfering with following the plan of care? Select all that apply. A) I don't drive so I was unable to fill my prescription. B) I consult the list of low sodium foods when preparing meals. C) My social security check does not come until next week. D) I dropped the strips for my finger-stick blood glucose testing in the bath water. E) "My daughter helps me with my range of motion exercises every morning and afternoon."

Ans: A, C, D Feedback: Common factors that contribute to a client not following the plan of care include inability to afford treatment (social security check) and limited access to treatment (doesn't drive; damaged testing strips).

Which example reflects client variables that influence outcome achievement? Select all that apply. A) The client was born with cystic fibrosis. B) The nurse works at a hospital in a diverse community. C) Nursing interventions are consistent with standards of care. D) The client is a college graduate and is employed. E) The client engages in activities associated with Ramadan.

Ans: A, D, E Feedback: Important client variables that influence outcome achievement include the physical health of the client, level of education attained, and cultural practices that impact life and health practices. Nurse variables, such as working in a diverse community, and standards of practice also influence client outcome achievement.

17. A nurse working in a hospital setting discovers problems with the delivery of nursing care on the pediatric unit. Which of the following suggestions from the Institute of Medicine's Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) could help redesign and improve care? Select all that apply. A) Base care on continuous healing relationships. B) Customize care based on available resources. C) Keep the nurse as the source of control. D) Share knowledge and allow for free flow of information. E) Practice evidence-based decision making.

Ans: A, D, E Feedback: The Institute of Medicine's Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) suggests 10 new rules to redesign and improve care: (1) care based on continuous healing relationships, (2) customization based on client needs and values, (3) the client as the source of control, (4) shared knowledge and the free flow of information, (5) evidence-based decision making, (6) safety as a system property, (7) the need for transparency, (8) anticipation of needs, (9) continuous decrease in waste, and (10) cooperation among clinicians.

11. In what type of documentation method would a nurse document narrative notes in a nursing section? A) Problem-oriented medical record B) Source-oriented record C) PIE charting system D) Focus charting

Ans: B Feedback: A source-oriented record is one in which each health care group keeps data on its own separate form (e.g., physicians, nurses, and laboratory). Progress notes written by nurses using this method are narrative notes.

14. Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? A) Problem-oriented medical record B) Charting by exception C) PIE charting system D) Focus charting

Ans: B Feedback: Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing.

What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation? A) Intuitive thinking B) Critical thinking C) Traditional knowing D) Rote memory

Ans: B Feedback: Each element of evaluation requires the nurse to use critical thinking about how best to evaluate the client's progress toward valued outcomes.

8. Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN

Ans: B Feedback: Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is correct.

A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do? A) Ask the visitors to leave the room. B) Ask the client if visitors should remain in the room. C) Tell the client to ask the visitors to leave the room. D) Wait until the visitors leave to begin the procedure.

Ans: B Feedback: If visitors are in the client's room, check with the client to see whether she or he wants the visitors to stay during the procedure.

26. A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? A) Client assessment B) Intervention carried out C) Written plan of care D) Multidisciplinary interventions

Ans: B Feedback: In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus the nurse would document the intervention carried out. Client assessment is not a part of the PIE notes, because this information is recorded on flow sheets for each shift. Although the PIE system uses a nursing plan-of-care format, there is no written plan of care. The PIE system is not multidisciplinary; it provides a documentation system for nursing only.

17. A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? A) PIE system B) Minimum data set C) OASIS D) Charting by exception

Ans: B Feedback: Long-term care documentation is specified by the RAI with the minimum data set forming the foundation for the assessment. This is required in all facilities certified to participate in Medicare or Medicaid. OASIS is used in the home health care industry.

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would this outcome be evaluated? A) Asking the client to verbally repeat the steps of the injection B) Asking the client to demonstrate self-injection of insulin C) Asking family members how much trouble the client is having with injections D) Asking the client how comfortable he or she is with injections

Ans: B Feedback: Psychomotor outcomes describe the client's achievement of new skills and are evaluated by asking the client to demonstrate the new skill.

