NUR 100 FINAL

All of the following are crucial needs of the dying patient except: 1. Control of pain 2. Love and belonging 3. Freedom from decision making 4. Preservation of dignity and self-worth

3. Freedom from decision making To help patients and families achieve the best possible quality of life, determine the goals of care, and select the appropriate interventions

A hospice program emphasizes: 1. Prolongation of life 2. Hospital-based care 3. Palliative treatment and control of symptoms 4. Curative treatment and alleviation of symptoms

3. Palliative treatment and control of symptoms Care of the terminally ill patient and his or her family

which of the following is not one of the five steps of the nursing process? 1. planning 2. evaluation 3. assessment 4. hypothesis testing

4. hypothesis testing

When using ice massage for pain relief, which of the following is correct? (Select all that apply.) A. Apply ice using firm pressure over skin. B. Apply ice for 5 minutes or until numbness occurs. C. Apply ice no more than 3 times a day. D. Limit application of ice to no longer than 10 minutes. E. Use a slow, circular steady massage.

A. Apply ice using firm pressure over skin. B. Apply ice for 5 minutes or until numbness occurs. E. Use a slow, circular steady massage.

A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation? A. Critical thinking B. Managing an adverse event C. Exercising self-discipline D. Time management

A. Critical thinking

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? A. Physical care technique B. Activity of daily living C. Indirect care measure D. Lifesaving measure

A. Physical care technique Administering a tube feeding is an example of a physical care, a direct care technique.

Which of the following signs or symptoms in an opioid-naive patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? A. Oxygen saturation of 95% B. Difficulty arousing the patient C. Respiratory rate of 10 breaths/min D. Pain intensity rating of 5 on a scale of 0 to 10

B. Difficulty arousing the patient Sedation is a concern because it may indicate that the patient is experiencing opioid-related side effects. Advancing sedation may indicate that the patient may progress to respiratory depression.

A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: A. Evaluative measures. B. Expected outcomes. C. Reassessments. D. Standards of care.

B. Expected outcomes. The absence of diarrhea and abdominal pain and the ability to identify the correct diet are expected outcomes. If outcomes had not been met, the nurse would reassess. The low-residue diet is a standard of care, but the patient's ability to describe it is an outcome. An evaluative measure is the nurse questioning the patient about symptoms.

A patient who needs nursing and rehabilitation following a stroke would most benefit from receiving care at a A. Primary care center. B. Restorative care setting. C. Assisted-living center. D. Respite center.

B. Restorative care setting.

When assessing an older adult who is showing symptoms of anxiety, insomnia, anorexia, and mild confusion, one of the first assessments includes which of the following? A. The amount of family support B. A 3-day diet recall C. A thorough physical assessment D. Threats to safety in her home

C. A thorough physical assessment

After a nurse receives a change-of-shift report on his assigned patients, he prioritizes the tasks that need to be completed. This is an example of a nurse displaying which practice? A. Organizational skills B. Use of resources C. Time management D. Evaluation

C. Time management Completing a priority to-do list is a useful time-management skill. Change-of-shift report can help you sequence activities on the basis of what you learn about the patients' conditions and the care the patient has received.

When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a: A. critical pathway. B. nursing care plan. C. concept map. D. diagnostic label.

C. concept map.

A student nurse employed as a nursing assistant may perform care: A. as learned in school. B. expected of a nurse at that level. C. identified in the hospital's job description. D. requiring technical rather than professional skills.

C. identified in the hospital's job description. Rationale: Student nurses should never perform a task that is not in the job description of the facility with which they work.

On entering a room the nurse sees the patient crying softly. What is the most therapeutic response? A. Using silence B. Asking, "Why are you crying today?" C. Using therapeutic touch D. Stating, "I see that you're crying."

D. Stating, "I see that you're crying." Stating an observation encourages patients to share without putting the patient on the defensive.

Place the steps of the scientific method in their correct order with number 1 being the first step of the process. 1. Formulate a question or hypothesis. 2. Evaluate results of the study. 3. Collect data. 4. Identify the problem. 5. Test the question or hypothesis. a. 4, 3, 1, 5, 2 b. 3, 4, 1, 2, 5 c. 4, 3, 2, 1, 5 d. 3, 4, 1, 5, 2

a. 4, 3, 1, 5, 2

When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.) a. An observation of how a patient turns and moves in bed b. The unit policy and procedure manual c. The care recommendations of a physical therapist d. The results of a diagnostic x-ray film e. Your experiences in caring for other patients with similar problems

a. An observation of how a patient turns and moves in bed c. The care recommendations of a physical therapist d. The results of a diagnostic x-ray film

Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) a. Impaired Skin Integrity related to physical immobility b. Fatigue related to heart disease c. Nausea related to gastric distention d. Need for improved Oral Mucosa Integrity related to inflamed mucosa e. Risk for Infection related to surgery

a. Impaired Skin Integrity related to physical immobility c. Nausea related to gastric distention

A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: a. Patient's level of function. b. Patient's willingness to perform self-care. c. Patient's level of consciousness. d. Patient's health management values.

a. Patient's level of function. Observing a patient perform activities physical, socially, psychologically, and developmentally assesses his or her level of function. In the case of this question the nurse assesses physical functional level. Observation does not measure willingness to perform self-care but the ability to do so. Observing physical performance of self-hygiene is not a measure of level of consciousness nor does it reveal a patient's values.

when caring for patients, the nurse must understand the difference between religion and spirituality. religious care helps individuals: a. maintain their belief systems and worship practices b. develop a relationship with a higher being c. establish a cultural contentedness with the purpose of life d. achieve the balance needed to maintain health and well-being

a. maintain their belief systems and worship practices

A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? a. Achieving wound healing of the foot ulcer b. Enhancing patient knowledge about the effects of diabetes c. Providing a dietitian consultation for diet retraining d. Improving patient adherence to diabetic diet

b. Enhancing patient knowledge about the effects of diabetes

A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply.) a. Providing mouth care every 4 hours b. Maintaining intravenous (IV) infusion at 100 mL/hr c. Administering prochlorperazine (Compazine) via rectal suppository d. Consulting with dietitian on initial foods to offer patient e. Controlling aversive odors or unpleasant visual stimulation that triggers nausea

b. Maintaining intravenous (IV) infusion at 100 mL/hr d. Consulting with dietitian on initial foods to offer patient

Which of the following nursing diagnoses is stated correctly? (Select all that apply.) a. Fluid Volume Excess related to heart failure b. Sleep Deprivation related to sustained noisy environment c. Impaired Bed Mobility related to postcardiac catheterization d. Ineffective Protection related to inadequate nutrition e. Diarrhea related to frequent, small, watery stools.

b. Sleep Deprivation related to sustained noisy environment d. Ineffective Protection related to inadequate nutrition

shared theory a. very abstract; attempts to describe nursing in a global context b. specific to a particular situation; brings theory to the bedside c. applies theory from other disciplines to nursing practice d. addresses a specific phenomenon and reflects practice

c. applies theory from other disciplines to nursing practice

king a. Based on the theory that focuses on wellness and prevention of disease. b. Based on the belief that people who participate in self-care activities are more likely to improve their health outcomes. c. Based on 14 activities, the nurse should assist patients with meeting needs until they are able to do so independently. d. Based on the belief that nurses should work with patients to develop goals for care.

d. Based on the belief that nurses should work with patients to develop goals for care.

Which of the following is an example of the general adaptation syndrome? 1. Alarm reaction 2. Inflammatory response 3. Fight-or-flight response 4. Ego-defense mechanisms

1. Alarm reaction Alarm reaction, resistance stage, and the exhaustion stage

Practice guidelines for the treatment of adults with low back pain is an example of: 1. Clinical guidelines 2. Quantitative nursing research 3. Outcomes management research 4. A randomized controlled trial (RCT)

1. Clinical guidelines are systemically developed statements about a plan of care for a specific set of clinical circumstances involving a specific patient population.

Which definition does not characterize stress? 1. Efforts to maintain relative constancy within the internal environment 2. A condition eliciting an intellectual, behavioral, or metabolic response 3. Any situation in which a nonspecific demand requires an individual to respond or take action 4. A phenomenon affecting social, psychological, developmental, spiritual, and physiological dimensions

1. Efforts to maintain relative constancy within the internal environment Stress is an experience a person is exposed to through a stimulus or stressor

A patient and his or her family facing the end stages of a terminal illness might best be served by a: 1. Hospice 2. Rehabilitation center 3. Extended care facility 4. Crisis intervention center

1. Hospice The focus is palliative care, not curative treatment.

Which statement about loss is accurate? 1. Loss may be maturational, situational, or both. 2. The degree of stress experienced is unrelated to the type of loss. 3. Loss is only experienced when there is an actual absence of something valued. 4. The more an individual has invested in what is lost, the less the feeling of loss

1. Loss may be maturational, situational, or both. Life changes are natural and often positive, which are learned as change always involves necessary losses.

Which statement about loss is accurate? 1. Loss may be maturational, situational, or both. 2. The degree of stress experienced is unrelated to the type of loss. 3. Loss is only experienced when there is an actual absence of something valued. 4. The more an individual has invested in what is lost, the less the feeling of loss.

1. Loss may be maturational, situational, or both. Life changes are natural and often positive, which are learned as change always involves necessary losses

The scope of nursing practice is legally defined by: 1. State Nurse Practice Acts 2. Professional nursing organizations 3. Hospital policy and procedure manuals 4. Health care providers in the employing institutions

1. State Nurse Practice Acts Determines the legal boundaries within each state

Mary Jones is a newly diagnosed patient with diabetes. The nurse shows Mary how to administer an injection. This intervention activity is: 1. Teaching 2. Managing 3. Counseling 4. Communicating

1. Teaching An acquisition of new knowledge or psychomotor skills

Major homeostatic mechanisms are controlled by all of the following except: 1. Thymus gland 2. Pituitary gland 3. Medulla oblongata 4. Reticular formation

1. Thymus gland Neurophysiological responses to stress function through negative feedback

Rehabilitation services begin: 1. When the patient enters the health care system 2. After the patient's physical condition stabilizes 3. After the patient requests rehabilitation services 4. When the patient is discharged from the hospital

1. When the patient enters the health care system Initially focuses on the prevention of complications related to the illness or injury. After the condition stabilizes, rehabilitation helps to maximize the patient's level of independence

The nurse puts restraints on a patient without the patient's permission and without a physician's order. The nurse may be guilty of: 1. Battery 2. Assault 3. Neglect 4. Invasion of privacy

1. battery Unintentional touching without consent

theory is essential to nursing practice because it: (select all that apply) 1. contribute to nursing knowledge 2. predicts patient behaviors in situations 3. provides a means of assessing patient vital signs 4. guides nursing practice 5. formulates health care legislation 6. explains relationships between concepts

1. contribute to nursing knowledge 2. predicts patient behaviors in situations 4. guides nursing practice 6. explains relationships between concepts

While obtaining a health history, the nurse asks Mr. Jones if he has noted any change in his activity tolerance. this is an example of which interview technique? 1. direct question 2. problem solving 3. problem seeking 4. open-ended question

1. direct question

Which of the following models is based on the physiological, sociocultural, and dependence- independence adaptive modes? 1. Roy's adaptation model 2. Orem's model of self-care 3. King's model of personal, interpersonal, and social systems 4. Rogers' life process interactive person- environmental model

1. roy's adaptation model

Mrs. Kay comes to the family clinic for birth control. The nurse obtains a health history and performs a pelvic examination and Pap smear. The nurse is functioning according to: 1. Protocol 2. Standing order 3. Nursing care plan 4. Intervention strategy

1.Protocol Guides decisions and interventions for specific health care problems or conditions

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?"

2, 4, 1, 5, 3

Evaluation is: 1. Only necessary if the health care provider orders it 2. An integrated, ongoing nursing care activity 3. Begun immediately before the patient's discharge 4. Performed primarily by nurses in the quality assurance department

2. An integrated, ongoing nursing care activity Whenever you have contact with a patient, you continually make clinical decisions and redirect nursing care; this is an ongoing process

The nursing care plan calls for the patient, a 300-lb woman, to be turned every 2 hours. The patient is unable to assist with turning. The nurse knows that she may hurt her back if she attempts to turn the patient by herself. The nurse should: 1. Turn the patient by herself. 2. Ask another nurse to help her turn the patient. 3. Rewrite the care plan to eliminate the need for turning. 4. Ignore the intervention related to turning in the care plan.

2. Ask another nurse to help her turn the patient. Certain nursing situations require you to obtain assistance by seeking additional personnel, knowledge, or nursing skills. You will need assistance with this patient to help turn and position the patient safely.

Trying questionable and experimental forms of therapy is a behavior that is characteristic of which stage of dying? 1. Anger 2. Bargaining 3. Depression 4. Acceptance

2. Bargaining Cushions and postpones awareness of the loss by trying to prevent it from happening

The criteria used to determine the effectiveness of a nursing action are based on the: 1. Nursing diagnosis 2. Expected outcomes 3. Patient's satisfaction 4. Nursing interventions

2. Expected outcomes They are the expected favorable and measurable results of nursing care.

An example of an extended care facility is a: 1. Home care agency 2. Skilled nursing facility 3. Suicide prevention center 4. State-owned psychiatric hospital

2. Skilled nursing facility Where they receive supportive care until they are able to move back into the community

A health care issue often becomes an ethical dilemma because: 1. Decisions must be made based on value systems 2. The choices involved do not appear to be clearly right or wrong 3. Decisions must be made quickly, often under stressful conditions 4. A patient's legal rights coexist with a health professional's obligations

2. The choices involved do not appear to be clearly right or wrong Ethical problems come from controversy and conflict.

Measuring the patient's response to nursing interventions and his or her progress toward achieving goals occurs during which phase of the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Nursing diagnosis

2. evaluation Determines whether the patient's condition or well-being has improved after the application of the nursing process

which of the following is the correctly stated nursing diagnosis? 1. needs to be fed related to broken right arm 2. impaired skin integrity related to fecal incontinence 3. abnormal breath sounds caused by weak cough reflex 4. impaired physical mobility related to rheumatoid arthritis

2. impaired skin integrity related to fecal incontinence

the nurse is caring for a patient admitted to the neurological unit with the diagnosis of a stroke and right-sided weakness. the nurse assumes responsibility for bathing and feeding the patient until the patient is able to begin performing these activities. the nurse in this situation is applying the theory developed by? 1. neuman 2. orem 3. roy 4. peplau

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

the following statement appears on the nursing care plan for an immunosuppressed patient: "the patient will remain free from infection throughout hospitalization." this statement is an example of a: 1. long-term goal 2. short-term goal 3. nursing diagnosis 4. expected outcome

2. short-term goal

the information obtained in a review of systems (ROS) IS: 1. objective 2. subjective 3. based on the nurses perspective 4. based on physical examination findings

2. subjective

During a change-of-shift report: 1. Two or more nurses always visit all patients to review their plan of care. 2. The nurse should identify nursing diagnoses and clarify patient priorities. 3. Nurses should exchange judgments they have made about patient attitudes. 4. Patient information is communicated from a nurse on a sending unit to a nurse on a receiving unit.

