FINAL Fundamentals of nursing

ANS: B An individual over age 18 may sign the form allowing organ donation upon death. In this situation, the parents would need to sign the form because the teenager is under age 18. The nurse cannot allow the patient to sign the organ donation document because he is younger than age 18. The physician will be notified about the patient's wishes after the parents agree to donate the organs. The nurse caring for the patient does not contact the United Network for Organ Sharing. A transplant coordinator will be the liaison for this organization.

A 17-year-old patient, dying of heart failure, wants to have his organs removed for transplantation after his death. What action by the nurse is correct? a. Prepare the organ donation form for the patient to sign while he is still oriented. b. Instruct the patient to talk with his parents about his desire to donate his organs. c. Notify the physician about the patient's desire to donate his organs. d. Contact the United Network for Organ Sharing after talking with the patient.

ANS: C The criterion for hospice care is being expected to live less than 6 to 12 more months. Patients with a terminal illness are not eligible until that point. Palliative care provides assistance with pain management when a patient is not eligible for hospice care. An advance directive can be completed by any person, even those who are healthy.

A cancer patient asks the nurse what the criteria are for hospice care. What should the nurse answer? a. Having a terminal illness, such as cancer b. Needing assistance with pain management c. Expected to live less than 6 to 12 more months d. Completion of an advance directive

ANS: B Loss of a body part from injury is a situational loss. Maturational losses occur as part of normal life transitions. Perceived loss is not obvious to other people. Uncomplicated is not a type of loss; it is a description of normal grief.

A man is hospitalized after surgery that amputated both lower extremities owing to injuries sustained during military service. The nurse should recognize his need to grieve for what type of loss? a. Maturational loss b. Situational loss c. Perceived loss d. Uncomplicated loss

ANS: D Using the nursing process along with applying components of the nursing critical thinking model will help the new graduate nurse make the most appropriate clinical decisions. Care plans should be individualized, and recalling facts does not utilize critical thinking skills to make clinical decisions. The new nurse should not rely on the charge nurse to determine priorities of care.

A new graduate nurse will make the best clinical decisions by applying the components of the nursing critical thinking model and which of the following? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process

ANS: B The risks associated with the use of restraints are serious. A restraint-free environment is the first goal of care for all patients. Many alternatives to the use of restraints are available, and the nurse should try all of them before notifying the patient's health care provider. The situation states that the patient is touching the items, not trying to pull them out. At this time, the patient's well-being is not at risk. The nurse will have to check on the patient frequently and then will determine if the health care provider needs to be informed of the situation. Restraints can be used (1) only to ensure the physical safety of the resident or other residents, (2) when less restrictive interventions are not successful, and (3) only on the written order of a health care provider. The health care provider needs to know the situation but also needs to know that all approaches possible have been used before writing an order for restraints. Allowing the patient to pull out any of these items could cause harm to the patient.

A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that he should not touch these lines, but the patient continues. What is the best action by the nurse at this time? a. Apply restraints loosely on the patient's dominant wrist. b. Try other approaches to prevent the patient from touching these care items. c. Notify the health care provider that restraints are needed immediately to maintain the patient's safety. d. Allow the patient to pull out lines to prove that the patient needs to be restrained.

ANS: A Law often requires that an autopsy be performed if death occurred during incarceration; as the result of foul play, homicide, or suicide; or as an accidental death, as occurs in car accidents. The nurse must understand the policies that are applied in cases of foul play death and must ensure that the decedent's body is properly cared for after death, despite the emotional feelings of individuals in close contact with the decedent.

A correctional facility nurse is called to the scene of a deceased inmate. The correction officer wants to quickly move the body to the funeral home because he is not comfortable with death. The inmate's body will need to be transported where? a. Coroner's office for an autopsy b. Police department for an investigation c. Directly to the inmate's family d. Warden for inspection

ANS: C Families can have limited knowledge when asked to make important ethical decisions. Nurses have the time, patience, and knowledge base to assist the family to understand their ethical situation and to help them make their own educated decision. Advance directives are completed by the person who is dying. Funeral guidance is best provided by a chaplain or a caretaker.

A couple is informed that their fetus' condition is incompatible with life after birth. Nurses can best help the couple with their end-of-life decision making by offering them which of the following? a. An advance directive to complete b. Brief discussion and funeral guidance c. Time and careful explanations d. Instructions on how to proceed

ANS: B A dying individual will likely have a decline in renal and liver functioning. Because of reduced organ functioning, a decreased dose would be in order, so the individual does not develop toxic levels of the medications.

A dying patient with liver and renal failure requires pain medication. The nurse anticipates that the medication dose will be a. Given at appropriate milligrams per kilogram medication levels. b. A decreased dose from milligrams per kilogram levels. c. An increased dose from milligrams per kilogram levels. d. Given at midrange for dosing at recommended levels.

ANS: D It is a federal law to require facilities to develop policies about organ donation. The transplant coordinator has additional education on providing answers about organ donation. Not all religions allow for organ donation. A patient may be on life support during organ removal to preserve organ tissues. Autopsy compromises organ integrity; removal should occur prior.

A family is grieving after learning of a family member's accidental death. The transplant coordinator requests to talk with the family about possible organ and tissue donation. The nurse recognizes that a. All religions allow for organ donation. b. Life support must be removed before organ and tissue retrieval occurs. c. The best time for organ and tissue donation is immediately after the autopsy. d. The transplant coordinator is working in accordance with federal law.

ANS: C The older adult is in the mature thinking stages of development according to Piaget and Kohlberg. According to Gould, the older adult needs help in realistically appreciating his/her accomplishments and in fostering continued development. Erikson's theory proposes that the older adult faces integrity versus despair. To avoid despair, the nurse should allow the patient to actively participate in an independent activity, such as preparing his/her own room with personal belongings. Offering a reward does not address the need for continued independence. Encouraging participation in social events again does not address independence, and the question is asking for the best first intervention. Advising the patient to attend all mandatory activities as the first intervention does not allow for the patient's independence. Some activities may be mandatory, but by first allowing the patient to decorate her room, the nurse is fostering independence and is helping the patient feel welcome and more at home.

A formerly independent and active older adult becomes severely withdrawn upon admission to a nursing home. When approaching this patient, which intervention should the nurse plan first? a. Offer a reward for participation in all events. b. Encourage the patient to attend all social events scheduled for the patients. c. Allow the patient to incorporate personal belongings into her room. d. Advise the patient of the importance of attending mandatory activities.

ANS: B Humility and responsibility are displayed when the nurse realizes lack of knowledge and requests an orientation to the unit. The other answer choices represent inappropriate actions in this situation and are not examples of humility and responsibility. The nurse should explore all options before refusing an assignment. The nurse should not make assumptions. Assuming is not an example of critical thinking. Admitting lack of knowledge is an example of humility, but going home does not illustrate an example of responsibility.

A new nurse is pulled from the surgical unit to work on the oncology unit. The nurse displays the critical thinking attitudes of humility and responsibility by a. Refusing the assignment. b. Asking for an orientation to the unit. c. Assuming that patient care will be the same as on the other units. d. Admitting lack of knowledge and going home.

ANS: C The privacy section of the HIPAA provides standards regarding accountability in the health care setting. These rules include patient rights to consent to the use and disclosure of their protected health information, to inspect and copy their medical record, and to amend mistaken or incomplete information. This document limits who is able to access a patient's record. It establishes the basis for privacy and confidentiality about patients in any manner. The book is located where only staff would have access. It is not the responsibility of the new nurse to move items used by others on the patient unit. The listing is protected as long as it is used appropriately as needed to provide care. There is no need to move the book to a more secluded area.

A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the front desk of the nursing station so patients can be located easily. What action is most appropriate for the nurse to take? a. Move the book to the upper ledge of the nursing station for easier access. b. Talk with the nurse manager about the listing being a violation of the Health Insurance Portability and Accountability Act (HIPAA). c. Use the book as needed while keeping it away from individuals not involved in patient care. d. Ask the nurse manager to move the book to a more secluded area.

ANS: B The Joint Commission requires accredited hospitals to have written nursing policies and procedures. These internal standards of care are specific and need to be accessible on all nursing units. For example, a policy/procedure outlining the steps to follow when changing a dressing or administering medication provides specific information about how nurses are to perform. The nurse being observed may not be doing the procedure according to the agency's policy or procedure. The procedure taught in nursing school may not be consistent with the policy or procedure for this agency. The patient is not responsible for maintaining the standards of practice. Patient input is important, but it's not what directs nursing practice.

A newly hired experienced nurse is preparing to change a patient's abdominal dressing and hasn't done it before at this hospital. Which action by the nurse is best? a. Ask another nurse to do it so the correct method can be viewed. b. Check the policy and procedure manual for the agency's method. c. Change the dressing using the method taught in nursing school. d. Ask the patient how the dressing change has been recently done.