When a charge nurse evaluates the need for additional staff nurses and additional monitoring equipment to meet the client's needs, the charge nurse is performing an evaluation termed ... A) process evaluation B) structure evaluation C) outcome evaluation D) summary evaluation

Ans: B Feedback: Structure evaluation focuses on the attributes of the setting or surroundings where health care is provided.

10. A physician's order reads "up ad lib." What does this mean in terms of client activity? A) May walk twice a day B) May be up as desired C) May only go to the bathroom D) Must remain on bed rest

Ans: B Feedback: The abbreviation "up ad lib" means the client may be up as desired.

A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague? A) No other steps need to be taken, since the client was not seriously injured. B) The colleague should inform the nurse that a full report of the incident needs to be made. C) The colleague should monitor the client closely for any adverse effects of the fall. D) The colleague should report the incident in a peer review of the nurse.

Ans: B Feedback: The colleague should tell the nurse that a full report needs to be made. If appropriate, the colleague could help the nurse identify what contributed to her not raising the bed railings in an effort to prevent it from happening in the future.

21. A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse? A) "I am sorry that you had to suffer this way. The nurse on night duty should be fired." B) "It's hard to be in bed and ask for help. You ring for a nurse who never seems to help." C) "You seem to be impatient. The nurses work very hard and they do whatever they can." D) "I can see that you are angry. What the nurse did is wrong, and it won't happen again."

Ans: B Feedback: The nurse should empathize with the client to perceive how the client is feeling. The nurse shares his or her perception with the client, which makes him comfortable to share his anxieties, fear, and concerns. The first response conveys pity on the client, which is inappropriate. In the third response, the nurse is taking the side of the nursing staff and the client may not like it. The fourth response is nontherapeutic.

The researchers developing classifications for interventions are also committed to developing a classification of which of the following? A) Diagnoses B) Outcomes C) Goals D) Data clusters

Ans: B Feedback: The researchers involved in the development of NICs are also committed to developing a classification of client outcomes for nursing interventions, called Nursing Outcomes Classifications (NOCs). This research aims to identify, label, validate, and classify nursing-sensitive client outcomes and indicators, evaluate the validity and usefulness of the classification in clinical field-testing, and define and test measurement procedures for the outcomes and indicators.

19. Which activity does the nurse perform during the evaluating stage? Select all that apply. A) Validates with the client the problem of constipation. B) Collects data to determine the number of catheter-associated infections on the nursing unit. C) Increases the frequency of repositioning from every two hours to every one hour. D) Sets a goal of ambulating from bed to room door and back to bed. E) Identifies smoking and sedentary lifestyle as risk factors for hypertension.

Ans: B, C Feedback: During the evaluation stage, the nurse modifies the plan of care if desired outcomes are not achieved (increased frequency of repositioning) and collects data, such as number of infections, to monitor quality and effectiveness of nursing practice. During the diagnosis stage, the nurse identifies factors contributing to the client's health problem, such as smoking and sedentary lifestyle, and validates the identified health problems (such as constipation) with the clients. The nurse establishes plan priorities and sets goals with the client and family during the outcome identification and planning.

18. A nurse is counseling a novice nurse who gives 150% effort at all times and is becoming frustrated with a health care system that provides substandard care to clients. Which of the following advice would be appropriate in this situation? Select all that apply. A) Tell the new nurse to help other nurses perform their jobs, thus ensuring quality client care is being delivered. B) Encourage the new nurse to leave her problems at work behind, instead of rehashing them at home. C) After establishing a reputation for delivering quality nursing care, have her seek creative solutions for nursing problems. D) Tell her to view nursing care concerns as challenges rather than overwhelming obstacles, and seek help for solutions. E) State that if resources do not permit quality care, it is not the role of the new nurse to explore change strategies within the institution.

Ans: B, C, D Feedback: The following items are good advice for nurses experiencing burnout: Learn to give quality care during designated work period; leave on time; avoid the temptation to do the work of others; and leave work concerns at work. After establishing a reputation for delivering quality nursing care, seek creative solutions for nursing problems (strategies to increase nursing resources, motivation, morale) and try them — hopefully with a support network. View concerns as challenges rather than overwhelming obstacles. Develop a realistic sense of how much nursing care (and of what quality) can be delivered with existing resources. If resources do not permit quality care, explore change strategies within the institution. If administration is not supportive, explore other practice settings.