2.The nurse should identify nursing diagnoses and clarify patient priorities. An effective change-of-shift report describes each patient's health status and lets staff on the next shift know what care the patients will require

Trying questionable and experimental forms of therapy is a behavior that is characteristic of which stage of dying? 1. Anger 2. bargaining 3. Depression 4. Acceptance

2.bargaining Cushions and postpones awareness of the loss by trying to prevent it from happening

What is the appropriate order for the following steps of evidence-based practice (EBP)? 1. Integrate the evidence. 2. Ask the burning clinical question. 3. Create a spirit of inquiry 4. Evaluate the practice decision or change. 5. Share the results with others. 6. Critically evaluate the evidence you gather. 7. Collect the most relevant and best evidence.

3, 2, 7, 6, 1, 4, 5

While working in a rehabilitation facility, it is important to obtain nursing histories and develop a therapeutic nurse-patient relationship. Which of the following lists in correct order the phases of Peplau's theory as applied in this setting. The nurse: 1. Ensures that the patient has access to appropriate community resources for long-term care. 2. Collaborates with the patient to identify specific patient needs 3. Collects essential information from the patient's health record. 4. Works with the patient to develop a plan for resolving patient issues.

3, 4, 2, 1 The following phases characterize the nursepatient interpersonal relationship: preorientation (data gathering), orientation (defining issue), working phase (therapeutic activity), and resolution (termination of relationship).

An incident report is: 1. A legal claim against a nurse for negligent nursing care 2. A summary report of all falls occurring on a nursing unit 3. A report of an event inconsistent with the routine care of a patient 4. A report of a nurse's behavior submitted to the hospital administration

3. A report of an event inconsistent with the routine care of a patient An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a patient.

A research report includes all of the following except: 1. The researcher's interpretation of the study results 2. A description of methods used to conduct the study 3. A summary of other research studies with the same results 4. A summary of literature used to identify the research problem

3. A summary of other research studies with the same results The summary details the results of the study and explains whether a hypothesis is supported. The results of other studies are not presented.

A student nurse who is employed as a nursing assistant may perform any functions that: 1. Have been learned in school 2. Are expected of a nurse at that level 3. Are identified in the position's job description 4. Require technical rather than professional skill

3. Are identified in the position's job description Need to perform only those tasks that appear in the job description for a nurse's aide or assistant

How would you distinguish between theories and assumptions? 1. Assumptions are tested, and theories are not. 2. Theories organize reality, but assumptions are not real. 3. Assumptions are assumed to be true, but theories are not. 4. Theories test hypotheses, but assumptions need no scientific proof

3. Assumptions are assumed to be true, but theories are not. A theory is a set of concepts, definitions, and assumptions that explains a phenomenon, and assumptions are the "taken for granted" statements.

If an error is made while recording, the nurse should: 1. Erase it or scratch it out. 2. Leave a blank space in the note. 3. Draw a single line through the error and initial it. 4. Obtain a new nurse's note and rewrite the entries

3. Draw a single line through the error and initial it. Do not erase, apply correction fluid, or scratch out errors made while recording; it may appear as if you were attempting to hide information or deface the record.

Crisis intervention is a specific measure used for helping a patient resolve a particular, immediate stress problem. This approach is based on: 1. An in-depth analysis of a patient's situation 2. The ability of the nurse to solve the patient's problems 3. Effective communication between the nurse and patient 4. Teaching the patient how to use ego-defense mechanisms

3. Effective communication between the nurse and patient The nurse helps the patient make the mental connection between the stressful event and the patient's reaction to it

A hospice program emphasizes: 1. Prolongation of life 2. Hospital-based care 3. Palliative treatment and control of symptoms 4. Curative treatment and alleviation of symptoms

3. Palliative treatment and control of symptoms Care of the terminally ill patient and his or her family

Research studies can most easily be identified by: 1. Examining the contents of the report 2. Looking for the study only in research journals 3. Reading the abstract and introduction of the report 4. Looking for the word research in the title of the report

3. Reading the abstract and introduction of the report Together, the abstract and introduction tell you if the topic of the article is similar to your PICO question or related closely enough to provide you with useful information.

When a patient-centered goal has not been met in the projected time frame, the most appropriate action by the nurse would be to: 1. Rewrite the plan using different interventions. 2. Continue with the same plan until the goal is met. 3. Repeat the entire sequence of the nursing process to discover needed changes. 4. Conclude that the goal was inappropriate or unrealistic and eliminate it from the plan.

3. Repeat the entire sequence of the nursing process to discover needed changes. If the goals have not been met, you may need to adjust the plan of care by the use of interventions, modify or add nursing diagnoses with appropriate goals and expected outcomes, and redefine priorities

Gathering, verifying and communicating data about the patient to establish a database is an example of which component of the nursing process? 1. planning 2. evaluation 3. assessment 4. implementation 5. nursing diagnosis

3. assessment

Mr. Davis tells the nurse that he has been experiencing more frequent episodes of indigestion. The nurse asks if the indigestion is associated with meals or a reclining position and asks what relieves the indigestion. This is an example of which interview technique? 1. direct question 2. problem solving 3. problem seeking 4. open-ended question

3. problem seeking

the planing step of the nursing process includes which of the following activities? 1. assessing and diagnosing 2. evaluating goal achievement 3. setting goals and selecting interventions 4. performing nursing actions and documenting them

3. setting goals and selecting interventions

The patient for whom you are caring needs a liver transplant to survive. This patient has been out of work for several months and doesn't have health insurance or enough cash. Even though several ethical principles are at work in this case, what are the principles from highest to lowest priority? 1. Accountability: You as the nurse are accountable for the wellbeing of this patient. 2. Respect for autonomy: This patient's autonomy will be violated if he does not receive the liver transplant. 3. Ethics of care: The caring thing that a nurse could provide this patient is resources for a liver transplant. 4. Justice: The greatest question in this situation is how to determine the just distribution of resources.

4, 2, 3, 1

Ethical dilemmas often arise over a conflict of opinion. Reliance on a predictable series of steps can help people in conflict find common ground. All of the following actions can help resolve conflict. What is the best order of these actions in order to promote the resolution of an ethical dilemma? 1. List the actions that could be taken to resolve the dilemma. 2. Agree on a statement of the problem or dilemma that you are trying to resolve. 3. Agree on a plan to evaluate the action over time. 4. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. 5. Take time to clarify values and distinguish between facts and opinions—your own and those of others involved. 6. Negotiate a plan.

4, 5, 2, 1, 6, 3

Which of the following is correctly charted according to the six guidelines for quality recording? 1. "Was depressed today." 2. "Respirations rapid; lung sounds clear." 3. "Had a good day. Up and about in room." 4. "Crying. States she doesn't want visitors to see her like this."

4. "Crying. States she doesn't want visitors to see her like this." When recording subjective data, document the patient's exact words within quotation marks whenever possible.

A student nurse practicing primary leadership skills would demonstrate all of the following except: 1. Being sensitive to the group's feelings 2. Recognizing others for their contributions 3. Developing listening skills and being aware of personal motivation 4. Assuming primary responsibility for planning, implementation, follow-up, and evaluation

4. 4. Assuming primary responsibility for planning, implementation, follow-up, and evaluation As a student nurse, you have a responsibility for the care given to your patients, and you assume accountability for that care.

In a situation in which there is insufficient staff to implement competent care, a nurse should: 1. Organize a strike 2. Refuse the assignment 3. Inform the patients of the situation 4. Accept the assignment but make a protest in writing to the administration

4. Accept the assignment but make a protest in writing to the administration Need to follow the institution's policies and procedures on how to handle these situations and use the chain of command

Nursing paradigm includes the following linkages; 1. Person 2. Health 3. Environment or situation 4. All of the above

4. All of the above Person: The recipient of nursing care, level of health, environment; all are possible causes

Health promotion programs are designed to help patients: 1. Reduce the incidence of disease 2. Maintain maximal function 3. Reduce the need to use more expensive health care services 4. All of the above

4. All of the above Reduce the incidence of disease, minimize complications, and reduce the need to use more expensive health care resources

The nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. In helping the parents resolve this ethical conflict, the nurse knows that the first step is: 1. Exploring reasonable courses of action 2. Identifying people who can solve the difficulty 3. Clarifying values related to the cause of the dilemma 4. Collecting all available information about the situation.

4. Collecting all available information about the situation. Incorporate as much information as possible from a variety of sources such as laboratory and test results; the clinical state of the patient; current literature about the condition; and the patient's religious, cultural, and family situation.

The primary purpose of a patient's medical record is to: 1. Provide validation for hospital charges. 2. Satisfy requirements of accreditation agencies. 3. Provide the nurse with a defense against malpractice. 4. Communicate accurate, timely information about the patient.

4. Communicate accurate, timely information about the patient. The patient's medical record should be the most current and accurate continuous source of information about the patient's health care status

A confused patient who fell out of bed because side rails were not used is an example of which type of liability? 1. Felony 2. Battery 3. Assault 4. Negligence

4. Negligence

Which statement about an institutional ethics committee is correct? 1. The ethics committee would be the first option in addressing an ethical dilemma. 2. The ethics committee replaces decision making by the patient and health care providers. 3. The ethics committee relieves health care professionals from dealing with ethical issues. 4. The ethics committee provides education, policy recommendations, and case consultation.

4. The ethics committee provides education, policy recommendations, and case consultation. The ethics committee is an additional resource for patients and health care professionals.

Which of the following is not true of standing orders? 1. Standing orders are commonly found in critical care and community health settings. 2. Standing orders are approved and signed by the health care provider in charge of care before implementation. 3. With standing orders, nurses have the legal protection to intervene appropriately in the patient's best interest. 4. With standing orders, the nurse relies on the health care provider's judgment to determine if the intervention is appropriate

4. With standing orders, the nurse relies on the health care provider's judgment to determine if the intervention is appropriate The nurse needs to exercise good judgment and decision making before actually delivering any interventions.

clinical decision making requires the nurse to: 1. improve a patient's health 2. standardize care for the patient 3. follow the health care provider's orders for patient care 4. establish and weigh criteria in deciding the best choice of therapy for a patient

4. establish and weigh criteria in deciding the best choice of therapy for a patient

the following statements appear on a nursing care plan for a patient after a mastectomy: "incision site approximated; absence of drainage or prolong erythema at incision site; and patient remains afebrile." these statements are examples of: 1. long-term goals 2. short-term goals 3. nursing diagnosis 4. expected outcomes

4. expected outcomes

the first part of the nursing diagnosis statement: 1. may be stated as a medical diagnosis 2. identifies the cause of the patient problem 3. identifies appropriate nursing intervention 4. identifies an actual or potential health problem

4. identifies an actual or potential health problem

Completing nursing actions necessary for accomplishing a care plan is an example of which component of the nursing process? 1. planning 2. evaluation 3. assessment 4. implementation 5. nursing diagnosis

4. implementation

a nursing diagnosis: 1. identifies nursing problems 2. is not changed during the course of a patient's hospitalization 3. is derived from the physician's history and physical examination 4. is a statement of a patient response to a health problem that requires nursing intervention

4. is a statement of a patient response to a health problem that requires nursing intervention

the second part of the nursing diagnosis statement: 1. is usually stated as a medical diagnosis 2. identifies the expected outcomes of nursing care 3. identifies the probable cause of the patient problem 4. is connected to the first part of the statement with the phrase "related to"

4. is connected to the first part of the statement with the phrase "related to"

a nurse ensures that each patient's room is clean;well ventilated; and free from clutter, excessive noise, and extremes in temperature. which theorist's work is the nurse practicing in this example? 1. henderson 2. orem 3. king 4. nightingale

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

the interview technique that is most effective in strengthening the nurse-patient relationship by demonstrating the nurses's willingness to hear the patients thoughts is: 1. direct question 2. problem solving 3. problem seeking 4. open-ended question

4. open-ended question

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A. "CPOE reduces transcription errors." B. "CPOE reduces the time needed for health care providers to write orders." C. "CPOE eliminates verbal and telephone orders from health care providers." D. "CPOE reduces the time nurses use to communicate with health care providers."

A. "CPOE reduces transcription errors."

The staff on the nursing unit are discussing implementing interprofessional rounding. Which of the following statements correctly describe interprofessional rounding? (Select all that apply.) A. Allows team members to share information about patients to improve care B. Provides an opportunity for early patient discharge planning C. Improves communication among health care team members D. Allows each of the health care team members to identify separate patient goals E. Allows each health care provider an opportunity to delegate a task.

A. Allows team members to share information about patients to improve care B. Provides an opportunity for early patient discharge planning C. Improves communication among health care team members

A health care provider writes the following order for an opioid-naive patient who returned from the operating room following a total hip replacement: "Fentanyl patch 100 mcg, change every 3 days." On the basis of this order, the nurse takes the following action: A. Calls the health care provider and questions the order B. Applies the patch the third postoperative day C. Applies the patch as soon as the patient reports pain D. Places the patch as close to the hip dressing as possible

A. Calls the health care provider and questions the order Fentanyl patches are not indicated for acute pain. They are indicated for patients with chronic pain who are opioid tolerant.

A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? (Select all that apply.) A. Checked the IV infusion rate B. Checked the type of IV solution C. Confirmed from nurses' notes the time of dressing change D. Inspected the condition of the IV dressing at the site E. Checked clarity of IV solution

A. Checked the IV infusion rate D. Inspected the condition of the IV dressing at the site The condition or status of the IV site is determined by checking the IV infusion rate and the condition of the IV site dressing. Checking the type of solution is important to ensure that correct therapy is being administered but is not a measure of the IV site condition. Confirming a dressing change or the appearance of the IV solution is not an indicator of the IV site status.

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) A. Checks scientific literature or policy and procedure Correct B. Reassesses the patient's condition Correct C. Collects all necessary equipment Correct D. Delegates the procedure to a more experienced nurse E. Considers all possible consequences of the procedure

A. Checks scientific literature or policy and procedure B. Reassesses the patient's condition C. Collects all necessary equipment E. Considers all possible consequences of the procedure

Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? A. Cognitive B. Interpersonal C. Psychomotor D. Consultative

A. Cognitive This is an example of a cognitive skill, being used before consultation. It involves critical thinking and decision making so the nurse is able to deliver a relevant nursing intervention.

