Wellness Final

अब Quizwiz के साथ अपने होमवर्क और परीक्षाओं को एस करें!

9. The statement "ongoing collection of data" best describes which phase of the nursing process? a. Planning b. Evaluation c. Assessment d. Implementation

ANS: C Keeping the five steps of the nursing process in mind, a nurse conducts ongoing assessment (data collection) as a patient's condition changes and modifies the patient's plan of care on the basis of those findings.

7. The nurse is completing an assessment on a patient with sudden onset of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient's clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient's abdominal pain? a. Evaluation b. Interpretation c. Reflection d. Inference

Answer: b Nurses use interpretation to understand and explain the meaning of data. In this case, the nurse must first interpret the assessment data before reflecting on its meaning, evaluating its reliability or credibility, and making inferences that will have an impact on treatment options.

1. The most commonly reported illicit drugs are a. marijuana and hashish. b. oxycontin and oxycodone. c. fentanyl and oxycontin. d. Robitussin with codeine and Tylenol with codeine.

3. How would you differentiate correlational research from experimental research? a. Correlational research examines a relationship between two variables, and experimental research examines a causal relationship between variables. b. Correlational research examines a relationship between two variables, and experimental research describes data and characteristics about a population. c. Correlational research examines a causal relationship between two variables, and experimental research examines relationship variables. d. Correlational research describes data and characteristics about a population, and experimental research examines a relationship between two variables.

3. Which statement below is not true about fluid intelligence? a. Increases throughout middle adulthood b. Supports reasoning, abstraction, and problem solving c. Represents basic information-processing skills d. Peaks in adolescence and progressively declines beginning around age 30

5. When the nurse is establishing goals for a community health initiative, which strategy is most important to incorporate in the planning process? a. Collaboration with key stakeholders b. Help from professional interpreters c. Location of schools and businesses d. Gender of primary care providers

6. Which of the following statements most accurately reflects the nursing process? a. Cyclical in nature and steps overlap b. Can be delegated to increase productivity c. Must be completed in an orderly sequence from beginning to end d. Should follow standard structure for all patients

7. Identify physician-initiated interventions: a. Administer antibiotic intravenously twice a day. b. Enable progressive ambulation as tolerated. c. Check vital signs four times a day. d. Provide preadmission teaching.

7. The following factor should be considered first when developing a teaching plan: a. The patient's priorities b. The patient's vital signs c. The patient's insurance coverage d. The patient's economic resources

7. The hallmark of the older adult populations is a. increases in diversity. b. highest death rates in the U.S. c. Alzheimer's disease. d. urinary incontinence.

8. Which of the following is an important component in evaluating patient outcomes and the plan of care? a. Nursing judgment and critical thinking b. Communication with the interdisciplinary team c. Implementing every intervention d. Nursing attitude

9. VARK is an acronym for a. verbal, aural, read/write, and kinesthetic. b. verbal, aural, readiness, and kinesthetic. c. verbal, auditory, readiness, and kinesthetic. d. verbal, auditory, read/write, and kinesthesia.

10. Which factor(s) is/are likely to influence the transition from adolescence to adulthood? (Select all that apply.) a. Cultural beliefs b. Societal values c. Personal beliefs and expectations d. Governmental rules e. Societal expectations

a b c

5. What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? (Select all that apply.) a. Patient's treatment preferences b. Cultural and ethnic influences c. Professional level of expertise d. Current evidence-based research e. Convenience to the nursing staff

a b c d

8. Which body is responsible for defining and disseminating information on nursing diagnoses? a. North American Nursing Diagnosis Association International b. International and American Nurses Association c. Individual State Boards of Nursing d. The Joint Commission

ANS: A Nursing diagnoses are established and revised biannually by NANDA International, Inc. (NANDA-I), a professional nursing organization that provides standardized language to identify patient problems and plan customized care.

10. Which statement illustrates the most measurable outcome indicator? a. Demonstrates dressing change b. Shares innermost thoughts c. Understands instructions d. Shows personal remorse

ANS: A "Demonstrates dressing change" is a measurable outcome indicator. Outcome identification, added by the ANA in 1991 as a specific aspect of the nursing process, involves listing behaviors or observable items that indicate attainment of a goal. The other options are not measurable as written.

2. In providing care to a newly admitted patient, the nurse's inferences are more accurate if based upon which of the following? a. Objective data b. Assumptions c. Intuition d. Experience

ANS: A Because objective data is based upon observable data that can usually be replicated by another provider, it is the more valid basis for inferences. The accuracy of the inferences is directly related to the accuracy of what the inference is based upon. Assumptions are beliefs that are taken for granted and "assumed" true. Knowing or feeling that you know something without specific evidence is one explanation of intuition. Explanation is a way of describing a conclusion, not data.

13. Which action should the nurse take 30 minutes after administering oral pain medication to a patient? a. Evaluate the effectiveness of the administered pain medication. b. Teach progressive relaxation strategies to relieve muscle tension. c. Assess the patient's coping skills to reduce expressed anxiety. d. Encourage the patient to read or watch TV to provide pain distraction.

ANS: A Evaluation focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment. During the evaluation step of the nursing process, nurses use critical thinking to determine whether a patient's short- and long-term goals were met and desired outcomes were achieved.

3. During the postoperative assessment on a patient, the nurse has a "hunch" that the patient has a postoperative complication based upon a. intuition. b. interpretation. c. information processing. d. inference.

ANS: A Knowing or feeling that you know something without specific evidence is one explanation of intuition. Intuition is a valid characteristic of expert clinical judgment acquired through knowledge, practice, and experience. It is described as how expert nurses use intuition to facilitate problem solving because this "hunch" (most likely intuition) is based upon experiential knowledge.

7. In preparing to administer medications to a patient, the nurse notes a medication that she has never administered. If the nurse administers the medication without researching the medication, this represents which error in critical thinking? a. Lack of information b. Illogical thinking c. Close-mindedness d. Erroneous assumptions

ANS: A The nurse cannot critically think about something he or she does not know. As a result, knowledge deficit can cause errors in thinking. The nurse in practice must continue to build his or her knowledge base in order to provide safe and appropriate care. This is particularly relevant to the increased numbers of medications that nurses administer, and the possible interactions with other medications and foods. The nurse can make a medication error if new or unfamiliar medications are not researched prior to administering to patients.

1. What is the nurse's role as patient advocate? (Select all that apply.) a. Explain to the patient the nurse's viewpoint. b. Provide necessary education and interpret information. c. Accept the patient's decision and support his or her wishes. d. Give the patient the physician's explanation of his or her viewpoint.

ANS: B, C The nurse as the patient advocate must first provide education and interpret information in an unbiased manner. Then the nurse must accept the patient's decision and support his or her wishes even if it is different from the nurse's own viewpoint or that of other health care personnel.

1. The nurse uses critical thinking to interpret data. Which of the following data sources are objective? (Select all that apply.) a. Patient interview b. Laboratory values c. Body language d. X-ray results e. Vital signs f. Breath sounds

ANS: B, D, E, F Objective data is observable data that is assessed through vision, hearing, smell, and touch. Subjective data includes patient history and nonverbal data such as body language, facial expressions, etc.

5. Which statement is a correctly written example of an actual nursing diagnosis? a. Impaired memory related to patient complaint of becoming confused with the time change b. Risk for injury related to stumbling when walking as evidenced by patient report of occasional difficulty playing basketball c. Activity intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea on exertion and significant drop of oxygen saturation from 98% to 88% with activity d. Ineffective health maintenance as evidenced by inability to complete activities of daily living related to lack of familial support system

ANS: C Actual nursing diagnoses are written with three parts, whereas risk nursing diagnoses and health-promotion nursing diagnoses contain only two parts. Three-part nursing diagnosis statements include (1) the patient's identified need or problem (i.e., NANDA-I nursing diagnostic label), (2) the etiology or underlying cause (i.e., related to [r/t]), and (3) signs and symptoms (i.e., as evidenced by [AEB] or as manifested by [AMB]). Sleep Deprivation related to frequent sleep interruption as evidenced by patient complaint of diarrhea 10 times throughout the night and feeling fatigued is an example of a three-part nursing diagnosis statement.

4. In using intuition to address a clinical problem, the expert nurse bases his or her approach upon which of the following? a. Judgment b. Data collection c. Experiential knowledge d. Logical deduction

ANS: C Alfaro-LeFevre (2009) describes how expert nurses use intuition to facilitate problem solving because this "hunch" (most likely intuition) is based upon experiential knowledge. Less experienced nurses rely more on logic and a step-by-step approach when encountering the same issue. In either situation, intuition based upon critical thinking requires analysis and evidence to support actions.

5. A new graduate nurse explains a new approach in the positioning of patients with chronic low back pain. The nurse preceptor responds, "That is not the way we do it here." The preceptor's response illustrates which error in critical thinking? a. Lack of information b. Erroneous assumptions c. Illogical thinking d. Bias

ANS: C Illogical thinking is often characterized by hasty generalizations and assumptions that do not consider the evidence. Another trait associated with this type of thinking is related to following tradition and uses the argument that "we have always done it this way." When illogical thinking is used, creativity in thinking can be limited, and new ideas and approaches do not evolve. In nursing, illogical thinking can occur if nurses do not stay current, and care can be compromised.

5. Nursing students all belong to National Student Nurses Association when they are attending a specific nursing program. This is an important aspect of their socialization to the profession as it demonstrates which criteria of a profession? a. Providing service to society b. Accepting responsibility for actions and omissions c. Participating in an organization that supports and advances the profession d. Making independent decisions based on their scope of practice

ANS: C Students begin their socialization to the profession by participating in an organization, which is one criteria of a profession.

2. A disoriented patient is admitted to the hospital accompanied by his spouse. From whom should the nurse collect subjective data on this patient? a. An experienced nurse on the unit b. The patient's medical record c. The patient's wife d. His physician

ANS: C Subjective data (i.e., symptoms) are spoken. Patients' feelings about a situation or comments about how they are feeling are examples of subjective data. Data shared by a source verbally are considered subjective. Subjective data may be difficult to validate because they cannot be independently and objectively measured. Subjective data are most often gathered during a patient interview or health history. Use of an interpreter may be necessary when the patient or family members speak a language unfamiliar to the nurse. Subjective data are typically documented in the patient's medical record as direct quotations; for example, "I didn't get much sleep last night" or "I've had diabetes since I was 10 years old."

2. Nurses are most likely to utilize which of the following theories or models in their leadership role? a. Maslow and Erikson b. Health Belief Model c. Lewin d. Von Bertalanffy

ANS: C The nurse will use Lewin's change theory most often in the leadership role. Maslow's hierarchy of needs, Erikson's developmental theory, and the Health Belief Model will be utilized most during patient care and education.

1. What term best describes the nature of the nursing process? a. Static b. Linear c. Dynamic d. Predictable

ANS: C The nursing process is dynamic, changing over time in response to patients' individual needs. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any setting and at every level of care, from the intensive care unit to outpatient wellness clinics.

10. Which is true about patient teaching sessions? a. Present all of the information so the patient can learn all that is needed. b. Present the patient with one idea at a time. c. Ensure the presence of a family member at each session. d. End with a written quiz to ensure understanding of the information.

7. A toddler's parent expresses frustration over trying to get her toddler to bed at night. She explains that she has "tried everything." When asked about a bedtime routine, the mother states she has established no set bedtime, she just waits until the child falls asleep in front of the TV. What is the best advice for the nurse to give the mother? a. Stop the television and just put the child to bed without ceremony. b. Establish a set bedtime with a quiet routine beforehand. c. Continue to allow the child to fall asleep in front of the TV. d. Put the child in time-out whenever he or she resists going to bed.

8. The IRB is a review committee that has regulations that avoid exploitation of vulnerable populations. This is inherent in which ethical principle? a. Beneficence b. Justice c. Respect for persons d. Informed consent

3. Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.) a. Noncompliance b. Readiness for Enhanced Knowledge c. Ineffective Coping d. Health-Seeking Behaviors e. Anxiety

b d

3. A team meeting of physicians and nurses is convened to discuss a specific patient's problems and to determine goals for the patient. During the meeting, specific accountability related to patient care for both the physicians and nurses involved is established. All members of the meeting show mutual respect by valuing each other's clinical competence that is necessary to provide quality patient care. Of the following functions of a nurse, which one is demonstrated in the above example? a. Delegation b. Advocacy c. Collaboration d. Management

ANS: C This is an example of the dynamic interpersonal process of collaboration in which health care professionals constructively solve problems and learn from each other.

1. What is an example of Nightingale's contributions to nursing? a. Graduated as the first trained U.S. nurse b. Practiced nursing in the Civil War c. Established the Red Cross d. Emphasized respect for patients' needs and rights

ANS: D Clara Barton practiced nursing in the Civil War and established the Red Cross. Linda Richards was the first U.S. trained nurse. Nightingale emphasized patients' needs and rights.

3. Prior to identifying accurate nursing diagnoses, what action must be taken by the nurse? a. Reading the patient's history b. Setting realistic, measurable goals c. Comparing evidence-based practices d. Clustering related patient data

ANS: D In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. Reading the patient's history is part of assessment. Goal setting and considering evidence-based practice are part of planning.

4. A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse's first action? a. Tell the child that if she stops crying, her parents can be with her. b. Check to see what pain medication is ordered for the child. c. Notify the surgeon of the child's postoperative condition. d. Assess the child to determine why she is crying.

ANS: D Nurses assess the state of a patient's physical, psychological, emotional, environmental, cultural, and spiritual health to gain a better understanding of his or her overall condition.

7. What phrase best describes the essence of critical thinking? a. Understanding without conscious reasoning b. Providing care based on nursing experience c. Consulting with a primary care provider d. Seeking solutions to problems

ANS: D Seeking solutions to problems describes the essence of critical thinking. Paul (1988) describes critical thinking as a complex process during which individuals think about their thinking to provide clarity and increase precision and relevance in a specific situation while attempting to be fair and consistent.

2. Which intervention would be most important for the nurse to include in a patient's care plan if the patient is unable to complete activities of daily living without becoming fatigued? a. Instruct the patient to shower and shave simultaneously b. Discourage the patient from bathing while hospitalized c. Encourage the patient to rest between bathing activities d. Ask the patient's spouse to assist with all bathing

2. Which resource is most helpful when prioritizing identified nursing diagnoses? a. Nursing Interventions Classification (NIC) b. Gordon's functional health patterns c. Maslow's hierarchy of needs d. Nursing Outcomes Classification (NOC)

4. When developing treatment plans, which assumption should the nurse make about individual clients within vulnerable populations? a. Educational levels are minimal. b. Economic resources are strong. c. Personal beliefs are important. d. Support systems are extensive.

5. The unique ability of the patient to understand and integrate health-related knowledge is known as a. basic literacy. b. medical literacy. c. health literacy. d. consumer literacy.

9. A researcher is studying the effect of exercise on heart rate. Which type of variable is heart rate? a. Quantitative b. Qualitative c. Dependent d. Independent

1. The nurse facilitates the use of the intellectual standard of critical thinking of significance by posing which question to determine the patient's understanding of his or her new diagnosis of type 1 diabetes mellitus on his or her lifestyle? a. "What information do I need to provide to teach the patient?" b. "Do you understand how to administer your insulin?" c. "What are the signs of low blood glucose?" d. "How will this diagnosis impact your career?"

ANS: D Significance focuses on how important the information (diagnosis of diabetes mellitus) is to the issue being addressed. Because the nurse is attempting to determine the understanding of the new diagnosis, a focus on how the disease will affect the person's lifestyle focuses on the significance to the patient. The other questions address content, knowledge about DM, not on its effect on the patient's lifestyle/adjustment.

4. Which of the following actions by the nurse demonstrates "doing for" as described in Swanson's theory? a. Going the extra mile b. Thoroughly assessing in order to know what the patient thinks c. Seeking cues and expertise from colleagues about the patient's condition d. Preserving the patient's dignity and performing competently

ANS: D The "doing for" process of Swanson's theory includes preserving the patient's dignity and performing competently. The other answers are either part of the caring process or are part of the practice of knowing the patient.

