NUR 2101 Module 4 (Info For Final)

Which patient scenario allows the physician to perform needed procedures without the need to obtain informed consent first? a. An unconscious patient is brought into the ER after an auto accident. b. The patient speaks only Russian and requires the services of a translator. c. The patient is deaf and communicates through sign language or lip reading. d. The patient is not an American citizen and does not have any health insurance.

a. An unconscious patient is brought into the ER after an auto accident. Informed consent may not be obtained from an unconscious trauma patient. Informed consent must be obtained with a translator for patients who do not speak English. Deaf patients require sign language translators. Lack of health insurance does not eliminate the need for informed consent.

A nurse tells a patient with a recent back injury that damage to the nerves is comparable to a water hose that has been pinched off and that time is needed to allow normal nerve transmission. Which technique did the nurse use? a. Analogy b. Discovery c. Role playing d. Demonstration

a. Analogy Analogies add to verbal instruction by providing familiar images that make complex information more real and understandable. Discovery is a useful tool for teaching problem solving and is a technique for cognitive learning. During role play your patients play themselves or someone else in the situation. Demonstrations are useful when teaching psychomotor skills.

The nurse is frustrated with an agitated patient and tells him "Now stay in that bed or I will make you stay there!" Which tort has the nurse just committed? a. Assault b. Battery c. Incursion d. Onslaught

a. Assault The nurse has committed assault by threatening the patient. No actual contact is required for an assault to occur. Battery occurs when the patient is touched without consent. Onslaught and incursion are not legal terms.

Which is the appropriate action for the nurse manager when a nurse refuses to assist with an abortion due to personal ethical beliefs? a. Assign the nurse to care for other patients. b. Counsel the nurse about professional responsibility. c. Report the nurse's refusal to the State Board of Nursing. d. Inform the nurse that the refusal will lead to termination.

a. Assign the nurse to care for other patients. The nurse manager should assign the nurse to care for other patients so that the nurse does not have to go against personal ethical beliefs. Counseling the nurse about professional responsibility will not resolve the current staffing issue and the nurse will not change ethical beliefs about abortion. Reporting the nurse to the State Board of Nursing and threatening termination are not appropriate as nurses are allowed to refuse assignments such as abortions based on their personal ethical beliefs.

Which ethical principle is violated when the patient is not told the truth about the medical diagnosis and therefore is not able to decide on the course of treatment? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

a. Autonomy Autonomy refers to a person's independence. As a principle in bioethics, autonomy represents an agreement to respect a patient's right to determine a course of action. Justice refers to the principle of fairness: fair treatment and fair distribution of health care resources. Fidelity refers to the agreement to keep promises and is based on the virtue of caring. Nonmaleficence is actively seeking to do no harm.

The nurse respects the patient's wish not to be intubated even though the patient will most likely die as a result of the decision. Which ethical theory is demonstrated by the action of the nurse? a. Autonomy b. Justice c. Utilitarianism d. Responsibility

a. Autonomy Autonomy refers to the patient's right to make decisions and determine a course of action. This is upheld when the nurse respects the patient's wish not to be intubated. Justice refers to the principle of treating all patients fairly. Utilitarianism determines the value of something based primarily on its usefulness and benefit for the greater good. Responsibility refers to reliability and dependability in the performance of duties.

The nurse cuts an unconscious patient's long hair in order to wash and brush it. The patient wakes up and is very upset after seeing the short hair. Which tort did the nurse commit? a. Battery b. Assault c. Slander d. Negligence

a. Battery Battery is intentional offensive touching without consent or lawful justification. Assault is an intentional threat toward another person that gives that person a reasonable fear of harmful contact. No actual contact is required for an assault to occur. Negligence is an unintentional tort. Slander is making malicious statements that can damage an individual's reputation.

The nurse is caring for a patient with the nursing diagnosis impaired religiosity related to inability to participate in religious services while hospitalized. Which nursing intervention is most appropriate for this patient? a. Call the patient's religious leader to coordinate bedside services for the patient. b. Help the patient to make a list of important values and ideals in the patient's life. c. Use therapeutic touch and authentic presence to support the patient spiritually. d. Encourage the patient to focus on physical healing before meeting spiritual needs.

a. Call the patient's religious leader to coordinate bedside services for the patient. The patient is distressed because of the inability to participate in religious services while hospitalized. The best way for the nurse to address the religious need of the patient is to call the patient's religious leader to coordinate bedside services for the patient. This will facilitate meeting the patient's religious needs. Helping the patient to list values and using therapeutic touch will not meet the patient's religious needs. Encouraging the patient to focus on physical healing before meeting spiritual needs minimizes the patient's priorities and may be seen as condescending.

The nurse has received an order to administer warfarin 100 mg PO today to the patient. This amount seems high to the nurse. Which are the appropriate actions of the nurse? (Select all that apply.) a. Clarify the order with the physician. b. Document suspicion about the order. c. Notify the nursing supervisor on duty. d. Administer the medication as ordered. e. Question the pharmacist about the dosage.

a. Clarify the order with the physician. c. Notify the nursing supervisor on duty. e. Question the pharmacist about the dosage. Nurses are responsible for carrying out medical treatment unless the physician's or health care provider's order is in error, violates hospital policy, or is harmful to the patient. Therefore it is imperative to assess all orders and, if they appear to be erroneous or harmful to the patient, to obtain further clarification from the physician or health care provider. 100 mg is not an appropriate dosage of warfarin so it should not be administered to the patient. Do not carry out the order if there is a risk that harm will come to your patient; therefore do not administer the medication. The nursing supervisor should be notified. The pharmacist should be contacted about the order. Inform the nurse manager or the nursing supervisor. The nurse does not document suspicions or opinions, just objective, factual information.

The family is unsure what treatment is appropriate for the comatose patient who is terminally ill. Which steps will the nurse take to help the family process this ethical dilemma? (Select all that apply.) a. Consider all possible treatment options. b. Calculate the odds of the patient's survival. c. Clarify own values and opinions about the issues. d. Provide personal opinions about treatment options. e. Gather all relevant information about the situation.

a. Consider all possible treatment options. c. Clarify own values and opinions about the issues. e. Gather all relevant information about the situation. The nurse should gather all relevant information, clarify own values and opinions about the issue, and consider possible courses of action. Seven steps are used when solving an ethical dilemma: (1) Asking "is it an ethical dilemma?", (2) gathering all information, (3) examining and determining one's own values and opinions about the issue, (4) stating the problem clearly, (5) considering possible courses of action, (6) negotiating an outcome, and (7) evaluating the action. Calculating the odds of the patient's survival and providing personal opinions about treatment options are not steps of the process.

The nurse is providing discharge instructions to the patient. Which grade level should the instructions be written at as the nurse does not know the patient's educational background? a. Fifth-grade b. Seventh-grade c. Ninth-grade d. Eleventh-grade

a. Fifth-grade Individualize teaching materials to meet the patient's needs and match the patient's reading level; if a nurse does not know the patient's reading level, information should be provided at a fifth-grade or lower level. Sixth-, eighth-, and ninth-grade levels are too high.

The patient is distressed because hospitalization has prevented participation in church services and adherence to important prayer rituals. Which nursing diagnosis is most appropriate for this patient? a. Impaired religiosity related to inability to participate in religious services b. Noncompliance related to failure to adhere to prescribed treatment regimens c. Disturbed thought processes related to delirium and altered level of consciousness d. Ineffective role performance related to discrimination and inadequate coping

a. Impaired religiosity related to inability to participate in religious services Impaired religiosity is an appropriate diagnosis for this patient because hospitalization has prevented participation in the patient's religious services. Nothing in the scenario indicates that the patient is noncompliant, has experienced discrimination, or is delirious.

Which nursing diagnosis is most appropriate for a patient who is having difficulty with accepting the reality of a lung cancer diagnosis by attempting to hide periods of shortness of breath from the nurse? a. Ineffective denial related to threat of unpleasant reality of lung cancer b. Noncompliance related to failure to adhere to prescribed treatment plan c. Effective therapeutic regimen management related to illness symptom reduction d. Readiness for enhanced decision making related to realignment of personal values

a. Ineffective denial related to threat of unpleasant reality of lung cancer The patient is experiencing ineffective denial related to threat of unpleasant reality of lung cancer by hiding episodes of shortness of breath. The patient is not displaying noncompliance with the treatment plan, effective therapeutic regimen management, or readiness for enhanced decision making.

The patient suffers a large hematoma at the site after arterial blood gases (ABGs) are drawn by the respiratory therapist. Which statement is appropriate to enter in the patient's chart? a. Patient has a painful, raised 2-inch × 2-inch hematoma inside his right wrist after ABGs were drawn there. b. The patient must have moved during the ABG draw because there is a huge bruise inside his wrist. c. The respiratory therapist had a hard time getting the patient's ABGs drawn and caused bruising. d. The respiratory therapist obviously didn't know what he was doing and traumatized the patient's wrist.

a. Patient has a painful, raised 2-inch × 2-inch hematoma inside his right wrist after ABGs were drawn there. Narrative notes must be objective without opinions, speculation, or blame. The nurse should chart the location and size of the hematoma along with the reason. The nurse should not speculate that patient moved or that the respiratory therapist did not know how to perform the skill.

