Nurse Practitioner Roles and Responsibilities, Exams of Nursing

Download Nurse Practitioner Roles and Responsibilities and more Exams Nursing in PDF only on Docsity! Essentials for Nursing Practice, 9th Edition Potter Test bank Chapter Contents: Chapter 1. Professional Nursing Chapter 2. Health and Wellness Chapter 3. The Health Care Delivery System Chapter 4. Community-Based Nursing Practice Chapter 5. Legal Principles in Nursing Chapter 6. Ethics Chapter 7. Evidence-Based Practice Chapter 8. Critical Thinking Chapter 9. Nursing Process Chapter 10. Informatics and Documentation Chapter 11. Communication Chapter 12. Patient Education Chapter 13. Managing Patient Care Chapter 14. Infection Prevention and Control Chapter 15. Vital Signs Chapter 16. Health Assessment and Physical Examination Chapter 17. Medication Administration Chapter 18. Fluid, Electrolyte, and Acid-Base Balances Chapter 19. Complementary, Alternative, and Integrative Therapies Chapter 20. Caring in Nursing Practice Chapter 21. Cultural Competence Chapter 22. Spiritual Health Chapter 23. Growth and Development Chapter 24. Self-Concept and Sexuality Chapter 25. Family Dynamics Chapter 26. Stress and Coping Chapter 27. Loss and Grief Chapter 28. Activity and Exercise Chapter 29. Immobility Chapter 30. Safety Chapter 31. Hygiene Chapter 32. Oxygenation Chapter 33. Sleep Chapter 34. Pain Management Chapter 35. Nutrition Chapter 36. Urinary Elimination Chapter 37. Bowel Elimination Chapter 38. Skin Integrity and Wound Care Chapter 39. Sensory Perceptions Chapter 40. Surgical Patient = Chapter 01: Professional Nursing Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. A nurse uses effective strategies to communicate and handle conflict with nurses and other health care professionals. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating? a.Informatics b.Quality improvement c.Teamwork and collaboration d.Evidence-based practice ANS: C Teamwork and collaboration uses effective strategies to communicate and handle conflict. Informatics includes navigating electronic health records. Quality improvement uses tools such as flow charts and diagrams to improve care. Evidence-based practice integrates best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. PTS: 1 DIF: Cognitive Level: Applying (Application) REF:11 OBJ: Describe the purpose of professional standards of nursing practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2.A nurse is employed by a health care agency that provides an informal training session on how to properly use a new vital sign monitor. Which type of education did the nurse receive? a.In-service education b.Advanced education c.Continuing education d.Registered nurse education ANS: A In-service education programs are instruction or training provided by a health care agency or institution designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution. Some roles for RNs in nursing require advanced graduate degrees, such as a clinical nurse specialist or nurse practitioner. There are various educational routes for becoming a registered nurse (RN), such as associate, diploma, and baccalaureate. Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses associations, professional nursing organizations, and educational and health care institutions. PTS:1DIF:Cognitive Level: Applying (Application) REF:6 OBJ: Discuss the importance of education in professional nursing practice. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 3.A nurse listens to a patients lungs and determines that the patient needs to cough and deep breath. The nurse has = 8.A nurse is directing the care and staffing of three cardiac units. The nurse is practicing in which nursing role? a.Advanced practice registered nurse b.Nurse researcher c.Nurse educator d.Nurse administrator ANS: D A nurse administrator manages patient care and the delivery of specific nursing services within a health care agency. An advanced practice registered nurse has a masters degree in nursing; advanced education in pathophysiology, pharmacology, and physical assessment; and certification and expertise in a specialized area of practice. A nurse educator works primarily in schools of nursing, staff development departments of health care agencies, and patient education departments. The nurse researcher investigates problems to improve nursing care and further define and expand the scope of nursing practice. PTS:1DIF:Cognitive Level: Applying (Application) REF: 9 OBJ: Describe the roles and career opportunities for nurses. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A nurse is presenting at an interdisciplinary meeting about the multiple external forces that are influencing nursing today. Which examples should the nurse include? (Select all that apply.) a.Health care reform b.Threat of bioterrorism c.Population demographics d.Role of nurse manager e.Nursing shortage ANS: A, B, C, E Multiple external forces affect nursing today, including health care reform, demographic changes of the population, increasing numbers of medically underserved, need for emergency preparedness, threat of bioterrorism, workplace issues, and the nursing shortage. Role of nurse manager is not an external force affecting nursing, but is one role of the registered nurse. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:4 OBJ: Discuss the influence of social, political, and economic changes on nursing practices. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 2.A nurse is teaching the staff about the characteristics of a profession. Which information should the nurse include? (Select all that apply.) a.Extended education b.Theoretical body of knowledge c.Code of ethics for practice d.Practice developments e.Provision of a specific service ANS: A, B, C, E = Professions possess the following characteristics: An extended education of members and a basic liberal education foundation A theoretical body of knowledge leading to defined skills, abilities, and norms Provision of a specific service Autonomy in decision making and practice A code of ethics for practice Practice developments are not a characteristic of a profession, but are essential for nurses to stay current by gaining new knowledge about the latest research and practice developments. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 5 OBJ: Discuss the characteristics of professionalism in nursing. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 3.A nurse is teaching the staff about Quality and Safety Education in Nursing, which identified six competencies for nursing. Which information should the nurse include in the teaching session? (Select all that apply.) a. Informatics b.Safety c.Health policies d.Informatics e.Quality improvement ANS: A, B, D, E The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative to respond to reports about safety and quality patient care by the IOM. The QSEN initiative encompasses the competencies of patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. Health policy is health related issues at the government level, not a competency. PTS:1DIF:Cognitive Level: Applying (Application) REF:10 | 11 OBJescribe the purpose of professional standards of nursing practice. TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 4.A nurse wants to become an advanced practice registered nurse (APRN) and have a higher degree of independence. Which advanced roles could the nurse pursue? (Select all that apply.) a.Clinical nurse specialist b.Nurse manager c.Nurse practitioner d.Nurse midwife e.Nurse anesthetist ANS: A, C, D, E The advanced practice registered nurse (APRN) is the most independently functioning nurse. An APRN has a masters degree in nursing; advanced education in pathophysiology, pharmacology, and physical assessment; and certification and expertise in a specialized area of practice. There are four core roles for the APRN: clinical nurse specialist (CNS), nurse practitioner (NP), certified nurse midwife (CNM), and certified RN anesthetist (CRNA). = Nurse managers do not require an advanced degree. PTS:1DIF:Cognitive Level: Applying (Application) REF: 8 OBJ: Describe the roles and career opportunities for nurses. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care REF:21OBJ:Explain the three levels of prevention. TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 6.A married father of four has recently been diagnosed with emphysema resulting from a long history of smoking. At a family counseling session a nurse helps the family to understand that this diagnosis is classified as a(n): a.acute illness. b.tertiary prevention. c.chronic illness. d.internal variable. ANS: C Chronic illness is one that lasts more than 6 months. Acute illness is short term and intense but resolves. Tertiary prevention strives to prevent complications and deterioration. Internal variables include a patients developmental stage, and intellectual, emotional, and cultural background. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 24 OBJ: Explain the impact of illness on a patient and family. TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 7.Which information by a patient indicates teaching by the nurse was successful for the best definition of health? a.State of complete well-being b.Absence of disease c.Vital signs within normal range d.Maintenance of a normal weight ANS: A The World Health Organization defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmary. People without disease are not necessarily healthy. Vital signs within normal range and maintenance of a normal weight do not encompass the holistic definition of health. PTS:1DIF:Cognitive Level: Applying (Application) REF: 15-16 OBJ: Describe health promotion and illness prevention activities. TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 8.A patient with newly diagnosed diabetes is concerned about the risk for developing foot ulcers because the mother had a foot amputated as a result of the disease. This is an example of which of the following? a.Health promotion b.Health practices c.Health beliefs d.Holistic health ANS: C Health beliefs are a persons ideas and attitudes about health. Health promotion activities such as routine exercise and good nutrition help patients maintain or enhance their present levels of health and reduce their risks for developing certain diseases. Holistic health generally is a comprehensive view of a person as a biopsychosocial and spiritual being. Health practices are activities that individuals perform to care for themselves. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:19 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9.A patient with diabetes is diligent about testing blood sugar before meals. Which model is the nurse using when the nurse realizes the patient is taking preventative actions for health and represents the third component of this model? a.B asic Human Needs b.Health Belief c.Holistic Health d.Tertiary Prevention ANS: B The third component of the Health Belief model is the likelihood that a patient will take preventative action. The third component of the Basic Human Needs model (Maslow) is love and belonging. The Holistic Health model focuses on physical, social, psychological, and spiritual health and does not contain distinct components. Tertiary prevention is not a health model. PTS:1DIF:Cognitive Level: Applying (Application) REF:16 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. Which will best assist a nurse in understanding a patients use of tying a silver dollar to the stomach of a newborn infant to heal an umbilical hernia? a.C ultural background b.Maslows Hierarchy of Needs c.World Health Organizations definition of health d.Primary prevention ANS: A Cultural background influences a persons beliefs, values, and customs. It influences personal health practices. Maslows Hierarchy of Needs will not help the nurse to understand the behavior because this is a model to help prioritize care. The definition of health by the WHO will not help the nurse to understand the behavior because it is a definition. Primary prevention occurs before a sickness or dysfunction and includes immunizations. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:20 OBJ: Describe the variables influencing health beliefs and health practices. TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 11. Upon taking a history of a patient, the nurse learns the patient smokes a pack of cigarettes per day. How should the nurse interpret this finding? a.This is an example of a health belief. b.This is an example of health promotion. c.This is an example of a negative health behavior. d.This is an example of a basic physiological human need. ANS: C Negative health behaviors include activities that are harmful to health, including smoking. Health beliefs are a persons ideas, convictions, and attitudes about health and illness. Health promotion activities such as routine exercise and good nutrition help patients maintain or enhance their present levels of health and reduce their risks for developing certain diseases. The lowest level of needs on the hierarchy consists of very basic physiological needs such as oxygen, water, food, sleep, and sex. PTS:1DIF:Cognitive Level: Applying (Application) REF:16 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 12. When teaching a 15-year-old patient with diverticulitis about foods that should be avoided, a nurse takes the stage of growth and development into consideration. Which factor or variable did the nurse take into consideration? a.Cultural factor b.External variable c.Socioeconomic factor d.Internal variable ANS: D Internal variables include a persons stage of growth and development, intellectual background, emotional factors, and spiritual factors. External variables include family practices, socioeconomic factors, and cultural background. PTS:1DIF:Cognitive Level: Applying (Application) REF:19-20 OBJ: Describe the variables influencing health beliefs and health practices. TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 13.A nurse working in a rural public health clinic is developing a smoking cessation program for patients in the county. This corresponds with Healthy People 2020 s efforts to provide direction for health care efforts on what level? a.National b.Community c.Individual d.Family ANS: B With passive strategies of health promotion, individuals gain from the activities of others without acting themselves. For example, the city puts fluoride in the municipal drinking water, or milk manufacturers fortify homogenized milk with vitamin D. With active strategies of health promotion, individuals adopt specific health programs. Weight reduction and smoking cessation programs require patients to be actively involved in measures to improve their present and future levels of wellness while decreasing the risk for disease. Environmental and sociological do not relate to health promotion strategies. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 20 OBJ: Describe health promotion and illness prevention activities. TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 19.A nurse teaches a patient about physiological risk factors. Which information by the patient indicates more teaching is needed? a.A physiological risk factor is heredity. b.A physiological risk factor is environment. c.A physiological risk factor is pregnancy. d.A physiological risk factor is obesity. ANS: B The environment is not a physiological risk factor; the other options are physiological risk factors. Physiological risk factors involve the physical functioning of the body. For example, physical conditions such as pregnancy or obesity place increased stress on physiological systems. Heredity or genetic predisposition to specific illness is a major physical risk factor. PTS:1DIF:Cognitive Level: Applying (Application) REF:21-22 OBJ: Discuss four types of risk factors and the process of risk-factor modification. TOP: Nursing Process: Evaluation MSC: NCLEX: Reduction of Risk Potential 20.Upon taking a health history from a patient, the nurse notices the patient uses positive health behaviors. Which behavior did the nurse find? a.Smokes b.Eats poorly c.Has sedentary lifestyle d.Maintains proper sleep patterns ANS: D Positive health behaviors are activities related to maintaining, attaining, or regaining good health and preventing illness. Common positive health behaviors include getting immunizations, maintaining proper sleep patterns, getting adequate exercise, and eating healthy foods. Negative health behaviors include activities that are harmful to health such as smoking, abusing drugs or alcohol, following a poor diet, and refusing to take necessary medications. PTS:1DIF:Cognitive Level: Applying (Application) REF: 16 OBJ: Describe health promotion and illness prevention activities. TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 21.A nurse must take into consideration illness behaviors of patients. Which is an internal variable the nurse should assess? a.Social support b.Visibility of symptoms c.Accessibility of the health care system d.Nature of the illness ANS: D Internal variables influence the way patients behave when they are ill. These are a patients perceptions of symptoms and the nature of the illness. External variables influencing a patients illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. PTS:1DIF:Cognitive Level: Applying (Application) REF: 25 OBJ: Describe the variables influencing illness behavior. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Adaptation 22.A nurse allows a patient to place pictures of the family in the room. Which need is being met? a.Basic needs b.Physiological needs c.Self-actualization d.Love and belongingness ANS: D In Maslows hierarchy of needs, the third level on the hierarchy is love and belongingness, which is a desire to belong to groups. It consists of the need to feel love by others and to be accepted. The highest level of needs on the hierarchy is self-actualization, which is the desire to become everything that one is capable of becoming. The lowest level of needs on the hierarchy consists of very basic physiological needs such as oxygen, water, food, sleep, and sex. PTS:1DIF:Cognitive Level: Applying (Application) REF:18 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Basic Care and Comfort 23.Which model exemplifies a patient who states the following, I am responsible for my own health and well-being and I will partner with you (my nurse) to make sure I am ready to be discharged after surgery? a.Basic Human Needs Model b.Absence of Disease Model c.Holistic Health Model d.Healthy People 2020 Model ANS: C The intent of the holistic health model is to empower patients to engage in their own recovery, thereby assuming some responsibility for health maintenance. Basic human needs are related to a hierarchy of needs involving lower needs to self-actualization. Healthy People 2020 provides evidenced-based objectives to: (1) achieve increased quality and years of healthy life, and (2) eliminate health disparities. There is no absence of disease model. PTS:1DIF:Cognitive Level: Applying (Application) REF:19 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 24.A nurse is preparing to help patients with health promotion, wellness education, and illness prevention activities. Which action should the nurse take first ? a. Explore available support groups. b. Identify risk factors. c.Provide patient teaching. d.Implement risk factor modification. ANS: B Identifying risk factors is the first step in health promotion, wellness education, and illness prevention activities. Once you identify risk factors, implement appropriate and relevant health education programs that help a person to change a risky health behavior. Support groups, teaching, and risk factor modification follow after identifying risk factors. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:23 OBJ: Discuss four types of risk factors and the process of risk-factor modification. TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 25.A smoker has confided to the nurse that he or she feels like a failure because he or she began smoking again after not having had a cigarette for more than a week. What is the nurses best response? a.Lets discuss what triggered you to start smoking again so you can avoid it in the future. b.You understand that smoking is the number one cause of death in the United States, correct? c.Did you know that your insurance premiums will increase if you continue to smoke? d.My mother died last year of lung cancer. ANS: A Relapse often feels like a failure, but the person needs to view it as a learning process. Discussing possible triggers will allow learning to take place. What he or she learns from relapse can be applied to the next attempt to change. Saying that smoking is the number one cause of death and insurance premiums will increase do not allow for learning to take place. Saying that your mother died last year of lung cancer does not focus on patient learning, but rather focuses on the nurse, which is inappropriate. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:23-24 OBJ: Discuss four types of risk factors and the process of risk-factor modification. ANS: A The nurse should use a holistic approach to patient education to help patients manage their disease. This education enhances wellness and improves quality of life for patients living with chronic illnesses or disabilities. Consulting with a disease specialist, reviewing insurance, and providing disease-specific education are too narrow a focus. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 24 OBJ: Discuss the nurses role in health and illness. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Adaptation 32.A registered nurse in a rehabilitative unit is working with a veteran with chronic back pain that was caused as a result of an injury received while in military service in Iraq. The nurses goal is to assist the veteran to learn self- management skills to help promote health. Which statement by the nurse will best support this goal? a.Do you have plans to return to active duty? b.You need to take your pain medication as prescribed. c.Perhaps you need to consider going to a different health care provider. d.Why dont you keep a log of what causes the pain to become worse? ANS: D Self-management involves learning about responses to illnesses through daily life experiences and as a result of trial and error. Plans to return to active duty and going to a different health care provider do not focus on responses to the illness (chronic back pain). Just focusing on taking pain medication does not focus on the goal of self- management skills. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 24 OBJ: Discuss the nurses role in health and illness. TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 33.A pregnant mother of two children has been experiencing severe morning sickness and fatigue. Friends and family members have been providing her family with meals, and her husband has been taking responsibility for the housework. This is an example of which type of behavior? a.Illness b.Wellness c.Social d.Antisocial ANS: A Illness behavior often results in patients being released from roles, social expectations, or responsibilities. Wellness behaviors focus on improving health, like jogging. Social behaviors involve groups. Antisocial behavior involves socially unacceptable actions. PTS:1DIF:Cognitive Level: Applying (Application) REF: 24-25 OBJ: Describe the variables influencing illness behavior. TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 34.A patient states, I will avoid social situations where people are drinking alcohol so I am not tempted to start drinking again. The nurse assesses the patient to be in which stage of change? a.Contemplation b.Precontemplation c.Maintenance d.Engagement ANS: C Maintenance is the ability for sustained change over time. This stage begins 6 months after action has started and continues indefinitely. It is important to avoid relapse. I have a problem with drinking, and I really think I need to work on it is an example of the contemplation stage. There is nothing that I really need to change is an example of the precontemplation stage. There is no such stage as engagement. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:23 OBJ: Discuss four types of risk factors and the process of risk-factor modification. TOP:Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 35. Which order should the nurse prioritize care for the patient using Maslows theory from lower-level needs to higher-level needs? a. Self-esteem b. Physiological needs c. Self-actualization d. Love and belonging e. Safety and security a.b, e, d, a, c b.d, b, c, a, e c.b, e, d, c, a d.d, b, a, c, e ANS: A Maslows (1987) model describes human needs using a hierarchical pyramid divided into five levels: physiological needs, safety and security, love and belonging, self-esteem, and self-actualization. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:17-18 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.Using the health promotion model while rendering care enables a nurse to do which of the following? (Select all that apply.) a.Help the patient pursue health. b.Detect the presence of illness. c.Promote health behaviors in a patient. d.Assess a familys response to illness. e.Plan interventions to achieve self-actualization. ANS: A, C The purpose of the health promotion model is to explain the reasons that individuals engage in health activities and is not for use with families or communities. You will use this model to help your patients carry out healthy behaviors in their daily lives. This model helps the patient pursue health. Self-actualization is the final stage in Maslows hierarchy and does not relate to the health promotion model. This model does not focus on illness. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:17 OBJiscuss the health belief, health promotion, basic human needs, and holistic health models of health and illness and their relationship to patients attitudes toward health and health practices.TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance a.Technological advances b.Old age c.Cancer d.Poverty ANS: D Poverty is still deadlier than any disease and is the most frequently cited reason for death in the world today. Technological advances, old age, and cancer are not the most cited reason for death. PTS:1DIF:Cognitive Level: Applying (Application) REF:45 OBJiscuss the implications that issues challenging the health care system have for nursing.TOP:Nursing Process: Implementation MSC:NCLEX: Reduction of Risk Potential 7.A nurse is teaching the staff about the Prospective Payment System (PPS). Which information should the nurse include in the teaching session? a. PPS establishes cost-based reimbursement for health care. b. PPS provides reimbursement for every service the patient receives. c. PPS establishes reimbursement rates based upon diagnosis-related groups (DRGs). d. PPS provides money to the patient for health promotion use. ANS: C PPS established diagnosis-related groups (DRGs). Established by Congress in 1983, the PPS eliminated cost-based reimbursement, which is reimbursement for every service the patient receives. Hospitals serving patients using Medicare were no longer paid for all costs incurred in delivering care to a patient. Instead, inpatient hospital services for patients using Medicare were combined into 468 DRGs. PPS provides a preset amount of money to hospitals and health care providers for DRGs, not for health promotion. Managed care focuses on health promotion. PTS:1DIF:Cognitive Level: Applying (Application) REF: 32 OBJ: Compare the various methods for financing health care. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 8.A 74-year-old patient was admitted to the hospital with diabetic ketoacidosis. How will the hospital be reimbursed by Medicare? a.Based upon the diagnostic-related group b.Based upon the cost of care c.Based upon the actual length of stay d.Based upon the number of medications ANS: A Payment is based upon the diagnostic-related group. Established by Congress in 1983, the prospective payment system eliminated cost-based reimbursement. Hospitals serving patients using Medicare were no longer paid for all costs incurred to deliver care to a patient. Instead, inpatient hospital services for patients using Medicare were combined into 468 diagnosis-related groups. Hospitals receive a set dollar amount for each patient based on the assigned DRG, regardless of the patients length of stay or use of services in the hospital or the number of medications. PTS:1DIF:Cognitive Level: Applying (Application) REF: 32 OBJ: Compare the various methods for financing health care. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 9.A patient tells the nurse that he or she does not understand the purpose of capitation. What is the nurses best response? a.To provide high-quality care at the highest cost to the hospital, not the patient b.To provide the least expensive care for patients regardless of outcomes c.To build a payment plan that includes the best standards of care at the lowest cost d.To ensure that all patients receive the same care for the same cost in all hospitals ANS: C The purpose of capitation is to build a payment plan for select diagnoses or surgical procedures that includes the best standards of care and essential diagnostic and treatment procedures at the lowest cost. Capitation does not cause the hospitals to pay the highest cost but to determine quality care for the lowest cost. Capitation does not provide the least expensive care for patients for outcomes because best standards are the outcome. Capitation does not make all patients receive the same care for the same cost in all hospitals. PTS:1DIF:Cognitive Level: Applying (Application) REF:32 OBJ:Explain the advantages and disadvantages of managed health care. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 10.A single mother with three children uses the public health department services in the county to immunize her children. Which level of health care did the mother use? a.Continuing care b.Preventative care c.Secondary acute care d.Restorative care ANS: B Preventative care includes services such as immunizations, screenings, poison control information, mental health counseling and crisis prevention, and community legislation. Continuing care is assisted living. Secondary acute care involves emergency and radiological procedures. Restorative care involves rehabilitation services and home care. PTS:1DIF:Cognitive Level: Applying (Application) REF:34OBJescribe the six levels of health care. TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 11.A registered nurse working as a school nurse for a small poor rural school district has noticed an increase in children arriving at school without having eaten breakfast. The nurse has discussed this issue with the school principal and is working on a proposal to ask the school district to explore a school breakfast program. Which level of care did the nurse use? a.Primary care b.Continuing care c.Restorative care d.Tertiary care ANS: A In the settings that deliver preventative and primary care, such as schools, physicians or health care providers offices, occupational health clinics, and nursing centers, health promotion is a major theme. Continuing care involves assisted living and psychiatric day care. Restorative care involves rehabilitation and home care. Tertiary care involves intensive care and psychiatric facilities. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:34 OBJ: Explain the relationship between levels of health care and levels of prevention. TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 12.A small business owner has consulted with an occupational health nurse regarding health promotion activities for the employees. The registered nurse explores the possibility of providing an area outside the new office complex where employees can walk during their breaks. Which level of care did the nurse use? a.Continuing care b.Restorative care c.Primary care d.Tertiary care ANS: C In the settings that deliver preventative and primary care, such as schools, physicians or health care providers offices, occupational health clinics, and nursing centers, health promotion is a major theme. Continuing care involves assisted living and psychiatric day care. Restorative care involves rehabilitation and home care. Tertiary care involves intensive care and psychiatric facilities. PTS:1DIF:Cognitive Level: Applying (Application) REF:34 OBJ: Explain the relationship between levels of health care and levels of prevention. TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 13.A grocery store clerk does not have a family health care provider. The clerk has had a sore throat for the past week and recently began running a fever. The clerk goes to the local community hospitals emergency room for treatment. Which level of care did the clerk use? a.Continuing care b.Restorative care c.Primary care d.Tertiary care ANS: D Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units are sites that provide secondary and tertiary levels of care. Continuing care involves assisted living and psychiatric day 21.Which other term can the nurse use to describe the Omnibus Budget Reconciliation Act of 1987? psychiatric patients. PTS:1DIF:Cognitive Level: Applying (Application) REF:36 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 19.A 17-year-old patient was seriously injured in a motor vehicle accident and has been transferred from an acute care hospital to a rehabilitation/restorative facility. Which action should the nurse take to ensure the best outcome for this patient? a.Make sure that the patient gets enough rest. b.Push the patient beyond his or her limits. c.Request that nobody visit for the first few days. d.Involve the family early in the rehabilitation process. ANS: D In restorative settings, nurses recognize that success is dependent on effective and early partnering with patients and their families. Although rest is good, family involvement is the priority. Pushing the patient beyond his or her limit is not helpful. Not letting anybody visit is contraindicated. PTS:1DIF:Cognitive Level: Applying (Application) REF:37 OBJiscuss the role of nurses in different health care delivery settings. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 20.A patient who experienced a stroke 4 days ago has been discharged from the hospital and will be undergoing outpatient rehabilitation. How should the nurse prepare the patient for this level of care? a.The patient will be admitted to the rehabilitative unit of the hospital. b.The patient will have scheduled appointment times for therapy. c.The patient will have home visits from all members of the multidisciplinary team. d.The patient will be at home for all of the treatments ordered by the primary health care provider. ANS: B When patients receive rehabilitation services in outpatient settings, patients get treatment at specified times during the week but remain at home the rest of the time. Inpatient rehabilitation services would require admission to an inpatient facility. Some rehabilitation is offered in the home but usually only certain members of the health care team visit. Home rehabilitation services would have the treatments performed in the home, but not for outpatient rehabilitation. PTS:1DIF:Cognitive Level: Applying (Application) REF:38 OBJiscuss the role of nurses in different health care delivery settings. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care Services offered by adult day care centers allow family members to maintain their lifestyles and employment and a.Medicaid Act b.Nursing Home Reform Act c.Diagnostic Related Group Act d.Magnet Recognition Act ANS: B The nursing center industry has become one of the most highly regulated industries in the United States. The Omnibus Budget Reconciliation Act of 1987, also known as the Nursing Home Reform Act, raised the standard of services provided by nursing centers. The Medicaid act provides insurance to low-income families. The diagnostic related group was formed from the Medicare Act. The American Nurses Credentialing Center (ANCC) established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice. PTS: 1 DIF: Cognitive Level: Understanding (Comprehension) REF:39 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 22.A new registered nurse who recently began working in a nursing center has been asked to complete a Resident Assessment Instrument (RAI) on a newly admitted resident. What is the primary purpose of this instrument? a.To provide a database to better understand the health care needs of this population b.To provide the nursing staff with an overall physical assessment of the resident c.To provide statistical evidence to support a universal health care policy d.To provide medications for the residents to take on a daily basis ANS: A The facility needs to complete the RAI on all residents. The RAI consists of the Minimum Data Set (MDS), Resident Assessment Protocols (RAPs), and utilization guidelines of each state. The RAI ultimately provides a national database for nursing facilities so that policy makers will better understand the health care needs of the long-term care population. Although it does provide a physical assessment, the primary purpose is to better understand the needs of this population. It does not provide evidence for a universal health care policy or medications to be used for this population group. PTS:1DIF:Cognitive Level: Applying (Application) REF:39 OBJiscuss the role of nurses in different health care delivery settings. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 23.An 81-year-old widow with mild dementia has self-care capabilities. The widow recently moved in with her daughter, a 46-year-old working mother with three children. In considering how to have care for her mother when she is working, what is the most appropriate option the nurse should suggest? a.A rehabilitation center b.A nursing center c.An adult day care center d.A hospice center ANS: C still provide home care for their relatives. A hospice is a system of family-centered care that allows patients to live and remain at home with comfort, independence, and dignity while alleviating the strains caused by terminal illness; this is inappropriate because the widow does not have a terminal illness. Rehabilitation is the use of multiple therapies such as physical, psychological, occupational, speech, and social services to help restore a person to the fullest physical, mental, social, vocational, and economic usefulness possible; this is not appropriate because the widow can provide self-care. A nursing center is a nursing home; it is too early for this because the widow can provide self-care. PTS:1DIF:Cognitive Level: Applying (Application) REF:40 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 24.A 78-year-old widow needs assistance with medications, housekeeping, and laundry, and would like to maintain independence. Which is the best option for the nurse to suggest? a.Assisted living b.Respite care c.Nursing center d.Rehabilitation center ANS: A Assisted living provides independence, security, and privacy at the same time. These facilities promote independence and physical and psychosocial health. Services in an assisted living facility include medication management, exercise and educational activities, social activities, laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping. Respite care is a service that provides short-term relief or time off for people providing home care to an ill, disabled, or frail older adult. Nursing center is a nursing home; this is too early to recommend because the widow wants to maintain independence. Rehabilitation is the use of multiple therapies such as physical, psychological, occupational, speech, and social services to help restore a person to the fullest physical, mental, social, vocational, and economic usefulness possible; this is not appropriate because the widow can provide self-care. PTS:1DIF:Cognitive Level: Applying (Application) REF:39 OBJiscuss the types of settings in which professionals provide various levels of health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 25.Which patient is most suitable for admission into hospice? a.A 63-year-old man with a fractured femur b.A 45-year-old woman with terminal end-stage renal failure c.A 14-year-old patient with leukemia that is in remission d.A 78-year-old patient with dementia that wanders ANS: B A patient entering a hospice is at the terminal phase of illness, and the patient, family, and physician agree that no further treatment will reverse the disease process. A fractured femur, leukemia in remission, and dementia are not conditions that are terminal, and so are not appropriate for hospice. Chapter 04: Community-Based Nursing Practice Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A student nurse is beginning the community-based primary care rotation. The student nurse anticipates that the assignment in community-based health care will most likely be at which organization? a.An acute care hospital b.A rehabilitation hospital c.A nursing home d.A high school ANS: D High schools focus on primary rather than acute care and provide knowledge about health and health promotion that occurs outside traditional health care institutions, such as hospitals, rehabilitation hospitals, and nursing homes. PTS:1DIF:Cognitive Level: Applying (Application) REF:50 | 51 OBJ: Explain the relationship between public and community health nursing. TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 2.A nurse is practicing as a community health nurse. What is the primary focus of care for this nurse? a.Providing care to subpopulations b.Practicing care in existing services c.Being a specialist in public health science d.Having a case management certification ANS: A The community health nurse provides direct care services to subpopulations within that community. Community health nursing is nursing care provided in the community, with the primary focus on the health care of individuals, families, and groups in the community. A community health nurse is not the same thing as a specialist in public health nursing. A community health nurse does not have to have case management certification. Although the community health nurse may practice care in existing services, the primary focus is on the subpopulations care. PTS:1DIF:Cognitive Level: Applying (Application) REF:52 OBJ: Differentiate community health nursing from community-based nursing. TOP:Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 3.A community health nurse is using the goals of the Healthy People 2020 to focus care. Which goal is the priority? a.To increase the life expectancy of people in the United States b.To increase the health status of people throughout the world c.To eradicate the human immunodeficiency virus (HIV) d.To reduce health care costs ANS: A The overall goals of Healthy People 2020 are to increase the life expectancy and quality of life and to eliminate health disparities through an improved delivery of health care services to people in the United States. The focus is on the United States, not the world. It does not focus on one disease or on reducing health care costs. PTS:1DIF:Cognitive Level: Applying (Application) REF: 51 OBJ: Describe the role of the community health nurse. TOP:Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 4. The teen pregnancy rate in one community significantly increased; as a result, the school system was seeing an increase in the dropout rate of teenage mothers. A nurse recently worked with the local school system to develop a day care program for the children of high school students so that they could return to school. Which technique did the nurse use? a. Incorporating immunizations for the infants and mothers b.Responding to changes within the community c.Influencing chronic environmental factors d.Managing disease ANS: B Successful community health nursing practice involves building relationships with the community and responding to changes within the community. No immunizations were given. There was no mention of managing disease in this scenario. The nurse did not influence chronic factors. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 53 OBJ: Describe the role of the community health nurse. TOP:Nursing Process: Evaluation MSC: NCLEX: Health Promotion and Maintenance 5.A nurse notices that a particular area of the community had food poisoning. The nurse collected data from the people who were affected, identified a local restaurant that served all the people, and determined it was the chicken dish that caused the poisoning. Which community health nurse competency did the nurse demonstrate? a.Public health b.Educator c.Epidemiologist d.Case manager ANS: C As epidemiologist, community health nurses use basic principles of epidemiology such as tracking health problems; collecting and analyzing data to identify disease trends, outbreaks of illnesses, and disease incidence rates; and planning strategies to prevent or contain outbreaks. With the goal of helping patients assume responsibility for their own health care, the role of educator is important in a community-based setting. Case management means making an appropriate plan of care based on assessment of patients and families and coordinating needed resources and services for the patients well-being across a continuum of care. A community health nurse is not the same thing as a public health nurse and is not a competency of community health nursing. PTS:1DIF:Cognitive Level: Applying (Application) REF:58 OBJescribe selected competencies important for success in community-based nursing practice.TOP:Nursing Process: Evaluation MSC:NCLEX: Safety and Infection Control 6.Upon assessment the nurse finds the following: a 46-year-old immigrant patient from the Czech Republic has diabetes and hypertension and just recently moved in to live with a family member who must travel frequently. The patient speaks English very well. The community health nurse knows that this patient may be vulnerable because of which assessment finding? a.Age b.Immigration status c.Diabetes d.Language ANS: B Vulnerable populations include individuals living in poverty, elderly people, homeless individuals, those in abusive relationships, people with substance abuse problems and/or mental illnesses, and new immigrants. For some immigrants access to health care is limited because of legal status, language barriers and lack of benefits, resources, and transportation. Being 46 years old does not place the patient in the elderly category. Diabetes does not make the patient vulnerable. The patient speaks English, so that is not an issue. PTS:1DIF:Cognitive Level: Applying (Application) REF:54 OBJ: Explain the characteristics of patients from selected vulnerable populations that influence a nurses approach to care. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 7.A nurse wants to use the most important competency in community nursing. Which competency should the nurse use? a.Caregiver b.Case manager c.Educator d.Epidemiologist ANS: A The most important role is caregiving. Using the nursing process and critical thinking skills, a nurse develops appropriate, individualized nursing care for specific patients and their families. Case management means making an appropriate plan of care based on assessment of patients and families and coordinating needed resources and services for the patients well-being across a continuum of care. Community-based nurses teach their patients individually or in groups. Community health nurses use basic principles of epidemiology, such as tracking health problems; collecting and analyzing data to identify disease trends, outbreaks of illnesses, and disease incidence rates; and planning strategies to prevent or contain outbreaks. PTS:1DIF:Cognitive Level: Applying (Application) REF:56 OBJescribe selected competencies important for success in community-based nursing practice.TOP:Nursing Chapter 05: Legal Principles in Nursing Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1. Which information indicates the nurse has an accurate understanding of the State Nurse Practice Act? a. It is a federal senate bill. b. It is a law enacted by the federal government. c. It is a statute enacted by state legislature. d. It is a judicial decision. ANS: C 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. PTS:1DIF:Cognitive Level: Applying (Application) REF:63 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 2.A student nurse must pass the NCLEX before practicing as a registered nurse. NCLEX stands for Examination. a.Nursing Council of Licensing b.Nightingale Code of Licensure c.Nursing Code of Licensure d.National Council Licensure ANS: D To be licensed in a state, a nurse must have a passing score on the National Council Licensure Examination (NCLEX) to obtain the initial license and meet the educational requirements set by the state. Nursing Council of Licensing, Nightingale Code, and Nursing Code examinations do not exist to practice as a nurse. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:63 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 3.A registered nurse was accused of patient abandonment when the nurse became angry, quit the job, and left the hospital before the end of the shift. This is an example of violating legal standards/guidelines set by which organization? a.The State Department of Health b.The Joint Commission c.The State Board of Nursing d.The National League for Nursing ANS: C Nurse Practice Acts permit the State Board of Nursing to set rules, regulations, and guidelines that specifically define the standard of care in nursing practice. An example is the guidelines that define patient abandonment. 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. PTS:1DIF:Cognitive Level: Applying (Application) REF:63 OBJ: Explain the legal concepts of standard of care and informed consent. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 4. An RN suffers from chronic back pain that was the result of an injury suffered when pulling a patient up in bed. The nurse is addicted to pain medication and has recently been accused of stealing narcotics. This is an example of which violation of the law? a. Misdemeanor b.Tort c.Malpractice d.Felony ANS: D 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 persons 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. PTS:1DIF:Cognitive Level: Applying (Application) REF:63-64 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 5. The nurse is caring for a patient who refuses to cooperate for a dressing change. The nurse tells the patient that he or she will tie the patient down if the patient does not hold still. Which action did the nurse commit? a.Assault b.Unintentional tort c.Battery d.Felony ANS: A 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. An example of an assault in nursing practice is to threaten to restrain a patient for an x-ray procedure when the patient has refused consent. Battery is intentional offensive touching without consent or lawful justification. Negligence is an unintentional tort. A felony is a serious offense that results in significant harm to another person or society in general, like misusing controlled substances. PTS:1DIF:Cognitive Level: Applying (Application) REF:64 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 6. Which chart entry by a nurse would require follow up? a.0815 Patient found on floor. b.0816 Patient assessed and helped back to bed. c.0818 Physician notified of incident. d.0820 Occurrence report completed. ANS: D Do not document in the nurses notes that an occurrence report was completed . All the other entries are accurate. Objectively record the details of the event and any statements the patient makes. At the time of the event, always assess the patient thoroughly, and then contact the health care provider to examine him or her. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 66 OBJ: Identify nursing interventions to improve patient safety. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 7. To establish the elements of malpractice against a nurse, which must be proved by the patient? a.The patient must have been harmed as a result of the injury. b.The patient must have paid for the health care services. c.The patient must show evidence of malicious intent. d.The patient must demonstrate personal accountability. ANS: A 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 nurses breach of duty, and (4) the patient has accrued damages as a result of the injury. The patient paying, showing evidence of malicious intent, and demonstrating personal accountability are not elements of malpractice. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:64 OBJ:Explain the concept of negligence and identify the elements of professional negligence.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 8. Which behavior is the best way for a nurse to avoid being liable for malpractice? a.Purchasing quality malpractice insurance coverage on a yearly basis b.Practicing nursing that meets the generally accepted standard of care c.State Board of Nursing d.Institute of Medicine ANS: B The Good Samaritan Law protects the nurse because CPR is within a nurses scope of practice. Although Good Samaritan Laws provide immunity to the nurse who does what is reasonable to save a persons life, if the nurse performs a procedure for which he or she has no training, the nurse will be liable for any injury resulting from that act. Therefore, provide only care that is consistent with your level of expertise. The insurance policy, state boards of nursing, and Institute of Medicine do not provide protection to the nurse under the Good Samaritan Law. PTS:1DIF:Cognitive Level: Applying (Application) REF:66 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Evaluation MSC: NCLEX: Management of Care 14.Which patient would the nurse consider to be competent to give informed consent? a.A 27-year-old unconscious patient b.A 16-year-old emancipated minor c.A 43-year-old patient who is drunk d.A 33-year-old patient who has been declared legally incompetent ANS: B Even though an emancipated minor has not achieved the legal age of consent, he or she may give consent for procedures and treatment. If a patient is unconscious, you need to obtain consent from a person legally authorized to give consent on his or her behalf. A patient who is legally incompetent needs to have the consent of a legal guardian, which is determined through a legal proceeding. A person who is drunk cannot fully understand the procedure and cannot sign the consent form. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:67-68 OBJ: Explain the legal concepts of standard of care and informed consent. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 15.A patient is confused and is attempting to get out of the hospital bed. The nurse is tired after working for more than 10 hours and is concerned for the patients safety. What is the best action that the nurse should take to prevent the patient from harm? a.Restrain the patient with wrist restraints. b.Place the patient with a belt restraint in a chair. c.Sedate the patient with medication. d.Ask a family member to sit with the patient. ANS: D Asking a family member to sit with the patient is the best answer because it does not restrain the patient physically or chemically. The Joint Commission has set guidelines for the use of restraints in hospitals. These regulations set the standard that all patients have the right to be free from seclusion and physical or chemical restraints except to ensure the patients safety in emergency situations. The standards specifically prohibit restraining patients for staff convenience, punishment, or retaliation. PTS:1DIF:Cognitive Level: Applying (Application) REF:6BJ:List sources for standards of care for nurses. TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 16. As part of the admission process the nurse asks if the patient has an advance directive. The patient doesnt know for sure. What is the nurses best response? a. It is autopsy permission. b. It is a living will. c. It is informed consent. d. It is an organ donation card. ANS: B Many times the decision regarding lifesaving treatment is in writing in the patients living will or advance directive. Living wills are documents instructing the health care provider to withhold or withdraw life-sustaining procedures in a patient who is terminally ill. Advanced directives are not an organ donation card, nor informed consent, nor autopsy permission. PTS:1DIF:Cognitive Level: Applying (Application) REF:69 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 17. 