ANS: B Anniversary reactions can reopen grief processes. A nurse should openly acknowledge the loss and talk about the common renewal of grief feeling around the anniversary of the individual's death. This facilitates normal mourning. The nurse is not attempting to alleviate a physical pain. The actions are of open communication, not evaluation. Palliative care refers to comfort measures for symptom relief.

A nurse encounters a family that experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child's death. The nurse spends time with them discussing their child's life and death. The nurse's action best demonstrates which nursing principle? a. Pain management technique b. Facilitating normal mourning c. Grief evaluation d. Palliative care

ANS: A, E, F Examples of an occurrence include an error in technique or procedure such as failing to properly identify a patient. Institutions generally have specific guidelines to direct health care providers how to complete the occurrence report. The report is confidential and separate from the medical record. The nurse is responsible for providing information in the medical record about the occurrence. It is also best for the nurse to discuss the occurrence with nursing management only. The risk management department of the institution also requires complete documentation. The fact that an occurrence report was completed is not documented in the patient's medical record. No discussion of why the omission in procedure occurred should be documented in the patient's medical record. Errors should be discussed only with those who need to know such as the health care provider, appropriate administrative personnel, and risk management.

A nurse gives an incorrect medication to a patient without doing all of the mandatory checks, but the patient has no ill effects from the medication. What actions should the nurse take after reassessing the patient? (Select all that apply.) a. Notify the health care provider of the situation. b. Document in the patient's medical record that an occurrence report was filed. c. Document in the patient's medical record why the omission occurred. d. Discuss what happened with all of the other nurses and staff on the unit. e. Continue to monitor the patient for any untoward effects from the medication. f. Send an occurrence report to risk management after completing it.

ANS: B The nurse has a duty to report this situation to protect the children. Any health care professional who does not report suspected child abuse or neglect may be liable for civil or criminal legal action. The person making the report has legal immunity if the report is made in good faith. Talking with the parents is not mandated by law. There is no obligation to tell the parents that they will be reported to authorities. There is no obligation for the nurse to take pictures of the children.

A nurse notices that his neighbor's preschool children are often playing on the sidewalk and in the street unsupervised and repeatedly takes them back to their home and talks with the parent available, but the situation continues. What immediate action by the nurse is mandated by law? a. Talk with both parents about safety needs of their children. b. Contact the appropriate community child protection agency. c. Tell the parents that the authorities will be contacted shortly. d. Take pictures of the children to support the overt child abuse.

ANS: A Certain criteria are necessary to establish nursing malpractice. In this situation, although harm was caused, it was not because of failure of the nurse to perform a duty according to standards the way other nurses would have performed in the same situation. The nurse would have had to have done the procedure correctly, or the patient most likely would not have survived without any residual problems such as brain damage. The fact that the patient sustained injury as a result of age and physical status does not mean the nurse breached any duty to the patient. The nurse would need to make sure the defense attorney knew that the cardiopulmonary resuscitation (CPR) was done correctly. Without intervention, the patient most likely would not have survived. The prosecution would try to prove that a breach of duty had occurred, which had caused injury, not that cardiopulmonary resuscitation was done correctly. The defense team, not the prosecution, would explain the correlation between brittle bones and rib fractures during CPR.

A nurse performs cardiopulmonary resuscitation (CPR) on a 92-year-old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering, and for malpractice. What key point will the prosecution attempt to prove? a. The CPR procedure was done incorrectly. b. The patient would have died if nothing was done. c. The patient was resuscitated according to policy. d. Patients with brittle bones might sustain fractures when chest compressions are done.

ANS: C In the concrete operations period, children begin to cooperate and share new information about the acts they perform. Parents will be able to adjust their approaches to guide the child into helpful activities within the home, such as bargaining about chores in exchange for privileges. With the birth of a second child, most parents find that the strategies that worked well with the first child no longer work at all. After birth, children grow according to their genetic blueprint and gain skills in an orderly fashion, but at each individual's own pace. The need for a sense of fulfillment is usually experienced by middle-aged adults, not children. School-aged children need praise to discourage a sense of inferiority; providing praise is the best choice for encouraging positive behaviors while nurturing growth and development.

A nurse should instruct the parents of a 10-year-old child to keep which of the following theoretical principles in mind when dealing with a behavioral problem at home? a. Strategies that worked well with the first child will be equally as effective for the second child. b. Encourage the child to volunteer some time at a local hospital to instill a sense of fulfillment. c. Bargaining about chores in exchange for privileges may be an effective method of encouraging helpful activities. d. Do not offer praise for accomplishments and punishment for behavioral issues.

ANS: D Institutional practice guidelines are established standards and policies that can be used in court to make judgments about nursing actions. Intellectual standards are guidelines or principles for rational thought. Fairness and independent reasoning are two examples of critical thinking attitudes that are designed to help nurses make clinical decisions.

A nurse who is caring for a patient with a pressure ulcer fails to apply the recommended dressing according to hospital policy. If the patient is harmed, the nurse could be subject to legal action for not adhering to a. Fairness. b. Intellectual standards. c. Independent reasoning. d. Institutional practice guidelines.

ANS: B Malpractice insurance provided by the employing institution covers nurses only while they are working within the scope of their employment at that institution. It is always wise to find out if malpractice insurance is provided by a secondary place of employment, in this case, the pharmacy, or the nurse should carry an individual malpractice policy to cover situations such as this.

A nurse works full-time on the oncology unit at the hospital and works part-time on weekends giving immunizations at the local pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient's arm and is now being sued. How will the hospital's malpractice insurance provide coverage for this nurse? a. It will provide coverage as long as the nurse followed all procedures, protocols, and policies correctly. b. The hospital's malpractice insurance covers this nurse only during the time the nurse is working at the hospital. c. As long as the nurse has never been sued before this incident, the hospital's malpractice insurance will cover the nurse. d. The hospital's malpractice insurance will provide approximately 50% of the coverage the nurse will need.

ANS: A Concept maps challenge the student to synthesize data and identify relationships between nursing diagnoses. Reflective journaling involves thinking back to clarify concepts. Reading assignments and lecture do not best provide an instructor the ability to evaluate students' abilities to synthesize data.

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? a. Concept mapping b. Reflective journaling c. Reading assignment with a written summary d. Lecture and discussion

ANS: A Although nursing students are not employees of the health care agency where they are having their clinical experience, they are expected to perform as professional nurses would in providing safe patient care. Different levels of standards do not apply. Nursing students, just as nurses, provide safe, complete patient care, or they don't. No standard is used for nursing students other than that they must meet the standards of a professional nurse. The nursing instructor, not the nurse assigned to the patient, is responsible for the actions of the nursing student.

A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, "I don't understand what the big deal is. As my instructor, you are there to protect me and make sure I don't make mistakes." What is the best response from the nursing instructor? a. "You are expected to perform at the level of a professional nurse." b. "You are expected to perform at the level of a nursing student." c. "You are practicing under the license of the nurse assigned to the patient." d. "You are expected to perform at the level of a skilled nursing assistant."

ANS: D When nursing students work as nursing assistants or nurse's aides when not attending classes, they should not perform tasks that do not appear in a job description for a nurse's aide or assistant. The nursing student should always follow the directions of the nurse, unless doing so violates the institution's guidelines or job description under which the nursing student was hired. The nursing student should be able to safely complete the procedures delegated as a nursing assistant, and reviewing those not done recently is a good idea, but it has nothing to do with the situation. This option does not address the situation that the nursing student acted outside the job description for the nursing assistant position. The focus of the discussion between the nursing faculty member and the nursing student should be on following the job description under which the nursing student is working.

A nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while she was working as a nursing assistant. What advice is best for the nursing faculty member to give to the nursing student? a. "Just be careful when you are doing new procedures and make sure you are following directions by the nurse." b. "Review your procedures before you go to work, so you will be prepared to do them if you have a chance." c. "The nurse should not have allowed you to insert the nasogastric tube because something bad could have happened." d. "You are not allowed to perform any procedures other than those in your job description even with the nurse's permission."

ANS: B The critically thinking nurse should explore all options for pain relief first. The nurse should use critical thinking to determine the cause of the pain and determine various options for pain, not just ordered pain medications. The nurse can act independently to determine all options for pain relief and does not have to wait until after the health care provider rounds are completed. Explaining the cause of the pain does not address options for pain relief.

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explain to the patient that nothing else has been ordered. b. Explore other options for pain relief. c. Offer to notify the health care provider after morning rounds are completed. d. Discuss the surgical procedure and reason for the pain.