The nurse is caring for a patient who expresses anger about being abandoned and unloved by God since becoming ill. Which nursing diagnosis is appropriate for this patient? a. Spiritual distress related to perceived alienation from God b. Risk for loneliness related to social and physical isolation c. Acute confusion related to hallucinations and misperceptions d. Impaired memory related to inability to remember familiar prayers

a. Spiritual distress related to perceived alienation from God The nursing diagnosis spiritual distress related to perceived alienation from God is appropriate for this patient due to feelings of alienation from God since becoming ill. The patient scenario does not indicate social or physical isolation, impaired memory, or hallucinations. Feeling abandoned by God is not a hallucination.

The nurse is providing discharge instructions to a patient with memory loss after a head injury. What is the most appropriate action of the nurse? a. Teach the patient and a responsible family member at the same time. b. Teach the patient using simple terminology and a louder tone of voice. c. Teach the patient the most important information first followed by lesser facts. d. Teach the patient immediately before discharge so the patient will remember it.

a. Teach the patient and a responsible family member at the same time. The discharge information should be provided to the patient's responsible family member as well as the patient since the patient may not remember it. Speaking loudly will not help the patient to remember the information. Giving the most important information first immediately before discharge will not help the patient to remember the information.

Which is the most appropriate learning goal for new parents who are learning infant CPR? a. The parents will demonstrate infant CPR skills. b. The parents will be able to understand CPR skills. c. The infant will not require further hospitalization. d. The parents will call the hospital if the infant stops breathing.

a. The parents will demonstrate infant CPR skills. A learning objective describes what the patient or guardian(s) will be able to do after successful instruction. The objective contains an active verb describing what the learner will do after the objective is met (demonstrate). Understand does not specify the behavior or content to be learned and is not an active verb. The parent's "understanding" is not measureable, and learning goals need to be measureable. The best learning goal in the case of a skill is to demonstrate that skill. The learning objectives should focus on the parents as they are the learners; it should not focus on the infant. The parents should call the hospital for help but this does not relate to the skill being taught, CPR.

In which case might the patient be ordered by the court to receive treatment? a. The patient has infectious TB and refuses to take the prescribed antibiotics. b. The patient's mother refuses a vaccine for her child because he is allergic to it. c. A Jehovah's Witness refuses a blood transfusion based on religious convictions. d. A patient refuses treatment to slow the advancement of an inoperable brain tumor.

a. The patient has infectious TB and refuses to take the prescribed antibiotics. Patients whose refusal of treatment may endanger the health of the public may be ordered by the court to receive treatment. An example of this is a patient who has infectious TB and refuses to take prescribed antibiotics. The court will not require Jehovah's Witness patients to receive blood transfusions or require surgery for inoperable tumors. Allergy to a vaccine is a valid reason for refusal.

Which attitude of the nurse will facilitate effective care for hospice patients? a. The patient needs the nurse's presence and personal connection. b. Remaining silent signifies a noncaring attitude toward the patient. c. Reminiscing with the patient only makes a difficult situation worse. d. The patient does not recognize the impact of the loss if no tears are shed.

a. The patient needs the nurse's presence and personal connection. Patients need the presence and personal connection of the nurse as they progress through the dying process. By silently sharing a moment of sadness with a patient or family member, you communicate caring and send the message that you respect and accept their feelings in the moment. Do not assume that other people react to loss or grief as you do or that a particular behavior necessarily indicates grief. Encouraging patients to tell stories about their loved one gives them an opportunity to provide information in a natural, unstructured, and meaningful way.

The nurse is caring for a patient who will have surgery. The nurse witnesses the patient sign the informed consent document, and then the nurse adds her signature as a witness. What does the nurse's signature on the document mean? a. The patient signed the form, not someone else. b. The patient accepts the potential risks of the procedure. c. The patient fully understands the procedure to be performed. d. The patient agrees with the surgeon's planned treatment approach.

a. The patient signed the form, not someone else. The nurse's signature on the consent form indicates only that the patient signed the form, not someone else. The nurse's signature on the consent form does not indicate that the patient accepts the potential risks of the procedure, fully understands the procedure to be performed or agrees with the surgeon's planned treatment approach.

Which action demonstrates that the patient is experiencing the reorganization stage of mourning after having a stillborn baby? a. The patient volunteers at a local infant loss support group. b. The patient sits for hours and hours just looking at the empty crib. c. The patient has panic attack with shortness of breath and chest pain. d. The patient turns to alcohol to numb the overwhelming pain of the loss.

a. The patient volunteers at a local infant loss support group. During the final phase of reorganization, which usually requires a year or more, the person accepts unaccustomed roles, acquires new skills, and builds new relationships. In the numbing phase, a person has periods of extremely intense emotion and reports feeling "stunned" or "unreal." The numbing phase lasts from several hours to a week. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, people need to experience this painful phase of grief. During the phase of disorganization and despair, an individual spends much time thinking about how and why the loss occurred. The person often expresses anger at anyone he or she believes to be responsible. Gradually this phase gives way to an acceptance that the loss is permanent.

Which patient is appropriate for the nursing diagnosis readiness for enhanced knowledge related to the prescribed treatment regimen? a. The patient who asks the nurse how a pill organizer can help to ensure that all medications are taken on time. b. The patient who insists that the blood sugar levels will never stabilize no matter how many medications are taken. c. The patient who believes that influenza was contracted as a result of the flu immunization last year. d. The patient who was just diagnosed with diabetes and has no idea about how to inject insulin.

a. The patient who asks the nurse how a pill organizer can help to ensure that all medications are taken on time. Readiness for enhanced knowledge related to the prescribed treatment regimen indicates that the patient is already knowledgeable and wishes to learn more. Readiness for enhanced knowledge is appropriate for the patient who asks the nurse how a pill organizer can help to ensure that all medications are taken on time. Readiness for enhanced knowledge is not appropriate for patients who do not want to learn or who have not obtained a basic understanding of the concepts already.

Which ethical area is challenged when the nurse feels bound to refuse to assist with an abortion procedure? a. Values b. Culture c. Confidentiality d. Social networking

a. Values The nurse is having a conflict in values because of religious beliefs and abortion. A value is a personal belief about the worth of an idea, a custom, or an object. Confidentiality is not the issue because no confidences have been broken. Social networking is online communication, which is not the issue in this scenario, values are the issue. The nurse is not having a conflict in culture, but in beliefs and values.

Which statement made by the patient indicates readiness for learning about colostomy care? a. "I don't want to look at it and I can't imagine caring for it." b. "The sooner I can take care of it, the sooner I can go home." c. "I never thought I would have to take care of something like this." d. "I hope I can still wear a bathing suit with this thing."

b. "The sooner I can take care of it, the sooner I can go home." "The sooner I can take care of it, the sooner I can go home" indicates that the patient is ready to learn about how to take care of the colostomy. The patient realizes that discharge from the hospital depends on the ability to care for the colostomy so the patient is amenable to teaching about how to care for it. "I don't want to look at it and I can't imagine caring for it" indicates that the patient does not wish to learn about colostomy care. "I never thought I would have to take care of something like this" is an emotional statement that indicates a need for support from the nurse. "I hope I can still wear a bathing suit with this thing" addresses a need for reassurance about appearance and activity after colostomy surgery.

The nurse is caring for a patient who generally copes well after losing a child many years ago but becomes despondent each year on the anniversary of the death. Which is the best statement by the nurse? a. "That kind of reaction is very rare after so long a time. It would be best to avoid the cemetery on dates that might trigger this type of reaction." b. "What happens to you is understandable and common in people who have lost loved ones." c. "I find that hard to believe. We all grieve basically the same way, and I know that I would not react that way after such a long time." d. "The fact that you reacted so strongly is concerning to me. This could be the beginning of some psychological issues."

b. "What happens to you is understandable and common in people who have lost loved ones." Reinforce the understanding that people grieve differently and that feelings change or resolve over time. Some people have "anniversary reactions" (heightened or renewed feelings of loss or grief) months or years after a loss. They worry that they are losing ground when signs of grief reappear after a period of relative calm. Offer reassurance that anniversary reactions are common, and encourage pleasant reminiscence.

Which of the following is true for a patient to receive home hospice care? a. Caregiver support is available during normal business hours. b. A primary caregiver must be living in the home with the patient. c. If the patient goes to the hospital, all prehospital orders are canceled. d. In the hospital, the home hospice care person must provide personal care.

b. A primary caregiver must be living in the home with the patient. For a patient to receive home hospice care, a primary caregiver must be living in the home. The primary caregiver receives support from professional and volunteer hospice team members who are available 24 hours a day. If a patient receiving home hospice care goes to the hospital for the management of acute symptoms, a hospice nurse coordinates care between the home and hospital settings, but does not provide actual patient care.

The nurse administers the wrong dose of medication and then blames the mistake on a co-worker. Which ethical principle is violated by the nurse? a. Fidelity b. Accountability c. Confidentiality d. Social networking

b. Accountability Accountability refers to the nurse's ability to take responsibility for actions or decisions. The nurse in this situation failed to be accountable for the medication error by blaming it on a co-worker. Confidentiality is the protection of patient information so that it is not shared with others. Fidelity is an agreement to keep a promise. Social networking refers to the use of social media to connect with patients, family members, and friends.