1. The best approach for a nurse who is performing an assessment on a patient from an ethnic group the nurse knows nothing about is to a. use the information the nurse already knows about the other ethnic groups that may be similar to the patient's group to come up with assessment questions. b. ask the same questions the nurse typically asks of all patients and not deviate from the questions on the assessment form. c. ask the patient to explain what he or she believes his or her health problem is and what he or she thinks caused it. d. ask the patient to help the nurse understand anything about the patient's ethnic group that may have a bearing on the patient's health care needs.

ANS: D The best strategy by the nurse is to approach the situation with humility and admit he knows nothing about the patient's ethnic group but would like to learn about anything that would be significant to the patient's care. "Use the information the nurse already knows about the other ethnic groups that may be similar to the patient's group to come up with assessment questions" is incorrect because it amounts to guessing or pretending rather than just admitting he doesn't know what he needs to in order to provide ethnically appropriate care. The result could mean the nurse would miss something important to the patient. "To ask the same questions the nurse typically asks of all patients and not deviate from the questions on the assessment form" is incorrect since it would completely ignore the patient's ethnic differences and would end in something important being missed. "Ask the patient to explain what he or she believes his or her health problem is and what he or she thinks caused it" is incorrect because it addresses the patient's health problem but doesn't include other ethnic-specific information that would be important in providing care for this patient.

4. A nurse has graduated from a nursing program and is participating in a new graduate program at a local hospital as a continuing socialization to the role of the nurse. At what level is the nurse functioning at this point in the nurse's career? a. Expert b. Competent c. Novice d. Advanced Beginner

ANS: D The nurse is an advanced beginner for 2 to 3 years after graduating and doesn't reach the level of competence until the end of that time period.

8. Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. Medical diagnoses are imbedded in nursing diagnoses. b. Nursing diagnoses are derived from medical diagnoses. c. Medical diagnoses are not relevant to nursing diagnoses. d. Medical diagnoses may be interrelated to nursing diagnoses.

Answer: d Nursing diagnoses consider the underlying etiology, needs, potential concerns, and patient response to a patient's medical diagnosis, so the two types of diagnoses are interrelated. Medical diagnoses are not imbedded or derived from medical diagnoses because that would limit the scope of assessment and care that is provided for patients. Nurses consider the medical diagnosis as one aspect of concern when identifying an actual or potential health problem and the patient's response, so medical diagnoses are relevant, but not the focus of nursing diagnoses.

What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I? a. Insurance documentation b. Professional autonomy c. Role delineation d. Patient safety

Answer: d Safety is the most important reason for using standardized language to communicate patient's needs and information. Using the same definitions of terms helps nurses and other health care professionals interpret the information. Helping with insurance documentation, supporting professional autonomy, and clarifying the nursing role in patient care are uses for NANDA-I taxonomy, but they are not the most important.

6. What is the most important action for a nurse take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy? a. Share concerns with the nurse manager on the nursing unit b. Offer alternative care for a patient and family members c. Discuss how to address patient needs with physicians d. Provide evidence-based research to support nursing care

Answer: d Supporting a suggestion for a new nursing diagnostic label with research is required for consideration by NANDA-I. Sharing concerns, providing alternative care, and advocating for patients are all a part of the nursing role, but are not the most important part of having a diagnosis considered for inclusion in the NANDA-I taxonomy.

7. What is the most significant problem that may result from improperly written nursing diagnostic statements? a. Lack of direction for formulating patient plans of care b. Omission of physician or primary care provider orders c. Combining of two unrelated patient concerns d. Increased team collaboration needs

Answer: a Accurate nursing diagnostic statements provide direction for the development of individualized plans of care. Orders are part of the patient's assessment data. Combining unrelated patient problems is a function of diagnostic development, not a result of an improperly written statement. Poorly written nursing diagnostic statements may or may not result in increased team collaboration.

9. In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indication of bias? a. Collecting the patient's medical history b. Administering IV medications c. Performing oral care d. Completing a bed bath

Answer: a Donning gloves every time the nurse enters the patient's room may reflect bias related to the care of a patient with HIV infection and may interfere with the development of a therapeutic relationship with the patient. The patient with HIV is on standard precautions unless there are complications that put the nurse at risk of blood or body fluid exposure. It would be appropriate for the nurse to wear gloves during the other activities.

4. What action by the nurse would most ensure accurate interpretation of patient communication? a. Providing feedback regarding the conveyed message b. Writing down the patient's conversational highlights c. Assuming significant cultural differences exist d. Verifying the patient's emotional state

Answer: a Feedback is the most effective way to avoid misinterpretation of a message. It helps ensure that the message sent is perceived by the receiver in a way that is consistent with the intention of the sender. Writing down conversational highlights is a form of documentation that can still be misinterpreted unless feedback is sought. Avoid making assumptions regarding cultural differences. Verifying a patient's emotional state provides insight into a patient's state of mind, but it does not ensure accurate interpretation of a conversation.

6. Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge. d. Patient's incision will be well approximated each time it is assessed by the nurse.

Answer: a Goals are to be patient-focused, realistic, and measurable. Only the first goal meets these three criteria.

6. Which of the following actions reflects inductive reasoning? a. Using subjective and objective data to confirm a diagnosis b. Assessing for specific clinical presentations based on a disease process c. Correlating elevated blood pressure to pathophysiology d. Validating an automatic blood pressure cuff reading with a manual measurement

Answer: a Inductive reasoning uses specific facts or details to make conclusions and generalizations (i.e., going from specific to general). Using assessment data (specific data) to arrive at a conclusion (diagnosis) is an example of induction. Deductive reasoning involves generating facts or details from a major theory, generalization, or premise (i.e., from general to specific). The validation of a disease process (general) by specific assessment parameters (signs and symptoms, diagnostic study results, etc.) is an example of a deduction.

7. What action should the nurse take if an alert and oriented patient asks the nurse for personal contact information? a. Ask the patient why the personal information is needed. b. Report the interaction to the nursing supervisor immediately. c. State that it would not be appropriate to share that information. d. Change the subject, and hope that the patient does not ask again.

It is important for the nurse to immediately communicate that sharing personal contact information with patients is inappropriate and violates professional role boundaries. Asking "why" questions and changing the subject are nontherapeutic. Neither action will discourage the patient from further infringing on the nurse's personal right to privacy. Reporting the interaction to a supervisor may be helpful for preventing other nurses from experiencing similar requests; however, the first action taken by the nurse should be to maintain professional role boundaries.

6. What strategy would be most effective in communicating with a highly anxious adult immediately before surgery? a. Providing specific, concise instructions b. Detailing likely causes of their anxiety c. Focusing on postoperative details d. Using instructional multimedia DVDs

Answer: a Only essential information supplied in short, succinct sentences can be comprehended by adults who are extremely anxious. The source of this patient's anxiety is already stated to be the surgery, so the nurse need not elaborate on it. Postoperative teaching is best completed well in advance of surgery and reinforced after completion of the procedure. Multimedia DVDs are not effective teaching tools immediately before surgery. They may be helpful for a patient to watch at least 24 hours before a scheduled procedure to allow time for elaboration on topics not totally understood by the patient. Nurses must always check with the patient to verify that critical information is understood regardless of what form of communication has been used.

10. During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse's use of which intellectual standard of critical thinking? a. Clarity b. Logic c. Precision d. Significance

Answer: a Patient information must first meet the intellectual standard of clarity before it is evaluated for precision, logic, or significance.

7. What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests

Answer: a Patient needs are always the primary focus of nursing interventions. Nursing concerns, physician priorities, and family requests can provide additional guidance in the development of a patient-centered plan of care.

5. What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis? a. Defining characteristics are not part of a risk diagnosis. b. There is no cause and effect relationship established. c. Defining characteristics are subjective in a risk diagnosis. d. There are no nursing interventions prescribed with a risk diagnosis.

Answer: a Risk diagnoses do not have defining characteristics; actual and health-promotion nursing diagnosis statements have defining characteristics. Risk diagnoses do not establish a cause and effect, because they identify potential rather than existing problems. Risk diagnoses contain related or risk factors rather than defining characteristics, subjective or otherwise. Risk diagnoses, like actual diagnoses, have nursing interventions to address a patient's current or potential problem.

9. A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious.

Answer: a When a patient shares a concern, the first action by the nurse is to assess potential reasons for the patient's problem. Depending on the underlying reason for the patient's inability to sleep, the nurse may then want to administer prescribed sleep medication, teach the patient some relaxation techniques, or discuss patient behaviors with the primary care provider.

10. Which defense mechanism is being exhibited when a 27-year-old patient insists on having a parent present during routine care? a. Denial b. Regression c. Repression d. Displacement

Answer: b Young adults who require their parents' presence for routine care are exhibiting regression, which is behavior consistent with earlier stages of development. Patients in denial refuse to see the reality of their situation. Repression is storing painful feelings in the unconscious, causing them to be temporarily forgotten. Displacement transfers emotional energy away from the actual source of stress to an unrelated object or person.

10. A nurse has performed a physical examination of the patient and reviewed the laboratory results and diagnostics on the patient's chart. The nurse is performing which specific nursing function? a. Diagnosis b. Assessment c. Education d. Advocacy

Answer: b The nurse is performing the first step in the nursing process: assessment.

9. In Swanson's Caring Theory, the nurse demonstrates caring using several techniques. Which of the following is (are) included in the five caring processes? (Select all that apply.) a. Call patients by their first name to demonstrate a caring attitude. b. Sit at the bedside for at least 5 minutes each hour. c. Use touch based on the nurse's judgment of what is appropriate. d. Ask the patient to identify the most important thing to accomplish during the nurse's shift.

Answer: d The answer is based on the idea that the patient should always, whenever possible, be included in developing the plan of care and especially in setting his or her own goals. The other three answers are close, but something is wrong with each one. Calling patients by their first name to demonstrate a caring attitude is incorrect because the nurse should call each patient by his or her preferred name. Sitting at the bedside for at least 5 minutes each hour is incorrect because the nurse should sit at the bedside for 5 minutes each shift rather than each hour. Using touch based on the nurse's judgment is wrong because the nurse should allow the patient to decide how much touch is appropriate.

3. An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient

Answer: d The nurse collects primary data directly from patients who are alert and oriented. Family members and other members of the health care team may provide secondary data on patients.

8. What would be the best therapeutic response to a patient who expresses indecision about recommended chemotherapy treatments? a. "Can you tell me why you are undecided?" b. "It's always a good idea to have chemotherapy." c. "You should follow whatever your health care provider recommends." d. "What are you thinking about the treatments at this point?"

Answer: d Asking open-ended questions allows patients to share freely on a subject. "Why" questions, using closed-ended questions, and giving advice are all nontherapeutic communication techniques that limit patient reflection and sharing on topics of concern.

3. Which phrase best represents a related factor in an actual nursing diagnosis? a. Unsteady gait requiring the assistance of two people b. Redness and swelling around the incision site c. Ineffective adaptation to recent loss d. Patient complaint of restlessness

Answer: c Related factors are broad statements that indicate the cause for the defining characteristics, which are signs or symptoms identified from collecting the patient's data. Redness and swelling, unsteady gait, and complaint of restlessness are specific defining characteristics that would be clustered with other data to support the existence of an actual or health-promotion nursing diagnosis.

4. Health care workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs and practices of these patients. What important aspect of nursing professional practice are they exhibiting? a. Autonomy b. Accountability c. Cultural competence d. Autocratic leadership

Answer: c The nurse and other health care workers are exhibiting cultural competence by being responsive to patients' health beliefs and practices that are influenced by the individual's culture.

10. _______________ syndrome is a neurotoxic disorder that has been linked to febrile illness and aspirin use in children less than 18 years of age.

REYE

10. What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care, because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed.

Answer: c The nurse should evaluate the need to continue or discontinue a plan of care if a patient has met a short-term goal. It is unnecessary to consult the surgeon unless there is a concern. Discontinuing the care plan may be premature, and the decision needs to be evaluated before taking action. The patient's intake and output will continue to be monitored throughout hospitalization, not just for 1 hour after surgery.

1. What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the ways nurses think about patient care d. Facilitating communication among members of the health care team

Answer: c The nursing process is the methodology used to "think like a nurse." Providing patient-centered care and enhancing communication among health team members is facilitated through the use of care plans. Collaborating with rather than identifying members of the health care team is part of many plans of care.

4. The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first? a. Ask the patient to describe the chief complaint b. Request that another nurse be assigned to this patient c. Review data about the medical diagnosis and routine management d. Complete a physical assessment of the patient

Answer: c The priority action is to find the necessary information/data needed to guide the nursing care. The nurse cannot apply critical thinking about something that is unknown. If the nurse asks the patient to describe the chief complaint or completes the physical assessment with limited knowledge of the disease process, the nurse has nothing to corroborate or compare. Requesting another nurse to care for the patient does not address the lack of knowledge.

3. Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data? a. Do these findings make sense? b. How can this information be verified? c. What are the most significant factors in the problem? d. What is the relationship of this information to other data?

Answer: c Determining relationships is effective in establishing the relevance of data. Verification of information is related to accuracy, making "sense" relates to logic, and significance more closely relates to depth. The routine use of the intellectual standards helps improve critical thinking.

3. Which statement best describes for new parents how and when children develop first-order beliefs? a. During infancy, and once developed, such beliefs seldom change b. From life experiences during the toddler and preschool years c. Throughout life from first-hand experiences and information provided by authority figures d. From teen and young-adult peer interaction and mentorship of professional role models

Answer: c Individuals develop first-order beliefs beginning in childhood and continue to acquire them throughout life from first-hand experiences and what they are told by various authority figures. Therefore, first-order beliefs are acquired throughout life and not just in infancy, the first years of life, or adolescence. They form as the result of life experiences and from information provided by people perceived as having authority.

2. Which nursing theory of care describes how the nurse's presence in the nurse-patient relationship transcends the physical and material world, facilitating the development of a higher sense of self by the patient? a. Swanson's Theory of Caring Processes b. Madeline Leininger's Cultural Care Theory c. Watson's Theory of Human Science and Human Care d. Travelbee's Human-to-Human Relationship Model

Answer: c One of the major concepts of Watson's Theory of Human Caring is described in the stem of the question. Watson's theory is based on a holistic paradigm in which both the nurse and the patient transcend time and the physical and material world. Swanson's theory focuses on practical ways the nurse can help the patient through the use of the five caring processes. Leininger's theory focuses on maintaining and preserving the patient's cultural practices and ways of living but never mentions transcending beyond the physical world. Travelbee's theory focuses on the nurse and the patient creating a relationship bond, but the only mention of transcendence is that the nurse and the patient must transcend the roles that each has assumed.

5. After admitting a homeless patient to the floor, the nurse tells a colleague that "homeless people are too dumb to understand instructions." What action should the colleague take first? a. Ignore the nurse's prejudicial comment without responding b. Offer to trade assignments and care for the homeless patient c. Ask the nurse about the patient's personal history assessment data d. Challenge the nurse's thinking, pointing out the ability of all people

Answer: c The colleague should first ask the nurse to share information about the patient's background. This should encourage the nurse to consider the feelings and values of the patient and hopefully help the nurse to view the patient as a total individual. Ignoring the statement, offering to change assignments, or challenging the nurse's statement does not promote an enhanced nurse-patient relationship and may prevent the nurse from professional growth or make the nurse defensive.

5. A nurse makes a medication error, immediately assesses the patient, and reports the error to the nurse manager and the primary care provider. Which characteristic of a professional is the nurse demonstrating? a. Autonomy b. Collaboration c. Accountability d. Altruism

Answer: c The nurse is demonstrating accountability by taking responsibility for the error and reporting it after an initial assessment of the patient. Criteria of a profession include altruism (public service over personal gain), autonomy (independence), accountability, and diversity; however, in this case, the nurse is demonstrating accountability. Although collaboration is important for the health care team, it is not a criterion for a profession.