ANS: A, B, D, E The ethical doctrine of autonomy ensures the patient the right to refuse medical treatment. Living wills are written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. With this legal document, the patient is able to declare which medical procedures he or she wants or does not want when terminally ill or in a persistent vegetative state. Each state providing for living wills has its own requirements for executing the health care proxy or durable power of attorney for health care (DPAHC). This is a legal document that designates a person or persons of one's choosing to make health care decisions when the patient is no longer able to make decisions on his or her own behalf. This agent makes health care treatment decisions based on the patient's wishes. Cardiopulmonary resuscitation (CPR) is an emergency treatment provided without patient consent. Health care providers perform CPR on an appropriate patient unless a do not resuscitate (DNR) order has been placed in the patient's chart. The statutes assume that all patients will be resuscitated unless a written DNR order is found in the chart. Legally competent adult patients can consent to a DNR order verbally or in writing after receiving appropriate information from the health care provider. Differences among the states have been noted regarding advance directives, so the patient should check state laws to see if a state will honor an advance directive that was originated in another state.

A patient has just been told that he has approximately six months to live and asks about advance directives. Which statements by the nurse give the patient correct information? (Select all that apply.) a. "You have the right to refuse treatment at any time." b. "If you want certain procedures or actions taken or not taken, and you might not be able to tell anyone at the time, you need to complete documents ahead of time that give your health care provider this information." c. "You will be resuscitated at any time to allow you the longest length of survival." d. "You might want to think about choosing someone who will make medical decisions for you in the event that you are unable to make your desires known." e. "We will get someone who knows the state's guidelines to assist you in setting up your living will." f. "If you travel to another state, your living will should cover your wishes."

ANS: D The nurse uses creativity in this situation to figure out how the patient can stabilize himself while getting a drink of water. Humility is recognizing when more information is needed to make a decision. Confidence is being well prepared to perform nursing care safely. This question best illustrates the attitude of creativity. Risk taking is demonstrating the courage to speak out or to question orders based on the nurse's own knowledge base.

A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing himself with two hands on the water fountain. Which critical thinking attitude is utilized in this situation? a. Humility b. Confidence c. Risk taking d. Creativity

ANS: B An autopsy or postmortem examination may be requested by the patient or the patient's family, as part of an institutional policy, or if required by law. Because the patient's death occurred as a result of long-term illness, not under suspicious circumstances, and more than 24 hours after admission to the hospital, whether to conduct a postmortem examination would be decided by the family, and consent would have to be obtained from the family. The nurse needs to know the policy to follow regarding removal of lines when an autopsy is to be done. Asking about bathing the deceased patient is a valid question but is not priority, because the nurse needs to know the protocol to follow if an autopsy is to be done. Finding out which funeral home the deceased patient is to be transported to is valid but is not priority, because other actions must be taken before the deceased patient is transported from the hospital. Removal of lines and tubes is not a decision made by the family if an autopsy is to be done. The nurse must first check the protocol to be followed.

A patient with sepsis as a result of long-term leukemia dies 25 hours after admission to the hospital. A full code was conducted without success. The patient had a urinary catheter, an intravenous line, an oxygen cannula, and a nasogastric tube. What question is priority for the nurse to ask the family before beginning postmortem care? a. "Do you want to assist in bathing your loved one?" b. "Is an autopsy going to be done?" c. "To which funeral home do you want your loved one transported?" d. "Do you want me to remove the lines and tubes before you see your loved one?"

ANS: B, C Clear, concise, and timely communication is essential whenever charting in the patient's medical record occurs. Nursing students are not permitted to receive verbal orders. Documentation regarding communication with the health care provider must contain what was communicated by the nurse and the health care provider, orders if given, date, time, and identification of who is documenting the situation.

A patient's condition is slowly deteriorating. What actions should the nurse take to provide the best care possible? (Select all that apply.) a. Allow the nursing student to receive verbal orders from the physician in the room while the nurse is in the medication area down the hall. b. Document the patient's status changes in the medical record in a timely manner. c. Document that the health care provider has been notified of the specific patient status, including date and time that messages were left. d. Check the chart for frequent orders. e. Omit charting what the health provider's response is to notification of the patient's status change.

ANS: B Nurses who float need to inform the supervisor of any lack of experience in caring for the type of patients on the nursing unit. They also need to request and receive an orientation to the unit. Supervisors are liable if they give a staff nurse an assignment that he or she cannot safely handle. Before accepting employment, learn the policies of the institution regarding floating, and have an understanding as to what is expected. A basic orientation is needed, whereas a complete orientation of the functioning of the entire unit would take a period of time that would exceed what the nurse has to spend on orientation. Allowing the nurse to choose which meal time she would like is a nice gesture of thanks for the nurse, but it does not enable safe care. Having nursing assistive personnel may help the nurse complete basic tasks such as hygiene and turning, but it does not enable safe nursing care that she is ultimately responsible for.

A pediatric oncology nurse floats to an orthopedic trauma unit. What actions should the nurse manager of the orthopedic unit take to enable safe care to be given by this nurse? a. Provide a complete orientation to the functioning of the entire unit. b. Determine patient acuity and care the nurse can safely provide. c. Allow the nurse to choose which meal time she would like. d. Assign nursing assistive personnel to assist her with care.

ANS: C An official interpreter must be present to explain the terms of consent if a patient speaks only a foreign language. A family member or acquaintance who speaks a patient's language should not interpret health information. Family members can tell those caring for the patient what the patient is saying, but privacy regarding the patient's condition, assessment, etc., must be protected. There is no way that the nurse can know that the family member is translating exactly what the nurse is saying. Privacy must be ensured and accurate information must be provided to the patient. After consent is obtained for treatment, the health care provider would be notified because little can be done without consent. The health care provider needs to have the translator available during the history and physical, as well as at other times, but the first step is to get a translator to obtain informed consent because this is not an emergency situation. Using hand gestures and medical equipment is inappropriate when communicating with a patient who does not understand the language spoken. Certain hand gestures may be acceptable in one culture and not appropriate in another. The medical equipment may be unknown and frightening to the patient, and the patient still doesn't understand what is being said.

A recent immigrant who does not speak English is alert and requires hospitalization. What is the initial action that the nurse must take to enable informed consent to be obtained? a. Ask a family member to translate what the nurse is saying. b. Notify the health care provider that the patient doesn't speak English. c. Request an official interpreter to explain the terms of consent. d. Use hand gestures and medical equipment while explaining in English.

ANS: B The concept of hope is vital to nursing; it enables a person to anticipate positive experiences. Being patient and friendly and creating positive relationships are key concepts in all areas of nursing, but especially with depressed patients. The nurse's actions do not address time management, charity, or faith.

A severely depressed patient cannot state any positive attributes to his or her life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. The nurse is helping the patient to demonstrate which spiritual concept? a. Time management b. Hope c. Charity d. Faith

ANS: D Opioid medication is known to slow gastrointestinal transit time, which places the patient at high risk for constipation. Stimulant laxatives are indicated for opioid-induced constipation. Added water to the diet will allow water to be pulled into the GI tract, softening up stool. Massaging the patient's abdomen may cause further discomfort. Discontinuing pain medication is inappropriate for a terminally ill patient. Enema administration is not the first step in the treatment of opioid-induced constipation.

A terminally ill patient is experiencing constipation secondary to pain medication. What is the best way for the nurse to improve the patient's constipation problem? a. Massage the patient's abdomen. b. Contact the provider to discontinue pain medication. c. Administer enemas twice daily for 7 days. d. Use a stimulant laxative and increase fluid intake.

ANS: B Complicated or dysfunctional grief occurs when an individual has a complicated grieving process that interferes with common routines of life for excessively long periods of time. Normal grief is the most common reaction to death; it involves a complex range of normal coping strategies. Disenfranchised grief involves a relationship that is not socially sanctioned. Perceived grief is not a type of grief; perceived loss is a loss that is not obvious to other people.

A woman is called into her supervisor's office regarding her deteriorating work performance since the loss of her husband 2 years ago. The woman begins sobbing and saying that she is "falling apart" at home as well. The woman is escorted to the nurse's office, where the nurse recognizes the woman's symptoms as which of the following? a. Normal grief b. Complicated grief c. Disenfranchised grief d. Perceived grief

ANS: C In the formal operations period, adolescents and young adults begin to think about such subjects as achieving world peace, finding justice, and seeking meaning in life. Asking about a presidential election demonstrates that the adolescent is concerned about political issues that affect others besides her. Hitting would be a common schema during the sensorimotor stage of development. Using play to learn about the environment is indicative of the preoperational stage. During the concrete operations stage (ages 6 to 12 years), children are able to coordinate two concrete perspectives in social and scientific thinking, such as understanding the difference between "hiding" and "melting."