A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of: A. Comparing outcome criteria with actual response. B. Gathering outcome criteria. C. Evaluating the patient's actual response. D. Reprioritizing interventions.

A. Comparing outcome criteria with actual response. The key to this question is observation for change. The nurse compares the patient's actual self-report rating of nausea with the expected outcome of a reduction in nausea. Gathering outcome criteria simply involves having the patient rate nausea. Evaluating the behavior or self-report is the determination of the patient's actual response.

Which of the following does a nurse perform when discontinuing a plan of care for a patient? A. Confirms with the patient that expected outcomes and goals have been met B. Talks with the patient about reprioritizing interventions in the plan of care C. Changes the frequency of interventions provided D. Reassesses how goals were met

A. Confirms with the patient that expected outcomes and goals have been met

Which factors influence a person's approach to death? (Select all that apply.) A. Culture B. Age C. Spirituality D. Personal beliefs E. Previous experiences with death F. Gender G. Level of education H. Degree of social support

A. Culture C. Spirituality D. Personal beliefs E. Previous experiences with death H. Degree of social support

A patient who is having difficulty managing his diabetes mellitus responds to the news that his hemoglobin A1C, a measure of blood sugar control over the past 90 days, has increased by saying, "The hemoglobin A1C is wrong. My blood sugar levels have been excellent for the last 6 months." Which defense mechanism is the patient using? A. Denial. B. Conversion. C. Dissociation. D. Displacement.

A. Denial.

The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student: (Select all that apply.) A. Documents a medication given by another nursing student. B. Includes the date and time of the entry into the medical record. C. Enters assessment data into the electronic medical record using the computer mounted on the wall in the patient's room. D. Leaves a slip of paper with her user name and password in the patient's room. E. Starts to enter "Docusate sodium 100 mg ordered at 08:00 held. Patient declined to take dose stating, "I had several loose stools yesterday, and I'm afraid if I take this dose the problem will get worse," as a narrative comment.

A. Documents a medication given by another nursing student. D. Leaves a slip of paper with her user name and password in the patient's room.

Which of the following statements correctly describes the evaluation process? (Select all that apply.) A. Evaluation is an ongoing process. B. Evaluation usually reveals obvious changes in patients. C. Evaluation involves making clinical decisions. D. Evaluation requires the use of assessment skills. E. Evaluation is only done when a patient's condition changes.

A. Evaluation is an ongoing process. C. Evaluation involves making clinical decisions. D. Evaluation requires the use of assessment skills.

A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of: A. Evaluative measures. B. Expected outcomes. C. Reassessments. D. Reflection

A. Evaluative measures. Auscultation of lung sounds and inspection of mucus after the intervention of suctioning are examples of evaluative measures. An outcome would be clear secretions or clear lung sounds. It is not a reassessment because the nurse has not yet compared findings with expected outcomes. Suctioning is a standard of care.

A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to perform evaluation: A. Examining results of clinical data B. Comparing achieved effects with outcomes C. Recognizing error D. Self-reflection

A. Examining results of clinical data Examination of the IV site is an example of examining results of clinical data. The nurse will next take the results of the examination and compare them to the norms for a normal IV site to decide if the outcome of maintaining a site free of infection is achieved. No errors were identified in this example, and the nurse is not self-reflecting.

A registered nurse (RN) is providing care to a patient who had abdominal surgery 2 days ago. Which task is appropriate to delegate to the nursing assistant? A. Helping the patient ambulate in the hall B. Changing surgical wound dressing C. Irrigating the nasogastric tube D. Providing brochures to the patient on health diet

A. Helping the patient ambulate in the hall Helping the patient with activity is within the scope of nursing assistive duties. The other activities require the skill and knowledge of the RN.

A staff nurse is talking with the nursing supervisor about the stress that she feels on the job. Which of the following are true about work-related stress? (Select all that apply.) A. Job-related stress can affect the quality of patient care. B. Stress can affect nurses' efficiency and decision making. C. Nurses who talk about feeling stress are unprofessional and should calm down. D. Nurses frequently experience stress with the rapid changes in health care technology. E. Nurses cannot resolve job-related stress.

A. Job-related stress can affect the quality of patient care. B. Stress can affect nurses' efficiency and decision making. D. Nurses frequently experience stress with the rapid changes in health care technology.

A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? (Select all that apply.) A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice C. Eliminates need to create an individualized care plan for the patient D. Delivers evidence-based interventions for stage II pressure ulcer E. Summarizes the various approaches used for the practice concern or problem

A. Makes it quicker and easier for nurses to intervene B. Sets a level of clinical excellence for practice D. Delivers evidence-based interventions for stage II pressure ulcer

A year after her husband's death, a widow visits the unit on which he died. She talks about the anniversary and how much she misses him. Which type of grief is she experiencing? A. Normal B. Complicated C. Chronic D. Disenfranchised

A. Normal It is normal for anniversaries to prompt feelings of sadness and grief.

Which of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? (Select all that apply.) A. Only the patient should push the button. B. Do not use the PCA until the pain is severe. C. The PCA system can set limits to prevent overdoses from occurring. D. Notify the nurse when the button is pushed. E. Do not push the button to go to sleep.

A. Only the patient should push the button. C. The PCA system can set limits to prevent overdoses from occurring. E. Do not push the button to go to sleep.

A patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? A. Patient's self-report B. Behaviors C. Surrogate (wife) report D. Vital sign changes

A. Patient's self-report Patient's self-report of pain. Sleep is not an indicator of pain intensity. Unless a patient is stimulated, it is difficult to distinguish sleep from sedation, which may occur as a side effect of the opioid. Patients in pain sometimes sleep from exhaustion.

To best assist a patient in the grieving process, which of the following is most helpful to determine? A. Previous experiences with grief and loss B. Religious affiliation and denomination C. Ethnic background and cultural practices D. Current financial status.

A. Previous experiences with grief and loss Previous experiences with loss and grief help individuals develop coping skills and set a pattern of response to future episodes of loss and grief.

When planning care for the dying patient, which interventions promote the patient's dignity? (Select all that apply.) A. Providing respect B. Viewing patients as a whole C. Providing symptom management D. Showing interest E. Being present F. Using a preferred name

A. Providing respect B. Viewing patients as a whole D. Showing interest E. Being present F. Using a preferred name

A nurse in a community health clinic has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self-management of asthma medications. Identify appropriate evaluative indicators for self-management for this patient. (Select all that apply.) A. Quality of life B. Patient satisfaction C. Use of clinic services D. Adherence to use of inhaler E. Description of side effects of medications

A. Quality of life C. Use of clinic services D. Adherence to use of inhaler

A crisis intervention nurse is working with a mother whose Down syndrome child has been hospitalized with pneumonia and who has lost her child's disability payment while the child is hospitalized. The mother worries that her daughter will fall behind in special-school classes during hospitalization. Which strategies are effective in helping this mother cope with these stressors? (Select all that apply.) A. Referral to social service process reestablishing the child's disability payment B. Sending the child home in 72 hours and having the child return to school C. Coordinating hospital-based and home-based schooling with the child's teacher D. Teaching the mother signs and symptoms of a respiratory tract infection E. Telling the mother that the stress will decrease in 6 weeks when everything is back to normal

A. Referral to social service process reestablishing the child's disability payment C. Coordinating hospital-based and home-based schooling with the child's teacher D. Teaching the mother signs and symptoms of a respiratory tract infection

When teaching a patient about the negative feedback response to stress, the nurse includes which of the following to describe the benefits of this stress response? A. Results in neurophysiological response B. Reduces body temperature C. Causes a person to be hypervigilant D. Reduces level of consciousness to conserve energy.

A. Results in neurophysiological response Negative feedback senses an abnormal state such as lowered body temperature and makes an adaptive response such as shivering to generate body heat to return the body to hormonal homeostasis.

A nurse asks a nursing assistive personnel (NAP) to help the patient in room 418 walk to the bathroom right now. The nurse tells the NAP that the patient needs the assistance of one person and the use of a walker. The nurse also tells the NAP that the patient's oxygen can be removed while he goes to the bathroom but to make sure that it is put back on at 2 L. The nurse also instructs the NAP to make sure the side rails are up and the bed alarm is reset after the patient gets back in bed. Which of the following components of the "Five Rights of Delegation" were used by the nurse? (Select all that apply.) A. Right task B. Right circumstances C. Right person D. Right direction/communication E. Right supervision/evaluation

A. Right task B. Right circumstances C. Right person D. Right direction/communication

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? (Select all that apply.) A. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. B. Determining what is the patient care technician's current workload. C. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. D. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. E. The nurse confers with another registered nurse about organizing priorities.

A. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. C. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. D. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure.

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

A. The nurse manager regularly rounds on staff to gather input on unit decisions. B. The nurse manager sends thank-you notes to staff in recognition of a job well done. D. The nurse manager has an "innovation idea box" to which staff are encouraged to submit ideas for unit improvements.

The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call? (Select all that apply.) A. The patient's name, age, and admitting diagnoses B. The discussion of any allergies to food and medications that the patient has C. That the nurse receiving the report was advised that the patient is "needy" and "on the call light all the time" D. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol E. Description of any unresolved problems and current interventions in place

A. The patient's name, age, and admitting diagnoses B. The discussion of any allergies to food and medications that the patient has D. That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol E. Description of any unresolved problems and current interventions in place

A postoperative patient currently is asleep. Therefore the nurse knows that: A. The sedative administered may have helped him sleep, but it is still necessary to assess pain. B. The intravenous (IV) pain medication given in recovery is relieving his pain effectively. C. Pain assessment is not necessary. D. The patient can be switched to the same amount of medication by the oral route.

A. The sedative administered may have helped him sleep, but it is still necessary to assess pain.

A grieving patient complains of confusion, inability to concentrate, and insomnia. What do these symptoms indicate? A. These are normal symptoms of grief. B. There is a need for pharmacological support for insomnia. C. The patient is experiencing complicated grief. D. These are common complaints of the admitted patient.

A. These are normal symptoms of grief. Symptoms of normal grief include a variety of feelings, thought patterns, physical sensations, and behaviors.

Purposes of the Nursing Outcomes Classification (NOC) include which of the following? (Select all that apply.) A. To identify and label nurse-sensitive patient outcomes B. To test the classification in clinical settings C. To establish health care reimbursement guidelines Incorrect D. To identify nursing interventions for linked nursing diagnoses E. To define measurement procedures for outcomes

A. To identify and label nurse-sensitive patient outcomes B. To test the classification in clinical settings E. To define measurement procedures for outcomes The NOC classification offers a language for the evaluation step of the nursing process. The purposes of NOC are to (1) identify, label, validate, and classify nurse-sensitive patient outcomes; (2) field test and validate the classification; and (3) define and test measurement procedures for the outcomes and indicators using clinical data.

A patient has returned from the operating room, recovering from repair of a fractured elbow, and states that her pain level is 6 on a 0-to-10 pain scale. She received a dose of hydromorphone just 15 minutes ago. Which interventions may be beneficial for this patient at this time? (Select all that apply.) A. Transcutaneous electrical nerve stimulation (TENS) B. Administer naloxone (Narcan) 2 mg intravenously C. Provide back massage D. Reposition the patient E. Withhold any pain medication and tell the patient that she is at risk for addiction

A. Transcutaneous electrical nerve stimulation (TENS) C. Provide back massage D. Reposition the patient

What are the physical changes that occur as death approaches? (Select all that apply.) A. Unresponsiveness B. Erythema C. Mottling D. Restlessness E. Increased urine output F. Weakness G. Incontinence

A. Unresponsiveness C. Mottling D. Restlessness F. Weakness G. Incontinence

While caring for a patient with cancer pain, the nurse knows that a multimodal analgesia plan includes: (Select all that apply.) A. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. B. Stopping acetaminophen when the pain becomes very severe. C. Avoiding polypharmacy by limiting the use of medication to one agent at a time. D. Avoiding total sedation, regardless of the severity of the pain. E. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.

A. Using analgesics such as nonsteroidal antiinflammatory drugs (NSAIDs) along with opioids. E. The use of adjuvants (co-analgesics) such as gabapentin (Neurontin) to manage neuropathic type pain.

During the assessment interview of an older woman who is recently widowed, the nurse suspects that this woman is experiencing a developmental crisis. Which of the following questions provide information about the impact of this crisis? (Select all that apply.) A. With whom do you talk on a routine basis? B. What do you do when you feel lonely? C. How is having diabetes affecting your life? D. I know this must be hard for you. Let me tell you what might help. E. Do you have any changes in lifestyle habits: sleeping, eating, smoking, and drinking?

A. With whom do you talk on a routine basis? B. What do you do when you feel lonely? E. Do you have any changes in lifestyle habits: sleeping, eating, smoking, and drinking?

Nursing theories provide nurses with perspectives from which to: A. analyze patient data B. predict phenomena C. formulate legislation D. link science to nursing

A. analyze patient data

You have finished with several nursing interventions. To evaluate interventions, you need to examine the: A. appropriateness of the interventions and the correct application of the implementation process. B. nursing diagnoses to ensure that they are not medical diagnoses. C. care planning process for errors in other health care team members' judgments. D. interventions of each nurse to enable the nurse manager to correctly evaluate performance.

A. appropriateness of the interventions and the correct application of the implementation process. Rationale: When evaluating, the nurse needs to look at the patient's condition, the interventions used to improve the patient's status, and whether or not they were appropriate.

For a student to avoid a data collection error, the student should: A. assess the patient and, if unsure of the finding, ask a faculty member to assess the patient. B. review his or her own comfort level and competency with assessment skills. C. ask another student to perform the assessment. D. consider whether the diagnosis should be actual, potential, or risk.

A. assess the patient and, if unsure of the finding, ask a faculty member to assess the patient. Rationale: Data collection is an art that the nurse gets better at with experience, so asking for assistance from a colleague to help with an unsure finding can ensure that the diagnostic statement is correct.

Nurse-initiated interventions are A. determined by state Nurse Practice Acts. B. supervised by the entire health care team. C. made in concert with the plan of care initiated by the physician. D. developed after interventions for the recent medical diagnoses are evaluated.

A. determined by state Nurse Practice Acts. Rationale: Individual nurse practice acts determine nurse-initiated interventions.