7. Which core competency of advanced practice nursing is the Master of Science in Nursing (MSN) nurse educator exhibiting when counseling a student in therapeutic communication techniques? a. Leadership b. Ethical decision making c. Direct clinical practice d. Expert coaching

Answer: d A nurse educator who is teaching and counseling students is practicing expert coaching and guidance. A nurse educator with a master's degree practices the other competencies of leadership and ethical decision making in other situations. Although a nurse educator may also work as a nurse involved in direct patient care, this is not part of the educator role.

2. A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting

Answer: d In an emergent situation, the nurse initially focuses on the patient's chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.

9. Which statement is most accurate regarding symbolic expression? a. Skills confidence can be shared most effectively by nurses through wearing distinctive clothing. b. Clothing choices by a hospitalized patient rarely reflects his or her economic resources. c. Make-up use by a patient is unnecessary for any reason during hospitalization. d. Nondramatic make-up use and minimal accessorizing by nurses demonstrates professionalism.

Answer: d Nurses demonstrate professionalism by adhering to institutional dress codes that require minimal accessorizing and cosmetic use. Wearing distinctive clothing is not linked to skills confidence. Clothing choices often reflect the economic resources of an individual, and make-up use by a hospitalized patient is a personal preference that should be honored.

1. From the nurse's knowledge about the emerging adult according to Arnett's theory, which behavior by a 21-year-old hospitalized male patient is most appropriate for his age group? a. Talking about college courses that he is taking while working part-time at a restaurant b. Requesting that his mom be present when his IV line is started c. Stating that he cares for his disabled father and his 2-year-old daughter d. Becoming upset that he is not giving back to his community

1. The hospice nurse believes the nursing diagnosis chronic sorrow is significant in the recovery process of patients recently experiencing a loss. What is required to support the addition of new nursing diagnoses to the NANDA-I taxonomy? a. Clinical research and data collection b. Changes in patient status and life experience c. Anecdotal nursing experiences d. Patient requests

1. Which action by a 3-month-old infant would the nurse interpret as an example of Piaget's stage of primary circular reaction? a. Deliberately placing the thumb into the mouth b. Accidentally kicking a ball c. Searching for an object under a blanket d. Shaking a rattle

10. A teenage girl faces a long hospitalization after surgery. How can the girl's continued development be fostered? a. Encourage her to write her feelings in a journal. b. Divert her attention by playing video games. c. Encourage her to work on craft projects. d. Make sure her parents are constantly by her side.

10. Which situation indicates the greatest need for collaborative interventions provided by several health care team members? a. Hospice referral b. Physical assessment c. Activities of daily living d. Health history interview

2. A 58-year-old male is admitted for a small-bowel obstruction late Saturday night. The nurse obtains admitting orders, which include the need to place a nasogastric (NG) tube to low intermittent suction. During the assessment, the nurse determines that the patient does not speak English. What should the nurse do before placing the NG tube? a. Assess the presence of any family members who may speak English and the patient's native language. b. Take two additional staff members into the room when placing the tube so the patient can be restrained if needed. c. Request an interpreter by leaving a voicemail on his or her office extension. d. Do not place the NG tube because the physician would not want to frighten the patient.

2. The nurse has just received a postoperative patient to the floor postureteral stone manipulation. Choose the priority nursing diagnosis. a. Risk for urinary retention r/t general anesthesia and trauma to ureter b. Pain, acute r/t recent surgical procedure and verbalization of pain of 4 on scale 0-10 c. Risk for bleeding r/t surgical site injury d. Comfort, impaired r/t inability to urinate and verbalization "I am beginning to feel full"

2. Which activity best illustrates the use of the Health Promotion Model (HPM) by the nurse to increase the level of well-being for a patient immediately after surgery? a. Holding a pillow across his chest when coughing and deep breathing b. Encouraging the patient to eat his entire evening meal c. Changing his surgical dressing daily as ordered by the physician d. Asking his family to step out of the room during dressing changes

3. A nurse providing preventive care to an overweight patient with a family history of diabetes should engage in which priority care-planning activity for this patient? a. Calculating the patient's body mass index (BMI) and recommending a daily exercise routine b. Instructing the patient to perform blood glucose monitoring once daily c. Giving the patient a month's supply of insulin needles and syringes d. Participating in diabetes education classes offered at a local health facility

3. Prioritization of nursing diagnoses requires the use of which of the following tools? a. Maslow's hierarchy of needs b. Consideration of the ABC's, airway, breathing, circulation c. Basic life support assessment tool d. Advanced life support assessment tool

3. The nurse researcher provides participants with informed consent so that what ethical principle is upheld? a. Respect for persons b. Beneficence c. Justice d. Ethics

3. When a patient reports having dyspareunia, which question is it most appropriate for the nurse to ask? a. "Have you talked with your partner about this discomfort?" b. "Have you had these spasms since you became sexually active?" c. "Does the bleeding continue longer than five days?" d. "Do your breasts swell up large enough for you to need a larger bra?"

4. An example of implementation of evidenced practice by the nurse would be the nurse a. initiates a new policy protocol for the removal of c-collars and bed board restraints of the emergency department patient based on empirical research results. b. watched a news report on a new procedure for chest tube removal and implements the procedure on the patient needing chest tubes removed. c. saw a physician perform a manipulation for vertigo related to inner ear problems and decides to utilize the manipulation for the current patient experiencing vertigo. d. is assisting a physician with conscious sedation during a procedure and is asked to perform outside the nursing scope of practice.

4. Inclusion of the patient in the planning process is significant due to the fact that a. inclusion of the patient in the planning increases chances of goal attainment. b. the patient is the only person who should be setting goals. c. goal attainment is dependent on the excellence of the nurses' planning with the patient. d. patient participation is nice to include but not necessarily required.

4. The nurse is providing home-going teaching to Mr. K., a 59-year-old male patient who had his gallbladder removed yesterday. The nurse should consider further health literacy-related assessment when the patient states a. "Can you read that to me? My wife took my glasses home." b. "I don't understand what you are saying about what I can eat." c. "Do I have to take the pain medicine even if I don't feel I need it?" d. "Do I still need to use that breathing exerciser when I get home?"

4. Which nursing diagnosis is appropriate if a patient expresses an interest in learning? a. Readiness for Enhanced Knowledge b. Knowledge Deficit c. Information Processing d. Health-Seeking Behaviors

6. A father is upset because his preschool son has told him he wishes he were gone and pushes him and his wife apart whenever they are together. What advice should the nurse give the father? a. This is normal at this age and should resolve on its own. b. The child may need counseling to resolve his conflict. c. Tell the child this is inappropriate and will not be tolerated. d. The child needs to go to preschool to separate from his mother.

6. A weight-loss program that combines nutrition instruction with exercise is an example of teaching based on which domain of learning? a. Psychomotor b. Affective c. Psychosocial d. Cognitive

6. Three weeks after delivery, a patient started a diet of 800 calories per day and started jogging 2 miles twice per day. The nurse recognizes the patient's behavior may be influenced by which motivating factor? a. Body image b. Family roles c. Illness behavior d. Chronic illness

8. The nurse has provided home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement by the mother indicates a need for further instruction? a. We are going to her cousin's birthday party tomorrow! The whole family will be there! b. I will need to keep the incision clean and dry. c. Some mild exercise with periods of rest is best. d. I can administer the pain medicine as prescribed on the label every four hours.

8. Which of the following questions may help the nurse determine the mental health status of a patient? a. How often do you have trouble relaxing? How often do you feel nervous? Do you have thoughts of harming yourself? b. Do you exercise? Do you work out 3 times a week? c. Do you eat a low-calorie, high-fiber diet? d. Are you sexually active? Do you practice safe sex?

9. When teaching the patient mechanical barriers for birth control, the nurse would include which method? a. Diaphragm b. Transdermal patch c. Hormone injection d. Oral contraceptives

1. Goals are set during the planning step and (Select all that apply.) a. are broad statements of purpose that describe the aim of nursing care. b. represent short- or long-term objectives. c. are realistic and measurable. d. are generated by the patient without the input of the nurse.

a b c

3. Identify nurse-initiated interventions: (Select all that apply.) a. ordering heel protectors for patients susceptible to skin breakdown b. consultations with social workers c. preadmission teaching d. ordering pain medication

a b c

4. Identify the situation where collaborative interventions could be implemented: (Select all that apply.) a. physical therapy b. home health care c. palliative care d. performing surgery

a b c

1. What should the nurse consider before implementation of all nursing interventions? (Select all that apply.) a. Potential communication barriers b. Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient e. Time of most recent shift change

a b c d

8. Whom should the school nurse engage in discussion when conducting a needs assessment related to the high incidence of obesity in the school system? (Select all that apply.) a. Parents b. Students c. School staff d. Community members e. Firefighters and police

a b c d

8. When an injury to a child is suspicious for abuse, which is/are important to document? (Select all that apply.) a. Size and location of bruising b. Distinguishing characteristics of injuries c. Height and weight of the child d. Time of last meal e. General state of health of the child

a b c e

2. Standards of care guide practice through (Select all that apply.) a. prudent performance of the nursing process. b. accountability. c. universal standards. d. development of the patient care plan.

a b d

3. The nurse is caring for a group of older adults. Which patient(s) in this group is/are exhibiting normal signs of aging? (Select all that apply.) a. The patient with knee pain and wrinkles around the eyes b. The patient who needs reading glasses and states that the food tastes bland c. The patient who is confused and does not know the current year d. The patient who states that constipation is an increasing problem e. The patient who is showing signs of depression and hopelessness

a b d

6. If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.) a. Expressed desire to eat b. Report that food smells good c. Use of relaxation techniques before meals d. Preparation of home-cooked meals for self and family e. Uses nutritional information on labels to guide selections

a b d

8. Which entity or document specifically addresses the role of the nurse in research? (Select all that apply.) a. American Nurses Association standards of practice b. Institutional review board c. Hospital Magnet status d. Joint Commission e. MD Consult

a c

1. Which of the following questions should be included in the health assessment of the young adult? (Select all that apply.) a. Have you attempted to harm yourself in the past or do you have plans to do so now? b. What is your salary range? c. Do you keep guns in your house? d. Do you wear your seat belt?

a c d

7. Which action is a part of the evaluation step in the nursing process? (Select all that apply.) a. Recognizing the need for modifications to the care plan b. Documenting performed nursing interventions c. Determining if nursing interventions were completed d. Reviewing whether a patient met their short-term goal e. Identifying realistic outcomes with patient input

a d

1. Which of the following are components of delegation? (Select all that apply.) a. Assigning the correct task b. Assigning planning in the nursing process c. Having the LPN contact the physician for orders d. Using correct supervision to the delegate e. Assigning a task under the right circumstances

a d e

7. Patients are participating in a study to identify genetic disorders. What is a potential concern? (Select all that apply.) a. Violation of confidentiality if a disorder is revealed b. Possible adverse consequences related to employment c. Possible adverse consequences related to reputation d. Possible adverse consequences to insurability e. Inability to prevent the progression of genetic disorders

a e

7. Which intrinsic factor(s) would be of major concern to the nurse when the community has an outbreak of pertussis? (Select all that apply.) a. Age b. Gender c. Ethnic group d. Cultural background e. Immunization status

a e

1. In comparing the American Nurses Association (ANA) and the International Council of Nurses (ICN) definitions of nursing, what component does the ICN mention that is not included in ANA's definition and is indicative of a more global focus? a. Advocacy b. Health promotion c. Shaping health policy d. Prevention of illness

answer: C The ICN's definition of nursing expands on the ANA's definition by providing for the concept of shaping health policy as a responsibility of nursing.

1. For which reason are patients unlikely to introduce the topic of sex with health care providers? a. Most patients have few, if any, questions or problems relating to this topic. b. They are too embarrassed to discuss the topic of sex with a health care provider. c. Female patients prefer to discuss problems with female health care providers. d. They assume that health care professionals know little about sexual functioning.

1. The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she states, "You don't have to go over those—I'll read them at home." What should the nurse do? a. Contact the physician immediately. b. Consider the possibility of health literacy limitations and assess further. c. Stop the teaching, because the mother obviously has taken care of casts before. d. Explain to the mother that reading the instructions with her is required.

1. The nurse seeks assistance from the speech therapist on a patient's case to determine the patient's ability to swallow food. Which care technique is utilized here? a. Indirect communication b. Collaboration c. Delegation d. Assistive contribution

10. A client with metastatic cancer shares with the clinic nurse that he has only days or weeks to live. What type of community service would be most appropriate for the nurse to suggest to this client? a. Home health care b. Hospice care c. Forensic care d. Acute care

10. A patient is seeking information about leading indicators that show the importance of health promotion and illness prevention in the United States. To which government-sponsored program would the nurse refer the patient for the best source of information? a. The American Cancer Society website b. The Healthy People 2020 website c. The Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report d. The American Association of Hospitals home page

10. After reading various research articles and reviews on a subject, the nurse designs a practice change based on the literature. What stage of evidence-based practice is this? a. Maintaining the change b. Implementing the change c. Evaluating and critically appraising d. Synthesizing the evidence and developing a plan

2. A 14-year-old male is upset because he is shorter in stature and smaller in build than the other boys in his class. He is concerned about never growing. How should the nurse address his concern? a. Reassure him that everyone grows at his own rate. b. Reassure him that males often do not stop growing until they are 18-20 years old. c. Tell him that most males start their growth spurt around 9-14 years of age. d. Tell him to take in more protein in order to get his growth spurt started.

2. The Nursing Outcomes Classification (NOC) is used for what purpose in the planning step? a. State whether the outcomes are appropriate for the implementation phase b. Provide the list of standardized nursing sensitive outcome indicators c. Be utilized for risk for nursing diagnoses d. Only apply to illness-related nursing diagnoses

2. The mother of a 5-month-old infant is concerned because her child is not yet sitting on his own. What is the nurse's best response to her concerns? a. Informing the mother that this is not normal and recommending further evaluation b. Telling the mother that this is normal development for a 5-month-old c. Encouraging the mother to do sit-ups with the child to encourage muscle development d. Asking the mother if the child had any trauma at birth

2. The nurse decides to access a systematic review database to determine evidence-based practice related to the patient's treatment plan for a diagnosis of otitis media (i.e., ear infection). What database can provide that type of resource? a. Cumulative Index of Nursing and Allied Health Literature (CINAHL) b. Cochrane c. PubMed d. MD Consult

3. A 1-year-old child grabs an Easter egg and attempts to throw it across the room. The nurse knows that the child is exhibiting which scheme according to Piaget? a. Adaptation b. Assimilation c. Accommodation d. Equilibration

3. If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care? a. Fatigue b. Acute Pain c. Knowledge Deficit d. Body Image Disturbance

3. What action would be most appropriate for the home care nurse to take if an intrinsic factor appears to be contributing to a client's illness? a. Report the presence of multiple insects in the home to the health department. b. Document the intrinsic factor in the client's electronic health record. c. Explore the possible impact of changing jobs for stress reduction. d. Discuss the danger of having multiple throw rugs with the client.

3. Which nursing intervention is most important to complete before giving medication to a patient? a. Provide water to aid in the patient's ability to swallow the medication. b. Double-check the patient's allergies before giving the drug. c. Ask the patient to verify having taken the medication before. d. Place the patient in a side-lying position to prevent aspiration.

4. An active, older patient has been frequently evaluated for minor problems at the clinic since the death of her husband 3 months earlier. During one of her visits, she states that she has no energy to get through the day and no desire to keep up with her Tuesday night bridge club. Which type of holistic health model intervention should the nurse employ to help the patient cope with the loss of her husband?

4. How would the nurse differentiate between quantitative research and qualitative research? a. Quantitative research is inductive, and qualitative research is deductive. b. Quantitative research is observable and measurable, and qualitative research focuses on values and beliefs. c. Quantitative research is knowledge gained through understanding of meaning of the process, and qualitative research is knowledge gained through scientific research. d. Qualitative research is based on post-positivist philosophy, and quantitative research utilizes a constructivist philosophy.