The patient is the caregiver to the spouse with advanced dementia. The patient mourns the loss of the spouse's mind and personality even though the body is still physically functioning. Which type of grief is being experienced by the patient? a. Normal b. Anticipatory c. Complicated d. Disenfranchised

b. Anticipatory Anticipatory grief is the pain felt before the physical death of the loved one occurs. Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away. Disenfranchised grief occurs in situations in which others view a person's loss as insignificant or invalid.

Which term is used to describe a person who does not believe in the existence of a higher power but has had a meaningful life by contributing to the lives of others? a. Deist b. Atheist c. Fatalist d. Humanist

b. Atheist An atheist is a person who does not believe in the existence of a higher power or Supreme Being. Atheists search for meaning in life through their work and relationships with others. A humanist is devoted to the study of human nature and human welfare. A fatalist believes that all events were predetermined. A deist believes that God created the world but does not control how it functions.

Which ethical area is involved when the clinic releases genetic test results to the patient's employer without the patient's consent? a. Veracity b. Bioethics c. Justice d. Beneficence

b. Bioethics Bioethics is a division of ethics that deals with appropriate use of medical technology. Bioethics includes decisions regarding organ transplants, genetic testing, and quality of life. Beneficence refers to helping others. Justice refers to the principle of fairness: fair treatment and fair distribution of health care resources. Veracity is telling the truth.

The nurse is directed to take an unsafe patient assignment. What is the most appropriate first action of the nurse? a. Contact the State Board of Nursing. b. Contact the nursing supervisor on duty. c. Contact the hospital administrator on call. d. Refuse to accept the assignment and leave.

b. Contact the nursing supervisor on duty. If a nurse is assigned to care for more patients than is reasonable for safe care, the appropriate first action is to contact the nursing supervisor. If the nurse is required to accept the assignment, he or she must document this information in writing and provide the document to nursing administrators. Although documentation does not relieve a nurse of responsibility if patients suffer harm because of inattention, it shows that the nurse attempted to act appropriately. Refusing to care for the patients without appropriate help and leaving could be regarded as abandonment. Complaining to the administrator is not the first step, nor is calling the Board of Nursing.

The patient concentrates on the mind-numbing details of the spouse's funeral to delay dealing with the overwhelming pain of the loss. Which stage of grief is currently being experienced by the patient? a. Anger b. Denial c. Bargaining d. Acceptance e. Depression

b. Denial Individuals in the denial stage cannot believe or understand that a loss has occurred and shut down their feelings until they are able to process the grief a little at a time. In the anger stage, a person resists the loss, is angry about the situation, and sometimes becomes angry with God. During bargaining, the individual postpones awareness of the loss and tries to prevent the loss from happening by making deals or promises. A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interactions with others. During the stage of acceptance, the individual begins to accept the reality and inevitability of loss and looks to the future.

Which teaching approach is demonstrated when the nurse provides guidance while the patient performs the sterile dressing change? a. Telling b. Entrusting c. Reinforcing d. Participating

b. Entrusting The entrusting approach provides the patient the opportunity to manage self-care. The patient accepts responsibilities and correctly performs the task while a nurse observes the patient's progress and remains available for assistance. Telling involves explicit instructions with no feedback. Participating involves mutual goal setting with the patient helping decide the content. Reinforcing is using a stimulus that increases the probability of a response.

Which type of reinforcement is used when the nurse gives a sticker to a pediatric patient every time the incentive spirometer is used? a. Social b. Material c. Activity d. Negative

b. Material Examples of material reinforcers are food, toys, and music. These work best with young children. Use social reinforcers (e.g., smiles, compliments, words of encouragement, or physical contact) to acknowledge a learned behavior. Activity reinforcers (e.g., physical therapy) rely on the principle that a person is motivated to engage in an activity if there is an opportunity to participate in more desirable activity upon completion of this first activity. Negative reinforcement (frowning) may work but people usually respond better to positive reinforcement.

Which nursing interventions are appropriate for a terminally ill patient who is a devout Jew? (Select all that apply.) a. Arrange for a minister to provide the sacrament of anointing of the sick. b. Facilitate bedside Sabbath services for the patient and the family members. c. Allow the patient's family to maintain a vigil throughout the day and night. d. Provide snacks and meals for the patient and family only from sunset until dawn. e. Respect the decision of the patient and family not to put the patient on life support.

b. Facilitate bedside Sabbath services for the patient and the family members. c. Allow the patient's family to maintain a vigil throughout the day and night. e. Respect the decision of the patient and family not to put the patient on life support. Sabbath services are very important for people of Jewish faith so the nurse should attempt to facilitate bedside Sabbath services for the patient and the family members. Constant vigil at the bedside is also very important so the nurse should allow the patient's family to maintain a vigil throughout the day and night. Life support is often discouraged within the Jewish faith and the nurse must respect the wishes of the patient and family. It would only be appropriate for the nurse to arrange for a minister to provide the sacrament of anointing of the sick when the patient is Catholic and requests to receive the sacrament. Muslims do not eat anything from dawn until sunset during the month of Ramadan. Providing snacks and meals for the patient and family only from sunset until dawn would be inappropriate for a Jewish patient and family.

The nurse is accused of stealing narcotic pain medications from patients. Which type of crime may the nurse be charged with? a. Tort b. Felony c. Malpractice d. Misdemeanor

b. Felony A felony is a serious offense that results in significant harm to another person or society in general. Felony crimes may carry penalties of monetary restitution, imprisonment for greater than 1 year, or death. Examples of Nurse Practice Act violations that may carry criminal penalties include practicing nursing without a license and misuse of controlled substances. A misdemeanor is a crime that, although injurious, does not inflict serious harm. Torts are civil wrongful acts or omissions against a person or a person's property that are compensated by awarding monetary damages to the individual whose rights were violated. Malpractice is an example of negligence, sometimes referred to as professional negligence. The law defines nursing malpractice as the failure to use the degree of care that a reasonable nurse would use under the same or similar circumstances.

Which is the highest priority concern for the nurse who is educating the homeless patient about medications, appointments, and therapies for management of diabetes? a. Motivation b. Health literacy c. Developmental stage d. Psychomotor learning

b. Health literacy Health literacy includes patients' reading and math skills, comprehension, the ability to make health-related decisions, and successful functioning as a consumer of health care. It is a strong predictor of health status and patient outcomes. The homeless patient is at high risk for having minimal health literacy. Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills. Developmental stage is not as important as health literacy and developmental stage is more important when teaching children. Motivation is an internal impulse, such as an emotion or need, which prompts, guides, and sustains human behavior.

Which intervention is appropriate for the nursing diagnosis hopelessness related to disease progression? a. Withhold negative information about the patient's disease processes. b. Help the patient set realistic goals and then help the patient achieve them. c. Impress on the family the importance of limiting visiting hours to provide rest. d. Assure the patient that he will be well cared for and does not need to do anything.

b. Help the patient set realistic goals and then help the patient achieve them. To help patients feel more hopeful, remind them of their strengths and reinforce their expressions of courage, positive thinking, and realistic goal setting. Patients feel more hopeful when they have a sense of control. Family members of dying people identified the importance of maintaining connections. When people have strong relationships and a sense of emotional connectedness to others, they know that help is available. Offer information to patients about their illness, correct misinformation, and clarify patient's perceptions.

The nurse is caring for a patient who had a stroke because of lack of understanding about how to take the prescribed blood pressure medication. Which is the priority nursing diagnosis for this patient? a. Noncompliance related to patient's refusal to follow the prescribed treatment regimen b. Ineffective therapeutic regimen management related to lack of understanding about prescribed medications c. Ineffective health maintenance related to lack of expressed interest in taking prescribed medications correctly d. Readiness for enhanced decision making related to desire to choose the course of action that best meets health needs

b. Ineffective therapeutic regimen management related to lack of understanding about prescribed medications Ineffective therapeutic regimen management related to lack of understanding about prescribed medications is the priority nursing diagnosis for the patient because the patient's knowledge deficit about the prescribed medications led to the stroke. The nurse will help teach the patient about the medications and ensure that they are taken exactly as prescribed. Nothing indicates that the patient refused to follow the prescribed treatment plan or that the patient was not interested in taking the prescribed medications. Readiness for enhanced decision making is not the priority diagnosis as it does not address the patient's need to take prescribed medications correctly.

Which ethical principle is upheld when uninsured patients receive the same level of care as patients with private health insurance? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

b. Justice Justice refers to the principle of fairness. In health care, the term is used to reflect a commitment to fair treatment and fair distribution of health care resources. You may find reference to this principle during discussion about issues of access to care. It is not always clear just how to achieve a fair distribution of resources. Autonomy refers to independence and self-determination. Fidelity refers to the agreement to keep promises and is based on the virtue of caring. Nonmaleficence refers to the fundamental agreement to do no harm.

The patient grieves the security of a solid supportive marriage after the spouse has an affair. Which type of loss was experienced by the patient? a. Actual b. Perceived c. Situational d. Maturational

b. Perceived Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include job loss. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain and changes in living arrangements.