Information regarding a patient's health status may not be released to non-health care team members because: A. legal and ethical obligations require health care providers to keep information strictly confidential. B. regulations require health care institutions to document evidence of physical and emotional well-being. C. reimbursement issues related to patient care and procedures may be of concern. D. fragmentation of nursing and medical care procedures may be identified.

A. legal and ethical obligations require health care providers to keep information strictly confidential.

A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when: A. you compare assessed pain w/baseline pain. B. body language is incongruent with reports of pain relief. C. family members report that pain has subsided. D. vital signs have returned to baseline.

A. you compare assessed pain w/baseline pain.

A patient asks a nurse what the patient-centered care model for the hospital means. What is the nurse's best answer? A. "This model ensures that all patients have private rooms when they are admitted to the hospital." B. "In this model you and the health care team are full partners in decisions related to your health care." C. "This model focuses on making the patient experience a good one by providing amenities such as restaurant-style food service." D. "Patients and families sign a document providing them full access to their medical charts."

B. "In this model you and the health care team are full partners in decisions related to your health care." Patient- and family-centered care is based on the development of mutual partnerships among the patient, family, and health care team to plan, implement, and evaluate the patient's health care. The patient and the family are at the center of the care and are full partners in decision making.

A patient states, "I would like to see what is written in my medical record." What is the nurse's best response? A. "Only your family can read your medical record." B. "You have the right to read your record." C. "Patients are not allowed to read their records." D. "Only health care workers have access to patient records."

B. "You have the right to read your record."

As a nurse, you are assigned to four patients. Which patient do you need to see first? A. The patient who had abdominal surgery 2 days ago who is requesting pain medication B. A patient admitted yesterday with atrial fibrillation with decreased level of consciousness C. A patient with a wound drain who needs teaching before discharge in the early afternoon D. A patient going to surgery for a mastectomy in 3 hours who has a question about the surgery

B. A patient admitted yesterday with atrial fibrillation with decreased level of consciousness This patient is of high priority. The patient is experiencing the physiological problem of decreased level of consciousness, which is an immediate threat to his or her survival and safety. The nurse must intervene promptly and notify the health care provider of the life-threatening problem.

Which of the following is the best intervention to help a hospitalized patient maintain some autonomy? A. Use therapeutic techniques when communicating with the patient. B. Allow the patient to determine timing and scheduling of interventions. C. Encourage family to only visit for short periods of time. D. Provide the patient with a private room close to the nurse's station.

B. Allow the patient to determine timing and scheduling of interventions. Providing the opportunity for patients to have control of decisions concerning care allows them to maintain autonomy and dignity.

A family member of a dying patient talks casually with the nurse and expresses relief that she will not have to visit at the hospital anymore. Which theoretical description of grief best applies to this family member? A. Denial B. Anticipatory grief C. Yearning and searching D. Dysfunctional grief

B. Anticipatory grief Family members often grieve the impending loss of companionship, control, and sense of freedom and the mental and physical changes to be experienced by their loved one. Ultimately they grieve the impending death.

A faculty member is reviewing a nursing student's plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional website to identify interventions successful in reducing wandering in patients with dementia. The faculty member should evaluate which of the following? (Select all that apply.) A. Number of interventions B. Appropriateness of the intervention for the patient C. The prior use of interventions by other nursing staff D. Correct application of the intervention for the patient care setting E. The time it takes to provide interventions

B. Appropriateness of the intervention for the patient D. Correct application of the intervention for the patient care setting

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

B. Feedback focuses on one issue. C. Feedback offers concrete details. D. Feedback identifies ways to improve. E. Feedback focuses on changeable things.

A patient with type 2 diabetes is experiencing a lot of work-related stress and is fearful of losing his job. In addition, his wife is threatening divorce. His blood sugar is elevating, and his doctors want him to attend some stress-management classes. He says, "My blood sugar can't be high because of my work stress." What causes blood glucose to rise during stress? (Select all that apply.) A. Increases in antidiuretic hormone (ADH) B. Increases in cortisol C. Increases in aldosterone D. Increases in adrenocorticotropic hormone (ACTH) E. Increases in epinephrine

B. Increases in cortisol D. Increases in adrenocorticotropic hormone (ACTH) E. Increases in epinephrine

A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.) A. Reviewing the family caregiver's availability during medication administration times B. Making a judgment of the value of improved adherence for the patient C. Reviewing the number of medications and time each is to be taken D. Determining all consequences associated with the patient missing specific medicines E. Reviewing the therapeutic actions of the medications

B. Making a judgment of the value of improved adherence for the patient D. Determining all consequences associated with the patient missing specific medicines

Which of the following are components of interprofessional collaboration? (Select all that apply.) A. Interprofessional education does not impact the collaboration among interprofessional team members. B. Nurses are often viewed as the team leader because of their coordination of patient care. C. Effective interprofessional collaboration requires mutual respect and trust from all team members. D. Open communication improves the collaboration among the interprofessional team members. E. The goal of interprofessional collaboration is to improve the quality of patient care.

B. Nurses are often viewed as the team leader because of their coordination of patient care. C. Effective interprofessional collaboration requires mutual respect and trust from all team members. D. Open communication improves the collaboration among the interprofessional team members. E. The goal of interprofessional collaboration is to improve the quality of patient care.

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks if the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) A. Palliative care and hospice are the same thing. B. Palliative care is for any patient, any time, any disease, in any setting. C. Palliative care strategies are primarily designed to treat the patient's illness. D. Palliative care relieves the symptoms of illness and treatment. E. Palliative care selects home health care services.

B. Palliative care is for any patient, any time, any disease, in any setting. D. Palliative care relieves the symptoms of illness and treatment.

When a smiling and cooperative patient complains of discomfort, nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true? A. Chronic pain is psychological in nature. B. Patients are the best judges of their pain. C. Regular use of narcotic analgesics leads to drug addiction. D. Amount of pain is reflective of actual tissue damage.

B. Patients are the best judges of their pain.

When providing postmortem care, which action is a priority for the nurse? A. Locating the patient's clothing B. Providing culturally and religiously sensitive care in body preparation C. Transporting the body to the morgue as soon as possible D. Providing postmortem care to protect the family of the deceased from having to view the body

B. Providing culturally and religiously sensitive care in body preparation Various cultures and religions have specific postmortem care practices. Honoring these practices is important for the family as they prepare to mourn their loved one.

A patient with a 3-day history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The patient has been taking hydrocodone/APAP 5/325 up to four tablets/day before her stroke for arthritic pain. The health care provider's order reads as follows: "Hydrocodone/APAP 5/325 1 tab, per gastrostomy tube, q4h, prn." Which action by the nurse is most appropriate? A. No action is required by the nurse because the order is appropriate. B. Request to have the order changed to around the clock (ATC) for the first 48 hours. C. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. D. Begin the hydrocodone/APAP when the patient shows nonverbal symptoms of pain.

B. Request to have the order changed to around the clock (ATC) for the first 48 hours. The patient can be expected to have acute pain related to the G-tube insertion; in addition, she has a history of chronic pain. Her pain should be treated with ATC medication to match the timing of her pain.

A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the patient's plan of care. In which ways can the nurse develop trust with members of the conference team? (Select all that apply.) A. Is willing to challenge other members' ideas because the nurse disagrees with their rationale B. Shows competence in how to monitor patients' clinical status and inform the physician of critical changes C. Asks a more experienced nurse to attend the conference D. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly E. During the meeting focus on similar problems the nurse has had in delivering care to other patients.

B. Shows competence in how to monitor patients' clinical status and inform the physician of critical changes D. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly

While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is "WDL" (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this? A. The nurse caring for the patient forgot to document on the pulmonary system. B. The EMR uses a charting-by-exception format. C. The computer shut down unexpectedly when the nurse was documenting the assessment. D. Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.

B. The EMR uses a charting-by-exception format.

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

B. The call to the ostomy and wound care specialist is an indirect care measure. C. The cleansing of the skin is a direct care measure.

A new medical resident writes an order for oxycodone CR (Oxy Contin) 10 mg PO q2h prn. Which part of the order does the nurse question? A. The drug B. The time interval C. The dose D. The route

B. The time interval Long-acting or sustained-release opioids are dosed on a scheduled basis, not prn, to provide a base of continuous opioid analgesia.

You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: A. an increased appetite. B. an increased heart rate. C. a decrease in perspiration. D. a decrease in respiratory rate.

B. an increased heart rate.

A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills, she needs to: A. assign only bed-making and feeding skills. B. assess the knowledge of the certified nursing assistant. C. remind the staff member that she is working under the license of the RN. D. allow the staff member to perform only skills that the RN is able to teach certified nursing assistants to perform.

B. assess the knowledge of the certified nursing assistant. Rationale: The reason for ascertaining the nursing assistant's knowledge and skills is because the nurse does not want to delegate tasks that the assistant may not be able to do, thus, putting the patient's care in jeopardy.

A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of: A. evaluation. B. data collection. C. problem identification. D. testing a hypothesis.

B. data collection. Rationale: Assessment is the first stage of the nursing process, and is the process of gathering data to formulate the nursing diagnosis and care plan.

Nursing process is central to nursing practice. Nursing practice: A. is a theory B. derived from a theory C. is not adaptable to all patients D. generates knowledge for use in practice

B. derived from a theory

Your patient has met the goals set for improvement of ambulatory status. You would now: A. modify the care plan. B. discontinue the care plan. C. create a new nursing diagnosis that states goals have been met. D. reassess the patient's response to care and evaluate the implementation step of the nursing process.

B. discontinue the care plan. Rationale: When goals are met, the care plan for that goal is discontinued.

The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done: A. logically. B. haphazardly. C. independently. D. systematically.

B. haphazardly. Rationale: Critical thinking should be done using a systematic approach, using knowledge and experience to formulate an opinion.

You are about to administer an oral medication and you question the dosage. You should: A. administer the medication. B. notify the physician. C. withhold the medication. D. document that the dosage appears incorrect.

B. notify the physician. Rationale: If you find one to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and you still believe that it is inappropriate, use the agency chain of command to inform your direct supervisor.

A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record: A. an interpretation of patient behavior. B. objective data that are observed. C. lengthy entry using lay terminology. D. abbreviations familiar to the nurse.

B. objective data that are observed.

A travel nurse has taken an assignment at a health care facility where nurses assume responsibility for a caseload of patients over a period of time. This type of nursing exemplifies: A. team nursing. B. primary nursing. C. functional nursing. D. decentralized management.

B. primary nursing. Rationale: The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. Primary nursing supports a philosophy regarding nurse and patient relationships.

A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as: A. maturational. B. situational. C. sociocultural. D. posttraumatic.

B. situational. Rationale: External sources such as a job change, a motor vehicle crash, a death, or severe illness provoke situational crises.

A patient is suffering from shortness of breath. The correct goal statement would be written as: A. the patient will be comfortable by the morning. B. the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. C. the patient will not complain of breathing problems within the next 8 hours. D. the patient will have a respiratory rate of 14 to 18 breaths per minute.

B. the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift.

The nurse is evaluating the coping success of a patient experiencing stress from being newly diagnosed with multiple sclerosis and psychomotor impairment. Which of the following statements indicate that the patient is beginning to cope with the diagnosis? (Select all that apply.) A. "I'm going to learn to drive a car so I can be more independent." Incorrect B. "My sister says she feels better when she goes shopping, so I'll go shopping." C. "I'm going to let the occupational therapist assess my home to improve efficiency." D. "I've always felt better when I go for a long walk. I'll do that when I get home." E. "I'm going to attend a support group to learn more about multiple sclerosis."

C. "I'm going to let the occupational therapist assess my home to improve efficiency." E. "I'm going to attend a support group to learn more about multiple sclerosis."

Which comment to a patient by a new nurse regarding palliative care needs to be corrected? A. "Even though you're continuing treatment, palliative care is something we might want to talk about." B. "Palliative care is appropriate for people with any diagnosis." C. "Only people who are dying can receive palliative care." D. "Children are able to receive palliative care."

C. "Only people who are dying can receive palliative care." Palliative care is available to all patients regardless of age, diagnosis, and prognosis.

While administering medications, a nurse realizes that a prescribed dose of a medication was not given. The nurse acts by completing an incident report and notifying the patient's health care provider. The nurse is exercising: A. Authority. B. Responsibility. C. Accountability. D. Decision making.

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

Which example demonstrates a nurse performing the skill of evaluation? A. The nurse explains the side effects of the new blood pressure medication ordered for the patient. B. The nurse asks a patient to rate pain on a scale of 0 to 10 before administering the pain medication. C. After completing the teaching, the nurse observes a patient draw up and administer an insulin injection. D. The nurse changes a patient's leg ulcer dressing using aseptic technique.

C. After completing the teaching, the nurse observes a patient draw up and administer an insulin injection.

A grandfather living in Japan worries about his two young grandsons who disappeared after a tsunami. This is an example of: A. A situational crisis. B. A maturational crisis. C. An adventitious crisis. D. A developmental crisis.

C. An adventitious crisis. An adventitious crisis is a type of crisis resulting from a natural disaster such as a tsunami.

The nurse is interviewing a patient in the community clinic and gathers the following information about her: she is intermittently homeless, a single parent with two children who have developmental delays, and is suffering from chronic asthma. She does not laugh or smile, does not volunteer any information, and at times appears close to tears. She has no support system and does not work. She is experiencing an allostatic load. As a result, which of the following would be present during complete patient assessment? (Select all that apply.) A. Posttraumatic stress disorder B. Rising hormone levels C. Chronic illness D. Return of vital signs to normal E. Depression

C. Chronic illness E. Depression

The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system? A. Electronic health record B. Clinical documentation C. Clinical decision support system D. Computerized physician order entry

C. Clinical decision support system

What is the palliative care team's primary obligation for the patient with severe pain? A. Providing postmortem care. B. Teaching about grief stages. C. Enhancing the patient's quality of life. D. Supporting the family after the death.

C. Enhancing the patient's quality of life. Palliative care focuses on enhancing the patient's quality of life.

A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse: A. Reads the orders back to the health care provider to verify accuracy of transcribing the orders after receiving them over the phone. B. Documents the date and time of the phone conversation, the name of the physician, and the topics discussed in the electronic record. C. Gives a newly ordered medication before entering the order in the patient's medical record. D. Asks the preceptor to listen in on the phone conversation.

C. Gives a newly ordered medication before entering the order in the patient's medical record. When provider orders for new medication(s) are entered into an electronic medical record, the new orders are available to pharmacists using the same electronic system within the hospital. To improve patient safety, many hospitals have a policy that new medications are not to be administered (unless in an emergency) until a pharmacist reviews the new order(s) and verifies that there are no documented allergies to the medications, the ordered dose(s) are appropriate, and there are no potential medication interactions with medications already ordered for a patient. Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.