4. Strategies for stress relief when caring for an aging parent include all of the following except: a. Seek social support b. Place him or her in a nursing home c. Use community resources d. Utilize respite care services

4. Which behavior by the young adult patient indicates an understanding of patient education aimed at reducing the health risks for that age group? a. Smoking only 1 pack of cigarettes per day b. Limiting alcohol use to an occasional drink c. Using drugs found in a roommate's drawer for anxiety d. Having a relationship with a partner who was threatening in the past

4. Which of the following would be an inappropriate intervention for a patient with the nursing diagnosis of "Impaired Physical Mobility"? a. Use pressure relieving devices on bed and chair. b. Promote independence in performing all activities of daily living. c. Reinforce safety precautions with the patient and family. d. Perform active and passive range of motion three times daily.

5. A 16-year-old male patient has been involved in a motor vehicle accident. Every time the nurse enters his room, there are at least 4-5 friends laughing and talking with the patient. The nurse is frustrated in trying to get things done. What is the nurse's best action? a. Call security to escort the visitors from the room. b. Work with the boy and his friends to plan and coordinate activities to minimize interruptions. c. Ask the boy's parents to tell his friends to stay away. d. Post a "Do not disturb" sign on the door.

5. A 2-year-old child insists on having a drink of water and having a story read to him and says "Good night, sleep tight" at bedtime every night. The nurse knows the child is exhibiting which type of behavior? a. Controlling b. Ritualism c. Obsession d. Compulsion

5. A patient presents to the emergency room with chest pain. Which of the following is the priority nursing intervention? a. Administer acetaminophen immediately. b. Provide oxygen via nasal cannula as ordered by the physician. c. Provide emotional support. d. Prepare the patient for emergency surgery.

5. In using the PLISSIT model, what is the first action initiated by the nurse? a. Present basic information about sexual functioning. b. Ask permission to begin the sexual assessment. c. Inquire about any medications the patient is taking. d. Ask the patient about sexual activity and practices.

5. Knowledge gained from research in the 1970s about placing infants on their backs to prevent sudden infant death syndrome was not recommended to parents until the 1990s. This is an example of what barrier to evidence-based practice? a. Proliferation of research b. Implementation delay c. Information needs not being met d. Lack of readily available resources

5. The charge nurse of a cardiac unit running code situation is practicing what type of planning? a. Initial patient planning b. Acute patient planning c. Discharge patient planning d. Maintenance patient planning

5. Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery? a. Nurse will encourage use of sterile technique during each dressing change. b. Patient's white blood count will remain within normal range throughout hospitalization. c. Patient's visitors will be instructed in proper hand washing before direct interaction with patient. d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.

5. While assessing a patient for domestic violence, the nurse knows that which statement is true regarding domestic violence? a. It is a health risk factor only during young adulthood. b. It occurs across socioeconomic levels and cultural boundaries. c. Young women aged 20 to 24 have the lowest incidence of rape and sexual assaults. d. Women are the only victims of domestic violence whom nurses should be concerned about.

6. How is the toddler's need for autonomy best met? a. The parents' consistently meeting the child's needs b. Allowing the child limited choices c. Encouraging imaginative play d. Promoting experimentation to determine cause and effect

6. The following factors are not primary considerations when assessing health literacy: a. Age and role b. Gender and IQ score c. Cultural diversity components d. Economic resources

6. What is the best method for the public health nurse to determine whether community members are involved in outdoor physical activity? a. Meet with the parents of high school children. b. Complete a windshield survey of the community. c. Evaluate the number of community health club members. d. Check the local health statistics for the incidence of obesity.

6. Which of the following statements regarding older adults is not true? a. Common causes of death include heart disease, stroke, and influenza. b. Chronic illnesses include arthritis, COPD, and STDs. c. Declines in the immune system make older adults susceptible to infections. d. Acute injuries are often the result of falls and pneumonia.

7. A 65-year-old male patient has been a one-pack-per-day smoker for 40 years. He was recently diagnosed with early-stage chronic obstructive pulmonary disease (COPD) and would like to attend a smoking cessation class. The nurse recognizes smoking cessation as which level of prevention for this patient? a. Primary prevention b. Secondary prevention c. Statutory prevention d. Tertiary prevention

7. The nurse is performing a health assessment on a 15-year-old female patient. Which is the best way to obtain accurate information regarding her sexual activity? a. Ask the mother about the girl's sexual activity. b. Privately ask the girl about her sexual activity. c. Warn the girl about the dangers of sexual activity. d. Ask the girl if she wants birth control.

7. Which of the following is an example of collaboration? a. The nurse receiving orders from a physician b. The nurse and physical therapist creating an ambulation schedule for the patient c. The nurse arranging for discharge instructions to be provided to the patient and family d. The nurse providing the patient with a video on insulin injections

8. When teaching female reproduction to a group of high school students, the nurse uses what term to indicate the cessation of a woman's menstrual activity? a. Menarche b. Menopause c. Premenstrual syndrome d. Menstrual dysfunction

9. In examining a 3-month-old infant, you would expect to see all of the following except: a. Raising chest and head when prone b. Responding to own name c. Social smile d. Bringing hand to mouth

9. The nurse enters a patient's room to deliver a dinner tray and notices that the patient has not been out of bed since the previous day. The patient states that his condition has made him bed-ridden, although the nurse knows that he is capable of independent ambulation. Which type of reaction is the patient exhibiting?

9. The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider? a. Elevating the head of the patient's bed b. Administering oxygen by nasal cannula c. Assessing the patient's oxygen saturation d. Evaluating the patient's peripheral circulation

2. The nurse is teaching a patient about sexually transmitted diseases. Which of the following statements, if made by the nurse, could lead to the spread of STDs? (Select all that apply.) a. Always use latex condoms. b. If you don't have any symptoms then you probably don't have an STD. c. All HPV infections are low risk infections. d. There is no cure for HPV.

b c

1. Which factor(s) should be considered by the public health nurse before scheduling community infant immunization clinics? (Select all that apply.) a. Individual infant allergies b. Transportation availability c. Cost of immunization services d. Local attitudes toward immunization e. Personal feelings about immunization effectiveness

b c d

8. Which intervention can the nurse initiate independently while providing patient care? (Select all that apply.) a. Ordering a blood transfusion b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors e. Adjusting antibiotic dosages

b c d

9. Which of the following factors contributes to the nurse having difficulty keeping up with the latest patient care information? (Select all that apply.) a. Implementation delays b. Proliferation of research c. Volume of health care literature d. Hours spent in direct patient care e. The need to read 3 articles every day of the week

b c d

1. The nurse has found an article discussing insulin use in the diabetic patient. Which of the following would contribute to the belief that it is a valid study? (Select all that apply.) a. A small sample size b. Random assignment of patients to control and treatment groups c. No discussion of IRB approval d. Patient is kept blind as to which treatment is being used

b d

6. Which step(s) can nurses and health care providers take to remove barriers to identifying and treating victims of domestic violence? (Select all that apply.) a. Call the police. b. Ask about abuse. c. Ask for proof of domestic violence. d. Screen for domestic violence with all patients. e. Disregard reported abuse in spouses.

b d

1. A kindergartener's mother is concerned because the child has had two bouts of respiratory infections in the past three months since school started. What is the nurse's best response? a. "His immune system should be stronger by now; I think we will need to do some further screening." b. "His immune system is compromised because his schedule has changed. Be sure he gets to bed on time." c. "He is exposed to more germs now that he is in school. Let's go over good handwashing." d. "You should talk to the school about disinfecting the classroom."

1. The Nursing Interventions Classification (NIC) index is used for what purpose in the planning step? a. Provides guidance for selection of nursing interventions b. Is updated annually for accuracy c. Lists appropriate interventions for nursing diagnoses d. Is useful during the second step of the nursing process

1. The nurse found a research article and decided to implement the research findings in her practice on the unit. This is an example of a. evidence-based practice. b. research. c. research utilization. d. critical appraisal.

1. The nurse is caring for a 47-year-old mother of five young children who underwent a total abdominal hysterectomy yesterday for uterine cancer. During the night, the patient began having large amounts of vaginal bleeding. Her hemoglobin levels are being checked every 4 hours and have dropped dramatically since last evening. The physician calls into the unit and orders a blood transfusion of two units of packed red blood cells. When the nurse approaches the patient to explain the procedure and obtain consent, the patient says "I cannot take blood products ... it's against my religion." The most supportive intervention is a. hang the blood since her hemoglobin level is dropping. b. explain to her that she could die if she doesn't get the transfusion. c. encourage the patient to verbalize her feelings and contact the physician. d. wait until the next time her hemoglobin level is drawn to see if it goes down further.

10. While performing a physical assessment on a female patient, the nurse finds several bruises on the patient's inner thighs that are in various stages of healing and suspects that the patient may be a victim of sexual abuse. What should be the nurse's first action? a. Refer the patient to a sexual counselor. b. Tell the patient about the safe house for women. c. Ask the patient to describe how she got the bruises. d. Report the abuse immediately to the proper authorities.

2. How would you differentiate basic research from clinical research? a. Basic research is the application of theories in different populations, whereas clinical research is the testing of theories for effectiveness of interventions. b. Basic research is the generation of theories, whereas clinical research is the application of theories in different populations. c. Basic research is the generation of theories, whereas clinical research is the testing of theories for effectiveness of interventions. d. Basic research is the generation of knowledge, whereas clinical research is the generation of theories.

2. Which intervention should the college health clinic nurse implement as a secondary prevention strategy to identify students at risk for diabetes? a. Nutrition education on high-protein food availability b. Promotion of registration in fitness classes c. Blood glucose screening at the health fair d. Administration of prescribed insulin

2. Which of the following is a direct care intervention? a. Reviewing the most recent clinical results from the laboratory b. Collaborating with social services regarding patient discharge plans c. Performing patient education regarding use of an incentive spirometer d. Obtaining medical records from a previous admission

3. Documentation is a component of which part of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

4. The nurse feels that the results of a recent literature search and analysis about handwashing should be implemented in the entire hospital system. With whom would the nurse be required to collaborate? a. Colleagues caring for patients in her unit b. Colleagues in the community c. Administrators at the hospital d. Others in her department

4. The nurse is caring for an 11-year-old girl in a hospital. The nurse finds a bunch of gum wrappers in her bedside stand. Which is the most appropriate action by the nurse? a. Reprimand the girl for being so sloppy. b. Quietly clean up the mess and throw them away. c. Leave the wrappers as you found them. d. Tell the girl to clean up the mess.

5. An 8-year-old girl is newly diagnosed with type 1 diabetes. The nurse may expect fear and crying when teaching the child how to self-administer insulin injections due to which influencing factor? a. Self-concept b. Self-esteem c. Developmental level d. Hierarchy of needs

5. How does ethnography differ from grounded theory? a. Ethnography is the lived experience of a group of people, and grounded theory studies historical documents. b. Ethnography derives a theory from research data, and grounded theory is described as field notes. c. Ethnography is described as field notes, and grounded theory derives a theory from the research data. d. Ethnography studies historical documents, and grounded theory is the lived experience of a group of people.

5. The clustering of data is significant to the nursing diagnoses step because clustering of data will a. show the nurse assessment is complete for this patient. b. move the nurse toward accurate planning for the symptoms in clustered data. c. group the data of similar problems and aid in accurate nursing diagnosis identification. d. organize the data for clear assessment so further assessment can occur.

5. The term "ageism" refers to a. the act of getting older. b. the hallmark of older adult populations. c. prejudices and stereotypes applied to individuals based on their age. d. octogenarians.

6. The nurse has identified an article that is appropriate for the question and needs to interpret the information that is related to the patient the nurse is caring for. What step in the process of EBP is the nurse at? a. Synthesize the evidence and develop a plan. b. Formulate a question. c. Search for information and evaluate and critically appraise the information. d. Implement the plan.

6. The nurse working in the patient discharge center is practicing what type of planning? a. Initial patient planning b. Acute patient planning c. Discharge patient planning d. Maintenance patient planning

6. Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention? a. Ambulating a patient with ataxia and new right sided paresthesia b. Feeding a patient with cerebral palsy who recently aspirated c. Transporting a patient to the hospital entrance for discharge d. Administering prescribed programmed medications

7. The nurse is providing home care to a 62-year-old female who was recently diagnosed with insulin-dependent diabetes mellitus. What is the most important reason for the nurse to document the teaching session? a. The patient's insurance company requires documentation. b. The nurse's employer requires documentation of home care sessions. c. Other members of the health care team need to know the patient's progress. d. Insulin is a potentially dangerous medication and needs to be documented.

7. Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult? a. Providing a written copy of care options to the patient and family b. Collaborating with the patient's social worker to determine resources c. Listening to the patient's concerns and beliefs about proposed treatment d. Engaging the patient's family, friends, or care providers in conversation

7. Which group is referred to as the "sandwich generation?" a. Older adults who are caretakers for their elderly parents b. Younger adults who are reexamining their life choices c. Middle adults who are caretakers for multiple generations of their family d. Younger adults who are changing employment constantly

8. A patient diagnosed with an aggressive cancer is estimated to have 6 months to live. Two months later, the patient's wife calls the nurse's office because she is upset that her husband has taken up motorcycle racing and has already been injured twice. The nurse knows that the patient is experiencing a behavioral change in which factor due to the prognosis of his illness? a. Spirituality b. Physical attributes c. Self-concept d. Personal affect

8. The domain of learning directly related to a patient's motivation to learn is a. cognitive. b. psychomotor. c. affective. d. dependent on their reading level.

8. Which action by the day-shift nurse provides objective data that enables the night- shift nurse to complete an evaluation of a patient's short-term goals? a. Encouraging the patient to share observations from the day b. Leaving a message with the charge nurse before shift change c. Documenting patient assessment findings in the patient's chart d. Checking with the pharmacist regarding possible drug interactions

8. Which term indicates a mental health disorder that is frequently seen in older adults? a. Schizophrenia b. Bipolar disorder c. Depression d. Posttraumatic stress disorder

8. Written instructions showing pictures of the steps necessary to test a blood sugar, along with demonstration and a return demonstration of the steps, would most benefit which learners? a. Affective b. VARK c. Psychomotor d. Cognitive

9. For which person seen at a physician's office appointment would patient and family education be most critical? a. A 24-year-old male patient with a cold virus and on no medications b. A 45-year-old male patient on metformin for type 2 diabetes for the past 3 years c. A 75-year-old female patient just prescribed the anticoagulant warfarin d. A 40-year-old male asthmatic patient diagnosed 10 years ago and on albuterol

9. What is the best activity for a hospitalized school-age child to encourage continued appropriate development? a. Watching favorite television shows for 2 hours per day b. Keeping a journal of feelings while in the hospital c. Working on a paint-by-number project that can be completed in an afternoon d. Playing a favorite video game each afternoon

6. A patient is on the way to the hospital in an ambulance and is asked to participate in a research protocol for a new treatment for myocardial infarction. What is this an example of? (Select all that apply.) a. Standard practice b. An ethical dilemma c. A violation of informed consent d. A patient who is in a vulnerable population category e. Compliance with important ethical issues of justice and autonomy

c d

1. A nursing student is taking care of a patient with possible appendicitis and is curious about the best method of diagnosing this disorder. What does the nursing student have to consider in formulating a question using the PICO format (patient, population, or problem; intervention; comparison intervention; outcomes) to determine evidence-based practice? a. Problem: appendicitis; interventions: ultrasound versus CT scan; outcome: diagnosis of appendicitis b. Problem: pain; interventions: meperidine versus morphine; outcome: pain free c. Problem: fever; interventions: cooling measures versus antipyretics; outcome: normal temperature d. Problem: appendicitis; Interventions: complete blood count versus chemistry panel tests; outcome: painless

1. Which action would the nurse undertake first when beginning to formulate a patient's plan of care? a. List possible treatment options b. Identify realistic outcome indicators c. Consult with health care team members d. Rank patient concerns from assessment data

1. Which of the listed basic needs identified by Maslow must be addressed first when providing nursing care? a. Self-esteem b. Love and belonging c. Self-actualization d. Nutrition and elimination

10. What is the primary purpose of quality improvement? a. Recognizing the need to discipline employees violating policies b. Preventing patient injury that may contributor to the death of others c. Increasing institutional profits to support further scientific research d. Enhancing current practices to improve patient outcomes and care

2. A patient who had a hysterectomy 3 days ago says to the nurse, "I no longer feel like a real woman." Which response by the nurse would be most appropriate? a. "Don't worry about that. The feeling will probably go away." b. "You should talk to your doctor about how you feel." c. "I don't blame you. I would feel like half a woman also." d. "I hear your concern. Tell me more about your feelings."