Which of the following statements accurately describes a recommended guideline for implementation? Select all that apply. A) When implementing nursing care, remember to act independently, regardless of the wishes of the client/family. B) Before implementing any nursing action, reassess the client to determine whether the action is still needed. C) Assume that the nursing intervention selected is the best of all possible alternatives. D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful. E) Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.

Ans: B, D Feedback: When implementing nursing care, the nurse should act in partnership with the client/family and reassess the client to determine if the nursing action is still needed. The nurse should always question that the nursing intervention selected is the best of all possible alternatives. The nurse should consult colleagues and related nursing literature to see if other approaches might be more successful. The nurse should develop a repertoire of skilled nursing interventions, and check to make sure that the ones selected are consistent with standards of care and within legal/ethical guidelines to practice.

28. A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? A) PIE note B) Flow sheet C) Narrative note D) SOAP note

Ans: C Feedback: A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

Which is a responsibility of the nurse in the nurse-client-family team relationship? A) Provide creative leadership to make the nursing unit a satisfying and challenging place to work. B) Support the nursing care given by other nursing and non-nursing personnel. C) Educate the family to be informed and assertive consumers of health care. D) Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

Ans: C Feedback: Educating the family to be informed and assertive consumers of health care is a role responsibility in the nurse-client-family relationship. Responsibilities of the nurse in the nurse-health care team relationship include coordinating the inputs of the multidisciplinary team into a comprehensive plan of care. In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work, and supports the nursing care given by other nursing personnel.

The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform? A) Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO. B) Seek input from the family of how the client with aphasia normally communicates at home. C) Respond to the postoperative client's question that baths are given only in the morning. D) Request that family members provide ethnic/cultural foods of the African client's liking.

Ans: C Feedback: Guidelines for implementing indicate that the nurse implements care that is culturally sensitive and individualized for the client. The nurse forms a partnership with the client and family when implementing care. The response by the nurse indicating a set time for baths is not reflective of being open to individualizing client care. The other options are consistent with the guidelines for implementing.

The staff in a long-term care facility often plays loud rock music on the radio and designs children's games as exercise. What is the staff doing in this situation? A) Considering the hearing level of older adults B) Failing to consider visual deficits that occur with aging C) Ignoring the developmental needs of older adults D) Meeting needs for sensory input and exercise

Ans: C Feedback: Nurses must be careful not to let stereotypes about developmental stages and tasks influence client care. Playing loud rock music and designing children's games ignore the older adults' needs and is demeaning.

What role of the nurse is crucial to the prevention of fragmentation of care? A) Advocate B) Educator C) Counselor D) Coordinator

Ans: C Feedback: One of nursing's major contributions to the health care team is the role of coordinator. Care can easily become fragmented when clients are seen by numerous specialists—each interested in a different aspect of the client. It is important for the nurse to make rounds with other health care professionals and to read the results of consultations that clients have had with specialists. They can then interpret the specialists' findings for clients and family members, prepare clients to participate maximally in the plan of care before and after discharge, and serve as a liaison among the members of the health care team.

32. The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

Ans: C Feedback: Physiologic outcomes are physical changes in the client, such as pulse oximetry. An affective outcome involves changes in the client's values, beliefs, and attitude. Cognitive outcomes demonstrate increases in client knowledge. Psychomotor outcomes describe the client's achievement of new skills.

24. The nurse participates in a quality assurance program. Data from the previous year indicates a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. The nurse recognizes this is which type of evaluation? A) Design evaluation B) Process evaluation C) Outcome evaluation D) Structure evaluation

Ans: C Feedback: Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Structure evaluation focuses on the environment in which care is provided, whereas process evaluation focuses on the nature and sequence of activities carried out by implementing the nursing process. There is no design evaluation.

25. A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the first step? A) Plan of care B) Data, action, and response C) Problem selected D) Nursing activities during a shift

Ans: C Feedback: The SOAP method begins by selecting a problem from a list. PIE (problems, interventions, and evaluation) notes incorporate the plan of care into the progress notes. Focus DAR notes organizes entries by data, action, and response. The narrative notes are used to record relevant client and nursing activities throughout a shift.