The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response? A. HIPAA allows all hospital staff access to your medical record. B. HIPAA limits the information that is documented in your medical record. C. HIPAA provides you with greater protection of your personal health information. D. HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

C. HIPAA provides you with greater protection of your personal health information.

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? A. Knowing the source of the guideline B. Reviewing the evidence used to develop the guideline C. Individualizing how to apply the clinical guideline for a patient D. Explaining to a patient the purpose of the guideline

C. Individualizing how to apply the clinical guideline for a patient Individualizing patient care is still the important principle for implementing care, even when a clinical guideline is used. Explaining any interventions in a guideline to the patient is important but not the most critical factor in implementing care. Reviewing the source of the guideline and applicable evidence do not directly benefit a patient.

A nurse is teaching a patient about wound care that will need to be done daily at home after the patient is discharged. This is which priority nursing need for this patient? A. Low priority B. High priority C. Intermediate priority D. Nonemergency priority

C. Intermediate priority Teaching patients wound care for discharge is an intermediate priority. Intermediate priorities are nonemergency, nonlife-threatening, actual or potential needs that the patient and family members are experiencing.

What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? A. Measures a nurse's competency in interdisciplinary care B. Measures the number of adverse events in a hospital C. Measures quality of care within hospitals D. Measures referrals to a health care agency

C. Measures quality of care within hospitals HCAHPS is a survey that has become a standard for measuring and comparing quality of hospitals. It is a survey of patient perceptions.

A young mother is dying of breast cancer with bone metastasis and tells the nurse, "My body hurts so much. I can hardly move. Why is God making me suffer when I have done nothing bad in my life? I feel like giving up. How can I care for my children when I can't even care for myself?" What is the most appropriate nursing diagnosis for this patient? A. Spiritual Distress related to questioning God B. Hopelessness related to terminal diagnosis C. Pain related to disease process D. Anticipatory Grief related to impending death

C. Pain related to disease process Pain control is always the priority.

For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome? (Select all that apply.) A. Nurse provides four teaching sessions before discharge. B. Patient denies joint pain following heat application. C. Patient describes correct schedule for taking antiarthritic medications. D. Patient explains situations for using heat application on inflamed joints. E. Patient explains role family caregiver plays in applying heat to inflamed joint.

C. Patient describes correct schedule for taking antiarthritic medications. D. Patient explains situations for using heat application on inflamed joints.

What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record? A. Rip the papers up into small pieces and place the pieces into a standard trash can B. Place all papers in the flip-top binder designated for that patient that is located in the nurse's station on the patient care unit C. Place papers with patient information in a secure canister marked for shredding D. Burn documents with patient information in the steel sink located within the dirty supply room on the patient care unit

C. Place papers with patient information in a secure canister marked for shredding

Consultation occurs most often during which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation

C. Planning Rationale: When a nurse is unsure of how to proceed in the planning process, he or she will seek out another colleague's knowledge and experience to assist in planning interventions for the patient.

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? A. Opioid antagonists B. Antiemetics C. Stool softeners D. Muscle relaxants

C. Stool softeners Constipation is a common opioid-related side effect, and patients do not become tolerant to it.

The nurse reviews a patient's medical administration record (MAR) and finds that the patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? A. The patient's level of pain B. The potential for addiction C. The amount of daily acetaminophen D. The risk for gastrointestinal bleeding

C. The amount of daily acetaminophen The Food and Drug Administration (FDA) recommends a maximum daily dose of 4 g of acetaminophen, and many authorities believe that the maximum daily dose should be lower (3000 to 3200 mg/day) in the outpatient setting to reduce the risk of hepatotoxicity.

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

C. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" Evaluating patient expectations of care involves measuring his or her perceptions of care (e.g., if this particular patient thinks that he or she had received sufficient information).

The nursing process organizes your approach to delivering nursing care. To provide care to your patients, you will need to incorporate nursing process and: A. decision making. B. problem solving. C. interview process. D. intellectual standards.

C. interview process. Rationale: The interview process is an integral part of patient-centered care, and is continuous throughout patient interaction, regardless of the stage of the nursing process.

A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of: A. PIE documentation. B. SOAP documentation. C. narrative charting. D. charting by exception.

C. narrative charting.

Which of the following documentation entries is most accurate? A. "Patient walked up and down hallway with assistance, tolerated well." B. "Patient up, out of bed, walked down hallway and back to room, tolerated well." C. "Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk." D. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

D. "Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient? A. "The patient has a defiant attitude and is demanding test results." B. "The patient appears to be upset with the nurse because he wants his test results immediately." C. "The patient is demanding and is complaining about the doctor." D. "The patient stated feelings of frustration from the lack of information received regarding test results."

D. "The patient stated feelings of frustration from the lack of information received regarding test results."

A 34-year-old single father who is anxious, tearful, and tired from caring for his three young children tells the nurse that he feels depressed and doesn't see how he can go on much longer. Which of the following would be the nurse's best response? A. "Are you thinking of suicide?" B. "You've been doing a good job raising your children. You can do it!" C. "Is there someone who can help you during the evenings and weekends?" D. "What do you mean when you say you can't go on any longer?"

D. "What do you mean when you say you can't go on any longer?"

After a health care provider has informed a patient that he has colon cancer, the nurse enters the room to find the patient gazing out the window in thought. Which of the following are appropriate responses or actions of the nurse? (Select all that apply.) A. "I know another patient whose colon cancer was cured by surgery." B. Straighten the patient's bed and room C. "Have you thought about how you are going to tell your family?" D. "Would you like for me to sit down with you for a few minutes so you can talk about this?" E. Sit quietly with the patient

D. "Would you like for me to sit down with you for a few minutes so you can talk about this?" E. Sit quietly with the patient

A nurse assesses patients and uses assessment findings to identify patient problems and develop an individualized plan of care. The nurse is displaying: A. Organizational skills. B. Use of resources. C. Priority setting. D. Clinical decision making.

D. Clinical decision making.

Technological advances in health care A. Make the nurse's job easier. B. Depersonalize bedside patient care. C. Threaten the integrity of the health care industry. D. Do not replace sound personal judgment

D. Do not replace sound personal judgment

A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information? A. "Avoid rushing when documenting an entry in the medical record." B. "Use correction fluid to remove the entry." C. "Draw a single line through the statement and initial it." D. Enter only objective and factual information about a patient in the medical record.

D. Enter only objective and factual information about a patient in the medical record. Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.

Which task is appropriate for a registered nurse (RN) to delegate to a nursing assistant? A. Explaining to the patient the preoperative preparation before the surgery in the morning B. Administering the ordered antibiotic to the patient before surgery C. Obtaining the patient's signature on the surgical informed consent D. Helping the patient to the bathroom before leaving for the operating room

D. Helping the patient to the bathroom before leaving for the operating room Assisting the patient with toileting activities is within the scope of nursing assistive duties. The other activities require the skill and knowledge of the RN.

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: A. Opioid toxicity. B. Opioid tolerance. C. Opioid addiction. D. Opioid withdrawal.

D. Opioid withdrawal. The common symptoms of opioid withdrawal that are associated with physical dependence may develop when an opioid is withdrawn rapidly. Symptoms include shaking chills, abdominal cramps, and joint pain.

A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be: A. adjunctive therapy. B. nonopioids. C. NSAIDs. D. PCA pain management.

D. PCA pain management.

A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit? A. Environment B. Personnel C. Equipment D. Patient

D. Patient In preparing to administer the enema, the nurse did not prepare for the patient's physical and psychological comfort.

After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with diabetes. The nurse's behavior is an example of which of the following? A. Reflection-in-action B. Reassessment C. Reprioritizing D. Reflection-on-action

D. Reflection-on-action The nurse is performing reflection-on-action. This means that when you gather evaluative measures about a patient, reflection on the findings and the exploration about what the findings might mean improve your ability to problem solve. The other three measures occur during evaluation because the nurse is still actively intervening in the patient's care.

The nurse plans care for a 16-year-old male, taking into consideration that stressors experienced most commonly by adolescents include which of the following? A. Loss of autonomy caused by health problems B. Physical appearance, family, friends, and school C. Self-esteem issues, changing family structure D. Search for identity with peer groups and separation from family

D. Search for identity with peer groups and separation from family

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? A. TENS works by causing distraction. B. TENS therapy does not require a health care provider's order. C. TENS requires an electrical source for use. D. TENS electrodes are applied near or directly on the site of pain.

D. TENS electrodes are applied near or directly on the site of pain. TENS units act on both the central and peripheral nervous systems. The peripheral effect occurs through activation of the neuroreceptors at or near the source of pain; therefore the electrodes should be placed near the site.

You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient up for a bath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June 5.

D. The patient will identify the need to increase dietary intake of fiber by June 5. Rationale: Outcome statements should have measurable and realistic goals. In this case, the goal is both measurable (will identify the need to increase dietary intake by June 5) and realistic.

A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss: A. living wills. B. assisted suicide. C. passive euthanasia. D. advance directives.

D. advance directives. Rationale: Advance directives are written documents that outlay the patient's wishes, should he or she become incapacitated.

A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to: A. exchange information among health care members. B. provide information about patients from one unit to another unit. C. ensure proper care for the patient. D. aid in the hospital's quality improvement program.

D. aid in the hospital's quality improvement program.

The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate nursing process and: A. decision making. B. problem solving. C. intellectual standards. D. critical thinking skills.

D. critical thinking skills. Rationale: The nursing process and critical thinking go hand-in-hand in providing patient-centered care. The nursing process cannot be completed without critical thinking in forming nursing diagnoses, setting goals, interventions, and evaluation.

As a first-year nursing student, you are assigned to care for a dying patient. To best prepare you for this assignment, you will want to: A. complete a course on death and dying. B. control your emotions about death and dying. C. compare this experience to the death of a family member. D. develop a personal understanding of your own feelings about grief and death.

D. develop a personal understanding of your own feelings about grief and death. Rationale: The nurse cannot provide patient-centered nursing if the nurse does not understand his or her own feelings about death and dying.

You are caring for a patient who is depressed because the only child has gone away to college. The nurse will assess this type of depression as: A. actual loss. B. perceived loss. C. situational loss. D. maturational loss.

D. maturational loss. Rationale: When life keeps moving, such as kids growing up and moving away, it is considered maturational loss.

Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient's only treatment choice. This example describes the ethical principle of: A. autonomy. B. fidelity. C. justice. D. nonmaleficence.

D. nonmaleficence Rationale: Sometimes to improve a patient's condition, it is necessary to perform a procedure that will cause pain for the patient. The nurse must weigh the benefits and the risks with the patient in his or her quest to do no harm.

Concept mapping is one way to: A. connect concepts to a central subject. B. relate ideas to patient health problems. C. challenge a nurse's thinking about patient needs and problems. D. graphically display ideas by organizing data. E. all of the above.

E. all of the above. Rationale: Concept mapping helps the busy nurse, with numerous patients, focus on healing patients on an individual basis.

A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.) a. Assess condition of skin before making the call b. Rely on the nurse specialist to know the type of surgery the patient likely had c. Explain the patient's response emotionally to the repeated leaking of stool d. Describe the type of bag being used and how long it lasts before leaking e. Order extra colostomy bags currently being used

a. Assess condition of skin before making the call c. Explain the patient's response emotionally to the repeated leaking of stool d. Describe the type of bag being used and how long it lasts before leaking

neuman a. Based on the theory that focuses on wellness and prevention of disease. b. Based on the belief that people who participate in self-care activities are more likely to improve their health outcomes. c. Based on 14 activities, the nurse should assist patients with meeting needs until they are able to do so independently. d. Based on the belief that nurses should work with patients to develop goals for care.

a. Based on the theory that focuses on wellness and prevention of disease.

Nurses have developed theories in response to: (Select all that apply.) a. Changes in health care b. Prior nursing theories c. Changes in nursing practice d. Research findings e. Government regulations f. Theories from other disciplines g. physicians opinions

a. Changes in health care b. Prior nursing theories c. Changes in nursing practice d. Research findings f. Theories from other disciplines Nursing theories often build on the works of prior theories from nursing and other disciplines. As nursing education has expanded, so has the practice of nursing in response to changes in society and health care. In addition, nursing research, which serves as the foundation for evidence-based practice, has increased.

Which of the following examples are steps of nursing assessment? (Select all that apply.) a. Collection of information from patient's family members b. Recognition that further observations are needed to clarify information c. Comparison of data with another source to determine data accuracy d. Complete documentation of observational information e. Determining which medications to administer based on a patient's assessment data

a. Collection of information from patient's family members b. Recognition that further observations are needed to clarify information c. Comparison of data with another source to determine data accuracy

A nurse on a busy medicine unit is assigned to four patients. It is 10 am. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth patient requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the patient group? (Select all that apply.) a. Consider availability of assistive personnel to obtain the specimen b. Combine activities to resolve more than one patient problem c. Analyze the diagnoses/problems and decide which are most urgent based on patients' needs d. plan a family conference for tomorrow to make decisions about resources the patient will need to go home e. Identify the nursing diagnoses for the patient going home

a. Consider availability of assistive personnel to obtain the specimen b. Combine activities to resolve more than one patient problem c. Analyze the diagnoses/problems and decide which are most urgent based on patients' needs

A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.) a. Data collection. b. Data clustering. c. Data interpretation. d. Making a diagnostic statement. e. Goal setting

a. Data collection. c. Data interpretation.

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.) a. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs b. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves c. Helps nurses focus on the scope of nursing practice d. Creates practice guidelines for collaborative health care activities e. Builds and expands nursing knowledge

a. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs c. Helps nurses focus on the scope of nursing practice e. Builds and expands nursing knowledge

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? a. Engage the patient in setting mutual outcomes for distance he is able to walk b. Confirm with the patient's health care provider about ambulation goals c. Have physical therapy assist with ambulation d. Refer to medical record regarding nature of patient's physical problem

a. Engage the patient in setting mutual outcomes for distance he is able to walk

A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.) a. How is your diabetic diet affecting you and your family? b. You seem to not want to follow health guidelines. Can you explain why? c. What worries you the most about having diabetes? d. What do you expect from us when you do not take your insulin as instructed? e. What do you believe will help you control your blood sugar?

a. How is your diabetic diet affecting you and your family? c. What worries you the most about having diabetes? e. What do you believe will help you control your blood sugar?