2. Consequences of domestic violence include all of the following except: a. Unwanted/unplanned pregnancies b. STDs c. Drug abuse d. Type 1 diabetes and hyperglycemia

2. The following is not one of the "3 A's of health information" identified by the National Action Plan to Improve Health Literacy: a. Accessible b. Accurate c. Actionable d. Appropriate

2. The nurse knows that which patient is an example of the Wear-and-Tear Theory of Aging? a. A patient who is dying of cancer at age 35 b. A 55-year-old who runs half-marathons c. A patient with depression and suicidal thoughts who is 65 d. An 88-year-old with heart failure, kidney failure, and osteoarthritis

3. A parent of a preschool child is concerned because his teachers have complained about his aggressive behavior toward other children. Which of the following pieces of information is most important in helping the parent determine possible sources of this behavior? a. The types of playmates the child has b. The kinds of toys the child plays with c. Whether or not the child is allowed to roughhouse with his siblings d. The types of television programs the child watches

3. The relationship of the medical diagnosis to the nursing diagnosis is a. the medical diagnosis is embedded within the nursing diagnostic statement. b. nursing diagnoses are driven by/derived from the medical diagnosis. c. the medical diagnosis is not relevant to the nursing diagnosis. d. the medical and nursing diagnoses should complement each other.

3. Which following environmental situation would be the most beneficial in which to hold a patient teaching session? a. Waiting room of the physicians' office as all of the rooms are taken b. The nurse's station c. The patient's room as the roommate appears to be asleep d. The patient's room when the roommate is out in physical therapy

4. A 75-year-old male patient reports decreased frequency of sexual intercourse, although he does not express dissatisfaction or difficulty. He seems a little embarrassed by the discussion but is engaged and asks some questions. Which nursing diagnosis does the nurse determine is most appropriate for this patient? a. Sexual Dysfunction b. Disturbed Body Image c. Sedentary Lifestyle d. Readiness for Enhanced Knowledge

4. A preschooler's mother is concerned because her child behaves in a mean fashion toward her younger brother. The mother states, "She acts like she has no sympathy for him!" What is the nurse's best response? a. "She is very young to exhibit sibling rivalry." b. "What does her brother do to her to make her act this way?" c. "Do you fight at home? She is probably imitating you." d. "Preschoolers are not capable of putting themselves in another's place."

4. Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer? a. Reassessing for changes in the patient's physical condition b. Teaching the patient various methods of stress reduction c. Referring the patient for music and massage therapy d. Encouraging the patient to explore options for care

4. Which statement illustrates a characteristic of goals within the care planning process? a. Goals are vague objectives communicating expectations for improvement. b. Short-term goals need not be measurable, unlike long-term goals. c. Goal attainment can be measured by identifying nursing interventions. d. Long-term goals are helpful in judging a patient's progress.

6. Which statement is the best resource for the nurse to use when determining appropriate nursing care for a transsexual patient? a. Gender identity is altered by acute psychosis. b. Sexual attraction is to individuals of both genders. c. Gonadal gender, internal organs, and external genitals are contradictory. d. Anatomy associated with sexual identity is not consistent with gender identity.

7. The nurse has found a review of a specific EBP related to infection control that would be appropriate for all nurses in the ICU. To implement this research, the nurse must collaborate with a. one other nurse. b. the other nurses on the day shift. c. the hospital administration in charge of the entire facility. d. all the colleagues in the unit (the clinical microsystem).

7. When a patient is beginning a regimen of an antidepressant medication, which information should the nurse include in the medication teaching as it pertains to sexuality? a. "Your partner will be pleased because your sexual functioning is going to improve." b. "You may find that your desire for sex will decrease while on this medication." c. "Your skin will probably become supersensitive to touch, so you may need to change your activity during sex." d. "You will be unable to have an erection while taking your antidepressants."

8. A newborn's mother is concerned about Sudden Infant Death Syndrome (SIDS). What would the nurse advise her is the best way to prevent SIDS? a. To breastfeed b. To allow the infant to sleep in her bed c. To place the infant prone to sleep d. To place the infant supine to sleep

9. Outcome indicators are a. broad statements that reflect the nursing diagnosis. b. established by the physician. c. used to evaluate the quality of nursing interventions. d. criteria by which goal attainment is observed or measured.

9. The nurse is providing care to an 88-year-old male patient who just returned from the recovery room after a right hip replacement. The nurse plans to teach the patient prevention techniques for deep vein thrombosis. What is the best time to provide teaching? a. Do it right before the patient's next intravenous pain medication. b. Wait until tomorrow morning because he is in too much pain today. c. Leave written materials on his over-the-bed tray that he can read at his convenience. d. Wait until 10 to 15 minutes after his next intravenous pain medication

9. The outpatient clinic nurse develops a plan of care focusing on diet, exercise, and glucose monitoring for a preteen recently diagnosed with early-onset type 2 diabetes. On what type of interventions has the nurse based the client's care plan? a. Primary b. Progressive c. Secondary d. Tertiary

9. Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"? a. Goal not met; patient states he is tired. b. Goal not met; patient ambulated three times in room. c. Goal met; patient ambulated three times in the hallway. d. Goal met; patient ambulated three times in the hallway without SOB.

Chapter 24 Summary

LO 24.1 Explain sexual development through the life cycle: Sexual development follows the stages of physical and psychological growth and development. LO 24.2 Describe the structure and function of the male and female reproductive systems: The male external reproductive organs are the scrotum and the penis; the internal reproductive organs are the seminal vesicles in the testes and the prostate. Semen is produced in the internal organs and ejaculated from the penis during orgasm. The female external genitalia, known collectively as the vulva, include the mons pubis, labia majora, labia minora, clitoris, Skene's glands, and Bartholin's glands; the internal genitalia include the vagina, uterus, fallopian tubes, and ovaries. The breasts also are considered female reproductive organs because estrogen and progesterone influence them and because they are the organs of lactation. LO 24.3 Differentiate among sex, sexuality, and gender identity: A person's sex is defined by the internal and external genitalia. Sexuality is defined as the collective characteristics that mark the differences between male and female. Sexuality is associated with every aspect of an individual's life as it relates to sex and intimacy, whether associated with sex organs or not. Gender identity is one's self-concept with respect to being a male or female. 456 LO 24.4 Describe the sexual response cycles of men and women: The four phases in the female sexual response cycle are excitement, plateau, orgasm, and resolution. The phases consistently occur in this sequence, but the duration of each phase varies. The phases of the male sexual response are stimulation, erection, emission, ejaculation, and detumescence. After orgasm, males experience a refractory period during which they are physiologically incapable of having another orgasm. Because females do not have a refractory phase, they can have multiple orgasms. LO 24.5 Identify contraception options: Contraceptive methods with varying degrees of effectiveness are available for males and females. They include abstinence, withdrawal of the penis before ejaculation, rhythm method, male and female condoms, spermicides, oral contraceptives, intrauterine devices, vaginal rings, hormonal injections or transdermal patches, diaphragms, cervical caps, emergency contraception, hysteroscopic sterilization, and surgical sterilization. Some methods require a prescription, whereas others do not. LO 24.6 Discuss sexually transmitted diseases and their causes and treatments: Gonorrhea, syphilis, and chlamydia are caused by bacteria and can usually be treated and cured with antibiotics. Genital warts (caused by HPV) and genital herpes (due to herpes simplex) are caused by viruses; they can be treated but not cured. Human immunodeficiency virus is a blood-borne virus that may be acquired through sexual contact and exchange of bodily fluids; if untreated or unsuccessfully treated, HIV infection progresses to AIDS. The survival time for patients with AIDS has improved with the use of HAART. LO 24.7 Summarize factors that affect sexuality: Family values and beliefs, culture, religion, self-concept, body image, previous experiences, cognition, environment, personal expectations, and ethics all affect a person's acceptance and expression of sexuality. LO 24.8 List factors that affect sexual function: Underlying disease processes and injury can have a negative impact on sexual function, as can medications and relationship issues such as differences in value systems, communication issues, and control issues. Lifestyle factors such as work issues, family responsibilities, lack of time or sleep, and developmental and self-concept concerns are additional stressors that may lead to sexual dysfunction. LO 24.9 Recognize the impact of family dynamics on sexuality: Age, ethnicity, culture, religion, and values affect a family's ability to communicate about sexual issues and the family members' choices regarding abortion, sterilization, contraception, and sexual preferences. The family's decision-making style, whether decisions are made by one partner or by the couple, may affect the partners' sexual practices. Sexual expression and satisfaction are enhanced in relationships in which decision-making power is shared. LO 24.10 Implement a sexual assessment: Sexual health assessment is an integral component of a total health history and physical exam. LO 24.11 List nursing diagnoses appropriate for the care of patients with potential or identified sexuality concerns: Sexual Dysfunction and Ineffective Sexuality Patterns are the most commonly identified nursing diagnoses for concerns arising from sexuality. LO 24.12 Develop a patient-centered care plan designed to address sexuality needs: A patient's individualized plan evolves as the nurse uses the knowledge gained while gathering the patient's sexual health history, along with the experience of the nurse in dealing with sexual concerns. Ethical and legal standards associated with sexual issues must be maintained by the nurse during this phase. LO 24.13 Implement interventions to support enhanced patient sexuality before evaluating their effectiveness: Nurses may provide sexual health teaching on topics such as sex education, safe sex practices, contraceptive use, and self-examination techniques to assist patients in attaining their identified goals and outcomes. Documentation of patient outcomes should be noted in the electronic health record.

6. While doing her morning assessment, the nurse shares with her patients the tests and procedures they have scheduled for that day as well as when she expects to return to deliver their medications or do their treatments. Even though the hospital is a hectic and difficult environment to predict, the nurse regards this information session with her patients as an important way to demonstrate she cares. The rationale behind her action is a. to increase the patients' sense of security by making the environment more predictable for the patients. b. to ease her patients' fears since they may worry that she'll forget to give them their medications. c. to point out to her patients that the care they are receiving is consistent and delivered on time so they will rate her care higher when they leave the hospital. d. to allow the patients some flexibility in when they want to take their medications or have their tests and procedures done.

ANS: A The nurse is informing the patients about the day's schedule so they will know what to expect. The idea is to increase the predictability of an otherwise hectic and unpredictable environment. "To ease her patients' fears since they may worry that she'll forget to give them their medications" is incorrect since there's nothing in the stem of the question that indicates the patients are afraid she'll forget. "To point out to her patients that the care they are receiving is consistent and delivered on time so they will rate her care higher when they leave the hospital" is incorrect since the nurse's intention is to show the patients that she cares; this is not a patient-centered rationale but is intended to boost the nurse's satisfaction ratings. "To allow the patients some flexibility in when they want to take their medications or have their tests and procedures done" is incorrect since the patients are not being given options about when things will happen but are only being told in advance what will happen and when.

2. A nurse is gathering an admission assessment on a patient who recently emigrated from Japan and is a Buddhist. The man told the nurse that he normally meditates daily and lives almost exactly the way he did in Japan. However, he has not been able to walk for the past weeks. Based on the assessment findings, which questions would be important for the nurse to ask before implementing his nursing care? (Select all that apply.) a. What have you done to cope with your health problem? b. What do you call your health problem? What do you think is wrong? c. What concerns you most about the recommended treatment plan? d. What do you think caused your health problem?

ANS: A, B, C, D All assessment questions fit the scenario and are questions the nurse should explore with a patient who describes himself as someone from a very different culture and religion than the dominant health care culture. The patient should be given the opportunity to describe what he thinks is wrong and what he expects in terms of treatment. The nurse also needs to collect data on what health remedies the patient has tried to cope with the problem and anything that might concern him about the plan of care the nurse has developed.

2. A nurse is planning a program for educating a Hispanic community regarding nutritional practices. What would be the most important aspects that the nurse takes into consideration first? (Select all that apply.) a. Change theory and Health Belief Model b. Previous educational programs c. Cultural influences d. Hospital admissions from this community

ANS: A, C Since the nurse will be discussing nutrition to a specific cultural group, the nurse needs to understand the cultural influences on their nutritional practices. In addition the nurse needs to understand change theory to plan her education if she is attempting to have the group make changes in their nutritional practices. The Health Belief Model would also help in understanding the community's perceptions regarding barriers that facilitate or discourage adoption of the promoted behaviors.

2. In preparing for a certification examination, the nurse chooses to develop a concept map to help understand the content. This strategy is based upon which characteristics of concept maps? (Select all that apply.) a. Facilitates note taking b. Requires thinking aloud c. Fosters making correlations between concepts d. Validates content with an expert e. Organizes visual data

ANS: A, C, E Concept maps are a method to organize and visualize data in order to identify relationships and solve problems. Concept maps can be used for note taking, mapping nursing care plans, and preparing for exams. Through visual representations, the student can make correlations between related concepts.

1. The nurse recognizes the importance of a patient's beliefs in influencing the patient's behaviors and responses to health care problems. Which of the following are examples of a patient's beliefs? (Select all that apply.) a. A patient explains that the medication he is taking is helping him overcome his anxiety. b. A patient reflects on her values and uses them to help her make a decision about whether or not to have breast reconstruction surgery. c. A patient expresses a feeling of dread about the future to his nurse. d. A 78-year-old man signs a "Do Not Resuscitate Order" when he learns he's had a massive heart attack because, he explains, "he can hardly wait to go and be with his wife in heaven."

ANS: A, D "A patient explains that the medication he is taking is helping him overcome his anxiety" is correct because it describes a man who believes in the effectiveness of using medications that have been scientifically tested to help alleviate health problems such as anxiety. "A 78-year-old man signs a 'Do Not Resuscitate Order' when he learns he's had a massive heart attack because, he explains, 'he can hardly wait to go and be with his wife in heaven'" is correct because it describes a man whose religious beliefs helped him decide against undergoing life prolonging treatments because he says he believes in an afterlife in "heaven." "A patient reflects on her values and uses them to help her make a decision about whether or not to have breast reconstruction surgery" is incorrect because it describes a woman who used "values clarification" to help make a decision about her health care. "A patient expresses a feeling of dread about the future to his nurse" is incorrect because a feeling of dread is "anxiety" and is not a belief.

6. Which long-term goal is written correctly? a. Patient will remain afebrile throughout hospitalization. b. Patient will return to professional sports activities within 6 months. c. Nurse will prevent bone infection through antibiotic therapy for 3 weeks. d. Patient will demonstrate accurate use of crutches without assistance before discharge from emergency room.

ANS: B "Patient will return to professional sports activities within 6 months" is a correctly written long-term goal. Goals that are achievable within an immediate time frame of less than approximately one week are short-term goals, whereas goals that will take more time to achieve—weeks to months—are long-term goals. All short- and long-term goals must be (1) patient focused, (2) realistic, and (3) measurable.

3. A nurse recognizes the importance of active listening as a way to show the nurse cares. Which of the following actions by the nurse describes active listening? (Select all that apply.) a. Sitting at the patient's bedside and listening to the patient talk while inserting an IV b. Sitting in a chair facing a patient and making a mental note of the major points of the conversation c. Listening to what the patient says and what he means while she conducts her early morning assessment d. Engaging both the patient and the family members while taking careful notes of the conversation

ANS: B Active listening means doing nothing else but listening to the patient. It's about being attentive and engaged. "Sitting at the patient's bedside and listening to the patient talk while inserting an IV" is incorrect because the nurse is doing something else while the patient talks. "Listening to what the patient says and what he means while she conducts her early morning assessment" is also incorrect because the nurse is also conducting an early morning assessment while listening. "Engaging both the patient and the family members while taking careful notes of the conversation" is incorrect because the nurse is attending to note taking instead of only listening.