5. What is the nurse's best defense if a client alleges nursing negligence? A) Testimony of other nurses B) Testimony of expert witnesses C) Client's record D) Client's family

Ans: C Feedback: The client record is the only permanent legal document that details the nurse's interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence.

The nurse is caring for a client with a diagnosis of colon disease. The client has expressed to various members of the health care team the desire to be kept comfortable and to not continue further treatment. The client asks the nurse to be present when the client discusses the decision with other family members. In which professional nursing relationship is the nurse participating? A) Nurse-client B) Nurse-nurse C) Nurse-client-family D) Nurse-health care team

Ans: C Feedback: The nurse is fulfilling role responsibilities of the nurse-client-family relationship when being present for a discussion of the matter by the client and family.

7. Which of the following data entries follows the recommended guidelines for documenting data? A) "Client is overwhelmed by the diagnosis of pancreatic cancer." B) "Client's kidneys are producing sufficient amount of measured urine." C) "Following oxygen administration, vital signs returned to baseline." D) "Client complained about the quality of the nursing care provided on previous shift."

Ans: C Feedback: The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.

A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to UAP? Select all that apply. A) Ensure that UAPs closely follow the nursing process when providing care. B) Audit the client documentation that UAPs record after they perform interventions. C) Take frequent mini-reports from UAPs to ensure changes in client status are identified. D) Know what clinical cues the UAP should be alert for and why. E) Make frequent walking rounds to assess clients.

Ans: C, D, E Feedback: The nurse must take careful action to ensure that delegation results in safe and competent client care. This necessitates such measures as taking frequent mini-reports, identifying the clinical cues that UAPs should be aware of, and performing rounds often. UAPs are not normally educated to follow the nursing process nor to perform documentation.

23. The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? A) Assessment B) Outcome identification C) Implementation D) Evaluation

Ans: D Feedback: Assessing the client's response to a diuretic medication is an example of evaluation. During assessment, the nurse collects and synthesizes data to identify patterns. The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage.

26. The client's expected outcome is The client will maintain skin integrity by discharge. Which of the following measures is best in evaluating the outcome? A) The client's ability to reposition self in bed. B) Pressure-relieving mattress on the bed. C) Percent intake of a diet high in protein. D) Condition of the skin over bony prominences.

Ans: D Feedback: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse examines client data or behaviors that validate whether the outcome is met. The condition of the skin, especially over bony prominences, provides the best measure of whether skin integrity has been maintained.

27. An expected client outcome is, The client will remain free of infection by discharge. When evaluating the client's progress, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000, and the client's abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement? A) Goal partially met; client identified fever and presence of wound discharge. B) Client understands the signs and symptoms of infection. C) Goal partially met; client able to perform activities of daily living. D) Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.

Ans: D Feedback: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse has three options: met, partially met, or not met. An elevated white blood cell count and the presence of yellow-green wound discharge are clinical manifestations consistent with an infectious process, so the outcome has not been met.

6. A nurse is documenting the intensity of a client's pain. What would be the most accurate entry? A) "Client complaining of severe pain." B) "Client appears to be in a lot of pain and is crying." C) "Client states has pain; walking in hall with ease." D) "Client states pain is a 9 on a scale of 1 to 10."

Ans: D Feedback: Information should be documented in a complete, accurate, relevant, and factual manner. Avoid interpretations of behavior, generalizations, and words such as "good."

A nurse administers a medication for pain but forgets to document it in the client's medical record. Legally, what does this mean? A) Nothing, the nurse's honesty will not be questioned. B) The nurse can add the documentation after the client goes home. C) The physician will verify that the nurse carried out the order. D) In the eyes of the law, if it is not documented, it was not done.

Ans: D Feedback: Nurses must carefully document each intervention. The legal truth is "if it wasn't documented, it wasn't done."

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? A) To implement evidence-based practice B) To ensure the order follows hospital policy C) To be sure interventions are individualized D) To be sure the intervention is safe

Ans: D Feedback: Nurses reassess the client and review the plan of care before initiating any nursing intervention. This is done to make sure that the plan of care is still responsive to the client's needs, and is safe for the particular client. In this case, the nurse would not give oral fluids to an unconscious client.