Which of the following describes a nurse's application of a specific knowledge base during critical thinking? (Select all that apply.) a. Initiative in reading current evidence from the literature b. Application of nursing theory c.Reviewing policy and procedure manual d. Considering holistic view of patient needs e.Previous time caring for a specific group of patients

a. Initiative in reading current evidence from the literature b. Application of nursing theory d. Considering holistic view of patient needs

The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.) a. Listen attentively to the patient's story. b. Use gestures that reinforce your questions or comments. c. Stand back away from the bedside. d. Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue.

a. Listen attentively to the patient's story b. Use gestures that reinforce your questions or comments. d. Maintain direct eye contact. Ask questions quickly to reduce the patient's fatigue.

which of the following statements related to theory-based nursing practice are correct? (select all that apply) a. Nursing theory differentiates nursing from other disciplines. b. Nursing theories are standardized and do not change over time. c. Integrating theory into practice promotes coordinated care delivery. d. Nursing knowledge is generated by theory. e. The theory of nursing process is used in planning patient care. f. Evidence-based practice results from theory-testing research.

a. Nursing theory differentiates nursing from other disciplines. c. Integrating theory into practice promotes coordinated care delivery. d. Nursing knowledge is generated by theory. f. Evidence-based practice results from theory-testing research. The overall goal of nursing knowledge is to explain the practice of nursing as different and distinct from the practice of medicine, psychology, and other health care disciplines. Theory generates nursing knowledge for use in practice, thus supporting evidence-based practice. The integration of theory into practice leads to coordinated care delivery and therefore serves as the basis for nursing. Although the nursing process is central to nursing, it is not a theory. Nursing theories are not stagnant and continue to evolve over time.

A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply.) a. Policy for conducting hourly rounds b. Staffing level c. Interruption by staff nurse colleague d. RN's years of experience e. Competency of patient care technician

a. Policy for conducting hourly rounds b. Staffing level c. Interruption by staff nurse colleague

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? a. Reconnect the drainage tubing b. Inspect the condition of the IV dressing c. Obtain the next IV fluid bag from the medication room d. Explain when the health care provider is likely to visit

a. Reconnect the drainage tubing

A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called: a. Reflection. b. Perseverance. c. Intuition. d. Problem solving.

a. Reflection The mother had difficulty breastfeeding first time. The nurse relied on reflection to consider her previous actions and review what was successful and the opportunities for improvement. The nurse has not yet problem solved but might do so after reflection in anticipation of the patient's next clinic visit.

A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude: a. Responsible b. Complete c. Accurate d. Broad

a. Responsible The nurse is demonstrating responsibility for correct medication and patient identification. The other three choices are critical thinking intellectual standards.

Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? (Select all that apply.) a. The intervention should be directed at reducing noise. Correct b. The intervention should be one shown to be effective in promoting sleep on the basis of research. Correct c. The intervention should be one commonly used by the patient's sleep partner. d. The intervention should be one acceptable to the patient. Correct e. The intervention should be one you used with other patients in the past.

a. The intervention should be directed at reducing noise. b. The intervention should be one shown to be effective in promoting sleep on the basis of research. d. The intervention should be one acceptable to the patient.

A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she rounds on the patient? (Select all that apply.) a. The nurse asks the patient to rate his pain on a scale of 0 to 10. b. The nurse asks the patient what caused his fall. c. The nurse asks the patient if he has had pain in his back in the past. d. The nurse assesses the patient's lower-limb strength. e. The nurse asks the patient what pain medication is most effective in managing his pain.

a. The nurse asks the patient to rate his pain on a scale of 0 to 10. Correct d. The nurse assesses the patient's lower-limb strength. Correct

Kolcaba's Theory of Comfort a. The nurse strives to relieve patients' distress. b. The nurse progresses through five stages of expertise. c. The nurse assists the patient to process and find meaning related to his or her illness. d. Matching nurse competencies to patient needs can improve patient outcomes.

a. The nurse strives to relieve patients' distress.

In which of the following examples is a nurse applying critical thinking skills in practice? (Select all that apply.) a. The nurse thinks back about a personal experience before administering a medication subcutaneously. b. The nurse uses a pain-rating scale to measure a patient's pain. c. The nurse explains a procedure step by step for giving an enema to a patient care technician. d. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis. e. A nurse offers support to a colleague who has witnessed a stressful event.

a. The nurse thinks back about a personal experience before administering a medication subcutaneously. b. The nurse uses a pain-rating scale to measure a patient's pain. d. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis.

In which of the following examples are nurses making diagnostic errors? (Select all that apply.) a. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data b. The nurse who measures joint range of motion after the patient reports pain in the left elbow c. The nurse who considers conflicting cues in deciding which diagnostic label to choose d. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping e. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

a. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data d. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping e. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (Select all that apply.) a. The skin around the wound is tender to touch. b. Fluid intake for 8 hours is 800 mL. c. Patient has a heart rate of 78 beats/min and regular. d. Patient has drainage from surgical wound. e. Body temperature is 38.3° C (101° F).

a. The skin around the wound is tender to touch. d. Patient has drainage from surgical wound. e. Body temperature is 38.3° C (101° F).

It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply.) a. Using a standardized checklist for essential information b. Asking the wife to briefly leave the room c. Completing the hand-off without inviting questions d. Doing prework such as checking laboratory results before giving a report Correct e. Including the wife in the hand-off discussion Correct

a. Using a standardized checklist for essential information d. Doing prework such as checking laboratory results before giving a report e. Including the wife in the hand-off discussion

A nurse is caring for a patient who recently lost a leg in a motor vehicle accident. The nurse best assists the patient to cope with this situation by applying which of the following theories? a. Roy b.Levine c.Watson d.Johnson

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

grand theory a. very abstract; attempts to describe nursing in a global context b. specific to a particular situation; brings theory to the bedside c. applies theory from other disciplines to nursing practice d. addresses a specific phenomenon and reflects practice

a. very abstract; attempts to describe nursing in a global context

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

a."I am thinking about joining the health committee at my church." b."I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." c."I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing."

Which of the following statements about evidence-based practice (EBP) made by a nursing student would require the nursing professor to correct the student's understanding? a."In evidence-based practice the patients are the subjects." b."It is important to talk with experts and patients when making an evidence-based decision." c."A nurse wanting to investigate the evidence to solve a problem starts by forming a PICOT question." d."It is important to ask a librarian for help when searching for literature to help you answer your PICOT question."

a."In evidence-based practice the patients are the subjects." Multiple research studies, expert opinion, personal experience, and patient preferences create the data source for EBP. Patients are not the subjects of EBP; they are typically the subjects in a research study.

A nurse is reading a research article. The nurse just finished reading a brief summary of the research study that included the purpose of the study and its implications for nursing practice. Which part of the article did the nurse just read? a.Abstract b.Analysis c.Discussion d.Literature Review

a.Abstract An abstract is a brief summary of the purpose of the article. It also includes the major themes or findings and the implications for nursing practice.

Which of the following properly applies an ethical principle to justify access to health care? (Select all that apply.) a.Access to health care reflects the commitment of society to principles of beneficence and justice. b.If low income compromises access to care, respect for autonomy is compromised. c.Access to health care is a privilege in the United States, not a right. d.Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics. e.Providers are exempt from fidelity to people with drug addiction because addiction reflects a lack of personal accountability. f.If a new drug is discovered that cures a disease but at great cost per patient, the principle of justice suggests that the drug should be made available to those who can afford it.

a.Access to health care reflects the commitment of society to principles of beneficence and justice. b.If low income compromises access to care, respect for autonomy is compromised. d.Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics.

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

a.Call the nursing supervisor to discuss the situation

The ethics of care suggests that ethical dilemmas can best be solved by attention to relationships. How does this differ from other ethical practices? (Select all that apply.) a.Ethics of care pays attention to the environment in which caring occurs. b.Ethics of care pays attention to the stories of the people involved in the ethical issue. c.Ethics of care is used only in nursing practice. d.Ethics of care focuses only on the code of ethics for nurses e.Ethics of care focuses only on understanding relationships.

a.Ethics of care pays attention to the environment in which caring occurs. b.Ethics of care pays attention to the stories of the people involved in the ethical issue e.Ethics of care focuses only on understanding relationships. Ethic of care focuses on environmental issues affecting care, the narratives of the patients and health care providers, and understanding relationships.

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

a.Failure to document a change in assessment data e.Failure to notify a health care provider about a change in the patient's condition

When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain? a.Fidelity b.Beneficence c.Nonmaleficence d.Respect for autonomy

a.Fidelity Fidelity means keeping promises. Keeping the promise in this case includes not just tending to the clinical need but evaluating the effectiveness of the interventions.

A nursing student is preparing to read the methods section of a research article. What type of information will the student expect to find in this section? (Select all that apply.) a.How the researcher conducted the study b.A description about how to use the findings of the study c.The number and type of subjects who participated in the study d.Summaries of other research articles that support the need for this study e.Implications for future research studies

a.How the researcher conducted the study c.The number and type of subjects who participated in the study The methods section explains how a research study was organized and conducted to answer the research question or test the hypothesis and how many subjects or people participated in the study.

The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with their chronic illness, which of the following principles should the nurse apply in practice? (Select all that apply.) a.Pay attention to the patient's spiritual identity throughout the course of her illness b.Select interventions that you know scientifically support spiritual well-being c.Listen to the patient's story each visit to the clinic and offer a compassionate presence d.When the patient questions the reason for her long-time suffering, try to provide answers e.Consult with a spiritual care advisor and have the advisor recommend useful interventions

a.Pay attention to the patient's spiritual identity throughout the course of her illness c.Listen to the patient's story each visit to the clinic and offer a compassionate presence A person's spiritual well-being can change over time; therefore it is important to pay attention to it over the course of his or her illness. Listening is a powerful way to support a patient's spirituality. Evidence-based interventions are preferred, but they must be agreed on by the patient and tailored to his or her perspectives and not just those of the nurse. Patients are not looking for answers. What is spoken as a spiritual question is most often an expression of spiritual pain. Using spiritual care advisors is a valuable resource but should be selected by the patient, not independently by the nurse; and any interventions should be mutually agreed on among nurse, patient, and advisor.

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) a.Taking or selling controlled substances b.Refusing to provide health care information to a patient's child c.Reporting suspected abuse and neglect of children d.Applying physical restraints without a written physician's order e.Completing an occurrence report on the unit

a.Taking or selling controlled substances d.Applying physical restraints without a written physician's order

Select the three factors that are evident when a healing relationship develops between nurse and patient. a.The nurse being able to realistically mobilize hope for the patient b.The patient being able to share fears of loss with significant others c.Finding an interpretation or understanding of the patient's illness that is acceptable to the patient d.Understanding your own beliefs about spirituality e. Helping the patient use spiritual resources that he or she chooses

a.The nurse being able to realistically mobilize hope for the patient c.Finding an interpretation or understanding of the patient's illness that is acceptable to the patient e. Helping the patient use spiritual resources that he or she chooses According to Benner (1984) three factors are evident when a healing relationship develops between nurse and patient: realistically mobilizing hope for the nurse and patient; finding an interpretation or understanding of the illness, pain, anxiety, or other stressful emotion that is acceptable to the patient; and helping him or her use social, emotional, and spiritual resources. It is important that the patient be able to share fears of loss with significant others or express spiritual needs and that the nurse helps the patient choose spiritual resources, but these are not reflective of the nurse-patient relationship.

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following best describes the role of the nurse in the resolution of ethical dilemmas? a.To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations. b.To study the literature on current research about the possible clinical interventions available for the patient in question. c.To hold a point of view but realize that respect for the authority of administrators and physicians takes precedence over personal opinion. d.To allow the patient and the physician to resolve the dilemma on the basis of ethical principles without regard to personally held values or opinions.

a.To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations. A nurse's point of view is essential to full discussion of ethical issues because of the nature of the relationship that nurses develop with patients and the intensity and intimacy of contact with the patient and family.

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are defining characteristics that support a nursing diagnosis of Spiritual Distress related to loss of family members? (Select all that apply.) a. "I need to call my sister for support." b. "I have nothing to live for now." c.. "Why would my God do this to me?" d. "I need to pray for a miracle." e. "I want to be more involved in my church."

b. "I have nothing to live for now." c.. "Why would my God do this to me?" Patients most likely to have a diagnosis of spiritual distress are facing loss or terminal or serious illness and have poor personal relationships. Indicating that there is nothing to live for now and wondering why God would do this to him reflect dispiritedness (e.g., expressing lack of hope, meaning, or purpose in life; anger toward God). The other responses show a potential for enhancement of spiritual well-being.

A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will perform which of the following evaluation measures to determine success of her instruction? a. Patient weight b. Asking patient to identify three low-sodium foods to eat for lunch c. A calorie count of food d. Patient description of how food selections are made

b. Asking patient to identify three low-sodium foods to eat for lunch

orem a. Based on the theory that focuses on wellness and prevention of disease. b. Based on the belief that people who participate in self-care activities are more likely to improve their health outcomes. c. Based on 14 activities, the nurse should assist patients with meeting needs until they are able to do so independently. d. Based on the belief that nurses should work with patients to develop goals for care.

b. Based on the belief that people who participate in self-care activities are more likely to improve their health outcomes.

Which of the following types of theory influence the "evidence" in current "evidence-based practice (EBP)"? a. Grand theory b. Middle-range theory c. Practice theory d. Shared theory

b. Middle-range theory The original grand theories served as springboards for the development of the more modern middle-range theories, which, through testing in research studies, provide the "evidence" for EBP and promotes the translation of research into practice.

A nurse is caring for a patient with a seriously advanced infection who asks to have a spiritual care provider come who can offer Blessingway, a practice that attempts to remove ill health. This patient is likely a member of which religion or culture? a. Hinduism b. Navajo c. Sikhism d. Judaism

b. Navajo Navajos use Blessingway as a way to remove ill health by means of stories, songs, rituals, prayers, symbols, and sand paintings.

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply.) a. Numbered order of diagnosis on the basis of severity b. Notion of urgency for nursing action c. Symptom pattern recognition suggesting a problem d. Mutually agreed on priorities set with patient e. Time when a specific diagnosis was identified

b. Notion of urgency for nursing action c. Symptom pattern recognition suggesting a problem d. Mutually agreed on priorities set with patient

Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? a. Probing b. Open-ended c. Problem-oriented d. Confirmation

b. Open-ended The best interview question for initially determining why a patient is seeking health care is by asking an open-ended question that allows the patient to tell his or her story. This is also a more patient-centered approach. Probing questions are asked after data are gathered to seek more in-depth information. Problem-oriented and confirmation are not types of interview questions.