12. What should be the focus of all nursing interventions? a. Early hospital discharge for patients b. Providing patient-centered care c. Reduction of health care spending d. Delegating appropriate nursing care

ANS: B All patients are required to have unique, patient-centered plans of care designed to meet their specific needs.

2. A co-worker is an excellent nurse but often assumes responsibility for other people's irresponsible behaviors. Her nurse manager notices that in the past several months she has become overly sensitive with her patients and that she complains of feeling stressed and worn out because she has taken on too much. She admits to having a family background that makes her suspect she has some co-dependent traits. How should her nurse manager proceed if the nurse's work continues to suffer? a. The manager should offer her emotional support for as long as she needs it. b. Help her recognize that she may be co-dependent and needs to get professional help. c. Take her to the next scheduled group therapy session in the mental health ward. d. Confront her about her inappropriate behavior and threaten to fire her if her work doesn't improve.

ANS: B From the scenario, the nurse needs help to recognize that she may be co-dependent and that it is impacting her work performance and the way she's treating her patients. She needs to seek out professional counseling. "The manager should offer her emotional support for as long as she needs it" is incorrect because the nurse manager needs to refer her for treatment and not drag out the situation indefinitely, which is implied in the answer. "Take her to the next scheduled group therapy session in the mental health ward" is incorrect since the nurse manager should not take responsibility away from the nurse but encourage the nurse to take responsibility for herself, which is the best way she can learn to help others. "Confront her about her inappropriate behavior and threaten to fire her if her work doesn't improve" is incorrect since it is not supportive but aggressive and confrontational in nature. The manager wants to help the nurse return to being an excellent nurse again and that would not happen if the manager fires her.

11. A nurse admits a patient to the cardiac care unit following the placement of a cardiac stent. Which step of the nursing process does the nurse do first? a. Planning b. Assessment c. Evaluation d. Implementation

ANS: B The nurse first assesses the patient. Collecting an extensive health history and completing a thorough head-to-toe physical assessment are typically required when a patient is admitted to a hospital or seeking health care from a primary care provider for the first time. This information provides a baseline for future reference. Shorter, focused assessments are conducted by the nurse routinely throughout hospitalization or during repeated clinic visits to assess a patient's change of status.

5. A nursing student walks into the patient's room and is unsure about when it is appropriate to use caring touch in a nurse-patient care situation. What should the student do? a. Leave the room and ask her clinical instructor when and where she should touch her patient. b. Ask the patient for permission to touch her before proceeding. c. Disregard the use of touch since she is unsure of how to maintain professional boundary when it comes to touching a patient. d. Assume all patients want to be touched and that they see it as an act of caring.

ANS: B Whenever a nurse is unsure about the use of touch, it's always best to ask the patient's permission. "Leave the room and ask her clinical instructor when and where she should touch her patient" is incorrect since the nursing instructor is not there and would not know the patient any better than the student. "Disregard the use of touch since she is unsure of how to maintain professional boundary when it comes to touching a patient" is incorrect since "caring touch" is an important way nurses convey they care. To disregard it is to ignore an important means of communication. It is better that the student keep practicing and gaining experience in using touch in order to learn how and when to use it to let her patients know she cares. "Assume all patients want to be touched and that they see it as an act of caring" is incorrect since not all patients want to be touched. The nurse should develop the skills of being able to read the patient's body language and when unsure, to ask permission.

6. The nurse uses a case study presentation to present an educational offering to the staff on the unit. This strategy improves the staff nurses' critical thinking through which of the following? a. Reviewing the literature b. Practicing application of knowledge c. Discussing with colleagues d. Role playing

ANS: B While the nurse may review the literature and discuss the presentation with colleagues in the preparation of the educational offering, the integration of a case study facilitates the critical thinking of the nurses attending through the application of knowledge. Role playing involves participants being involved in a "playing out" the content.

3. How might a nurse as a researcher approach the care of the patient? (Select all that apply.) a. Performing technical skills as learned b. Looking for problems and questioning practices c. Incorporating research she has read into her practice d. Carrying out procedures as they always have been done

ANS: B, C By looking for problems and questioning practices, the nurse is identifying problems that can be researched. By incorporating any new research into practice, the nurse is involved in evidence-based practice.

8. A 57-year-old male patient who was hospitalized with an admitting blood pressure of 240/120 asked the nurse if his family could bring in some meat and vegetable dishes from home. He explained that he cannot eat the foods on the hospital menu because it is summer and the hospital is only offering chicken and fish, which in his culture are "hot" foods that will interfere with his healing. Which response by the nurse would best demonstrate an application of Leininger's theory? a. Discourage the family from bringing in food, explaining that the idea of "hot" and "cold" foods is a superstition without scientific basis. b. Negotiate home-prepared food options with the patient and his family to ensure that treatment for the patient's blood pressure is supported. c. Explain that the patient will need to have home-prepared foods evaluated by the dietary staff to ensure that they are acceptable options. d. Tell the family to bring in any foods they want, to help preserve the patient's cultural practices and dietary preferences.

Answer: b According to Leininger's theory, negotiation and adaptation are part of what nurses do to accommodate the patient's cultural ways of life. As long as the foods from home have low concentrations of sodium or other ingredients that are known to affect blood pressure, the nurse can accommodate the patient's beliefs and cultural dietary practices as well as the medical plan of care. Rejecting the patient's cultural traditions and/or accepting them without regard for the well-being of the patient are unacceptable actions. Food given to patients from family members does not need to be evaluated by the dietary staff before consumption.

4. What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice

Answer: b Each nursing diagnosis label identifies either a patient problem or need, which is its purpose. Resolving patient confusion, meeting accreditation requirements, and articulating the nurse's scope of practice are not related to the purpose of the nursing diagnostic process.

3. If a patient is grimacing, what assessment statement or question would be most beneficial to identifying the underlying cause of the nonverbal communication? a. "Did you lose something?" b. "You appear to be having pain." c. "I will turn off the lights and let you rest." d. "May I get you something to relieve your tension?"

Answer: b Grimacing is a common nonverbal sign of pain. Sharing an observation encourages the patient to elaborate on nonverbal communication. Asking the patient whether something is lost indicates that the nurse has not attended to the nonverbal cues of the patient. It is important to do an assessment of the patient before initiating any interventions.

5. If a patient's verbal and nonverbal communications are inconsistent, which form of communication is most likely to convey the true feelings of the patient? a. Written notes b. Facial expressions c. Implied inferences d. Spoken words

Answer: b Nonverbal communication is the more accurate mode of conveying feelings. When a patient's verbal and nonverbal cues are incongruent, it is important to explore observations made by the nurse to discern the true feelings of the patient. Written notes, implied inferences, and spoken words do not provide the opportunity for observing nonverbal cues.

2. In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking? a. "What do I know about this situation?" b. "What additional details do I need to gather?" c. "Does the clinical presentation correlate with the diagnosis?" d. "Are the treatments appropriate for the diagnosis?"

Answer: b Precision relates to providing sufficient detail to lead to an exact understanding of the situation. What do I know about this situation? is focused on self-reflection about what is known about the situation. Does the clinical presentation correlate with the diagnosis? relates to relevance. Are the treatments appropriate for the diagnosis? relates to logic.

1. The nurse receives change of shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse's action? a. Problem solving b. Decision making c. Judgment d. Reasoning

Answer: b The nurse used decision making to guide which patient to see first, based on an analysis of patient data and care needs. Problem solving is used when the nurse is faced with a situation that requires analysis and a solution. Judgment is used in the decision-making process but does not result in the actual decision. Reasoning is logical thinking that may be used in decision making but, again, is not the actual result. Decision making culminates in a definitive action.

9. A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. Resume all interventions for previously identified nursing diagnoses. b. Perform the steps of the nursing process related to the patient's current condition. c. Seek physician input related to updating the nursing diagnosis statements. d. Evaluate the success of the acute care plan for management of the cardiac arrest.

Answer: b The patient's condition requires immediate performance of the lifesaving steps of the nursing process. All other answers are secondary actions. The nurse later resumes all interventions for previously identified nursing diagnoses and evaluates the success of the acute care plan for management of the cardiac arrest. Nurses do not seek the input of the physician for creation of nursing diagnoses.

1. Nurses need to understand how beliefs and values are different. A nurse begins to offer information to a patient and the patient says, "I've already heard all of that before and I don't agree with any of it." How should the nurse proceed? a. Ask the patient to explain his values. b. Ask the patient to explain what he believes. c. Ask the patient about his prejudicial attitude. d. Confront the patient about the values conflict he's experiencing.

Answer: b The purpose of the question is contained in the stem, to determine whether the student can distinguish between a belief and a value. By asking the patient to explain what he or she believes, the nurse is asking an open-ended question to find out what part of what the nurse is saying the patient believes and what part he or she does not believe. Asking the patient to explain his or her values is incorrect because there is no mention in the stem about the patient saying his or her values are different from what the nurse is trying to say. Asking the patient about his or her prejudicial attitude is incorrect because there is nothing in the stem that indicates a prejudicial attitude. Confronting the patient about the values conflict he or she is experiencing is incorrect because there is nothing in the stem that indicates the patient is experiencing a values conflict. He or she simply does not believe the same thing the nurse believes.

6. The nurse in the emergency department is caring for an 8-year-old who has had a serious asthma attack. When the nurse attempts to explain the problem to the child's mother, she smells cigarette smoke on the mother's breath. The nurse asks the mother if she has been smoking and the mother responds, "Yes, and I know they've told me before I can't smoke around him." What should the nurse do next? a. Ask the patient's mother what she values more, her child or her habit. b. Ask the patient's mother to explain what she believes about smoking and asthma. c. Ask the patient's mother about her prejudicial attitude toward smoking. d. Confront the patient's mother about the values conflict she's experiencing.

Answer: b The nurse should begin by asking the mother what she believes because the nurse does not know at this point. When working with a patient who has an addiction, the nurse should begin at the assessment phase of the nursing process and attempt to build a trusting relationship with the patient. Asking the mother what she values more, her child or her habit, is incorrect because the issue is not about the mother's values but about what she knows and what she believes. Asking the mother about her prejudicial attitude toward smoking is incorrect because there is nothing in the stem to indicate the mother is prejudiced toward or against smoking. Confronting the mother about the values conflict she is experiencing is incorrect because there is nothing in the question to indicate the mother is having a values conflict. She may not believe what the health care professionals are telling her or she may not believe that she can quit smoking. She may need to be convinced that she can do it, and the best way to make that happen is to build a trusting relationship with her rather than alienate her with accusatory remarks.

4. As the nurse explained the preoperative instructions to the patient, the patient's older brother suddenly stepped into the doorway and yelled, "People who go under the knife always die. Don't do it! They're going to kill you." What type of higher-order belief is the patient's older brother displaying? a. Distress b. Stereotype c. Prejudice d. Denial

Answer: b The patient's brother is making a generalization that is a stereotype, which is a belief about a person, group, or an event that is thought to be typical of all others in that group. Although it is true that people occasionally die during surgery, it does not always happen as the brother fears. Distress is incorrect; the male is distressed, but distress is not a higher-order belief. Prejudice is incorrect because a prejudicial belief is a preformed opinion, usually an unfavorable one, about an entire group of people based on insufficient knowledge. Denial is wrong because he is not in denial, which is defined as a behavior of refusing to admit something is true.

3. What specific aspect of a profession does the development of theories provide? a. Altruism b. Body of knowledge c. Autonomy d. Accountability

Answer: b Theories establish a specific nursing body of knowledge that is unique to the discipline, which is one criterion of a profession.

2. Which nursing diagnosis is appropriately written? (Select all that apply.) a. Risk for Infection related to elevated temperature and white blood count b. Readiness for Enhanced Relationship as evidenced by mutual respect verbalized by spouses and expressed desire for improved communication c. Noncompliance related to inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Bleeding with the risk factor of prolonged clotting time e. Chronic Pain related to osteoarthritis as manifested by verbalized postoperative discomfort.

Answer: b, c, d Readiness for Enhanced Relationship is a heath-promotion nursing diagnosis and is written with two sections: the label and the defining characteristics. Noncompliance is a nursing diagnosis that requires a related factor and defining characteristics. Risk for Bleeding requires at least one risk factor, which it has as it is written. Use of related factors in a risk nursing diagnosis is not the accepted NANDA-I format. The nursing diagnosis of Chronic Pain is incorrectly written because it includes a medical diagnosis and a related factor that is supportive of acute rather than chronic pain.

10. What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.) a. Denies any difficulty falling asleep b. Elevated pulse rate auscultated at 140 BPM c. Continuous foot tapping throughout intake interview d. Demonstrates how to give insulin self-injection without hesitation e. Patient states, "I feel nervous all the time, especially when I am alone."

Answer: b, c, e An elevated pulse rate, continuous toe tapping, and verbalizing nervousness are consistent with extreme anxiety and should be clustered together. Ease of falling asleep and being able to focus on a challenging task, such as giving an injection, are not indicative of a patient experiencing a high level of anxiety.

8. Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice for the other team member. d. Call a meeting of the health care team to determine the needs of the patient.

Answer: c Knowing the scope of practice of the other team member is critical to understanding what is appropriate and safe to delegate to that person. It is unnecessary to locate or meet with all members of the health care team prior to delegation. Physicians are already aware of potential complications related to patient care.

5. On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses

Answer: c Nursing diagnoses emerge from groupings of clustered data collected during the assessment phase of the nursing process. The nurse documents the patient's medical diagnosis as one piece of data, which may be clustered with others to support a nursing diagnosis. Data collected from a nurse's intuition and first impressions may also be listed in the patient's assessment findings as long as they are objectively recorded without prejudice and are not judgmental in nature.

1. A hospitalized patient experiences a sharp, stabbing pain while visiting with his spouse. Both the patient and his wife become very concerned, and the patient's call light is activated. What referent initiated communication between the patient and the nurse? a. Interaction between the patient and his wife b. Concern on the part of the patient's spouse c. Pain experienced by the patient d. Activation of the call light

Answer: c Pain is the referent that initiated the communication process. The interaction between the patient and his wife was the result of the patient's pain as was the concern of the patient's spouse. The call light could be considered a channel through which the patient's interaction with the nurse began.

5. The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the critical-thinking skill of analysis in the nursing process? (Select all that apply. ) a. Assessing the patient for symptoms of hypoxia b. Providing oxygen according to standing orders c. Elevating the head of the bed, if not contraindicated d. Allowing the patient to be alone to rest more comfortably e. Discussing adaptations needed for daily activities with the patient

Answers: a, b, c Analysis involves assessing a situation and determining what should be done based on an appropriate rationale. In this case, assessing the patient for symptoms of hypoxia, providing oxygen as ordered, and elevating the head of the bed help determine the extent of air hunger, promote increased gas exchange, and ease the effort of breathing. Leaving a patient who has a low pulse oximetry reading alone is potentially dangerous. Discussing nonemergent information with a patient experiencing air hunger requires increased oxygen consumption and is inappropriate.

2. Which factor influences whether a message is effectively communicated? (Select all that apply.) a. Timing of the conversation b. Educational level of participants c. Mode of communication utilized d. Physical environment of discussion

Answers: a, b, c, d Timing of a conversation dramatically influences the receptivity of the receiver. The educational level of those seeking to communicate has an impact on the type of language and technical terminology that can be used in conversation. Using more than one mode of communication can enhance the effectiveness of a message. Making sure the environment is devoid of excess noise and distraction can facilitate a greater understanding of shared information.

2. A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized processes? (Select all that apply.) a. Code of ethics b. Licensing c. Body of knowledge d. Educational preparation e. Altruism

Answers: a, b, c, e Nursing as a profession has a code of ethics, licensing, a body of knowledge, and altruism. Because there are multiple paths of education for nursing and not a standard entry into practice, this is one criterion of a profession that is not standard and consistent.

4. Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Thoroughly review the patient's medical history b. Analyze the nursing assessment data to determine whether information is complete c. Outline an individualized plan of care to address each concern d. Consider potential complications to which the patient is susceptible e. Evaluate how the patient has responded to treatment

Answers: a, b, d Before determining the types of nursing diagnoses that are appropriate for a patient, the nurse must review and analyze all of the patient's data, including the medical history, for completeness and accuracy. Considering the vulnerability of a patient to potential complications permits the nurse to identify the need for risk nursing diagnoses. Outlining an individualized plan of care takes place during the planning stage of the nursing process after the nursing diagnoses have been identified. Evaluation of a patient's response to treatment is part of the evaluation stage of the nursing process.

9. Which factors affect the nursing shortage? (Select all that apply.) a. Aging faculty b. Increasing elderly population c. Job satisfaction due to adequate number of nurses d. Aging nursing workforce e. Greater autonomy for nurses

Answers: a, b, d The nursing workforce and nursing faculty are aging. The entire population is aging, which increases the need for more nurses. The insufficient number of nurses leads to job dissatisfaction and burnout.

8. Which of the following statements describes a component discussed in nursing theories? (Select all that apply.) a. Optimal functioning of the patient b. Interaction with components of the environment c. The conceptual makeup of the administration of the hospital d. The illness and health concept e. Safety aspect of medication administration

Answers: a, b, d There are four components that a nursing theory discusses: (1) the patient, (2) health, (3) environment, and (4) nursing—not the hospital administration.

6. Of the following, which are included in the ANA standards? (Select all that apply.) a. Standards for professional performance b. Code of ethics c. Standards of care d. Legal scope of practice e. Licensure requirements

Answers: a, c ANA standards have two parts: one is standards for professional performance, and the other is standards of care. ANA has a separate document that is a code of ethics. Nurse practice acts are a legal scope of practice.

8. The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select all that apply.) a. Teamwork b. Intuition c. Judgment d. Conflict management e. Advocacy f. Reasoning

Answers: a, d, e Interpersonal skills such as teamwork, conflict management, and advocacy engage others in the process of critical thinking. Intuition, judgment, and reasoning are intrapersonal aspects of critical thinking that the nurse may use personally to better understand a situation. LO: 4.2

7. A nurse is working with a 35-year-old patient who needs to decide whether to donate a kidney to his brother who has been in renal failure for 5 years. The patient shares with the nurse that the decision is especially difficult because he would not be able to continue to work in his current profession and would be unable to support his three small children if he ever needed dialysis. Which intervention(s) would be most appropriate for the nurse to implement in this situation? (Select all that apply.) a. Explain that it is unlikely that he will ever need dialysis even if he has only one kidney. b. Guide the patient through a values clarification process to help him make a decision based on his values. c. Provide information the patient needs to help him make an informed decision. d. Ask for his permission to contact the kidney donation team to answer any questions he may have.

Answers: b, c, d Encouraging the patient to make a decision based on his personal values, providing necessary information, and offering consultation with individuals most familiar with the kidney donation process are all excellent interventions. It would be impossible to predict whether a patient will need dialysis in the future, making this type of statement misleading.

10. A new nurse is about to insert a nasogastric tube for the first time but is not sure what equipment to gather or how to begin the procedure. The patient is an 80-year-old woman who is frightened and slightly confused. Which actions by the nurse would best demonstrate caring? (Select all that apply.) a. Offer the patient pain medication to help her calm down. b. Hold the patient's hand while inserting the nasogastric tube. c. Speak calmly while explaining the procedure to the patient beforehand. d. Ask another, more experienced nurse for assistance before initiating care.

Answers: c, d Using a calm voice and seeking help from an experienced nurse exhibit caring for the patient and will help to allay patient anxiety. Medicating a patient for pain before the experience will not automatically alleviate patient anxiety and may cause the patient to experience greater confusion. The nurse will need to use both hands to safely insert the nasogastric tube and promote a positive patient outcome, so the nurse is unable to hold the patient's hand during the procedure.

Chapter 1 summery

LO 1.1 Define nursing: Nursing is a holistic profession that addresses the many dimensions necessary to fully care for a patient. LO 1.2 Differentiate among the functions and roles of nurses: Nurses provide care to patients while functioning in multiple roles as care provider, educator, advocate, leader, change agent, manager, researcher, collaborator, and delegator. LO 1.3 Describe historical events in the evolution of nursing: Historically, the nursing profession has evolved from a religious and military background to meet the nursing needs of society. LO 1.4 Summarize nursing theories: Nurses use nursing theories to guide their practice. Nursing theories began with Florence Nightingale's work in 1860 and continue to the present. Each theory discusses the four concepts of nursing, person, health, and environment. LO 1.5 Identify non-nursing theories that influence nursing practice: Non-nursing theories that influence nursing practice include systems theory, developmental theory, change theory, theory of human needs, and leadership theories. LO 1.6 Articulate the criteria of a profession as applied to nursing: Nursing is evaluated against the criteria of a profession, which include altruism, body of knowledge, accountability, higher education, autonomy, code of ethics, professional organization, and licensure. LO 1.7 Discuss standards of practice and nurse practice acts: ANA standards of practice guide and direct the practice of nursing; state nurse practice acts define nurses' scope of practice. LO 1.8 Describe the socialization and transformation process of a nurse: Socialization into the nursing profession follows a process from novice to advanced beginner during nursing school. The nurse reaches the competent level after several years of practice. Transformation takes place when the student gains the ability to perceive and prioritize the situational needs of complex care. LO 1.9 Explain the levels of educational preparation in nursing and differentiate among the nurse's roles depending on education: Numerous levels of education (diploma, associate, baccalaureate, master's, and doctoral degrees) and career opportunities in nursing can be pursued. LO 1.10 List possible certifications in various arenas of nursing and professional organizations in nursing: Many different certifications are available to nurses who meet specific requirements and pass qualifying examinations. Nursing organizations represent all nurses and nursing specialties. LO 1.11 Discuss the future directions in nursing: Future directions in nursing include dealing with the nursing shortage, implementing new patient safety programs, and exploring the role of the independent nurse.

Chapter 13 Summary

LO 13.1 Define various types of nursing research: Basic research generates theories, applied research tests the application of research in different situations and populations, and clinical research is used when testing theories about the effectiveness of interventions. LO 13.2 Compare quantitative and qualitative research methods: Quantitative research designs are descriptive, correlational, experimental, and quasi-experimental. Qualitative research designs include phenomenological, grounded theory, ethnographic, and historical. LO 13.3 Explain the steps involved in the research process: Research includes a literature review, data collection, data analysis, dissemination of outcomes, and application to practice. Before conducting research, permission must be sought from an IRB, whose responsibilities include protecting the rights and welfare of the participants. LO 13.4 Explain research and its relationship to evidence-based practice: EBP is integration of the best available research evidence and the nurse's clinical expertise to make patient care decisions. EBP allows a nurse to address questions and problems by reviewing the research, clinical guidelines, and other resources to determine practice. EBP results in better patient outcomes, keeps nursing practice current, and increases the nurse's confidence in professional decision making. 189 LO 13.5 Discuss the steps required in conducting evidence-based research: Evidenced-based nursing research consists of assessing a need for change; developing a question that links the problem, interventions, and outcomes; searching for and synthesizing the best evidence; designing a plan for change; implementing the change; and integrating, maintaining, and evaluating the change. LO 13.6 Identify considerations for implementing research in nursing practice: Nurses should be able to recognize the different types of evidence levels to identify best practices. Nurses must understand that any single means to establishing care, even if it is an accepted method, may not meet the complex needs of individual patients or be consistent with patients' preferences or values. Collaboration among health care professionals can help with individualizing patient care while incorporating research into practice. LO 13.7 Explain the relationship of hospital Magnet status to nursing research and practice: The Magnet Recognition Program for hospitals supports an evidence-based environment, which includes the nurses' autonomy to improve quality of care by using evidence.

Chapter 14 Summary

LO 14.1 Define health literacy: Health literacy refers to a patient's ability to seek and understand information related to health care, disease prevention, and treatment of illness. Patients are unique in their ability to comprehend health care information. Health literacy directly affects the patient's ability to comprehend and integrate knowledge. LO 14.2 Explain the role of health literacy in nursing and patient education: Knowledge of a patient's health literacy level assists nurses in communicating instructions and educational information in an appropriate manner to ensure that the patient understands. LO 14.3 Identify the types of patient education and the settings in which patient education occurs: Patients are taught in formal settings, in which information is delivered throughout the community or in planned one-on-one sessions, and in informal settings, in which information is situation and patient specific. LO 14.4 Differentiate among the three domains of learning: There are three domains of learning: cognitive, psychomotor, and affective. When developing effective teaching plans, the nurse must consider how the individual learns. LO 14.5 Explain how learning styles affect patient teaching: Patient education should be conducted in the learning style preferred by the individual (i.e., verbal, aural, read/write, or kinesthetic or a combination of modes) and tailored to the patient's needs. LO 14.6 Describe factors affecting health literacy and patient education: Health literacy and patient education are affected by numerous factors, including cultural background, socioeconomic level, age or developmental stage, role, environment, and timing. LO 14.7 Carry out an assessment of the patient's health literacy and education needs: An assessment must be done before developing a patient teaching plan and should take into consideration the learner and the learning level, educational needs, and previous experiences of the learner. LO 14.8 Choose nursing diagnoses appropriate for use with patient education: Examples of nursing diagnoses appropriate for patients with learning needs are Deficient Knowledge, Readiness for Enhanced Knowledge, and Noncompliance. LO 14.9 Determine goals and outcome criteria for patient education: Goals are based on particular learning needs and established nursing diagnoses. LO 14.10 Implement teaching plans and evaluate their effectiveness: The nurse maximizes implementation of teaching plans by choosing the best environment, pacing the sessions according to the patient's condition, and providing information that is accurate, accessible, and actionable. The nurse should ask the learner to repeat or perform what has been taught to evaluate what has been learned. The patient education session should be documented in the medical record.

Chapter 16 Summary

LO 16.1 Define the concept of health in an individual and a corporate context: Individuals define health in terms of their values, experiences, and ways of living. Organizations and businesses define health in the context of their goals and objectives. LO 16.2 Compare the theoretical models of health and wellness that provide the basis for nursing practice: The Basic Human Needs Model, Health Belief Model, Health Promotion Model, and holistic health models provide a foundation for defining optimal physiologic and mental status while approaching health care delivery from different viewpoints. LO 16.3 Discuss health promotion and its relationship to wellness: The concepts of health promotion, wellness, and risk reduction are interconnected with a person's motivation and goals for achieving a predetermined level of health. LO 16.4 Explain the three levels of preventive care and the nursing interventions associated with each: Health promotion and specific protection strategies are two examples of appropriate ways in which nurses can work with their patients in primary prevention. The goal for health intervention during secondary prevention is early detection and diagnosis of health problems before patients exhibit symptoms of disease. Nursing care is focused on rehabilitation efforts in the tertiary stage of prevention. 233 LO 16.5 Summarize key aspects of each type of illness and the stages of illness behavior: Acute illness is typically characterized by an abrupt onset and short duration (<6 months), with clinical manifestations that appear quickly, may be severe, and resolve within a short period because they respond to treatment or are self-limited. Chronic illness is any condition in which a loss or abnormality of body function occurs that lasts longer than 6 months and requires ongoing, long-term care. Chronic health conditions may be controlled with lifestyle management or drug therapy, but they are considered to be irreversible. Stages of illness may progress from the acceptance of being ill to the resumption of previously assumed roles and activities. LO 16.6 Identify factors influencing health and their impact on illness: Many factors influence health and illness, including social determinants of health such as age; gender; availability of and access to health care; cultural, spiritual, and ethnic considerations; attitudes; monetary resources; environmental factors; genetics; lifestyle choices; self-concept; and health policies.

Chapter 17 Summary

LO 17.1 Describe major theories of human development: Many theories have evolved to describe human growth and development in cognitive, psychosocial, sexual, behavioral, and spiritual dimensions. Most of these theories outline developmental tasks and/or stages through which the person progresses toward higher levels of functioning. LO 17.2 Explain human development from conception to birth: Conception occurs with fertilization and implantation. The zygote is known as an embryo after 3 weeks and then as a fetus after 8 weeks. Rapid development and cell differentiation occur during the early weeks of pregnancy. The fetus continues to grow and develop until delivery. The developing fetus is susceptible to a variety of teratogens, including certain medications, illegal drugs, alcohol, radiation, and infectious agents. LO 17.3 Identify the primary developmental tasks of the newborn: The primary developmental tasks in the newborn period (birth to 1 month) involve adaptation to life outside the uterus and include learning to eat, developing sleep-wake patterns, and laying the groundwork for trust by having needs consistently met by the caregivers. LO 17.4 Outline infant developmental milestones: The infant period (1 month to 1 year) is marked by rapid growth. Primary developmental tasks include developing trust, adapting to the environment, and beginning refinement of fine and gross motor skills. LO 17.5 Describe the physical, psychosocial, and cognitive development of the toddler: The toddler attains control of bowel and bladder function, increases mobility, refines development of fine and gross motor skills, and expands language acquisition. Safety concerns in the toddler period include protection from injury as the child gains increased mobility in the environment. LO 17.6 Summarize growth and development during the preschool years: Preschoolers develop a sense of initiative as they continue to refine gross and fine motor skills. Safety concerns in this period include protection from injury as preschoolers become more active. LO 17.7 Discuss development that occurs during the school-age years: The school-age child grows in stature and weight and becomes capable of logical thought. Peer relationships exert a greater influence on the school-age child than on children in previous stages. Health and safety concerns in the school-age years include prevention of injury, particularly from play equipment such as bicycles. LO 17.8 Articulate physical, psychosocial, and cognitive adolescent development: Adolescents go through many physical changes. Peers become very important, and adolescents often try to isolate themselves from their parents. Teens make decisions based on the context of the situation and can understand much of what is happening when hospitalized. Safety concerns during the adolescent years include protection from injury. Health concerns include the promotion of a healthy diet and safe sexual practices and the support of mental health as the teen struggles with multiple physiologic and psychological changes.

Chapter 18 Summary

LO 18.1 Discuss theories on aging and adult development: Senescence is the biologic process of aging influenced by genetic factors. Theories on aging include the Wear-and-Tear Theory, aging at the cellular level, and the Cross-Linking Theory. Developmental theories include Gould's Theory on Adult Development and the life stages theories of Havighurst, Erikson, and Piaget. LO 18.2 Describe changes that occur as the body ages: Physical changes occur within all body systems as aging progresses and can affect mobility, cognition, and independence. LO 18.3 Identify physiologic, cognitive, emotional, and social changes that affect the young adult: The transitions that occur during young adulthood are influenced by cultural beliefs, societal values, and individual beliefs and expectations. Emerging adulthood is signified by a prolonged transition to adulthood as people pursue education and employment. The young adult is at a peak of cognitive and physical development. LO 18.4 Articulate health risks and concerns for the young adult: Many young adults tend to ignore health issues and adopt a "wait and see" attitude. Health risk behaviors associated with young adulthood include increased alcohol use, illicit drug use, and frequent STDs. Domestic violence is seen throughout adulthood but frequently begins in young adulthood. LO 18.5 Summarize the physiologic, cognitive, emotional, and social changes that occur in the middle adult age group: Middle adulthood may be difficult to define as attitudes about life often determine the extent to which individuals feel and act young or old. During middle adulthood, men and women begin to experience changes that, if unacknowledged, can lead to illness and disability. LO 18.6 Explain health risks and concerns for the middle adult: Cancer and cardiovascular disease are leading causes of death in middle adults. Disease prevention is an important aspect of patient education for this age group. Many middle adults are caring for children, grandchildren, and/or parents, adding unique stressors to life as they juggle career and family responsibilities. LO 18.7 Recognize the physiologic, cognitive, emotional, and social changes that affect the older adult: Older adults are living longer, and many remain independent until death. Others experience cognitive and physical changes that require care in the home or in a health care facility. LO 18.8 Outline health risks and concerns for the older adult: Many older adults are affected by aging in the form of chronic diseases that alter their independence. Musculoskeletal problems, respiratory disorders, cardiovascular diseases, cancers, and diabetes are increasingly common in this age group.