The patient is on a ventilator and has a heartbeat, but is brain dead. What should the nurse do? a. Explain that as long as the heart is beating, the patient is still alive. b. Provide a private area for the family to discuss organ donation options. c. Inform the family that the organs will be harvested when he is off the ventilator. d. Stress the importance of leaving the patient on the ventilator to harvest the corneas.

b. Provide a private area for the family to discuss organ donation options. Provide a private area for the family to discuss organ donation if this is an option. Many people do not understand "brain death." Family members often believe that the person is still alive because his or her heart is still beating. For their loved one to donate major organs (e.g., heart, lungs, liver), the body must be kept in good functional condition so the organs will not become damaged before donation. The patient remains on a ventilator until his or her organs are removed. Nonvital tissues such as corneas, skin, long bones, and middle ear bones can be removed at the time of death without maintaining vital functions.

The home care nurse suspects that the patient's bedsores are due to neglect from family caregivers. Which is the appropriate action of the nurse? a. Inform the caregivers that their actions are illegal. b. Report it to the proper legal authority immediately. c. Call the agency's security department to handle the problem. d. Prevent the caregivers from being responsible for the patient's care.

b. Report it to the proper legal authority immediately. Health care providers are required to report incidents such as child, spousal, or elder abuse; rape; gunshot wounds; attempted suicide; and certain communicable diseases. Health care providers are provided legal immunity if the report is made in good faith. Not reporting suspected abuse or neglect can cause a nurse to be liable in civil or criminal legal actions. It is not the nurse's responsibility to inform the caregivers of illegal activity or to prevent the caregivers from seeing the patient. The nurse is responsible for reporting the suspected abuse, not call security to handle the problem.

A patient refuses to remove a religious headscarf when being bathed. Which is appropriate action of the nurse? a. Remove the headscarf because its presence hinders hygiene. b. Respect the patient's wishes and work around the headscarf. c. Explain to the patient that the headscarf has no real spiritual value. d. Identify the refusal to remove the headscarf as a sign of spiritual distress.

b. Respect the patient's wishes and work around the headscarf. To care for and meet the spiritual needs of your patients, it is essential to respect each patient's personal beliefs. People experience the world and find meaning in life in different ways and the spiritual garment has meaning for the patient. Caring for your patients' spiritual needs requires you to be compassionate and remove any personal biases or misconceptions. You need to recognize that not all patients have spiritual problems. Patients bring certain spiritual resources that help them assume healthier lives, recover from illness, or face impending death.

Which nursing diagnosis is most appropriate for a patient whose friends and family have grown distant after the death of the patient's spouse? a. Impaired verbal communication related to alteration in sensory perception b. Risk for loneliness related to insufficient interactions with friends and family c. Health-seeking behavior related to desire for increased control of personal health d. Readiness for enhanced spiritual well-being related to expressed desire for prayer

b. Risk for loneliness related to insufficient interactions with friends and family The patient is at risk for loneliness because the patient's friends and family have grown distant after the death of the patient's spouse. The patient does not demonstrate any sensory perception, desire for increased control, or expressed desire for prayer based on the information presented.

The nurse is caring for a patient who has a do-not-resuscitate order from the physician in the chart. The patient stops breathing and his skin turns blue. What is the best action of the nurse to avoid a lawsuit for malpractice or wrongful death? a. Call the Rapid Response Team in case the patient's wife changes her mind. b. Stay with the patient and offer support to the family members in the room. c. Verify that the do-not-resuscitate order is signed by the physician and valid. d. Review the nursing policy and procedure manual for resuscitation guidelines.

b. Stay with the patient and offer support to the family members in the room. The nurse should follow the do-not-resuscitate order and allow the patient to die without lifesaving intervention. The nurse should stay with the patient and offer support to the family members in the room. The Rapid Response Team should not be called. The nurse should validate the do-not-resuscitate order before the patient stops breathing. The nurse should review the nursing policy and procedure manual for resuscitation guidelines before starting the shift.

Which nursing diagnosis indicates that the patient will have difficulty learning how to perform sterile dressing changes at home? a. Deficient knowledge related to diabetic wound management b. Stress overload related to ongoing emotional abuse and bullying c. Readiness for enhanced knowledge related to diabetes management d. Impaired physical mobility related to need to use a cane for ambulation

b. Stress overload related to ongoing emotional abuse and bullying The patient who is overly stressed will have difficulty learning procedures or concepts. The nurse should expect to spend extra time helping the patient to learn. Impaired physical mobility will not impair learning ability. The patient's deficient knowledge about wound management justifies the need for teaching. Readiness for enhanced knowledge indicates that the patient is ready to learn.

The nurse attempts to teach the patient about wound care in a loud semiprivate room with many distractions. Which is the appropriate action of the nurse? a. Explain to the patient that all of the information about wound care is in the handout provided. b. Take the patient to a quiet private treatment room to teach the patient about how to perform wound care. c. Ask the distraught roommate to please be considerate of the patient while the nurse is teaching about wound care. d. Arrange for the home-health nurse to provide teaching about wound care after discharge from the hospital.

b. Take the patient to a quiet private treatment room to teach the patient about how to perform wound care. A quiet area is needed for learning. Before learning anything, patients must be able to pay attention to or concentrate on the information they will learn. Physical discomfort, anxiety, and environmental distractions make it more difficult for a patient to concentrate. It is not appropriate to refer the patient to a handout. Asking the roommate to be considerate is inappropriate because the roommate is distraught. Deferring patient teaching to the home-health nurse is not appropriate.

Which organization will discipline the nurse for abandoning patients during an assigned shift? a. The Joint Commission b. The State Board of Nursing c. The State Department of Health d. The National League for Nursing

b. The State Board of Nursing The State Board of Nursing sets rules, regulations, and guidelines that specifically define the standard of care in nursing practice. An example is the guideline that defines patient abandonment. The State Board of Nursing also investigates allegations of nursing misconduct and disciplines nurses who have failed to comply with the state Nurse Practice Act. The State Department of Health, The Joint Commission, and the National League for Nursing do not set the legal rules and regulations for patient abandonment.

The chart lists the patient's daughter as having medical durable power of attorney for the patient. How does this impact the patient's care? a. The daughter is an attorney and plans to sue to the nursing staff and hospital for malpractice after the patient's death. b. The daughter can provide consent for medical procedures if the patient becomes unresponsive or disoriented. c. The patient's daughter must be consulted before asking the patient to consent to medical procedures. d. The patient's daughter will translate medical terminology used by health care providers when communicating with the patient.

b. The daughter can provide consent for medical procedures if the patient becomes unresponsive or disoriented. Medical durable power of attorney allows the patient's daughter to make medical decisions for the patient in the event that the patient is unable to do so. Medical durable power of attorney does not indicate a plan to sue for malpractice or require consultation before obtaining consent for procedures. Medical translation is not part of medical durable power of attorney.

Which actions by the nurse violate the American Nurses Association's Social Media Policy? (Select all that apply.) a. The nurse posts a professional profile on LinkedIn. b. The nurse describes a patient's injury on Facebook. c. The nurse posts opinions about co-workers on Twitter. d. The nurse writes a blog about the need for staffing ratios. e. The nurse posts a picture of a patient's wound on Instagram.

b. The nurse describes a patient's injury on Facebook. c. The nurse posts opinions about co-workers on Twitter. e. The nurse posts a picture of a patient's wound on Instagram. The American Nurses Association has developed a Social Media Policy (2011), which recommends that when using social media sites, a nurse should never name or describe a patient, never post an image of a patient, and never disparage a fellow employee or employer. The nurse is allowed to write a blog about staffing ratios and post a professional profile on LinkedIn.

The patient's family members disagree about which treatment is most appropriate for the terminally ill comatose patient. Which nursing intervention is most appropriate for this situation? a. The nurse will provide statistical information about the patient's odds of survival. b. The nurse will promote effective communication between the family members. c. The nurse will ask the family members to leave medical decisions to the physician. d. The nurse will wait until the patient is able to make the decisions about treatment.

b. The nurse will promote effective communication between the family members. The nurse should promote effective communication between the family members so that they can come to an agreement about the patient's treatment. Providing statistical information about survival odds is not helpful for moral decision making in this case. The family members should not leave the medical decision to the physician as the treatment may not be consistent with their beliefs. The patient will not be able to make decisions about treatment.

Which chart entry documents patient achievement of cognitive learning? a. The patient verbalized decreased desire to commit self-harm. b. The patient described three symptoms of diabetic ketoacidosis. c. The patient demonstrated how to perform active range of motion. d. The patient expressed satisfaction with ability to share feelings with others.

b. The patient described three symptoms of diabetic ketoacidosis. Cognitive learning includes what the patient knows and understands. All intellectual behaviors are in the cognitive domain. Describing symptoms of DKA is an example of cognitive learning. Psychomotor learning occurs when patients acquire skills that require the integration of knowledge and physical skills. Examples of psychomotor learning include how to perform active range of motion. Affective learning includes the patient's feelings, attitudes, opinions, and values such as decreased desires and satisfaction.