According to Piaget's formal operations level, a 13-year-old adolescent will likely a. Hit other students to deal with environmental change. b. Use play to understand her surroundings. c. Question her parents about an upcoming presidential election. d. Question where the ice is hiding when ice has melted in her drink.

ANS: B A 4-year-old child would be in the preoperational period. Children at this stage are still egocentric. Play is very important to foster cognitive development. Children should be allowed to play with any equipment that is safe and should be allowed to communicate feelings about their health care. The IV pump is not a safe piece of equipment for a 4-year-old child to play with. A baseball bat typically is not found in a hospital setting and is a potentially dangerous toy to play with in the hospital. The blood pressure cuff is a safer option. A 4-year-old child is of preschool age and more than likely is not able to read yet. Also, the book does not allow for any human interaction and communication if read alone.

According to Piaget's theory of cognitive development, the nurse should allow a hospitalized 4-year-old patient to safely play with a. The pump administering intravenous fluids. b. The blood pressure cuff. c. A baseball bat. d. A book to read alone in a quiet place.

ANS: A The OMH describes culture as the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Subcultures represent various ethnic, religious, and other groups with distinct characteristics from the dominant culture. Ethnicity refers to a shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics. Cultural backlash occurs when an individual rejects a new culture because experience with a new or different culture is extremely negative.

According to the Office of Minority Health (OMH), the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups are known as a. Culture. b. Subculture. c. Ethnicity. d. Cultural backlash.

ANS: A Nurses often witness suffering on a daily basis. Nurses, as humans, also experience grief and loss when they have been intensely involved in the patient's suffering and death. Offer comfort and understanding to colleagues, and maintain a stable patient care environment. It is inappropriate to create guilt by telling a grieving nurse to hurry back to her patients or by indicating that she is a bad role model. Suggesting that a colleague take sedative during a shift is dangerous for the safety of patients in her care.

After the anticipated demise of a chronically ill patient, the unit nurse is found crying in the staff lounge. The best response to her crying colleague would be a. "It is normal to feel this way. Give yourself some time to mourn." b. "Your other patients still need you, so hurry back to them." c. "You're being a bad role model to the unit's nursing students." d. "Why don't you take a sedative to cope?"

ANS: C At 18 months, the child is in the sensorimotor period of development. Piaget describes hitting, looking, grasping, and kicking as normal schemas to deal with the environment. The social worker does not need to be consulted in this case, nor is psychological counseling warranted, because the child is exhibiting normal behaviors. Play is an important part of all children's development. Removing the toys is not necessary because this child is exhibiting normal behaviors. Removing toys and the opportunity to play with them may actually hinder the child's development.

An 18-month-old patient is brought into the clinic for evaluation because the mother is concerned. The 18-month-old child hits her siblings and says only "No" when communicating verbally. According to Piaget's theory, what recommendation should the nurse make a priority? a. Consult the social worker because the child is hitting other children. b. Reassure the mother that the child is developmentally within specified norms. c. Encourage the mother to seek psychological counseling for the child. d. Remove all toys from the child's room until this behavior ceases.

ANS: B Jewish culture calls for family members or religious officials to stay with the decedent's body until the time of burial. A male provider is unnecessary. Requesting or expecting the family to go home is not providing culturally sensitive care.

An Orthodox Jewish Rabbi has been pronounced dead. The nursing assistant respectfully asks family members to leave the room and go home as postmortem care is provided. Which of the following statements from the supervising nurse reflects correct knowledge of Jewish culture? a. "I wish they would go home because we have work to do here." b. "Family members stay with the body until burial the next day." c. "I should have called a male colleague to handle the body." d. "I thought they would quietly leave after praying and touching the Rabbi's head."

ANS: C An obstetric nurse would not have been trained in performing a tracheostomy or a cricotomy, and doing so would be beyond what she has been trained or educated to do. The nurse did not do what another nurse would have done in the same situation. The nurse is not protected by the Good Samaritan Law because she acted outside of her scope of practice and training. The nurse should have acted within what she was trained and educated to do in this circumstance, not just stay with the patient.

An obstetrical nurse comes across an automobile accident. The patient seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from her purse to provide an airway. The patient survives and has a permanent problem with his vocal cords, making it difficult to talk. Which statement is true regarding the nurse's performance? a. The nurse acted appropriately and saved the patient's life. b. The nurse acted within the guidelines of the Good Samaritan Law. c. The nurse took actions beyond those that are standard and appropriate. d. The nurse should have just stayed with the patient and waited for help.

ANS: B The goal of transcultural nursing is culturally congruent care, or care that fits the person's valued life patterns and set of meanings. Culturally competent care reflects the ability of a nurse to bridge cultural gaps in caring and enables patients and families to achieve meaningful and supportive caring. It is a step toward reaching culturally congruent care. Ethnocentrism is a tendency to hold one's own way of life as superior to those of others. It is the cause of biases and prejudices. Cultural imposition is the use of one's own values and lifestyles as the absolute guide in dealing with patients and interpreting behaviors.

Care that includes the nurse learning about cultural issues involved in the patient's health care belief system and enable patients and families to achieve meaningful and supportive care is known as a. Ethnocentrism. b. Culturally competent care. c. Cultural imposition. d. Culturally congruent care.

ANS: B, D, E Many non-Western cultures see the cause of illness as being an imbalance between humans and nature. Method of diagnosis is described as holistic, and treatment of illness is mixed to include magico-religious, supernatural herbal, biomedical, etc. Western cultures view the cause of illness as biomedical using scientific, high-tech methods of diagnosis.

Compare the following statements. Which are considered predominant in non-Western cultures? (Select all that apply.) a. Causes of illness are biomedical in nature. b. Illness is an imbalance between humans and nature. c. Caring patterns are based in self-care and self-determination. d. Diagnoses are described as holistic. e. Treatment of disease can be magico-religious based.

ANS: B In some cases, information about a scientific discovery or a major medical breakthrough or an unusual situation is newsworthy. In this case, anyone seeking information needs to contact the hospital's public relations department to ensure that invasion of privacy does not occur. It is not the nurse's responsibility to decide independently the legality of disclosing information. The nurse does not have the right to allow the cameraman access to the neonatal unit. This would constitute invasion of privacy. The physician has no responsibility regarding this situation and cannot allow the cameraman on the unit. It is not the nurse's responsibility to find out how the pictures are to be used. This is a task for the public relations department.

Conjoined twins are in the neonatal department of the community hospital until transfer to the closest medical center. A photographer from the local newspaper gets off the elevator on the neonatal floor and wants to take pictures of the infants. What initial action should the nurse take? a. Escort the cameraman to the neonatal unit while a few pictures are taken quietly. b. Tell the cameraman where the hospital's public relations department is located. c. Ask the cameraman to wait while permission is obtained from the physician. d. Ask the cameraman how the pictures are to be used in the local newspaper.

ANS: A Critical thinking involves being able to decipher what is relevant and important in a given situation and to make a clinical decision based on that importance. Patient care can be provided in many ways. Clinical decisions should be based on evidence and research. Following physician's orders is not considered a critical thinking skill.

Critical thinking characteristics include a. Considering what is important in a given situation. b. Accepting one, established way to provide patient care. c. Making decisions based on intuition. d. Being able to read and follow physician's orders.

ANS: C Despite significant improvements in the overall health status of the U.S. population over the past few decades, the persistence of disparities in health status among ethnic and racial minorities continues to be a serious local and national challenge. Hispanics, African Americans, and some Asian subgroups are less likely than non-Hispanic whites to have a high school education and often experience poorer access to care and lower quality of preventive, primary, and specialty care.

Despite significant improvements in the overall health status of the U.S. population over the past few decades, disparities among ethnic and racial minorities have a. Decreased as education levels equal those of non-Hispanic whites. b. Disappeared in relation to non-Hispanic white populations. c. Remained a serious challenge locally and nationally. d. Decreased faster than anticipated.

ANS: A Populations with health disparities have a significantly increased incidence of disease or increased morbidity and mortality when compared with the general population.

Eliminating disparities in the health status of people from diverse racial, ethnic, and cultural backgrounds has become one of the two most important priorities of Healthy People 2020 because populations with health disparities have a. Increased incidence of disease. b. Lower levels of morbidity. c. Lower mortality rates. d. Decreased incidence of disease.

ANS: D Yearning and searching characterize the second bereavement phase in the Bowlby Attachment Theory. Emotional outbursts are common in this phase. During the numbing phase, the family may feel a sense of unreality. During disorganization and despair, the reason why the loss occurred is constantly questioned. Bargaining is part of the Kübler-Ross stages, not of the Bowlby Attachment Theory.

Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member's unexpected death, the surviving family members begin to cry and scream in despair. The nurse recognizes this as the Bowlby Attachment Theory stage of a. Numbing. b. Disorganization and despair. c. Bargaining. d. Yearning and searching.