Chapter 2 Summery

LO 2.1 Describe the differences between beliefs and values and how they develop: Beliefs are mental representations of reality, or what a person thinks is real or true; values are enduring beliefs that help the person decide what is right and wrong and determine what goals to strive for and what personal qualities to develop. Beliefs and values are developed through personal experiences, family influences, culture, ethnic background, spirituality, religion, and education. LO 2.2 Explain the use of the values clarification process in dealing with a values conflict: The nurse needs to recognize when a values conflict exists and seek ways to identify the underlying factors causing the concern. A values clarification tool can be used to help patients examine past life experiences and consider where they spend their time, energy, and money to provide insight into what they truly value and believe. Values clarification can help nurses become more aware of their own personal values and beliefs that impact professional nursing practice. LO 2.3 Summarize how the beliefs of nurses and patients influence health care: The beliefs of both nurses and patients influence how patients are treated, what patients listen to and act upon, and patient outcomes. LO 2.4 Discuss the major concepts of four nursing theories of caring: Leininger's Cultural Care Theory states that culturally based nursing actions are intended to preserve, accommodate, or reconstruct the patient's meaningful health or life patterns. Watson's Human Science and Human Care Theory is a holistic model of care in which the nurse's focus is on 10 carative factors. According to Travelbee's Human-to-Human Relationship Model, the nurse assists the patient through five phases of a relationship and, if necessary, to find meaning in these experiences. Swanson's Middle Range Theory of Caring focuses on five processes of relationship-based caring for the nurse: maintaining belief, knowing, being with, doing for, and enabling the patient. LO 2.5 Articulate ways in which nurses develop into caring professionals: Nurses develop caring skills through life experiences, observation of both positive and negative role models, and interaction with strong professional mentors. LO 2.6 Identify behaviors that demonstrate caring: Nurses demonstrate caring through presence, consistency, predictability, touch, and listening.

Chapter 23 Summary

LO 23.1 Describe various types of community health nursing: Three major types of community health nursing are public health, community-based, and home health care. Public health nursing focuses on addressing the needs of populations in collaboration with interdisciplinary teams. Community-based nursing provides care for individuals within specific areas such as schools, prisons, or businesses. Home health nurses assess and treat homebound clients requiring direct care. LO 23.2 Identify examples of the three levels of prevention: Primary prevention includes activities designed to prevent disease and disability. Secondary prevention focuses on screening and limiting the impact or recurrence of an illness or phenomenon with early interventions. Tertiary prevention is directed at treatment of individuals already diagnosed with a disease or disability. LO 23.3 Discuss factors affecting the health of a community: Factors include disease agents, such as bacteria or viruses, as well as other etiologic factors such as excessive or deficit nutritional intake, chemical agents, physical agents, and socioeconomic factors (e.g., where one works, whether one lives in an urban or rural setting, and the impact that social unrest or disaster can have on the health of a community). LO 23.4 Articulate an awareness of various target populations, including vulnerable people within a community: Target populations include groups of people who have or are at risk for injury, disease, or disability, including those most vulnerable, such as the homeless, infants, elderly people, substance abusers, the mentally ill, and refugees and immigrants. LO 23.5 Complete a community or home health assessment using data collection tools such as the OASIS data set: Demographic and data collection tools for community assessment are available for use and analysis at the international, national, state, and community levels. The OASIS assessment instrument is designed to collect comprehensive data on home health care clients. LO 23.6 Identify nursing diagnoses for clients or populations of interest: Examples of nursing diagnoses used to address the needs of clients in the different types of community nursing are Risk for Injury, Ineffective Community Coping, Caregiver Role Strain, Social Isolation, and Nutrition Imbalance: Less Than Body Requirements. LO 23.7 Use measurable goals to develop community-based plans of care: Developing measurable goals in community-based nursing may involve collaboration with a variety of health care providers as well as stakeholders who have a significant interest in the outcomes of the goals. LO 23.8 Implement collaborative interventions to address the needs of the identified target population or client: Interventions in community health settings often require referrals and advocacy to help populations and clients successfully reach established goals. It is vital that nurses establish and maintain strong relationships with community agency personnel to enhance cooperation.

Chapter 3 Summary

LO 3.1 Identify key components of the communication process: A referent initiates communication between a sender and a receiver during which a message is sent through a channel and followed by feedback to ensure accuracy. LO 3.2 List examples of the verbal and nonverbal modes of communication: The most common and accurate mode of communication is nonverbal, which uses various forms of body language and voice inflection. Verbal communication may be spoken, written, or electronic. LO 3.3 Recognize various types of communication: Effective intrapersonal, interpersonal (including interprofessional), small-group, and public communication skills must be used by nurses to adequately meet the needs of patients, families, and the communities in which they practice. LO 3.4 Describe how significant aspects of the nursing process are implemented in the nurse-patient helping relationship: The relationship focuses on addressing identified patient needs. The nurse must use all steps of the nursing process to build a trusting relationship focused on positive patient outcomes. LO 3.5 Discuss factors affecting the timing of patient communication: Several factors influence the ability of patients to respond to nurse-initiated communication. They include pain level, anxiety, and environmental factors such as distractions or level of privacy. LO 3.6 Recognize the roles of respect, assertiveness, collaboration, delegation, and advocacy in professional nursing communication: Nurses communicate professionally by showing respect, advocating for patients, and assertively conveying patient needs during collaboration and delegation. LO 3.7 Identify social, therapeutic, and nontherapeutic communication techniques: Nurses must practice using a variety of therapeutic communication techniques to address the needs of patients. Nontherapeutic communication may be considered social in nature and shifts conversational focus away from the concerns of patients. LO 3.8 List defense mechanisms used by patients while communicating: Individuals under extreme stress may use defense mechanisms to protect themselves and their psyches to better cope with the reality of life experiences. LO 3.9 Illustrate methods of communicating in special situations: Nurses may use a variety of methods such as whiteboards, computer tablets, physical touch, and online resources to communicate effectively with sensory-impaired or nonverbal patients. Assessing family and community dynamics facilitates enhanced communication and patient safety.

Chapter 4 Summary

LO 4.1 Identify the relationship between critical thinking and clinical reasoning: Critical thinking is a required competency of professional nurses and is defined as a deliberate, reflective process that guides decision making and problem solving. Clinical reasoning requires critical thinking, knowledge, and expertise for decision making in clinical situations. LO 4.2 Summarize how theories of critical thinking apply to professional nursing practice: The interaction of reflection, evidence, standards, and theoretical underpinnings fosters critical thinking. Critical thinking is used by nurses for decision making, clinical judgment, reasoning, problem solving, and organizing and prioritizing care. LO 4.3 Describe the intellectual standards of critical thinking: Thinking critically requires competence in fundamental intellectual standards. These standards include clarity, accuracy, precision, relevance, depth, breadth, logic, significance, and fairness of the thinking process. LO 4.4 Discuss critical-thinking components and attitudes: Effective critical thinking depends on specific components such as having an adequate knowledge base, reasoning, making inferences, and validating. Possessing the attributes of responsibility, accountability, creativity, perseverance, integrity, and humility assists nurses in the application of critical thinking to nursing practice. LO 4.5 Apply principles of critical thinking in nursing practice: Critical thinking is essential at each step of the nursing process for clinical decision making. It is an expectation of professional practice that nurses update and maintain their competency and knowledge base. Maintaining competency through professional development and research reviews is facilitated by the nurse using critical-thinking skills. Decisions related to delegation, collaboration, and teamwork largely depend on the use of critical-thinking standards. LO 4.6 Explain errors to avoid in providing safe and competent patient care: Patient safety is potentially threatened by errors in critical thinking that include bias, lack of knowledge, illogical thinking, closed-mindedness, and erroneous assumptions. LO 4.7 Describe methods for improving critical thinking in nursing: Nurses can improve clinical decision making through discussions with colleagues, think aloud activities, literature review, intentional application of knowledge, concept mapping, simulation exercises, role playing, and written work.

Chapter 5 Summary

LO 5.1 Define the nursing process: The nursing process is the scientific method through which professional nurses systematically identify and address actual or potential patient problems. Critical thinking, using the nursing process, allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs, establish realistic goals, and customize interventions with members of the health care team. LO 5.2 Describe the historical development and significance of the nursing process: The five primary steps of the nursing process were clearly identified by the early 1960s and have remained virtually unchanged since then, with only the addition of a subcategory to planning, outcome identification, in the early 1990s. Professional nursing practice in all types of settings is based on the nursing process. It is used to assess individuals, families, and communities; diagnose needs; plan attainable goals; implement specific interventions; and evaluate degrees of goal attainment. LO 5.3 Articulate the characteristics of the nursing process: The nursing process requires nurses to think critically. It is dynamic, organized, and collaborative, and it is universally adaptable to various types of health care settings. LO 5.4 Describe the steps in the nursing process: During the assessment step of the nursing process, patient care data are gathered. In the diagnosis step, patient data are analyzed to identify patient problems and then are stated as specific nursing diagnoses. During the third step of the nursing process, planning, the nurse prioritizes the nursing diagnoses and identifies goals with specific outcome identification. The implementation step includes initiating specific nursing interventions designed to help achieve established goals. During the evaluation step, the nurse determines goal attainment, the effectiveness of interventions, and whether the plan of care should be discontinued, continued, or revised. LO 5.5 Explain the significance of the cyclic and dynamic nature of the nursing process: Use of the nursing process requires the professional nurse to continuously reassess patients, revise care as needed, and evaluate whether goals are being met. As goals are met, portions of the nursing plan can be eliminated or discontinued. Nursing care sometimes needs to be modified to meet previously unidentified needs. The ongoing process of evaluating and adjusting intervention strategies requires nursing care that is based on current evidence-based practice.

Chapter 7 Summary

LO 7.1 Explain basic nursing diagnosis methodology: Nursing diagnosis is the second step of the nursing process. When deciding on an accurate nursing diagnosis for a patient, the nurse makes clinical judgments about a patient's experiences and responses to identified problems or life events expressed during the data collection process. LO 7.2 Describe the historical development of NANDA-I and the nursing taxonomy: In 1973, the first conference of nurses met to develop a nursing taxonomy. The group continued to meet every 2 years and officially became the North American Nursing Diagnosis Association in 1982. In 2002, the group became NANDA International to acknowledge worldwide interest in nursing taxonomy. It continues with the original goals of generating, naming, and implementing nursing diagnostic categories, as well as revising the taxonomy, promoting research, and encouraging nurses to use the taxonomy in practice. LO 7.3 Differentiate among the three types of nursing diagnostic statements: Actual nursing diagnoses describe the response of a patient to a current need, problem, or life process. Risk nursing diagnoses identify specific potential problems in individuals vulnerable to developing complications due to their current disease state or life experience. Health-promotion nursing diagnoses are clinical judgments based on the expressed desire of patients, families, or groups for change (NANDA-I, 2012). LO 7.4 Outline nursing diagnoses with appropriate components: Actual nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion nursing diagnoses are also written with only two sections: a diagnosis label and defining characteristics. LO 7.5 Implement the steps for accurately identifying nursing diagnoses: Accurate identification of nursing diagnoses for patients is achieved through careful analysis and clustering of patient data, followed by verification of the specific nursing diagnoses for use with each individual patient. 103 LO 7.6 Discuss how to avoid common problems associated with the diagnostic process: To write concise, properly developed nursing diagnoses, the nurse must avoid clustering unrelated data, accepting erroneous data, using medical diagnoses as related factors in the nursing diagnostic statement, missing the true underlying etiology of a problem, and identifying multiple nursing diagnoses labels in one nursing diagnostic statement. LO 7.7 Articulate the contribution of nursing diagnoses to the individualized care of patients: As the second step of the nursing process, the nursing diagnosis provides a framework on which nurses provide care to patients in an organized and effective manner. An accurate nursing diagnosis promotes positive patient outcomes, quality patient care, and patient satisfaction.

Chapter 8 Summary

LO 8.1 Articulate nursing actions that take place during the planning process: During planning, the professional nurse prioritizes the patient's nursing diagnoses, determines short- and long-term goals, identifies outcome indicators, and lists nursing interventions for patient-centered care. LO 8.2 Describe various measures used in prioritizing patient care: Maslow's hierarchy of needs and the ABCs of life support in the health care setting are helpful resources in prioritizing care. Collaboration with patients while developing goals can decrease the incidence of conflicting priorities. LO 8.3 Illustrate an understanding of goal development: Goals need to be patient centered, realistic, and measurable. Using measurable verbs and time limits when writing goals assists the nurse in evaluation of patient goal attainment. LO 8.4 Describe the relationship between outcome identification and goal attainment: Outcome identification, added by ANA in 1991 as a specific aspect of the nursing process, involves listing observable behaviors or items that indicate attainment of a goal. LO 8.5 Identify formats in which patient-centered plans of care can be developed: Each health care facility or agency has its own electronic health record or form on which patient care plans are formulated and documented. In some agencies and specialty units, standardized care plans, which must be individualized for each patient, are available to guide nurses in the planning process. The conceptual care map (CCM) is a format for nursing students to use when developing patient care plans. It helps students to accurately collect, analyze, and synthesize patient data that are used to identify appropriate nursing diagnoses, goals, and interventions. LO 8.6 Distinguish among the types of interventions: Independent interventions are nurse initiated, and dependent nursing interventions require an order from a patient's health care provider. Collaborative interventions require cooperation among a few or many members of the interdisciplinary health care team. LO 8.7 Discuss the importance of planning throughout patient care: Care planning begins when a patient and nurse first interact and continues until the patient no 115longer requires care. It takes place at a variety of times and places. It can include preadmission, acute care, home care, and discharge planning. Seamless communication throughout a patient's care ensures continuity of treatment and improved patient outcomes.

Chapter 9 Summary

LO 9.1 Explain the significance of implementation and evaluation in the nursing process: Nurses and other members of the interdisciplinary health care team provide care through interventions designed to promote, maintain, or restore a patient's health during the implementation phase of the nursing process. Implementation consists of performing a task and documenting each intervention. Evaluation focuses on the patient and the patient's response to nursing interventions and outcome attainment. Evaluation data are used by the nurse to adapt a plan of care on the basis of the patient's changing health status. LO 9.2 Describe different types of direct-care interventions: Direct care refers to interventions that are carried out by having personal contact with patients. Direct nursing interventions include reassessing patients, assisting with ADLs, giving physical care, counseling, and teaching. LO 9.3 Differentiate among various forms of indirect-care interventions: Indirect care includes nursing interventions performed to benefit patients without face-to-face contact. Indirect nursing interventions include communicating and collaborating with other health care team members, making referrals, doing research, advocating, delegating, and engaging in preventive actions such as patient education and health promotion. LO 9.4 Identify examples of independent nursing interventions: Independent nursing interventions are tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order. The extent to which nurses can implement independent nursing interventions is often determined by the area in which care is taking place. LO 9.5 Recognize dependent nursing interventions: Dependent nursing interventions are tasks the nurse undertakes that are within the nursing scope of practice but require the order of a physician or PCP to implement. They require nurses to pay strict attention to the details of what was ordered and to 126recognize when implementing a dependent nursing intervention is appropriate or should be withheld in consultation with the PCP. LO 9.6 Identify the significance of documentation in the implementation step: Nurses must document effectively to convey information accurately to other care providers. Within the HIPAA guidelines, patient documentation is provided to insurance companies and others for billing and reimbursement. LO 9.7 Apply evaluation principles used in the nursing process: Evaluation focuses on the patient and the patient's response to nursing interventions and outcome attainment. Evaluation is not a record of the care that was implemented. Information on the effectiveness of nursing interventions is a by-product of the evaluation process. During the evaluation phase, nurses use critical thinking to determine whether a patient's short- and long-term goals were met and the desired outcomes were achieved. LO 9.8 Describe the relationship between care plan modification and quality improvement: Care plan modification is based on the effectiveness of interventions to meet and improve desired patient outcomes. QI processes benefit patients and ultimately affect patient care. If certain patient outcomes are consistently improved by the implementation of specific nursing interventions, procedures can be changed on the basis of the QI research.

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