The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): a. Risk nursing diagnosis. b. Problem-focused nursing diagnosis. c. Health promotion nursing diagnosis. d. Wellness nursing diagnosis.

b. Problem-focused nursing diagnosis. This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses.

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. You have cared for her for only 2 hours but have a good relationship with her. What might be the most appropriate intervention for support of her spiritual well-being at this time? a. Make a referral to a professional spiritual care advisor b. Sit down and talk with the patient; have her discuss her feelings and listen attentively c. Move the patient's bible from her bedside cabinet drawer to the top of the over-bed table d. Ask the patient if she would like to learn more about the implications of having this type of tumor

b. Sit down and talk with the patient; have her discuss her feelings and listen attentively Establishing presence contributes to a patient's sense of well-being. It helps to prevent emotional and environmental isolation. Automatically referring a spiritual care advisor might not be the patient's wish. She may not see an advisor as a resource. Reading a bible can be an important ritual but at this time the patient needs to make a connection with someone who can help minimize loneliness and powerlessness. Providing instruction will be important, but the patient is not likely to be receptive at this time.

benner's skill acquisition a. The nurse strives to relieve patients' distress. b. The nurse progresses through five stages of expertise. c. The nurse assists the patient to process and find meaning related to his or her illness. d. Matching nurse competencies to patient needs can improve patient outcomes.

b. The nurse progresses through five stages of expertise.

A nurse is caring for a 78-year-old patient with chronic multiple sclerosis. The patient has severe fatigue, muscle weakness, severe muscle spasms, and difficulties with coordination and balance. Her disease will likely worsen. The nurse has gained the patient's trust and wants to assess her life satisfaction. Which of the following questions should the nurse ask? (Select all that apply.) A.How often are you able to attend your synagogue? b. What about your family makes you proudest? c. What does your husband do for you at home? d. Looking back, what is your greatest accomplishment? e. How has your illness affected the way you live your life spiritually at home?

b. What about your family makes you proudest? d. Looking back, what is your greatest accomplishment? Spiritual well-being is tied to a person's satisfaction with life and what he or she has accomplished in work, personally with family, and in relationships with others. Asking how often the patient attends synagogue assesses religious participation. Asking what the husband does for the patient at home assesses presence of community support. Asking how the illness has affected the patient's spiritual life at home assesses vocation.

The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? a. Orientation b. Working phase c. Data validation d. Termination

b. Working phase The gathering of information is the working phase of a patient-centered interview.

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? a. Incorrect clustering b. Wrong diagnostic label c. Condition is a collaborative problem. d. Premature closure of clusters

b. Wrong diagnostic label

If a nurse decides to withhold a medication because it might further lower the patient's blood pressure, the nurse will be practicing the principle of: A. responsibility. B. accountability. C. competency. D. moral behavior.

b. accountability Rationale: If a nurse decides to withhold medication, despite a provider's order, the nurse is then accountable for his or her actions, as the nurse made the independent decision because of his or her knowledge of the patient and the patient's situation at that moment in time.

which of the following is the first step of the research process? a. analyze data b. identify the problem c. conduct study d. use the findings

b. identify the problem

practice theory a. very abstract; attempts to describe nursing in a global context b. specific to a particular situation; brings theory to the bedside c. applies theory from other disciplines to nursing practice d. addresses a specific phenomenon and reflects practice

b. specific to a particular situation; brings theory to the bedside

A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow? a.A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. b.A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. c.The patient cannot make changes in the advance directive once admitted to the hospital. d.A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

b.A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

Using Maslow's hierarchy of needs, identify the priority for a patient who is experiencing chest pain and difficulty breathing. a.Self-actualization b.Air, water, and nutrition c.Safety d.Esteem and self-esteem needs

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

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? a.Fidelity b.Beneficence c.Nonmaleficence d.Respect for autonomy

b.Beneficence Beneficence means "doing well" by taking positive actions. It implies that the best interest of the patient (and society) outweighs self-interest.

It can be difficult to agree on a common definition of the word quality when it comes to quality of life. Why? (Select all that apply.) a.Average income varies in different regions of the country. b.Community values influence definitions of quality, and they are subject to change over time. c.Individual experiences influence perceptions of quality in different ways, making consensus difficult. d.The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. e.Statistical analysis is difficult to apply when the outcome cannot be quantified. f.Whether or not a person has a job is an objective measure, but it does not play a role in understanding quality of life.

b.Community values influence definitions of quality, and they are subject to change over time. c.Individual experiences influence perceptions of quality in different ways, making consensus difficult. d.The value of elements such as cognitive skills, ability to perform meaningful work, and relationship to family is difficult to quantify using objective measures. e.Statistical analysis is difficult to apply when the outcome cannot be quantified.

A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate? (Select all that apply.) a. Encourage family members to participate in the exercise. b.Have patient identify a quiet room in the home that has minimal interruptions. c. Suggest use of a quiet fan running in the room. d.Explain that it is best to meditate about 5 minutes 4 times a day. e.Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

b.Have patient identify a quiet room in the home that has minimal interruptions. c. Suggest use of a quiet fan running in the room. e.Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer. A quiet room with no distractions is conducive to meditation. The low buzz of a fan also blocks distractive noises. A patient should relax comfortably during meditation. Meditation is usually recommended 10 to 20 minutes twice a day. The activity should be conducted alone without distraction.

The application of utilitarianism does not always resolve an ethical dilemma. Which of the following statements best explains why? a.Utilitarianism refers to usefulness and therefore eliminates the need to talk about spiritual values. b.In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism. c.Even when agreement about a definition of usefulness exists in a community, laws prohibit an application of utilitarianism. d.Difficult ethical decisions cannot be resolved by talking about the usefulness of a procedure.

b.In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism. In increasingly diverse communities, ideas of usefulness have become equally diverse.

A researcher is studying the effectiveness of an individualized evidence-based teaching plan on young women's intention to wear sunscreen to prevent skin cancer. In this study, which of the following research terms best describes the individualized evidence-based teaching plan? a.Sample b.Intervention c.Survey d.Results

b.Intervention An intervention is an action or treatment performed by a researcher on a sample.

Two patient deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress? a.Keep a journal b.Participate in a unit meeting to discuss feelings about the patient deaths c.Ask the nurse manager to assign you to less difficult patients d.Review the policy and procedure manual on proper care of patients after death

b.Participate in a unit meeting to discuss feelings about the patient deaths By connecting and meeting with staff colleagues, you can talk about the experiences of caring for dying patients and learn that your feelings are likely shared by others. A journal is helpful but not the best way to relieve stress. A policy and procedure manual will not help you examine and understand the nature of the stress. Asking for a different assignment is no guarantee that another stressful experience will not develop.

A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? (Select all that apply.) a.Information provided by the head nurse b.Policies and procedures of the employing hospital c.State Nurse Practice Act d.Regulations identified in The Joint Commission manual e.The American Nurses Association standards of nursing practice

b.Policies and procedures of the employing hospital c.State Nurse Practice Act d.Regulations identified in The Joint Commission manual e.The American Nurses Association standards of nursing practice

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? a.Family member b.Surgeon c.Nurse d.Nurse manager

b.Surgeon The person performing the procedure is responsible for informing the patient about the procedure and its risks, benefits, and possible complications.

A group of nurses on the research council of a local hospital are measuring nursing-sensitive outcomes. Which of the following is a nursing-sensitive outcome that the nurses need to consider measuring? (Select all that apply.) a.Frequency of low blood sugar episodes in children at a local school b.The number of patients who develop a urinary tract infection from a Foley catheter c.Number of patients who fall and experience subsequent injury on the evening shift d.Number of sexually active adolescent girls who attend the community-based clinic for birth control e.Patient reported quality of life following coronary artery bypass graft surgery and cardiac rehabilitation

b.The number of patients who develop a urinary tract infection from a Foley catheter c.Number of patients who fall and experience subsequent injury on the evening shift Nurse-sensitive indicators are outcomes that are sensitive to nursing practice; these outcomes will improve if the quantity or quality of nursing care improves.

A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.) a.The nurse does not need any representation. b.The patient must prove injury, damage, or loss occurred. c.The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. d.The patient must prove that a breach in the prevailing standard of care caused an injury. e.The burden of proof is always the responsibility of the nurse.

b.The patient must prove injury, damage, or loss occurred. c.The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. d.The patient must prove that a breach in the prevailing standard of care caused an injury.

A nurse researcher wants to conduct historical research. Which of the following ideas for a study could the nurses conduct? (Select all that apply.) a.Determining the effect of unemployment on emergency room usage b.Understanding how Clara Barton shaped nursing in America c.Evaluating the effect of the Vietnam war on nursing leadership and practice d.Analyzing the evolution of nursing and patient care during recent disasters e.Investigating barriers to exercise in women who have become mothers in the past year

b.Understanding how Clara Barton shaped nursing in America c. Evaluating the effect of the Vietnam war on nursing leadership and practice d.Analyzing the evolution of nursing and patient care during recent disasters Historical studies are designed to establish facts and relationships concerning past events.

A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? a. "I can tell that your eating habits have led to your diabetes. Is that right?" b. "It's been difficult for people to find jobs. Is that why you work part time?" c. "You have four children; do you have any concerns about going home and caring for them?" d. "I wish patients understood how overeating affects their health."

c. "You have four children; do you have any concerns about going home and caring for them?" This is the only assessment approach that is not biased or does not show judgment about the patient's weight or occupational status. With the other options, the nurse is reacting to the patient on the basis of personal stereotypes and biases.

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

c. .Contact a child abuse hotline Nurses are mandated reporters of suspected child abuse. These assessment findings possibly indicate child abuse.

A patient states that he does not believe in a higher power but instead believes that people bring meaning to what they do. This patient most likely is an: a. Academic. b. Atheist. c. Agnostic. d. Anarchist.

c. Agnostic. Agnostics believe there is no known ultimate reality. They discover meaning in what they do or how they live because they find no ultimate meaning for the way things are. They believe that people bring meaning to what they do.

You are caring for a hospitalized patient who is Muslim and has diabetes. Which of the following items do you need to remove from the meal tray when it is delivered to the patient? a.Small container of vanilla ice cream b. A dozen red grapes c. Bacon and eggs d. Garden salad with ranch dressing

c. Bacon and eggs Islam prohibits the consumption of pork.

henderson a. Based on the theory that focuses on wellness and prevention of disease. b. Based on the belief that people who participate in self-care activities are more likely to improve their health outcomes. c. Based on 14 activities, the nurse should assist patients with meeting needs until they are able to do so independently. d. Based on the belief that nurses should work with patients to develop goals for care.

c. Based on 14 activities, the nurse should assist patients with meeting needs until they are able to do so independently.

The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: a. Cue. b. Reflection. c. Clinical inference. d. Probing.

c. Clinical inference. An inference is your judgment or interpretation of cues such as the shuffling gait and reduced leg strength. Any information gathered through your senses is a cue. Probing is a technique used in interviewing. Reflection is an internal process of thinking back about a situation.

A nurse changed a patient's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? (Select all that apply.) a. Clinical inference b. Basic critical thinking c. Complex critical thinking d. Experience e. Reflection

c. Complex critical thinking d. Experience The nurse relies on experience and the ability to adapt a procedure such as a dressing change (complex critical thinking) to make it successful.

By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude? a. Curiosity b. Adequacy c. Discipline d. Thinking independently

c. Discipline Discipline is being thorough in whatever you do. Using known criteria for assessment and evaluation, as in the case of pain, is an example of discipline.

A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? a. Insufficient cluster of cues b. Disorganization c. Insufficient number of cues d. Evidence that another diagnosis is more likely

c. Insufficient number of cues

A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? a. Infant crying at breast b. Infant unable to latch on to breast correctly c. Mother's deficient knowledge d. Lack of infant weight gain

c. Mother's deficient knowledge In this scenario the related factor is the mother's deficient knowledge. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to latch on to breast, and absent weight gain.

Which of the following categories of shared theories would be most appropriate for a patient who is grieving the loss of a spouse? a. Biomedical b. Leadership c. Psychosocial d. Developmental

c. Psychosocial You can use various psychosocial theories to help patients with loss, death, and grief.

A nurse begins a night shift, assuming care for a critically ill patient who was resuscitated earlier in the day from cardiac arrest. He survived and is physically stable, alert, oriented, and responding appropriately to the nurse's questions. Knowing that the patient experienced a period when his heart stopped beating, what would be the best approach for the nurse to use with him? a. Have family come to visit and focus discussion about their gratitude that the patient survived b. Change the subject when the patient begins talking about entering a dark tunnel when the doctors were resuscitating him c. Sit and encourage the patient to share what he experienced during resuscitation d. Provide the patient the opportunity to have passages from the bible read to him

c. Sit and encourage the patient to share what he experienced during resuscitation After the patient has had a near death experience, the nurse promotes spiritual well-being by remaining open and giving him or her a chance to explore what happened and supporting him as he shares what happened.

An aspect of clinical decision making is knowing the patient. Which of the following is the most critical aspect of developing the ability to know the patient? a. Working in multiple health care settings b. Learning good communication skills c. Spending time establishing relationships with patients d. Relying on evidence in practice

c. Spending time establishing relationships with patients Knowing the patient relates to a nurse's experience with caring for patients, time spent in a specific clinical area, and having a sense of closeness with them. However, a critical aspect to knowing the patient and thus being able to make timely and appropriate decisions is spending time establishing relationships with them.

A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? a. Giving the enema on time b. Talking with the patient about her past experiences with illness c. Talking with the patient about her concerns and acknowledging her sense of unfairness d. Beginning instruction on postoperative procedures

c. Talking with the patient about her concerns and acknowledging her sense of unfairness

During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? a. So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct? b. Have you taken anything for your headaches? c. Tell me what makes your headaches begin. d. Uh huh, tell me more.

c. Tell me what makes your headaches begin. An open-ended question that probes such as "Tell me what makes your headaches begin" encourages a fuller description of a situation. The statement "So you've had headaches periodically in the last week, and sometimes they cause you to feel nauseated—correct?" is a summative statement. Asking whether the patient has taken anything for the headaches is a closed-ended question. Saying "Uh huh, tell me more" is an example of back channeling.