ANS: A, B, E Naturalistic practitioners attribute illness to natural, impersonal, and biological forces that cause alteration in the equilibrium of the human body. Healing emphasizes use of naturalistic modalities, including herbs, chemicals, heat, cold, massage, and surgery. In contrast, personalistic practitioners believe that an external agent, which can be human (i.e., sorcerer) or nonhuman (e.g., ghosts, evil, deity), causes health and illness. Personalistic beliefs emphasize the importance of humans' relationships with others, both living and deceased, and with their deities.

Foster (1976) identified two distinct categories of healers cross-culturally. Of the following characteristics, which are congruent with the healing practices of naturalistic practitioners? (Select all that apply.) a. Illness is impersonal and is due to biological forces. b. Illness is caused by alterations in the body equilibrium. c. Sorcerers can cause health and illness. d. Human relationships should be emphasized. e. Healing modalities include herbs, massage, and surgery.

ANS: A The nurse facilitates mourning in family members who are still surviving. By acknowledging the pregnant woman's emotions, the nurse helps the mother bond with her fetus and recognize the emotions that still exist for the deceased child. The nurse is not attempting to help the patient eradicate grief, which would be unrealistic. Curative therapy and spiritual promotion are not addressed by the nurse's statement.

I know it seems strange, but I feel guilty being pregnant after the death of my son last year," said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her to better bond with her unborn child. This demonstrates which nursing technique? a. Facilitating mourning b. Providing curative therapy c. Promoting spirituality d. Eradicating grief

ANS: B Among Asian cultures, face-saving communication promotes harmony through indirect, ambiguous communication and conflict avoidance. American culture supports individualism, where people value assertive communication because it manifests the ideals of individual autonomy and self-determination.

In comparing American culture with Asian cultures, which of the following statements is true? a. American culture supports collectivism. b. Asian communication can be ambiguous. c. American communication patterns downplay autonomy. d. Asian communication is direct to avoid conflict.

ANS: A Knowledge of a patient's country of origin and its history and ecological contexts is significant to health care and is known as ethnic heritage and ethnohistory. Biocultural history identifies a patient's health risks related to the ecological context of the culture. Social organization refers to units of organization in a cultural group defined by kinship status and appropriate roles for their members. Religious and spiritual beliefs are major influences in the patient's worldview about health and illness, pain and suffering, and life and death. Nurses need to understand the emic perspective of their patients.

In performing a cultural assessment, knowledge of a patient's country of origin and its history and ecological contexts is known as a. Ethnohistory. b. Biocultural history. c. Social organization. d. Religious and spiritual beliefs.

ANS: D Islamic culture calls for modesty and same-sex caregivers whenever possible. Muslim faith discourages cremation and autopsy to preserve the sanctity of the soul of the deceased.

In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. This plan of care would include a. Male health care workers care for the body after death has occurred. b. Body preparation for autopsy. c. Body preparation for cremation. d. Female health care workers care for the body after death has occurred.

ANS: A Jean Piaget's theory includes four stages in sequential order: sensorimotor, preoperational, concrete operations, and formal operations. Intimacy versus isolation is part of Erik Erikson's psychosocial theory of development. Latency is stage 4 of Freud's five-stage psychosexual theory of development. The postconventional level of reasoning is part of Kohlberg's theory of moral development.

Jean Piaget's cognitive developmental theory focuses on four stages of development, including a. Formal operations. b. Intimacy versus isolation. c. Latency. d. The postconventional level.

ANS: D Nurses are able to use any or all of these action modes simultaneously. These actions require that nurses have knowledge of the patient's culture and have the willingness, commitment, and skills to work with patients and families in decision making. The outcome sought through these actions and decisions is meaningful, supportive, and facilitative care as judged by the patient.

Leininger (1991) identified three nursing decision and action modes to achieve culturally congruent care. These modes are "cultural care preservation or maintenance," "cultural care accommodation," and "cultural care repatterning." When assessing patients during the admission process, the nurse utilizes a. These action modes in a distinct order. b. These action modes individually, one at a time. c. Only one action mode per patient. d. All these action modes simultaneously.

ANS: B Professional nurses are responsible for making clinical decisions to take immediate action when a patient's condition worsens. Patient care should be based on evidence-based practice, not on tradition. Clear textbooks solutions to patient problems are not always available. Care plans should be individualized.

Professional nurses are responsible for making clinical decisions to a. Prove traditional methods of providing nursing care to patients. b. Take immediate action when a patient's condition worsens. c. Apply clear textbook solutions to patients' problems. d. Formulate standardized care plans for groups of patients.

ANS: C Upholding professional standards requires nurses to use critical thinking for the highest level of quality nursing care. Bypassing the patient's feelings is not practicing according to professional standards. The primary purpose of professional standards is not to establish minimal passing standards for testing. Patient care should be based on patient needs, not on nurses' needs.

Professional standards influence a nurse's clinical decisions by a. Bypassing the patient's feelings to promote ethical standards. b. Establishing minimal passing standards for testing. c. Requiring the nurse to use critical thinking for the highest level of quality nursing care. d. Utilizing evidence-based practice based on nurses' needs.

ANS: A The goal of transcultural nursing is culturally congruent care, or care that fits the person's valued life patterns and set of meanings. Patterns and meanings are generated from people themselves, rather than from predetermined criteria. Culturally congruent care is sometimes different from the values and meanings of the professional health care system. Ethnocentrism is a tendency to hold one's own way of life as superior to those of others. It is not part of culturally congruent care.

Providing culturally congruent care means providing care that a. Fits the patient's valued life patterns and set of meanings. b. Is based on meanings generated by predetermined criteria. c. Is the same as the values of the professional health care system. d. Holds one's own way of life as superior to those of others.

ANS: B Reviewing the effectiveness of interventions best describes evaluation. Examining the meaning of data is inference. Supporting findings and conclusions provides explanations. Searching for links between the data and the nurse's assumptions describes analysis.

The critical thinking skill of evaluation in nursing practice can be best described as a. Examining the meaning of data. b. Reviewing the effectiveness of nursing actions. c. Supporting findings and conclusions. d. Searching for links between data and the nurse's assumptions.

ANS: C The Worden Grief Tasks Model consists of four tasks. Task III is seen when the surviving family member begins to adjust to life without the deceased. Task I is accepting the reality of the loss, Task II is working through the pain of grief, and Task IV is emotionally relocating the deceased and moving on with life.

The father has recently begun to attend his children's school functions since the death of his wife. This would best be described as which task in the Worden Grief Tasks Model? a. Task I b. Task II c. Task III d. Task IV

ANS: A Family members will grieve differently. One sign of normal grief is keeping the deceased individual's room intact as a way to keep that person alive in the minds of survivors. This is happening after the family member is deceased, so it is not end-of-life grief. It is not abnormal or complicated grief; the child died recently.

The mother of a recently murdered child keeps the child's room intact. Family members are encouraging her to redecorate and move forward in life. The visiting nurse recognizes this behavior as _____ grief. a. Normal b. End-of-life c. Abnormal d. Complicated

ANS: A, B Nurses follow health care providers' orders unless they believe the orders are in error or may harm patients. Therefore, the nurse needs to assess all orders. If an order seems to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and the nurse still believe that it is inappropriate, the nurse should inform the supervising nurse or follow the established chain of command. The supervising nurse should be able to help resolve the questionable order, but only the health care provider who wrote the order or a health care provider covering for the one who wrote the order can change the order. Harm to the infant could occur if the medication dosage was too high. The nurse cannot change an order. Giving the amount calculated to be correct would not be what another nurse would do in the same situation. Although the pharmacy is an excellent resource, only the health care provider can change the order.

The nurse calculates the medication dose for an infant on the pediatric unit and determines that the dose is twice what it should be. The pediatrician is contacted and says to administer the medication as ordered. What is the next action that the nurse should take? (Select all that apply.) a. Notify the nursing supervisor. b. Check the chain of command policy for such situations. c. Give the medication as ordered. d. Give the amount calculated to be correct. e. Contact the pharmacy for clarification.

ANS: C The nurse should try to find out why the patient is crying to intervene appropriately. Telling the patient that she will return, providing tissues, and limiting visitors may be appropriate actions but do not address the reason why the patient is crying.

The nurse enters a room to find the patient sitting up in bed crying. How would the nurse display a critical thinking attitude in this situation? a. Tell the patient she'll be back in 30 minutes. b. Set a box of tissues at the patient's bedside before leaving the room. c. Ask the patient why she is crying. d. Limit visitors while the patient is upset.