Which situation gives the patient cause to sue for malpractice due to injury or harm? a. The patient developed an itchy rash after receiving a prescribed antibiotic. b. The patient died after being struck in the head by an oxygen tank during an MRI. c. The patient developed a sore throat after being intubated for emergency surgery. d. The patient developed permanent joint deformity due to severe rheumatoid arthritis.

b. The patient died after being struck in the head by an oxygen tank during an MRI. To establish the elements of malpractice, the patient or plaintiff must prove the following: (1) the nurse defendant owed a duty to the patient, (2) the nurse breached that duty, (3) the patient was injured because of the nurse's breach of duty, and (4) the patient has accrued damages as a result of the injury. Patient death due to injury from an oxygen tank in the MRI room is an example of malpractice as the professionals should have taken the proper precautions. Itchy rash after antibiotic use is a side effect. Sore throat after intubation is an expected complication. Permanent joint deformity due to severe rheumatoid arthritis is an unfortunate outcome of chronic illness.

Which assessment findings lead the nurse to inform the family that the patient's death is imminent? (Select all that apply.) a. The patient's pupils are fixed and dilated bilaterally. b. The patient is lethargic, drifting in and out of consciousness. c. The patient's breathing is harsh and congested with periods of apnea. d. The patient had only 40 mL in the urinary catheter bag for the last 8 hours. e. The patient's temperature is 102.6° F (39.2° C) but the hands and feet are cool and mottled.

b. The patient is lethargic, drifting in and out of consciousness. c. The patient's breathing is harsh and congested with periods of apnea. d. The patient had only 40 mL in the urinary catheter bag for the last 8 hours. e. The patient's temperature is 102.6° F (39.2° C) but the hands and feet are cool and mottled. Lethargy, harsh breathing, low urine output, fever, and mottled skin are all signs of imminent death. Fixed, dilated pupils indicate that death has already occurred.

Which behavior supports inclusion of the nursing diagnosis complicated grieving related to sudden death of a sibling in the patient's care plan? a. The patient donates the sibling's clothes to a local charity. b. The patient withdraws from relationships with friends and family. c. The patient adopts the sibling's dog and arranges for veterinary care. d. The patient arranges for the gravestone to be placed at the sibling's burial site.

b. The patient withdraws from relationships with friends and family. Withdrawing from relationships with friends and family is an unhealthy coping behavior and demonstrates complicated grieving. Adopting the dog, arranging for a gravestone, and donating clothes are all tasks to be completed after a death and indicate normal grieving.

Which action by the nurse will best allay a young child's fear about auscultation of breath sounds? a. Do nothing because the more fuss that is made about a procedure, the more anxiety it causes the patient. b. Explain to the patient that the stethoscope is used to listen to air going in and out of the lungs. c. Allow the child to listen to sounds with the stethoscope before the nurse uses it for assessment. d. Ask the child's mother to step outside the room because children frequently do better when alone.

c. Allow the child to listen to sounds with the stethoscope before the nurse uses it for assessment. Describe physical sensations that will occur during the procedure by telling the child that the stethoscope will not hurt. Providing information about procedures helps patients feel less anxious because they understand what to expect during the procedure. When preparatory instructions accurately describe the actual experience, the patient is able to cope more effectively with the stress from procedures and therapies. Doing nothing does not prepare the patient properly or address the anxiety. Involve the parents with young children.

A nurse is caring for a patient who survived cardiopulmonary resuscitation after almost drowning. How can the nurse best help the patient to deal with the aftereffects of the experience? a. Recommend that the patient avoid discussing the experience with family. b. Assume that the near-death experience was a positive experience for the patient. c. Be nonjudgmental and help the patient to work through the near-death experience. d. Explain that people who have not had a near-death experience will not understand.

c. Be nonjudgmental and help the patient to work through the near-death experience. After patients have survived a near-death experience (NDE), promote spiritual well-being by remaining open, giving patients a chance to explore what happened, and supporting patients as they share the experience with significant others. Patients who have an NDE are often reluctant to discuss it, thinking family or caregivers will not understand. Isolation and depression often occur. Furthermore, not all NDEs are positive experiences. However, individuals experiencing an NDE who discuss it openly with family or caregivers find acceptance and meaning from this powerful experience.

A nurse prepares to teach the patient about strategies to minimize feelings of powerlessness. Which techniques will the nurse implement that are the best for this type of learning? (Select all that apply.) a. Lecture b. Practice c. Discussion d. Role play e. Return demonstration

c. Discussion d. Role play Teaching methods for affective learning include role play and discussion. Lecture is effective for cognitive learning. Practice and return demonstration are best for psychomotor learning.

The nurse is caring for a patient who climbed out of bed and fell to the floor. What will the nurse do in regard to the incident report? (Select all that apply.) a. Include a recommendation for fall prevention interventions. b. Note in the patient's chart that an incident report was completed. c. Document how the patient was found and a description of the injuries. d. Indicate that the nursing assistant wasn't paying attention to the patient. e. Document fall prevention steps that were in place before the patient fell.

c. Document how the patient was found and a description of the injuries. e. Document fall prevention steps that were in place before the patient fell. The nurse will document how the patient was found and a description of the injuries. The nurse will also document fall prevention steps that were in place before the patient fell in order to aid the investigation into the event. The nurse will not suggest that the nurse assistant was not paying attention, chart that an incident report was completed, or make recommendations for fall precautions.

A patient with a rare neurological disease is misdiagnosed by the physician and told that the symptoms are psychosomatic. The patient's sense of self is shattered after being told "You are a waste of a hospital bed." Which ethical theory is violated in this situation? a. Liberty b. Fidelity c. Ethics of care d. Confidentiality

c. Ethics of care Ethics of care suggest that health care workers resolve ethical dilemmas by paying attention to relationships and stories of the participants and by promoting a fundamental act of caring. Attention to relationships distinguishes the ethics of care from other ethical viewpoints because it does not necessarily apply universal principles that are intellectual or analytical. The physician in this situation did not demonstrate any care or compassion for the patient and violated the ethics of care. Liberty is the freedom to choose without intimidation or oppression from others. Confidentiality was not breached as the physician did not share patient information with others or fail to provide privacy. Fidelity is an agreement to keep a promise.

Which ethical principle is violated when the nurse promises to administer pain medication to the patient every 2 hours throughout the shift and then fails to do so? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

c. Fidelity Fidelity refers to the agreement to keep promises. The principle of fidelity also promotes the obligation of a nurse to follow through with the care offered to patients. Autonomy refers to independence and self-determination, which is what the patient followed, but the question asked for which principle the nurse followed. Justice refers to fairness or equity of health care resources. Nonmaleficence refers to the fundamental agreement to do no harm.

A nurse wants to follow nursing standards of care. Which document should the nurse follow? a. National League for Nursing manuscript b. World Health Organization guiding principles c. Health care agency's written procedure manual d. US Department of Health and Human Services guidelines

c. Health care agency's written procedure manual The health care agency's written procedure manual is defined as a standard of care. Standards of care are defined by the following: (1) state Nurse Practice Acts, (2) state and federal hospital licensing laws and accreditation rules, (3) professional and specialty organizations, and (4) written policies and procedures of the nurse's health care agency. Manuscripts are not standards of care. The World Health Organization and US Department of Health and Human Services are not state or federal hospitals or professional and specialty organizations for nurses.

The nurse is caring for a preoperative patient before hysterectomy surgery. The patient tells the nurse that she plans to have lots of children in the future and is glad that the surgery won't keep her from getting pregnant in the future. Which is the best action of the nurse? a. Continue preparing the patient for the upcoming surgery. b. Contact the operating room and cancel the patient's scheduled surgery. c. Inform the surgeon so the patient can be provided with more information. d. Explain to the patient that the surgery will make her unable to get pregnant.

c. Inform the surgeon so the patient can be provided with more information. The nurse should inform the surgeon so the patient can be provided with more information. The patient does not understand the surgery to be performed as she thinks pregnancy will still be an option afterward. Obtaining informed consent is the responsibility of the surgeon so the nurse should not explain to the patient that pregnancy will not be possible after the surgery. The nurse should not continue the preoperative preparations as the patient is not informed about the upcoming surgery. The nurse should not cancel the patient's surgery unless directed to do so by the surgeon.

Which description of the state Nurse Practice Act is correct? a. It is a judicial decision. b. It is a federal senate bill. c. It is a statute enacted by state legislature. d. It is a law enacted by the federal government.

c. It is a statute enacted by state legislature. Nurse Practice Acts are examples of statutes enacted by state legislatures to regulate the practice of nursing. Common laws are based on judicial decisions or case law precedent. An example of a judicial decision that guides health care practice is Roe v. Wade, but not the Nurse Practice Act. An example of a federal statute that affects health care practice is the Americans With Disabilities Act, but not the Nurse Practice Act. The Nurse Practice Act is a state law, not a federal senate bill.

Which information must be obtained from the patient upon admission to the hospital? a. Patient's religious preference b. Health insurance authorization c. Presence of an advanced directive d. Primary physician telephone number

c. Presence of an advanced directive The Patient Self-Determination Act (1991) requires health care institutions to inquire whether a patient has created an advance directive, give patients information on advance directives, and document whether a patient states that he or she has an advance directive. Asking how payment will be made is not required by law and is not the responsibility of the nurse.