Mishel's Uncertainty in Illness a. The nurse strives to relieve patients' distress. b. The nurse progresses through five stages of expertise. c. The nurse assists the patient to process and find meaning related to his or her illness. d. Matching nurse competencies to patient needs can improve patient outcomes.

c. The nurse helps the patient to process and find meaning related to his or her illness

A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 ½ NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply.) a. IV site not tender b. Uses cane to walk c. Walked to end of hall d. No shortness of breath e. Slept better during night

c. Walked to end of hall d. No shortness of breath

Evaluation of spiritual care is necessary to determine if a patient's level of spiritual health has changed following intervention. If the use of rituals was part of a nurse's care plan, which of the following questions is most appropriate to evaluate its efficacy? a. Do you feel the need to forgive your wife over your loss? b. What can I do to help you feel more at peace? c. Were prayer or meditation helpful to you? d. Should we plan on having your family try to visit you more often in the hospital?

c. Were prayer or meditation helpful to you? Rituals include participation in worship, prayer, sacraments (e.g., baptism, Holy Eucharist), fasting, singing, meditating, scripture reading, and making offerings or sacrifices. When you include the use of rituals in a patient's plan of care, evaluate if the patient perceived these activities as useful. If not, other interventions will be necessary.

The nurses on a medical unit have seen an increase in the number of medication errors on their unit. They decide to evaluate the medication administration process based on data gained from chart reviews and direct observation of nurses administering medications. Which process are the nurses using? a.Evidence-based practice. b.Research. c.Quality improvement. d.Problem identification.

c. quality improvement Quality improvement studies evaluate how processes work in an organization. The nurses in this example are evaluating the medication administration process.

A patient who is recovering from a bilateral amputation of the legs below the knee shows transcendence when she states: a."My pain medicine helps me feel better." b."I know I'll get better if I just keep trying." c."I see God's grace and become relaxed when I watch the sun set at night." d."I have had a great life and a good marriage. My husband has been so helpful in my healing."

c."I see God's grace and become relaxed when I watch the sun set at night." Transcendence is the belief that a force outside of and greater than the person exists beyond the material world, in this case to help the patient cope with her loss and pain. The other options are more inner-focused and viable ways that help the patient cope.

A nurse researcher is collecting data following approval from the institutional review board (IRB). In which part of the research process is this nurse? a. Analyzing the data b.Designing the study c.Conducting the study d.Identifying the problem

c.Conducting the study Conducting the study includes tasks such as obtaining necessary approvals and implementing the study protocol to guide data collection.

When recruiting subjects to participate in a study about the effects of an educational program to help patients at home take their medications as ordered, the researcher tells the subjects that their names will not be used and no one but the research team will have access to their information and responses. This is an example of: a.Bias. b.Anonymity. c.Confidentiality d.Informed consent.

c.Confidentiality Confidentiality guarantees that any information a subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team.

A nurse researcher wants to know what factors are associated with a person's decision to exercise. The nurse distributes a survey to people who recently joined an exercise wellness program and analyzes the data to determine what factors and characteristics are most significantly linked to the decision to start exercising. What type of a research study is this? a.Qualitative b.Descriptive c.Correlational d.Randomized controlled trial

c.Correlational In the correlational study the nurse researcher is correlating characteristics or factors with the decision to start exercising.

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act? a.Patient Protection and Affordable Care Act (PPACA) b.Patient Self-Determination Act (PSDA) c.Health Insurance Portability and Accountability Act (HIPAA) d.Emergency Medical Treatment and Active Labor Act

c.Health Insurance Portability and Accountability Act (HIPAA)

The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and rights of the patient." This includes the protection of patient privacy. On the basis of this principle, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you obscured or deleted all patient identifiers? a.Yes, because patient privacy would not be violated since patient identifiers were removed b.Yes, because respect for autonomy implies that you have the autonomy to decide what constitutes privacy c.No, because, even though patient identifiers are removed, someone could identify the patient on the basis of other comments that you make online about his or her condition and your place of work d.No, because the principle of justice requires you to allocate resources fairly

c.No, because, even though patient identifiers are removed, someone could identify the patient on the basis of other comments that you make online about his or her condition and your place of work Information such as comments and photos on social media is widely distributed and becomes a risk for violation of privacy. People often inadvertently give "clues" or hints to the identity of a person, or people accessing your site could know your actual assignment or put "two and two" together.

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable? a.Nurses understand the principle of autonomy to guide respect for a patient's self-worth. b.Nurses have a scope of practice that encourages their presence during ethical discussions. c.Nurses develop a relationship with the patient that is unique among all professional health care providers. d.The nurse's code of ethics recommends that a nurse be present at any ethical discussion about patient care.

c.Nurses develop a relationship with the patient that is unique among all professional health care providers. A fundamental goal of this chapter is to promote and nurture the value of the nursing voice in ethical discourse.

A student nurse is developing a plan of care for a 74-year-old female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered? (Select all that apply.) a.Older adults do not routinely use complementary medicine to cope with illness. b.Older adults dislike discussing the afterlife and what might have happened to people who have passed on. c.Older adults achieve spiritual resilience through frequent expressions of gratitude. d.Have the patient determine if her husband left a legacy behind. e.Offer the patient her choice of rituals or participation in exercise.

c.Older adults achieve spiritual resilience through frequent expressions of gratitude. d.Have the patient determine if her husband left a legacy behind. e.Offer the patient her choice of rituals or participation in exercise. Older-adult patients achieve spiritual resiliency in expressing gratitude and finding ways to maintain purpose in life. Leaving legacies maintains a connection between the person left behind and the lost loved one. Older adults frequently use complementary medicine, rituals, and exercise to cope with illness and pain. Belief in the afterlife grows with aging.

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? a.Discussing patient conditions in the nursing report room at the change of shift b.Allowing nursing students to review patient charts before caring for patients to whom they are assigned c.Posting medical information about the patient on a message board in the patient's room d.Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

c.Posting medical information about the patient on a message board in the patient's room

A nurse is preparing to begin intravenous fluid therapy for a patient. Which category of theory would be most helpful to the nurse at this time? a. Grand theory b.Middle-range theory c.Practice theory d. Shared theory

c.Practice theory Practice theories bring theory to the bedside. Narrow in scope and focus, these theories guide the nursing care of a specific patient population at a specific time.

Nurses in a community clinic have seen an increase in the numbers of obese children. The nurses who care for children are discussing ways to reduce childhood obesity. One nurse asks a colleague, "I wonder what the most effective ways are to help school-aged children maintain a healthy weight?" This question is an example of a/an: a.Hypothesis. b.PICOT question. c.Problem-focused trigger. d.Knowledge-focused trigger.

c.Problem-focused trigger. A problem-focused trigger is a clinical problem you face while caring for patients; the nurses in this question have identified a clinical problem that they want to investigate further.

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? a.The nurse's automobile insurance b.The nurse's homeowner's insurance c.The Good Samaritan law, which grants immunity from suit if there is no gross negligence d.The Patient Care Partnership, which may grant immunity from suit if the injured party consents

c.The Good Samaritan law, which grants immunity from suit if there is no gross negligence The Good Samaritan law holds the health care provider immune from liability as long as he or she functions within the scope of his or her expertise.

A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? a. Review of systems approach b. Use of a structured database format c. Back channeling d. A problem-oriented approach

d. A problem-oriented approach This is an example of a problem-focused approach. The nurse focuses on assessing one body system (cardiovascular) to determine the nature of the patient's pain and other presenting symptoms.

A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of: a. Accuracy. b. Reflection. c. Risk taking. d. Basic critical thinking.

d. Basic critical thinking. Basic critical thinking is concrete and based on a set of rules or principles such as the guidelines in a hospital procedure manual. The nurse's approach is not accurate because accuracy requires use of all of the facts (e.g., the patient's discomfort). A critical thinker is willing to take risks to try different ways to solve problems; following one basic approach is not risk taking. This is also not an example of reflection.

A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: a. Collaborative data set. b. Diagnostic label. c. Related factors. d. Data cluster.

d. Data cluster. A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment).

A nurse enters a 72-year-old patient's home and begins to observe her behaviors and examine her physical condition. The nurse learns that the patient lives alone and notices bruising on the patient's leg. When watching the patient walk, the nurse notes that she has an unsteady gait and leans to one side. The patient admits to having fallen in the past. The nurse identifies the patient as having the nursing diagnosis of Risk for Falls. This scenario is an example of: a. Inference. b. Basic critical thinking. c. Evaluation. d. Diagnostic reasoning.

d. Diagnostic reasoning. Diagnostic reasoning begins when you interact with a patient or make physical or behavioral observations. An expert nurse sees the context of a patient situation (e.g., patient lives alone, has fallen in past), observes patterns and themes, and makes a diagnostic decision.

A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? a. Disturbed Sleep Pattern evidenced by frequent awakening b. Disturbed Sleep Pattern related to family caregiving responsibilities c. Disturbed Sleep Pattern related to need to improve sleep habits d. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

d. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? a. Patient will be turned every 2 hours within 24 hours. b. Patient will have normal bowel function within 72 hours. c. Patient's skin integrity will remain intact through discharge. d. Erythema of skin will be mild to none within 48 hours.

d. Erythema of skin will be mild to none within 48 hours.

A nurse researcher studies the effectiveness of a new program designed to educate parents to promote the immunization of children. The nurse divides the parents randomly into two groups. One group receives the typical educational program and the other group receives the new program. This is an example of which type of study? a.Historical b.Qualitative c.Correlational d. Experimental

d. Experimental In experimental studies the subjects are randomly assigned into groups with one group receiving the standard treatment and the other group receiving the intervention.

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? a.Value-belief pattern b. Cognitive-perceptual pattern c. Coping-stress-tolerance pattern d. Health perception-health management pattern

d. Health perception-health management pattern

A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention? a. Reporting hand-off at change of shift b. Ambulating patient down hallway c. Sleep hygiene d. IV fluid administration

d. IV fluid administration

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? a. Identifying the clinical sign instead of an etiology b. Identifying a diagnosis on the basis of prejudicial judgment c. Identifying the diagnostic study rather than a problem caused by the diagnostic study d. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

d. Identifying the medical diagnosis instead of the patient's response to the diagnosis. Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not change a medical diagnosis.

AACN's Synergy Model a. The nurse strives to relieve patients' distress. b. The nurse progresses through five stages of expertise. c. The nurse assists the patient to process and find meaning related to his or her illness. d. Matching nurse competencies to patient needs can improve patient outcomes.

d. Matching nurse competencies to patient needs can improve patient outcomes

The nurse writes an expected outcome statement in measurable terms. An example is: a. Patient will have normal stool evacuation. b. Patient will have fewer bowel movements. c. Patient will take stool softener every 4 hours. d. Patient will report stool soft and formed with each defecation.

d. Patient will report stool soft and formed with each defecation.

A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? a. Health perception-health management pattern b. Value-belief pattern c. Cognitive-perceptual pattern d. Self-perception-self-concept pattern

d. Self-perception-self-concept pattern This is an example of assessment of a patient's feelings about his worth and body image, which is the self-perception- self-concept health pattern.

A student nurse is telling a faculty member that her patient talked about gaining spiritual comfort from being focused on her inner self, including her values and principles. The instructor explains that this is an example of: a. Faith. b. Community. c. Interpersonal connection. d. Self-transcendence.

d. Self-transcendence. Self-transcendence is a sense of authentically connecting to one's inner self. Interpersonal connection is being connected with others and the environment. Faith is the ability of people to have firm beliefs despite lack of physical evidence and to believe in and establish transpersonal connections. With respect to spirituality, community is the shared faith between people and their support networks.

Middle Range Theory a. very abstract; attempts to describe nursing in a global context b. specific to a particular situation; brings theory to the bedside c. applies theory from other disciplines to nursing practice d. addresses a specific phenomenon and reflects practice

d. addresses a specific phenomenon and reflects practice

to assess, evaluate, and support a patient's spirituality, the best action a nurse can take is to: a. assist the patient to use faith to get well b. refer the patient to he health care facility chaplain c. provide the patient with a variety of religous literature d. determine the patients perceptions and belief system

d. determine the patients perceptions and belief system

every health care organization gathers data on health outcomes. examples of key quality- of - care or performance indicators include: a. discharge b. medications administered c. healthy births d. infection rates

d. infection rates

The components of the nursing metaparadigm include: a. person, health, environment, and theory b. health, theory, concepts, and environment c. nurses, physicians, health, environment, and nursing d. person, health, environment, and nursing

d. person, health, environment, and nursing

A nurse who works on a pediatric unit asks, "I wonder if children who interact with therapy dogs have reduced anxiety when they are in the hospital." In this example of a PICOT question, which of the following is the O? a.Children. b.Therapy dogs. c.The pediatric unit. d.Anxiety.

d.Anxiety. O stands for outcome; in this PICOT question, the outcome the nurse is concerned about is anxiety.

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

d.Applying ethical criteria. The use of ethical criteria for nursing judgment allows a nurse to focus on a patient's values and beliefs. Clinical decisions are then just, faithful to the patient's choices, and beneficial to the patient's well-being.

A patient is admitted to a medical unit. The patient is fearful of hospitals. The nurse carefully assesses the patient to determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is the nurse practicing patient advocacy? a.Seeking out the nursing supervisor to talk with the patient b.Documenting patient fears in the medical record in a timely manner c.Working to change the hospital environment d.Assessing the patient's point of view and preparing to articulate it

d.Assessing the patient's point of view and preparing to articulate it Assessing the patient's point of view and preparing to articulate it best reflects the concept of advocacy because it is standing up for the patient and having his or her views and wishes heard.

A group of nurses have identified that the elderly patients on their unit have a high incidence of pressure ulcers after they have a stroke. During a unit meeting, they discuss different interventions they think may reduce the development of pressure ulcers. What is the nurses' next step to investigate this clinical problem further? a.Conduct a literature review. b.Share the findings with others. c.Conduct a statistical analysis. d.Create a well-defined PICOT question.

d.Create a well-defined PICOT question. In this case the nurses need to develop a PICOT question next to search for appropriate evidence that might offer answers to this clinical problem.

You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action? a.Give the family the record b.Discuss the issues that concern the family with them c.Call the nursing supervisor d.Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

d.Determine from the medical record if the family has been granted permission by the patient to access his or her medical information Family members do not have the right to private personal health information without the consent of the patient. Confidentiality protects private patient information once it has been disclosed in health care settings.

A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? a.Health Insurance Portability and Accountability Act (HIPAA) b.Americans with Disabilities Act (ADA) c.Patient Self-Determination Act (PSDA) d.Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

d.Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? a.Obtain a court order to give the blood b.Coerce the husband into giving the blood c.Call security and have the husband removed from the hospital d.More information is needed about the wife's preference and if the husband has her medical power of attorney

d.More information is needed about the wife's preference and if the husband has her medical power of attorney Adult patients such as those with specific religious objection are able to refuse treatment for personal religious reasons, but there need to be clear directions on who can make the decision.