ANS: B Self-care strategies for nurses include talking with a close colleague and reflecting on feelings by writing in a journal. It is inappropriate for a nurse to talk with patients to resolve the nurse's grief. Although exercise is important for self-care, sleep is also important. Shutting oneself away from friends is not self-care; the nurse should spend time with people who are nurturing.

The nurse has had three patients die during the past 2 days. Which approach is most appropriate to manage the nurse's sadness? a. Telling the next patients why the nurse is sad b. Talking with a colleague or writing in a journal c. Exercising vigorously rather than sleeping d. Avoiding friends until the nurse feels better

ANS: A, C Slander occurred when the physician spoke falsely about the nurse, and libel occurred when the physician wrote false information in the chart. Both of these situations could cause problems for the nurse's reputation. Invasion of privacy is the release of a patient's medical information to an unauthorized person such as a member of the press, the patient's employer, or the patient's family. Assault is any action that places a person in apprehension of a harmful or offensive contact without consent. No actual contact is necessary. Battery is any intentional touching without consent.

The nurse hears a physician say to the charge nurse that he doesn't want that same nurse caring for his patients because she is stupid and won't follow his orders. The physician also writes on his patient's medical records that the same nurse, by name, is not to care for any of his patients because of her incompetence. What component(s) of defamation has the physician committed? (Select all that apply.) a. Slander b. Invasion of privacy c. Libel d. Assault e. Battery

ANS: B In collectivistic cultures, families are made up of distant blood relatives across three generations and fictive or nonblood kin. Kinship extends to both the father's and the mother's side of the family (bilineal) or is limited to the side of either father (patrilineal) or mother (matrilineal). Patrilineally extended families exist among Chinese and Hindus, where a woman moves into her husband's clan after marriage and minimizes ties with her own parents and siblings.

The nurse is caring for a Chinese patient who is reluctant to answer questions about her health background. The nurse asks the patient if she would like her husband present when health questions are asked. The nurse does this knowing that the Chinese culture is a collectivistic and patrilineal culture. What does this mean? a. Kinship extends to both the father's side and the mother's side of the family. b. Kinship is limited to the side of the father. c. Kinship is limited to the side of the mother. d. The husband becomes part of the wife's clan after marriage.

ANS: A Health care practitioners who have cultural ignorance or cultural blindness about differences generally resort to cultural imposition and use their own values and lifestyles as the absolute guide in dealing with patients and interpreting their behaviors. Culturally competent care is the care provided by the nurse who attempts to bridge cultural gaps in caring, work with cultural differences, and enable patients and families to achieve meaningful and supportive caring. The nurse in this case has not been able to do this. Any intercultural encounter consists of an inside or native perspective (emic worldview) and an outsider's perspective (ethic worldview). The nurse is obviously utilizing an ethic worldview. The nurse may be acultural, but she/he did not purposefully ignore the patient's need.

The nurse is caring for a Native American who has had recent surgery. In the patient's culture, it is a sign of weakness to complain of pain. In the nurse's culture, people who are having pain ask for pain medicine. The nurse has assumed that the patient has not been having pain and does not need medication because he has not complained of pain. What is the nurse doing? a. Utilizing cultural imposition by not asking the patient about his pain b. Striving to provide culturally congruent care by allowing the patient to suffer c. Operating from an emic worldview of the patient's cultural beliefs d. Practicing discrimination by not giving the patient pain medicine

ANS: B Nurses need to identify and contact patients' religious and spiritual leaders before problems occur. Nurses work with these leaders to mediate in times of crises. Canceling the procedure may occur, but not at this time. Doing so prematurely could lead to the patient's death. A family member cannot make decisions for a competent patient. Having the procedure done against the patient's wishes cannot be done.

The nurse is caring for a member of the Jewish faith who needs to undergo a critical procedure on Saturday. The patient is refusing the procedure because it is scheduled to be done on the Sabbath. The nurse impresses on the patient the urgency of the procedure, stating that delaying the procedure would put his life at risk. The patient continues to refuse. What should the nurse do? a. Cancel the procedure. b. Seek permission from the patient to contact the patient's rabbi. c. Have a family member sign the permit. d. Have the procedure done against patient wishes.

ANS: D In contrast to other types of interviews, cultural assessment is intrusive and time-consuming and requires a trusting relationship between participants. Miscommunication commonly occurs in intercultural interactions as the result of language and communication differences between and among participants, as well as differences in interpreting each other's behaviors. The goal is to generate knowledge about the patient's values, beliefs, and practices about nursing and health care.

The nurse is caring for a patient of Asian descent who speaks very little English. The nurse is especially concerned and attempts to develop a trusting relationship with the patient. She does this knowing that a. Cultural assessment needs to be done quickly to provide the best care early. b. Miscommunication cannot be tolerated in cultural assessment. c. The goal is to get the patient to conform to American health care norms. d. Cultural assessment is intrusive in contrast to other types of interviews.

ANS: C If the patient needs an interpreter, the nurse should ensure gender, age, and ethnic compatibility of the interpreter with the patient's preference and the topic of discussion. The nurse should direct questions to the patient and not to the interpreter and should have the interpreter ask the patient for feedback and clarification at regular intervals, not only at the end.

The nurse is caring for a patient who does not speak English. She decides to use an interpreter to explain procedures and to answer questions that the patient may have. In performing the interview, what should the nurse do? a. Direct questions to the interpreter to ask the patient. b. Disregard the age and gender of the interpreter. c. Direct questions to the patient. d. Ask the interpreter to ask the patient for clarification at the end.

ANS: A Nurses should determine the family social hierarchy as soon as possible to prevent offending patients and their families. Working with established family hierarchy prevents delays and achieves better patient outcomes. Encouraging the patient to sign against her social beliefs can cause familial strife. Explaining the level of jeopardy may create undue stress. Nurses should be able to determine the correct hierarchy and should not involve the physician at this time.

The nurse is caring for a patient who has emigrated from another country. The patient is in need of abdominal surgery but seems reluctant to sign the surgical permits. What is one tactic that the nurse should use? a. Determine the family social hierarchy. b. Encourage the patient to sign the permits. c. Call the physician so that surgery can be canceled. d. Impress on the patient that her life is in jeopardy.

ANS: A, B, D A school-aged child thrives on feelings of accomplishment. Drawing pictures, looking at children's books, and building blocks are all ways that a child this age could play while developing a sense of accomplishment. A 500-piece puzzle would be too difficult for a 6-year-old child to complete without the possibility of getting frustrated. Magazines and newspapers would be written at too high a reading level for a 6-year-old child. If play items offered to the child are too difficult, the child may become frustrated and may experience a feeling of inferiority.

The nurse is planning playroom activities for a hospitalized 6-year-old patient. Which of the following age appropriate items that the nurse should ensure are available? (Select all that apply.) a. Crayons and paper b. Children's books c. 500-piece puzzle d. Building blocks e. Magazines and newspapers

ANS: D The nurse should refer the patient to speak with a dietitian who is familiar with cultural food choices. If possible, he/she should develop a diet plan that includes the patient's cultural diet preferences and can provide culturally sensitive teaching brochures that describe healthy food choices. Rice and beans may be acceptable alternatives in a balanced diet. The nurse should include people in the family who help shop for and prepare food in the home, along with the wife.

The nurse is providing diabetic diet teaching to a Hispanic man and his wife. When the nurse is discussing foods that are acceptable, the wife continues to interrupt with statements like, "Oh, he doesn't eat that," or, "All he eats is rice and beans." What should the nurse do? a. Ask the wife to leave so he/she can focus on teaching the patient. b. Explain how "rice and beans" are not acceptable foods on a diabetic diet. c. Provide a diet plan with only food alternatives selected by the patient. d. Refer the patient and his wife to a dietitian familiar with Spanish food choices.

ANS: A An 8-year-child would be in the industry versus inferiority stage of development. During this stage, the child needs to be praised for accomplishments such as learning new skills. Developing devoted relationships is part of the identity versus role confusion stage, usually occurring during puberty. During the autonomy versus shame and doubt stage, limiting choices and harsh punishment lead to feelings of shame and doubt. Separation anxiety is usually a part of the trust versus mistrust stage.

The nurse is teaching a young adult couple about promoting the health of their 8-year-old child. The nurse knows that the parents understand the developmental stage their child is in according to Erikson when they state, "We should a. Provide proper support for learning new skills." b. Encourage devoted relationships with others." c. Limit choices and provide harsh punishment for mistakes." d. Not leave our child at school for longer than 3 hours at a time."

ANS: A Biophysical development refers to how our physical bodies grow and change. Nurses and other health care providers are able to quantify and compare the changes that occur as a newborn infant grows into adulthood against established norms to detect abnormalities. Biophysical development refers to physical growth, not cognitive development, social behaviors, or psychological development.