The nurse often forgets to administer the patient's medication exactly on time, frequently giving it 1 or 2 hours after it is due. Which ethical principle is violated by the nurse? a. Justice b. Judgment c. Responsibility d. Confidentiality

c. Responsibility Responsibility refers to trustworthiness and constancy in the performance of duties. The nurse is violating the principle of responsibility by failing to consistently administer the patient's pain medication on time. Justice refers to the principle of treating all patients fairly. Confidentiality is the protection of patient information so that it is not shared with others. Judgment is the ability to make sound decisions based on the available information.

The nurse educator uses manikins to teach patients how to correctly perform CPR on a victim of cardiac arrest. Which teaching technique is used by the nurse? a. Analogy b. Role play c. Simulation d. Enunciation

c. Simulation Simulation is a useful technique for teaching problem solving, application, and independent thinking. During individual or group discussion, the nurse presents a problem or situation pertaining to the patients' learning for patients to solve. In this case, the manikins are used to simulate a victim of cardiac arrest. During role play, your patients play themselves or someone else in the situation. Analogies add to verbal instruction by providing familiar images that make complex information more real and understandable. Enunciation is pronouncing words clearly.

The patient leaves behind nightly dinners with the family, babysitting assistance from friends, and the warmth of the local church community when moving across the country. Which type of loss was experienced by the patient? a. Conditional b. Perceived c. Situational d. Maturational

c. Situational Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain, changes in living arrangements. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. There is no such thing as a conditional loss.

The nurse filled out an incident report after a patient fall but makes no mention of the incident report in her notes in the patient's chart. What is the reason for this? a. The incident report includes the nurse's interpretations of what probably led the patient to get out of bed. b. A copy of the incident report is filed in the patient's chart along with the nurse's notes about the fall. c. The incident report is confidential and not intended to be used as evidence in a malpractice suit. d. The nurse does not want to risk a malpractice lawsuit by mentioning the creation of an incident report.

c. The incident report is confidential and not intended to be used as evidence in a malpractice suit. Incident reports are used by facilities to investigate the event and prevent possible recurrence. The nurse does not include presumptions or speculations about the incident in the patient chart or the incident report. The incident report is submitted to the unit manager, administration, and/or agency attorney for review. The incident report is never filed in the patient's chart. The presence of an incident report will not increase risk of a malpractice lawsuit.

The nurse is at the shopping mall when the sales clerk collapses in cardiac arrest. The nurse assists the victim and performs CPR until the paramedics arrive. Which action by the nurse could lead to a malpractice suit even though the state has a Good Samaritan law? a. The nurse went to visit the victim in the hospital the following day. b. The nurse accepted a small gift from the store in appreciation for her help. c. The nurse sent a bill to the victim to request payment for services rendered. d. The nurse provided both chest compressions and rescue breathing for the victim.

c. The nurse sent a bill to the victim to request payment for services rendered. Good Samaritan laws cover health care professionals who voluntarily provide aid in emergency situations. The nurse is no longer protected by the state's Good Samaritan law if a bill is sent to the victim to request payment for services rendered. The nurse is allowed to accept a small gift from the store in appreciation but cannot accept cash payment of any kind in order to be covered by the state's Good Samaritan law. There is nothing wrong with the nurse visiting the patient the next day. CPR guidelines call for rescue breathing and chest compressions.

Which behaviors support inclusion of the nursing diagnosis compromised family coping related to loss of home in a fire in the care plan? (Select all that apply.) a. The children missed school and the parents missed work during the first few days after the fire. b. All of the family members were able to stay at the home of a neighbor for the first week after the fire. c. The parents have not been able to speak to each other without screaming in anger for the last 2 weeks. d. The children still have occasional nightmares about the fire and the damage to the family home. e. The parents are so preoccupied with insurance frustration that they have not noticed that the oldest child is failing school.

c. The parents have not been able to speak to each other without screaming in anger for the last 2 weeks. e. The parents are so preoccupied with insurance frustration that they have not noticed that the oldest child is failing school. Inability to speak to each other without screaming and not noticing the needs of other family members demonstrate the appropriateness of compromised family coping as a nursing diagnosis. It is expected that the family members would miss work and school for the first few days after the fire. The family is fortunate that they were able to stay with a neighbor. Occasional nightmares are to be expected following a house fire and do not demonstrate compromised family coping skills.

Which assessment finding best indicates to the nurse that the teaching about a dressing change was successful? a. The patient understands how to change the dressing using sterile technique. b. The patient verbalizes understanding about how to change the sterile dressing. c. The patient correctly demonstrates the dressing change using sterile technique. d. The patient acknowledges the principles of sterile technique for dressing changes.

c. The patient correctly demonstrates the dressing change using sterile technique. Demonstration is the best method to evaluate a psychomotor skill. Examples of evaluating the effectiveness of teaching include having patients show how to perform a newly learned skill (e.g., self-catheterization) or asking patients to explain how they will incorporate newly ordered medications into their daily routines. Evaluating the effectiveness of teaching for a psychomotor skill includes a demonstration, not understanding or acknowledging. Just stating, "Yes" does not indicate learning like a demonstration does.

Which action demonstrates that the patient is experiencing the disorganization and despair stage of mourning? a. The patient puts the parent's estate and financial matters in order. b. The patient cannot eat or sleep for weeks after the loss of the parent. c. The patient sues the hospital for malpractice for not saving the parent's life. d. The patient falls sobbing to the floor when learning that the parent just died.

c. The patient sues the hospital for malpractice for not saving the parent's life. Expressing anger at the hospital for not saving the parent's life is an example of the disorganization and despair stage. Expressions of anger and hostility at an individual or institution responsible for the loss are seen with the disorganization and despair stage. The person may also take long periods to reflect on how and why the loss occurred. Falling sobbing to the floor and inability to eat or sleep demonstrate the yearning and searching stage. Putting the parent's financial estate in order demonstrates completion of a necessary monetary task after death.

While at the grocery store, the nurse witnesses another shopper collapse near the checkout. The nurse performs CPR and the patient survives after being treated at the hospital. The patient later attempts to sue the nurse for malpractice because several ribs were broken as a result of chest compressions. Why will the patient's lawsuit be thrown out of court? a. The patient should not have been at the grocery store with a history of heart disease. b. The patient needed to disclose her history of heart disease to the nurse before she collapsed. c. The patient's rib fractures occurred as a result of properly performed CPR by the nurse. d. The nurse's personal liability insurance company decided to settle rather than face a jury.

c. The patient's rib fractures occurred as a result of properly performed CPR by the nurse. The nurse is covered by the Good Samaritan law as long as the care provided meets expected standards. The patient's rib fractures occurred as a result of properly performed CPR by the nurse so the nurse may not be sued for malpractice. The insurance company would not settle because the patient did not have a case for malpractice. The patient was not expected to disclose the history of heart disease before collapsing. A history of heart disease does not preclude the patient from going shopping for groceries.

The patient undergoes surgery for a herniated disk and is paralyzed afterward. What must the patient prove to the court in order to win a malpractice lawsuit based on lack of informed consent? a. The patient's paralysis was not due to the surgeon's technique. b. The patient's signature on the consent form was witnessed by his nurse. c. The surgeon performed a laminectomy but the patient consented to a fusion. d. The surgeon performed a surgical procedure that was known to be high risk.

c. The surgeon performed a laminectomy but the patient consented to a fusion. If the patient consented to a fusion but the surgeon performed a laminectomy, the patient may win a malpractice suite based on lack of informed consent. The surgeon must perform the procedure indicated on the patient's consent form. The risk of the surgical procedure does not correlate with lack of informed consent. The patient's signature on the consent form may be witnessed by the surgeon or the nurse. The patient cannot win a malpractice lawsuit based on lack of informed consent because the paralysis was not caused by the surgeon.

Which situation will enable a nurse to use restraints? a. To punish a patient b. To ensure staff convenience c. To ensure the patient's safety d. To retaliate against poor behavior

c. To ensure the patient's safety Regulations set the standard that all patients have the right to be free from seclusion and physical or chemical restraints except to ensure the patient's safety in emergency situations. The standards specifically prohibit restraining patients for staff convenience, punishment, or retaliation.

After a massive earthquake, the emergency room staff focuses to provide care to the patients who are likely to survive rather than expending maximum effort on a few critically injured patients. Which ethical theory is demonstrated in this situation? a. Deontology b. Feminist ethics c. Utilitarianism d. Ethics of care

c. Utilitarianism Utilitarianism determines the value of something based primarily on its usefulness and benefit for the greater good. In this case, the emergency room staff focuses on saving the many rather than working to save the few. Deontology defines actions as right or wrong according to principles. The feminist ethic asks how ethical decisions will affect women. The ethics of care suggests that health care workers solve ethical dilemmas by the promotion of the fundamental act of caring.