19. A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called? A) Nursing care conferences B) Staff visits C) Interdisciplinary referrals D) Nursing care rounds

Ans: D Feedback: Nursing care rounds are procedures in which a group of nurses visits select clients individually at each client's bedside. The primary purposes are to gather information to help plan and evaluate nursing care and to provide the client with an opportunity to discuss care.

The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required? A) Nursing interventions must be consistent with standards of care and research findings. B) Nursing interventions must be culturally sensitive and individualized for the client. C) Nursing interventions must be compatible with other therapies planned for the client. D) Nursing interventions must be approved by other members of the health care team.

Ans: D Feedback: Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client. Nursing interventions can be independent, dependent, and interdependent. Independent nursing interventions are nurse-initiated interventions directed at the etiology of the client problem; they do not require approval from other members of the health care team.

25. The nurse participates in a quality assurance program and reviews evaluation data for the previous month. Which of the following does the nurse recognize as an example of process evaluation? A) A 10% reduction in the number of ventilator-associated pneumonia B) A 5% increase in the number of nosocomial catheter-related urinary tract infections C) 40% of all client rooms in the facility are private and equipped with a computer D) A nursing care plan was developed within the eight hours of admission for 97% of all admissions.

Ans: D Feedback: Process evaluation focuses on the nature and sequence of activities carried out by nurses implementing the nursing process, such as the timing of nursing care plan creation. Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as the number of ventilator-associated pneumonia and nosocomial catheter-related urinary tract infections. Structure evaluation focuses on the environment in which care is provided, such as the number of private rooms equipped with a computer.

When a nursing supervisor evaluates the staff nurse's performance with a group of clients to whom the staff nurse has provided nursing care, the supervisor is performing which type of evaluation? A) Outcome evaluation B) Summary evaluation C) Structure evaluation D) Process evaluation

Ans: D Feedback: Process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent.

30. The nurse is caring for the client with pneumonia. An expected client outcome is, The client will maintain adequate oxygenation by discharge. Which outcome criterion indicates the goal is met? A) Client taking antibiotic as ordered. B) Client identifies signs and symptoms of recurrence of infection. C) Client coughing and deep breathing every one hour. D) Client no longer requires oxygen.

Ans: D Feedback: The client who is maintaining adequate oxygenation would not require oxygen. The client could be able to do the other three options and still have problems with oxygenation.

22. A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports? A) Pay courtesy calls to staff members before attending the meeting. B) Wait for the physicians to arrive before exchanging notes. C) Avoid asking questions related to the medical record. D) Come prepared with material required to take notes.

Ans: D Feedback: The nurse should come prepared with material required to take notes during the change-of-shift reports. The nurse should not delay the meeting for change-of-shift report by paying courtesy calls to staff members before attending the meeting. Change-of-shift reports are not conducted in the presence of physicians, thus the nurse does not need to wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

The nursing student is caring for a Native American client who is admitted for deep vein thrombosis. The nursing student speaks with a nurse regarding the client's lack of eye contact with the student. The nurse responds that Native Americans view eye contact as an invasion of privacy. Which error did the nursing student make? A) Failure to act in partnership with the client. B) Failure to approach the client caringly. C) Failure to seek the client's input in the plan of care. D) Failure to provide culturally sensitive care.

Ans: D Feedback: The nursing student failed to provide culturally sensitive care by expecting the client to engage in eye contact. There is no information to suggest the nursing student failed to act in partnership with the client, approach the client caringly, or seek the client's input in the plan of care.

A student is ambulating a client for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome? A) Take the client's vital signs after ambulation. B) Ask the client's wife to assist with ambulation. C) Delay ambulation until the following shift. D) Ask another student to help with ambulation.

Ans: D Feedback: Unexpected outcomes do occur, such as the risk of a fall for the postoperative client who is ambulated for the first time. In anticipation, the student caregiver could ask another student to help ambulate the client, thus decreasing this risk.

23. A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation? A) Erase the incorrect statement and write the correct one. B) Cross out the wrong statement in a way that is not readable. C) Use correction fluid to obliterate what has been written. D) Cross out the incorrect statement with a single line.

Ans: D Feedback: When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, nor cross out the wrong statement in a way that makes the statement unreadable, nor use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.