The nurse knows that a priority reason for being knowledgeable about biophysical developmental theories is to a. Understand how the physical body grows. b. Predict definite patterns of cognitive development. c. Anticipate how patients' social behaviors develop. d. Describe the process of psychological development.

ANS: D The professional nurse is responsible for assessing patients each shift. Making informed, ethical decisions in the patient's best interest is practicing responsibly

The nurse needs a reminder of professional responsibility when performing which of these actions? a. Making an informed clinical decision b. Making an ethical clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments

ANS: D Human growth and development is a complex pattern of movement that involves changes in biological, cognitive, and socioemotional processes. Cognitive processes comprise changes in intelligence, use of language, and development of thinking. Socioemotional processes consist of variations in personality, emotions, and relationships with others. Height and weight, development of gross and fine motor skills, and sexual maturation resulting from hormonal changes during puberty are examples of changes resulting from biological processes.

The nursing instructor will need to provide further instruction to the student who states a. "Intellectual development is affected by cognitive processes." b. "Socioemotional processes can influence an individual's growth and development." c. "Breast development is an example of a change resulting from biological processes." d. "An individual's biological processes determine physical characteristics and do not affect growth and development."

ANS: A, C, D, E Diagnosing disease is not a nursing action. Evaluating the effectiveness of medical treatments is not a nursing action either. Nurses are to use the nursing process to evaluate the effectiveness of nursing interventions, not medical treatments. Identifying patient needs, determining priorities of care, setting realistic goals, and implementing nursing interventions are all steps in the clinical decision-making process.

The nursing process involves which of the following steps in the clinical decision-making process? (Select all that apply.) a. Identifying patient needs b. Diagnosing the disease process c. Determining priorities of care d. Setting goals e. Performing nursing interventions f. Evaluating effectiveness of medical treatments

ANS: B Nursing is an applied science, and to apply knowledge learned and develop critical thinking skills to make clinical decisions, the student should actively participate in all clinical experiences. Studying for longer hours, interviewing nurses, and attending skills labs do not provide opportunities for clinical decision making, as do actual clinical experiences.

The nursing student can best develop critical thinking skills by doing which of the following? a. Studying 3 hours more each night b. Actively participating in all clinical experiences c. Interviewing staff nurses about their nursing experiences d. Attending all open skills lab opportunities

ANS: D The primary goal of palliative care is to help patients and families achieve the best quality of life. Providing support for the patient's nurse is not the primary obligation when the patient is experiencing severe pain. Not all collaborative team members would be able to provide postmortem care, as is the case for nutritionists, social workers, and pharmacists. Teaching about stages of grief should not be the focus when severe pain is present.

The palliative team's primary obligation to a patient in severe pain includes which of the following? a. Supporting the patient's nurse in her grief b. Providing postmortem care for the patient c. Teaching the patient the stages of grief d. Enhancing the patient's quality of life

ANS: B According to Erikson, a 14-year-old adolescent is developing his identity versus role confusion. A teenager is very concerned with self and is often preoccupied with body image. Frequently, teenagers express themselves rebelliously as they struggle to discover their own identities. Rebellious behavior is very common and normal at this stage of development. A juvenile correctional facility usually is not necessary. Establishing companionship occurs in the young adult age group. Feeling the need to support future generations is usually experienced by the middle-aged adult

The parents of a 14-year-old boy express concern over their child's rebellious behavior. The nurse should plan to respond to the parents' concern by informing them that their a. Child should be referred to a juvenile correctional facility. b. Child's behavior is normal because the adolescent is trying to adjust to his emerging identity. c. Child's behavior is a matter of concern because he is likely conflicted about establishing companionship with a partner. d. Child's behavior is expected because he is expressing his need to support future generations.

ANS: B Action patterns are used by infants and toddlers to deal with the environment. For example, the infant who learns that sucking achieves a pleasing result generalizes that action to suck fingers, blankets, or clothing. Children remain egocentric into the preoperational period. Thumb sucking does not indicate transition away from egocentric thinking. No statements have supported thumb sucking as enhancing language development.

The parents of a 15-month-old child express concern to the nurse about their child's thumb-sucking habit. Which of these explanations related to the child's age and developmental level would be most appropriate for the nurse to give the parents? a. Thumb sucking at this age indicates a developmental delay and should be further assessed. b. Sucking achieves a pleasing result for infants, and generalizing that action by thumb sucking is normal. c. Thumb sucking at this age demonstrates a transition away from egocentric thinking. d. At this age, thumb sucking will enhance language development.

ANS: A Interpretation involves being orderly in data collection, looking for patterns to categorize data, and clarifying uncertain data. This nurse is clarifying the data in this situation. Evaluation involves determining the effectiveness of interventions. The nurse in this scenario is assessing the patient, not evaluating interventions. Self-regulation is reflecting on experiences. Explanation is supporting findings and conclusions. The nurse in this question is clarifying uncertain data (determining cause of the low pulse), not supporting the finding of a low pulse

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether he has any complaints or a history of heart problems. The nurse is utilizing which critical thinking skill? a. Interpretation b. Evaluation c. Self-regulation d. Explanation

ANS: A A 3-year-old child is going to use play to learn and discover the surrounding environment. Children at this age are egocentric and often are unable to see the world from any perspective other than their own. Very young children are not able to understand and comment on world events because their thinking has not advanced to abstract reasoning yet. A 3-year-old child is likely unable to read. Asking a child to perform an activity that is beyond his or her developmental abilities will likely result in frustration at not being able to complete the task.

The teaching plan for a 3-year-old child who is at risk for developmental delay should include which of these instructions for the parents? a. Encourage play as your child is exploring his or her surroundings. b. Insist that your child discuss various points of view, not just his or her own. c. Discuss world events with your child to foster language development. d. Actively encourage your child to read lengthy books to expedite reading and writing abilities.

ANS: C Listening to family members' stories validates the importance of the dying individual's life and reinforces the dignity of the person's life. Taking pictures of visitors does not address the value of a person's life. Calling organ donation and providing private visiting time are components of the dying process, but they do not validate a dying person's life.

Validation of a dying person's life would be demonstrated by which nursing action? a. Taking pictures of visitors b. Calling the organ donation coordinator c. Listening to family stories about the person d. Providing quiet visiting time

ANS: D A scientific knowledge base is the first component for clinical decision making. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. A critical thinking attitude is a guideline for how to approach a problem and apply knowledge to make a clinical decision.

What is the first component of the critical thinking model for clinical decision making? a. Experience b. Nursing process c. Attitude d. A scientific knowledge base

ANS: A Ethnicity refers to a shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics. Ethnicity is different from race, which is limited to the common biological attributes shared by a group such as skin color or blood type. In any intercultural encounter, there is an insider or native perspective (ethic worldview) and an outsider's perspective (ethic worldview). Ethnicity is best understood by those who are a part of that ethnicity and have an "emic" worldview.

When asked to describe the differences between ethnicity and race, what should the student nurse explain? a. Ethnicity refers to a shared identity, whereas race is limited to biological attributes. b. Ethnicity and race are actually the same and are based in cultural norms. c. Ethnicity can be understood only through an ethic worldview. d. Race refers to a shared identity, whereas ethnicity is limited to biological attributes.

ANS: D "If individuals experience repeated developmental failures, inadequacies sometimes result" is a true statement. Developmental failures could manifest with ineffective coping skills. However, when an individual experiences successes, health is promoted. Patients have unique patterns of growth and development that are not uniform. Nurses must consider the influence of culture and context on growth and development.

When caring for a middle-aged adult exhibiting maladaptive coping skills, the nurse is trying to determine the cause of the patient's behavior. From a growth and development perspective, what should the nurse recall? a. Individuals have uniform patterns of growth and development. b. Health is promoted based on how many developmental failures a patient experiences. c. Culture usually has no effect on predictable patterns of growth and development. d. When individuals experience repeated developmental failures, inadequacies sometimes result.

ANS: B Working with established family hierarchy prevents delays and achieves better patient outcomes. Nurses need to determine who has authority for making decisions within the family and how to communicate with the proper individuals. Do not assume that just because the woman is the primary caregiver, she will make decisions independently. Determine the family social hierarchy as soon as possible. Gender also differentiates role expectations.

When caring for a patient of a different culture, it is important for the nurse to understand that a. The nurse should protect the patient from family intrusion in her health care decisions. b. Working within the established family hierarchy produces better outcomes. c. Women as primary caregivers make independent health decisions. d. Gender is not a factor when it comes to role expectations.

ANS: B Asking the patient what pain relief methods have worked in the past is an example of exploring many options for pain relief. Administering medication based on a previous assessment is not practicing according to standards of care. The nurse is to conduct an assessment each shift on his/her patient and intervene accordingly. Nonpharmacological pain relief methods are available, as are medications for pain. Pain is subjective. The nurse should offer pain relief methods based on the patient's reports without being judgmental.