Even though immunization injections are momentarily painful to the patient, they are recommended because they will protect the community from infectious diseases. Which ethical system supports this practice? a. Duty ethics b. Deontology c. Utilitarianism d. Situation ethics

c. Utilitarianism Utilitarianism guides us to measure the effect, or consequences, that an act will have. The greatest good for the greatest number of people is the guiding principle for action in this system. By comparison, deontology focuses less on consequences and looks to the presence of pure principles of autonomy, justice, fidelity, beneficence, and nonmaleficence. Situation ethics considers the unique characteristics of an individual person or situation in order to reach the most ethical decision. Duty ethics refers to universal obligations such as telling the truth and respecting human life.

Which ethical principle is upheld when the nurse refuses to administer a placebo pill to the patient? a. Justice b. Culture c. Veracity d. Competency

c. Veracity Veracity is telling the truth. The nurse upholds the ethical principle of veracity by refusing to administer a placebo pill to the patient. Competency refers to the ability to perform a procedure to the accepted standard. Culture refers to shared beliefs and values of the group. Justice refers to the principles of fairness.

Which action by the nurse is an example of a legal issue rather than an ethical principle? a. Failing to shut the door completely when bathing the patient b. Providing lower doses of pain medications to patients with red hair c. Working as a registered nurse without a current nursing license d. Deciding not to stop and provide medical care at an accident scene

c. Working as a registered nurse without a current nursing license Working as a registered nurse without a current nursing license is a legal issue rather than an ethical issue. Failure to provide privacy violates the ethical principle of confidentiality. The ethical principle of justice is violated when redheaded patients are given lower doses of pain medication. Deciding not to stop and provide medical care at an accident scene violates the ethical principle of beneficence.

Which statements demonstrate that the patient is at the acceptance stage of learning? (Select all that apply.) a. "I do not have to learn how to do the dressing. My wife will do it for me." b. "I feel like such a failure for not consulting a podiatrist earlier about my foot." c. "I'll try to do the exercises you described if you will give me a cookie afterward." d. "I want to learn how to do this myself so I do not have to go to a rehab center." e. "I know that I have to give myself the injections because I could get a blood clot."

d. "I want to learn how to do this myself so I do not have to go to a rehab center." e. "I know that I have to give myself the injections because I could get a blood clot." The patient indicates acceptance by wanting to learn and understanding the importance of the teaching. Referring the care to the spouse, feeling like a failure, and wanting rewards do not demonstrate acceptance.

A patient who survived a near-death experience tells the nurse about feeling a deep sense of peace, light, and unconditional love while watching the health care providers perform resuscitation procedures. Which is the best response of the nurse? a. "Your experiences were probably due to side effects of the medications." b. "I will ask the doctor for a psychiatric evaluation since you are hallucinating." c. "It sounds like you are fearful of suffering associated with the dying process." d. "Your experience is similar to others who have survived near-death experiences."

d. "Your experience is similar to others who have survived near-death experiences." Patients who survive near-death experiences relate comparable experiences during resuscitation efforts. The nurse should reassure the patient that similar to those reported by others who have survived near-death experiences. The patient's experiences were not hallucinations or due to side effects of medications. The patient does not show any evidence of fearing suffering associated with the dying process.

Which action by the nurse is appropriate for a family with a terminally ill newborn? a. Call the rabbi to come to the bedside. b. Arrange for the infant to be baptized immediately. c. Call the hospital chaplain to pray with the family. d. Ask the family how their spiritual needs can be supported.

d. Ask the family how their spiritual needs can be supported. Nurses need to differentiate their personal spiritual beliefs from those of the patients and their families. The nurse's role is not to solve the spiritual problems of patients, but to provide an environment for your patients to express their spirituality. Having the baby baptized or calling the rabbi indicates that the nurse is applying personal spiritual values on the patient and family. Calling the chaplain assumes that the patient and family value a religious denomination.

Which is the first action of the nurse when teaching the patient how to perform colostomy care? a. Determine the patient's educational background and learning abilities. b. Identify a responsible family member to reinforce colostomy care teaching. c. Have the patient watch a video that demonstrates how to perform colostomy care. d. Assess the patient's level of comfort with looking at and caring for the colostomy.

d. Assess the patient's level of comfort with looking at and caring for the colostomy. The first action of the nurse is to determine the patient's readiness to learn about colostomy care. The nurse should assess the patient's level of comfort with looking at and caring for the colostomy before initiating any teaching. Identifying a family member to assist, determining the patient's educational background, and having the patient watch a video should all be done after assessing the patient's readiness to learn.

Which ethical principle is upheld when the registered nurse provides medical assistance to victims of an accident? a. Veracity b. Fidelity c. Autonomy d. Beneficence

d. Beneficence Beneficence refers to helping others. The nurse demonstrates this by providing medical assistance to victims of an accident. Autonomy is the right to personal freedom. Fidelity is keeping promises and veracity is telling the truth.

Which ethical principle is violated when the nurse is overhead talking about the patient's prognosis in the elevator? a. Judgment b. Advocacy c. Accountability d. Confidentiality

d. Confidentiality Confidentiality is the protection of patient information so that it is not shared with others. The nurse violated the ethical principle of confidentiality when the patient's prognosis was overhead in the elevator. Judgment refers to the ability to make appropriate decisions based on the situation. Advocacy refers to the nurse's responsibility to speak up for and protect the rights of patients. Accountability means that the nurse must be responsible for actions and decisions.

Which is the best method to begin teaching the adult patient how to self-administer tube feeding through a new gastrostomy tube? a. Analogies b. Detachment c. Role play d. Demonstration

d. Demonstration The nurse should begin to teach the patient by demonstrating how to administer tube feedings. The patient is then encouraged to assist until a return demonstration of the skill can be performed. Detachment is not a teaching approach. Role playing and analogies are not appropriate for teaching tube feeding administration.

The female patient grieves the loss of her child to adoption and finds it difficult to cope because the pregnancy was kept a secret from the family and community. Which type of grief is being experienced by the patient? a. Delayed b. Complicated c. Anticipatory d. Disenfranchised

d. Disenfranchised Disenfranchised grief occurs in situations in which others view a person's loss as insignificant or invalid or when the patient's friends and family are unaware of the loss. Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away. Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). The process of "letting go" before an actual loss or death has occurred is called anticipatory grief.

Which treatment would be refused by a patient who has requested palliative care? a. Therapeutic touch b. Supplemental oxygen c. Narcotic pain medications d. Knee-replacement surgery

d. Knee-replacement surgery Palliative care is practiced in any setting and focuses on the prevention, reduction, or relief of physical, emotional, social, and spiritual symptoms of disease or treatment at the end of life when cure is no longer possible. Knee-replacement surgery would not be appropriate for an end-of-life patient.

What is the primary difference between negligence and malpractice? a. Malpractice is intentional while negligence is unintended. b. Malpractice is a felony while negligence is a misdemeanor. c. Malpractice leads to more serious patient injury than negligence. d. Malpractice is committed by a licensed professional while negligence is not.

d. Malpractice is committed by a licensed professional while negligence is not. Malpractice may sometimes be referred to as professional negligence. Negligence occurs when the level of care provided to the patient falls below the generally accepted standard. When negligence is committed by a licensed professional, it is termed malpractice. Malpractice may be intentional or unintended. Malpractice may be considered a felony or a misdemeanor depending on the circumstances. Both negligence and malpractice can lead to serious patient injury.

A nurse is caring for a patient who is depressed because her children have gone away to college. Which type of loss is experienced by the patient? a. Perceived b. Situational c. Conditional d. Maturational

d. Maturational People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had the loss. For example, a person perceives that she is less loved by her parents and experiences a loss of self-esteem. Situational loss occurs as a result of an unpredictable life event. There is no such thing as a conditional loss.

Which ethical principle is upheld when the surgeon refuses to operate on the patient because potential benefit is minimal compared to the pain that the patient will endure? a. Autonomy b. Justice c. Fidelity d. Nonmaleficence

d. Nonmaleficence The principle of nonmaleficence (do no harm) promotes a continuing effort to consider the potential for harm even when it is necessary to promote health. It is helpful in guiding your discussions about new or controversial technologies. Autonomy deals with independence and self-determination. Justice refers to fairness or equity of health care resources. Fidelity refers to maintaining promises and faithfulness.

The nurse is caring for a patient who has just passed away. Which is the priority action of the nurse? a. Ask the family to leave the room so that postmortem care can be provided. b. Have the patient's family members sign consent forms for organ donation. c. Remove all drainage tubes and IV lines in case an autopsy is to be performed. d. Provide postmortem care in a manner consistent with religious or cultural beliefs.

d. Provide postmortem care in a manner consistent with religious or cultural beliefs. A nurse assumes responsibility for postmortem care (i.e., care of the body after death). Give postmortem care with dignity and sensitivity and in a manner consistent with a patient's religious or cultural beliefs. Ask family members if and how they would like to help care for the body. Make arrangements for a member of the professional staff (e.g., spiritual care provider) to stay with family members if they do not wish to participate in body care. Remove all catheters, tubes, or indwelling devices from the patient's body, except in the case of autopsy. In that case all medical devices should be left in place.

The nurse includes "The patient will demonstrate correct technique for self-injection of insulin" as a goal in the patient's care plan. Which type of learning is addressed by this goal? a. Cognitive b. Affective c. Perceptive d. Psychomotor

d. Psychomotor Psychomotor learning is the acquisition of motor skill such as injection of insulin. Cognitive learning is thinking in new ways. Affective learning is expression of emotions or beliefs. Perceptive means the ability to sense of show insight.

The nurse is caring for a patient who attempted to get out of bed and fell to the floor, causing a fractured hip. The nursing supervisor asks the nurse to rewrite her entry into the patient's chart to show that the patient's bed was lowered to the floor even though it was not. What is the best action of the nurse? a. Chart that the bed was lowered to reduce liability in case a malpractice lawsuit is filed. b. Ask the nursing assistant to chart that the patient's bed was lowered to the floor before the patient fell. c. Ask the nursing assistant if the patient's bed was lowered to the floor at the time of the fall. d. Remind the nursing supervisor that it is against regulations to alter or falsify the patient's chart.

d. Remind the nursing supervisor that it is against regulations to alter or falsify the patient's chart. It is against the standards of nursing care to alter or falsify information in the patient's chart. The nurse should not ask the nursing assistant to chart that the patient's bed was lowered either.

The nurse feels a deep sense of altruism and wonderment after successfully resuscitating a young athlete who suddenly collapsed in cardiac arrest. Which term best describes the sensation experienced by the nurse? a. Holy conviction b. Spiritual distress c. Divine expectation d. Self-transcendence

d. Self-transcendence Self-transcendence refers to connecting to your inner self, which allows you to go beyond yourself to understand the meanings of experiences, whereas transcendence is the belief that there is a positive force outside of and greater than oneself that allows you to develop new perspectives that are beyond physical boundaries. Spiritual distress is suffering due to lack of connectedness with a faith system. The nurse did not experience holy conviction or divine expectation.

Which example demonstrates a breach of confidentiality and a violation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996? a. Giving a report to the oncoming nurse in a conference room b. Discussing a patient's diagnosis with the patient's health care provider c. Providing patient information to the nursing assistant caring for the patient d. Sharing a patient's diagnosis and prognosis with other nurses in the cafeteria

d. Sharing a patient's diagnosis and prognosis with other nurses in the cafeteria Although HIPAA does not require things such as soundproof rooms in hospitals, it does mandate that nurses and health care providers avoid discussing patients in public hallways and provide reasonable levels of privacy in communicating with and about patients in any matter. Issues of disclosure, privacy, and confidentiality are important concerns when working with patients or peers infected with bloodborne illnesses such as human immunodeficiency virus (HIV) or acquired immunodeficiency virus (AIDS), hepatitis, and sexually transmitted illnesses. Providing continuity of care, giving reports, talking to the health care provider, and providing information to the nursing assistant do not violate HIPAA.

The patient sued the hospital for malpractice after developing a postoperative DVT and PE. The nurse's notes did not state that TED hose and sequential compression devices (SCDs) were applied even though they were ordered. Why did the court rule in favor of the patient in the case? a. DVT and PE can develop even if TED hose and SCDs are applied. b. The patient was informed that DVT and PE are known surgical risks. c. The nurse testified that SCDs and TED hose were applied as ordered. d. The nurse failed to document that TED hose and SCDs were applied as ordered.

d. The nurse failed to document that TED hose and SCDs were applied as ordered. Documentation of nursing care is the only record of what actually was done for a patient and will serve as proof that a nurse acted reasonably and safely. Nursing notes written at the time of the event are seen as better evidence of the facts of the event than any one person's memory. Failure to document application of TED hose and SCDs as ordered violates the nursing standard of careful, complete charting of patient care. Oral testimony of the nurse is not as reliable as written documentation. The nurse's testimony that the SCDs and TED hose were applied might have led the court to find in favor of the nurse. The patient's informed consent did not lead the court to find in favor of the patient in the malpractice trial. DVT and PE can develop even if TED hose and SCDs are applied but the nurse's failure to document application of TED hose and SCDs led the court to rule in favor of the patient.

Which action by the patient demonstrates reminiscence of a lost parent? a. The patient obtains a copy of the parent's will and inventories all assets. b. The patient returns to school to start a new career in business administration. c. The patient sues the hospital for malpractice after reviewing the medical record. d. The patient creates a scrapbook to remember special times spent with the parent.

d. The patient creates a scrapbook to remember special times spent with the parent. The patient demonstrates reminiscence by taking the time to remember the lost loved one through creation of a scrapbook. Suing the hospital for malpractice does not remember individual characteristics of the loved one or shared experiences. Returning to school indicates that the patient has reached the acceptance stage of grief and is moving on to new activities. Obtaining the will and completing inventory of assets demonstrates completion of necessary monetary tasks after death.

Which assessment finding leads the nurse to include hopelessness as a nursing diagnosis in the patient's plan of care? a. The patient does not wish to attend any type of religious services. b. The patient does not believe in a higher power, spirit guide, or God. c. The patient has a source of structure and guidance for difficult times. d. The patient has no motivation or resources to achieve any life goals.

d. The patient has no motivation or resources to achieve any life goals. Hope is energizing, giving individuals a motivation to achieve and the resources to use toward that achievement. The patient experiences hopelessness when there is no motivation or resources to achieve any life goals. Religion refers to the system of organized beliefs and worship that a person practices to outwardly express spirituality. Faith involves a belief in a higher power, spirit guide, God, or Allah. Spirituality offers a sense of connectedness. Spirituality is unique for each person. It is a unifying theme in life and a state of being.

Which sentence is appropriate to write in an incident report for a patient who got out of bed and fell? a. The patient probably urinated on the floor and slipped due to the wet floor. b. The patient's nurse assistant always takes forever to answer patient call lights. c. The patient never follows directions and always causes trouble for the nurses. d. The patient was found lying on the floor with his urinal on the floor next to him.

d. The patient was found lying on the floor with his urinal on the floor next to him. The nurse will objectively record the details of the event and any statements the patient makes including how the patient was found on the floor. The nurse should not attempt to blame the patient or other staff members for the incident. The nurse should not make conjectures about how the incident occurred.

Which patient learning goal is measurable? a. The patient will understand the importance of daily iron supplements. b. The patient will be able to learn sufficient information to be discharged. c. The patient will feel comforted by the nurses' presence during anxious periods. d. The patient will verbalize responsibility for obtaining daily weights each morning.

d. The patient will verbalize responsibility for obtaining daily weights each morning. Patient care plan goals must be measurable so that the nurse can determine whether or not the goal has been met. Measurable goals use objective terms such as verbalize, demonstrate, list, articulate, and perform. The patient's verbalization of responsibility for obtaining daily weights each morning is a measurable goal. The nurse cannot objectively determine if the patient understands, feel comforted, or learn sufficient information in order to determine whether or not the goal has been achieved.

Providing assistance to which victim would be covered under the state's Good Samaritan law? a. The unit secretary at the hospital suffers an anaphylactic reaction after eating nuts as a morning snack. b. A patient has a grand mal seizure in the hospital foyer when saying goodbye to his family. c. A patient at the clinic where the nurse is working suffers a cardiac arrest after walking in the door. d. Two people are badly hurt in a car accident on the nurse's way to work in the morning.

d. Two people are badly hurt in a car accident on the nurse's way to work in the morning. Good Samaritan laws encourage health care professionals to provide aid in case of emergencies outside of the workplace. An example of this would be two people who are badly injured in a car accident on the nurse's way to work. The nurse is legally bound to provide care to patients in the workplace. Providing assistance to another hospital employee is not covered under the Good Samaritan laws.

Which approach will be most successful for the nurse to teach a preschooler about tube feeding through a gastrostomy tube? a. Offer opportunities to discuss tube feeding options and answer questions. b. Hold the child while smiling and speaking softly to convey a sense of trust. c. Collaborate with the child to develop an individualized tube feeding schedule. d. Use simple terms and show the child a gastrostomy tube inserted into a teddy bear.

d. Use simple terms and show the child a gastrostomy tube inserted into a teddy bear. The nurse should allow the child to see and touch a gastrostomy tube inserted into a teddy bear to facilitate teaching about tube feeding. Holding the child while smiling is an appropriate teaching technique for an infant. The preschooler is not mature enough to develop an individualized tube feeding schedule or discuss tube feeding options.

Which assistance is provided to the patient and family by the hospice care providers? a. Education about resuscitation techniques if the patient stops breathing b. Options for ending the patient's life when the pain becomes too severe c. Financial support for funeral and burial services after the patient's death d. Volunteers to stay with the patient to give the family a break from caregiving

d. Volunteers to stay with the patient to give the family a break from caregiving Hospice care provides supportive services for patients who are at the end of life. This includes volunteers who can provide respite care to give the family a break from caregiving. Hospice care does not provide financial support for burial, assistance for ending the patient's life, or education about resuscitation.

When is the nurse covered by the health care agency's malpractice insurance? a. While caring for scouts at summer camp b. When providing first aid at a car accident c. While assisting a fellow passenger on a flight d. While providing care to patients in the agency

d. While providing care to patients in the agency If a nurse works for a health care institution, generally the institution's insurance will cover the nurse during employment. The nurse is not covered by the agency's malpractice insurance when volunteering at a scout camp. The nurse will need to carry additional insurance for this situation. Providing assistance on a flight or at the scene of a car accident may be covered by the state's Good Samaritan law.