Which of these patient scenarios is most indicative of critical thinking? a. Administering pain relief medication according to what was given last shift b. Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past c. Offering pain relief medication based on physician orders d. Explaining to the patient that his reports of severe pain are not consistent with the minor procedure that was performed

ANS: B, C, D No one theory successfully describes all the intricacies of human growth and development. Today's nurses need to be knowledgeable about several theoretical perspectives when working with patients. These theories form the basis for meaningful observation of an individual's pattern of growth and development. They provide important guidelines for an understanding of important human processes that allows the nurse to begin to predict human responses, not medical diagnoses, and to recognize deviations from the norm. Recognizing your own moral developmental level is essential in separating your own beliefs from those of others when helping patients with their moral decision-making process. Growth and development, as supported by a life span perspective, is multidimensional.

When developing a plan of care concerning growth and development for a hospitalized adolescent, what should the nurse do? (Select all that apply.) a. Stick with one developmental theory for consistency. b. Apply developmental theories when making observations of the individual's patterns of growth and development. c. Compare the individual's assessment findings versus established normal findings. d. Recognize his/her own moral developmental level. e. Apply a unidimensional life span perspective.

ANS: A Freud believed that adult personality is the result of how an individual resolved conflicts between sources of sexual pleasure and the mandates of reality. Freud had a strong influence on Erik Erikson, but Erikson's theory differed from Freud's in that it focused on psychosocial stages rather than psychosexual stages. Freud's five stages of psychoanalytical development in sequential order include oral, anal, phallic, latency, and genital. The phallic stage precedes the genital stage. In theory, problems in adult life would be due to unresolved conflicts and failures.

When utilizing Freud's psychoanalytical/psychosocial theory, the nurse recalls that a. Adult personality is the result of resolved conflicts between sources of sexual pleasure and the mandates of reality. b. Development occurs throughout the life span and focuses on psychosocial stages. c. The genital stage precedes the phallic stage of development. d. Problems evident in adult life are due to early successes and resolution of earlier developmental stages.

ANS: C Self-reflection utilizes critical thinking when thinking back on the effectiveness of interventions and how they were performed. The other options are not the best examples of self-reflection but do represent good nursing practice. Using an objective approach and obtaining data in an orderly fashion does not involve purposefully thinking back to discover the meaning or purpose of a situation. Providing evidence-based explanations for nursing interventions does not always involve thinking back to discover the meaning of a situation

Which of the following demonstrates a nurse utilizing self-reflection to improve clinical decision making? a. Uses an objective approach in all situations b. Obtains data in an orderly fashion c. Improves a plan of care while thinking back on interventions performed d. Provides evidence-based explanations for all nursing interventions

ANS: D Nursing interventions during the preoperational period (age 2 to 7 years) should recognize the use of play (such as handling equipment) to help the child understand the events taking place. Giving the parents a book and not involving the child is not the best option, because the nurse should explain all procedures to children and their parents. Children tend to ask a lot of questions; therefore limiting questions may increase anxiety. Parents and the child all should be involved in preoperative teaching because the parents will be the primary caregivers upon discharge.

Which of these approaches would be most appropriate for the nurse to use when teaching a 4-year-old patient about a scheduled surgery? a. Give the parents a book to read about the procedure and do not discuss the procedure with the child to decrease anxiety. b. Set boundaries before teaching by telling the child that she can ask only three questions because time is limited. c. Insist that the parents wait outside the room to ensure privacy of the child. d. Allow the child to touch and hold medical equipment such as thermometers and syringes.

ANS: B The nurse should not assume when a patient is going to be discharged and document this information in a plan of care. Making assumptions is not an example of a critical thinking skill. The patient's reactions to testing, having several nursing diagnoses, and a description of the patient's coping abilities are all appropriate to document in the nursing plan of care.

Which of these findings, if identified in a plan of care, should the registered nurse revise because it is not characteristic of critical thinking and the nursing process? a. Patient's reactions to diagnostic testing b. Nurse's assumptions about hospital discharge c. Identification of five different nursing diagnoses d. Documentation of patient's ability to cope with loss

ANS: C This is a characteristic of the sensorimotor stage (birth to 2 years), where schemas become self-initiated activities. For example, the infant who learns that sucking achieves a pleasing result generalizes the action to suck fingers, blanket, or clothing. Successful achievement leads to greater exploration. By age 6, the child is in the preoperational stage of development. The child is expected to be egocentric, even though language ability is progressing. Play becomes a primary means by which children foster their cognitive development; therefore playing with a doll is considered normal at this age. Children see objects and persons from only one point of view—their own—at this stage.

Which of these manifestations, if identified in a 6-year-old patient, should the nurse associate with a possible developmental delay based on Piaget's theory? a. The child speaks in complete sentences but often talks only about himself. b. The child still plays with a favorite doll that he has had since he was a toddler. c. The child continues to suck his thumb. d. The child describes an event from his own perspective, even though the entire family was present.

ANS: C Understanding normal growth and development helps nurses predict, prevent, and detect deviations from patients' own expected patterns. The nurse can then compare expected patterns of activity based on age with the patient's stated activity patterns to determine deviations from the patient's own expected patterns. Asking the patient to describe his/her usual daily activities will provide the nurse with useful information about the patient's own expected patterns. How many hours are spent watching television or in front of a computer and how many times the patient exercises in a week are closed-ended questions. These questions would not provide the nurse with as much information about the patient's expected patterns when his/her stated patterns are compared with expected patterns for the patient's age group to detect delays

Which of these statements would be most appropriate for a nurse to state when assessing an adult patient for growth and developmental delays? a. "How many times per week do you exercise?" b. "Are you able to stand on one foot for 5 seconds?" c. "Would you please describe your usual activities during the day?" d. "How many hours a day do you spend watching television or sitting in front of a computer?"

ANS: D The family of a dying Hindu remains at the bedside to place a drop of the holy water from the River Ganges on the patient's lips immediately after death to help his or her soul to the next life. The family of a critically ill Jewish patient will turn his or her head eastward or to the right side. A dying Hispanic patient will not be left alone, so that a close kin is able to hear the patient's wishes, allowing the soul to leave in peace. Anointing of the sick is a Roman Catholic sacrament.

Which statement is true relative to caring for a Hindu patient who is dying? a. The family will turn his head eastward or to the right. b. A close kin will stay with the patient to hear his last wishes. c. Anointing of the sick is a common right of the dying. d. The family will place a drop of water on the patient's lips.

ANS: D Gesell's theory of development states that environment plays a part in child development, but it does not have any part in the sequence of development. Other factors influencing growth and development include biological, cognitive, and socioemotional processes. Environmental factors support, change, and modify the pattern of development, but they do not generate progressions of development. Each child's pattern of growth and development is unique and is directed by gene activity. Not every child develops certain skills at the same time. Children grow according to their own genetic blueprint.

While assessing an 18-month-old toddler, the nurse distinguishes normal from abnormal findings by remembering that Gesell's theory of development states a. "The developmental stage of the toddler is affected solely by environmental influence." b. "Developmental patterns are not affected by gene activity." c. "Skill development should be identical to that of other toddlers in the playroom." d. "Environmental influence does not affect the sequence of development."

ANS: C The nurse must use critical thinking skills in this situation to adapt positioning technique. In practice, patient procedures are not always presented as in a textbook, but they are individualized. A urologist consult is not warranted for position, but perhaps instead for difficulty in insertion. Postponing insertion of the catheter is not an appropriate action.

While caring for a hospitalized older adult female post hip surgery, the new graduate nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. The nurse exhibits critical thinking to perform this task by a. Following textbook procedure. b. Notifying the physician of the need for a urologist consult. c. Adapting the positioning technique to the situation. d. Postponing catheter insertion until the next shift.

ANS: D Each health care facility has personnel who are familiar with the state laws and can assist the patient in revising a living will. They may be in the admissions or risk management department. Checking with the health care provider about the presence of a living will on the chart has nothing to do with the patient's desire to change the living will. The question states that the patient wants to change his living will. Asking whether he has talked to his lawyer recently is a closed-ended question that passes the responsibility to someone else, that is, the attorney, and does not address the patient's current desire to change the living will. It is the nurse's responsibility to find an appropriate person in the facility to assist the patient. A living will can be changed whenever the patient decides to change it, as long as the patient is competent.

While recovering from a severe illness, a hospitalized patient states that he wants to change his living will, which he signed nine months ago. Which response by the nurse is most appropriate? a. "Check with your admitting health care provider whether a copy is on your chart." b. "Have you talked with your attorney recently about a living will?" c. "Your living will can be changed only once each calendar year." d. "Let me check with someone here in the hospital who can assist you."