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 patients diagnosis with the patients health care provider c.Providing patient information to the nursing assistant caring for the patient d.Sharing with other nurses in the cafeteria that a patient is HIV positive ANS: D Although HIPAA does not require such things 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 blood-borne 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. PTS:1DIF:Cognitive Level: Applying (Application) REF:70 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 18. An RN has been caring for a patient. The nurse received an erroneous order for a medication. The primary health care provider has a reputation for impatience and irritability. Knowing this health care providers nature, which action by the nurse would be most appropriate? a.Clarify the order with the pharmacy. b.Ask the patient to remember. c.Clarify the order with the primary health care provider. d.Ask another nurse to look at the order to try to clarify it. ANS: C A nurse will assess all physician or health care provider orders, and if the nurse determines they are erroneous or harmful, obtain clarification from that physician or health care provider. Calling pharmacy, asking the patient, and asking another nurse are not the best ways to handle erroneous orders. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:70 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 19. Which task can a nurse safely delegate to a student nurse who is working as a nursing assistant? a.Distributing medications to patients b.Administering insulin injections c.Collecting intake and output data d.Assessing patients ANS: C During the time when a student nurse works as an employee of a health care facility, perform only tasks that appear in a job description for a nurses aide or nursing assistant. For example, even if a student nurse has learned how to administer intramuscular medications, do not perform this task as a nurses aide. PTS:1DIF:Cognitive Level: Applying (Application) REF:71 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Assessment MSC: NCLEX: Management of Care 20. Only one nurse was scheduled to care for 12 postsurgical patients with a nursing assistant. The nurse is concerned for the safety of the patients and the nursing license. What is the most appropriate first step in this situation? a.Contacting the nursing supervisor and documenting the action b.Refusing to care for the patients without appropriate help and leaving c.Contacting the State Board of Nursing and documenting the action d.Contacting the hospital administrator on call to complain and documenting the action ANS: A If a nurse is assigned to care for more patients than is reasonable for safe care, he or she should notify 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. PTS:1DIF:Cognitive Level: Applying (Application) REF:72 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 26.A nurse is maintaining precise records regarding the dispensing, wasting, and storage of a drug that is securely locked. Which drug is the nurse administering? a.Routine medication b.Controlled substance c. Over-the-counter medication d.Substance not requiring an order ANS: B Controlled substances are securely locked away, and only authorized personnel have access to them. Maintain precise records regarding the dispensing, wasting, and storage of controlled substances. There are criminal penalties for the misuse of controlled substances. Routine and over-the-counter drugs are not controlled substances. Controlled substances required an order by a licensed physician or in some states advanced practice nurses. PTS:1DIF:Cognitive Level: Applying (Application) REF:72 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 27.Which action is the nurse required by law to perform when a patient is admitted? a.Notify the family. b.Notify the attorney. c.Ask how payment will be made. d.Ask about advance directives. ANS: D 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. Notifying the family and attorney is breaking confidentiality. Asking how payment will be made is not required by law and is not the responsibility of the nurse. PTS:1DIF:Cognitive Level: Applying (Application) REF:69 OBJescribe the legal obligations and role of nurses regarding federal and state laws that affect health care.TOP:Nursing Process: Implementation MSC: NCLEX: Management of Care 28.A nurse must ask a family member to consider an organ donation. In which order should the nurse contact the individuals? a. Spouse b. Parent c. Guardian d. Grandparent e. Adult son or daughter f. Adult brother or sister a.a, c, e, f, b, d b.a, e, f, b, d, c c.a, e, b, f, d, c d.a, b, e, f, d, c ANS: C You approach individuals in the following order to consider organ or tissue donations: (1) spouse, (2) adult son or daughter, (3) parent, (4) adult brother or sister, (5) grandparent, and (6) guardian. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:69 OBJ: Define the legal relationships of nurse-patient, nurse-health care provider, nurse-nurse, and nurse-employer. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A nurse is about to administer a medication and notices that the physicians or primary health care providers order looks incorrect regarding the amount of the medication. What should the nurse do? (Select all that apply.) a.Notify the physician or health care provider. b.Do not carry out the order. c.Document the suspicion that the dosage is incorrect. d.Administer the medication. e.Notify the supervisor or nurse manager. ANS: A, B, E Nurses are responsible for carrying out medical treatment unless the physicians or health care providers 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. Do not carry out the order if there is a risk that harm will come to your patient; therefore do not administer the medication. Inform the nurse manager or the nursing supervisor. The nurse does not document suspicions or opinions, just objective, factual information. PTS:1DIF:Cognitive Level: Applying (Application) REF:70-71OBJ:List sources for standards of care for nurses. TOP:Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 2.A nurse wants to follow the American Nurses Associations Social Media Policy (2011). Which actions should the nurse take? (Select all that apply.) d.Nonmaleficence ANS: C 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. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 78 OBJ: Describe and defend patient advocacy and the nurses role. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 4.A registered nurse knows that an oncology patient undergoing a bone marrow transplant will spend weeks in isolation in the hospital. During that time the patient will be at an increased risk for infection and other complications and may not recover. The nurse ensures that the patient has been given information regarding the risks and potential benefits of the procedure. The nurse is following which ethical principle? a.Autonomy b.Justice c.Fidelity d.Nonmaleficence ANS: D 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. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 78 OBJ: Describe and defend patient advocacy and the nurses role. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 5.A registered nurse is working on a pediatric oncology unit and caring for four children undergoing chemotherapy. Today a new nursing assistive personnel (NAP) who has passed a competency examination is assigned to the team. The nurse will delegate a portion of the fundamental nursing tasks to the NAP during the shift, but realizes that he or she is still responsible for his or her own actions and is accountable for the care. The nurse is following which principle of behavior? a.Ethical dilemma b.Code of ethics c.Bioethics d.Feminist ethics ANS: B The code of ethics reflects underlying principles that include responsibility, accountability, respect for confidentiality, competency, judgment, and advocacy. An ethical dilemma exists when the right thing to do is not clear or when members of the health care team cannot agree on the right thing to do. The study of bioethics represents a particular branch of ethics (i.e., the study of ethics within the field of health care). Feminist ethics proposes that we routinely ask how ethical decisions will affect women as a way to repair a history of inequality (Lindeman, 2005). PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 78 OBJ: Describe and defend patient advocacy and the nurses role. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 6.The mother of a 45-year-old patient is a retired physician and requests to discuss the patients plan of care with the nurse caring for the patient. What is the nurses best response to this request? a.I will need to ask permission from my supervisor before I can share that information. b.I will show you the chart, just follow me and we can discuss your questions and concerns. c.I would suggest that you leave me out of your family problems. I am here to care for the patient. d.I will have to get the patients permission before I can share that information. ANS: D Even family members or friends of the patient are not permitted access to the patients personal health information without the patients consent. Federal legislation known as HIPAA (Health Insurance Portability and Accountability Act of 1996) requires that those with access to personal health information not disclose the information to a third party without patient consent. The nurse does not need to ask permission from the supervisor because HIPAA laws state what the nurse can do. I would suggest that you leave me out of your family problems is inappropriate because it ignores the request of the family member. Showing the chart and discussing the care is a violation of HIPAA. PTS:1DIF:Cognitive Level: Applying (Application) REF: 80 OBJ: Describe and defend patient advocacy and the nurses role. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 7.A nurse bases ethical decisions on the effect, or consequences, an act will have and uses the following guidelines: the greatest good for the greatest number of people. Which ethical system is the nurse using? a.Legal b.Deontology c.Utilitarianism d.Ethics of care ANS: C 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. Ethical issues differ from legal issues. Legal issues are resolved by reference to laws that tend to be concrete and publicly determined. 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. PTS:1DIF:Cognitive Level: Applying (Application) REF:81 OBJiscuss the foundations of ethics and ethical practice in nursing. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 8.A registered nurse has recently been reassigned to the gynecology unit at the hospital. The nurse is strongly against abortion because of religious beliefs and contacts the nursing supervisor regarding the assignment because the unit cares for women who are undergoing abortions. The nurse is having a conflict in which area? a.Confidentiality b.Values c.Social networking d.Culture ANS: B 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. PTS:1DIF:Cognitive Level: Applying (Application) REF:77 OBJ: Describe the process for recognizing and resolving an ethical dilemma. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 9.A 9-year-old patient was severely burned and has been undergoing whirlpool treatments to debride the wounds. The patient is crying and does not want to go to the physical therapy department for treatment. The registered nurse caring for the patient knows that, even though it is uncomfortable, the patient needs to have the therapy for the wounds to heal properly. The nurse is demonstrating which ethical principle? a.Autonomy b.Bioethics c.Justice d.Beneficence ANS: D The principle of beneficence promotes taking positive, active steps to help others. It encourages a nurse to do good for the patient. Beneficence guides decisions in which the benefits of a treatment pose a risk to the patients well- being or dignity. Autonomy refers to independence and self-determination. The study of bioethics represents a particular branch of ethics (i.e., the study of ethics within the field of health care). 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. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 78 OBJ: Describe and defend patient advocacy and the nurses role. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 10. Although a registered nurse has been working for several years as a staff nurse on an adult oncology unit, the nurse recently transferred to a pediatric unit in the hospital. The nurse will be in orientation for several days to learn about the different systems and will need to demonstrate proficiency in various pediatric areas such as medication administration. Which behavior is the nurse demonstrating? a.C ompetency b.Judgment c.Advocacy d.Utilitarianism ANS: A In the practice of nursing, competence ensures the provision of safe nursing care (proficiency in pediatric medication administration). The agreement to practice with competence is a common denominator for all state regulations and is in the nursing code of ethics. Judgment refers to the ability to form an opinion or draw sound conclusions. Advocacy involves speaking up for patient care issues from your unique perspective and advocating REF:80 OBJiscuss the foundations of ethics and ethical practice in nursing. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16.The code of ethics for nursing sets forth ideals of nursing conduct and was developed by what organization? a.The Board of Nursing b.The American Medical Association c.The National League for Nursing d.The American Nurses Association ANS: D The American Nurses Association (ANA) and the International Council of Nurses (ICN) publish codes of ethics for nurses that set principles of behavior for them to embrace. The Board of Nursing regulates nursing programs and nursing practice. The American Medical Association deals with physicians. The National League for Nursing is an agency concerned with nursing education. PTS: 1 DIF: Cognitive Level: Remembering (Knowledge) REF:78 OBJiscuss the foundations of ethics and ethical practice in nursing. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 17.A nurse is processing an ethical dilemma by focusing on relationships and stories of the participants. Which ethical system is the nurse using? a.Deontology b.Utilitarianism c.Feminist ethics d.Ethics of care ANS: D 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. Deontology defines actions as right or wrong based on right-making characteristics such as truth and justice. You use utilitarian ethics when determining the value of something based primarily on its usefulness and effects or consequences. Feminist ethics proposes that we routinely ask how ethical decisions will affect women as a way to repair a history of inequality. PTS:1DIF:Cognitive Level: Applying (Application) REF:81 OBJiscuss the foundations of ethics and ethical practice in nursing. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 18.A nurse is teaching the staff about how to process an ethical dilemma. Which order should the nurse use to present the steps? a. Evaluate the action. b. Negotiate the outcome. c. State the problem clearly. d. Gather all relevant information. e. Examine own values and opinions. f. Consider possible courses of action. a.d, e, c, f, a, b b.d, e, c, f, b, a c.d, c, e, f, a, b d.d, e, c, b, f, a ANS: B The steps to process an ethical dilemma include the following: (1) Is this an ethical dilemma? (2) Gather all information relevant to the case. (3) Examine and determine your own values and opinions about the issues. (4) State the problem clearly. (5) Consider possible courses of action. (6) Negotiate the outcome. (7) Evaluate the action. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:82 OBJ: Describe the process for recognizing and resolving an ethical dilemma. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.A nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. To help the parents resolve this conflict, which steps should the nurse take to process the ethical dilemma? (Select all that apply.) a.Identifying people who can solve this dilemma b.Gathering all relevant information surrounding this dilemma c.Clarifying own values and opinions about the issues d.Consulting a professional ethicist regarding how to proceed with this dilemma e.Considering possible courses of action ANS: B, C, E 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 ones 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. Identifying people who can solve this dilemma and consulting a professional ethicist are not steps of the process. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:82 OBJ: Describe the process for recognizing and resolving an ethical dilemma. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care ANS: D EBP is a systematic approach to determine the most current and relevant evidence on which to base patient care decisions. Melnyk and Fineout-Overholt recommend a six-step process for EBP: (1) Ask a clinical question; (2) Collect the most relevant and best evidence; (3) Critically review and evaluate/appraise the evidence gathered; (4) Combine/Integrate evidence with ones clinical expertise and patient preferences and values in making a practice decision or change; (5) Evaluate the practice decision or change; (6) Communicate results of the change. Collecting the best evidence is step 2. Integrating evidence is step 4. Critically appraising the evidence is step 3. PTS:1DIF:Cognitive Level: Applying (Application) REF: 91 OBJ: Describe the steps of evidence-based practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 6. The nurse manager of a 30-bed medical surgical unit has noticed that the fall rate of postoperative patients has increased in the past 2 months. The nurse manager wants to address this situation using evidence-based practice. Which type of trigger did the nurse manager use? a. Literature-focused trigger b.Problem-focused trigger c.Knowledge-focused trigger d.Expectations-focused trigger ANS: B A problem-focused trigger is one you face while caring for patients or a trend you see on a nursing unit. A knowledge-focused trigger is a question that arises as a result of new information available on a topic, such as current information in literature. Titler et al. (2001) suggest using problem- and knowledge-focused triggers to think critically about clinical and operational nursing-unit issues. It does not include literature or an expectations trigger. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 91-92 OBJ: Describe the steps of evidence-based practice. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 7.A registered nurse who works for a surgical intensive care unit (ICU) has recently read several articles in professional nursing journals about the use of quiet time in the ICU to enhance patient outcomes. The nurse would like to apply the research findings to the unit. How did the nurse formulate the clinical question? a.Measurement-focused trigger b.Problem-focused trigger c.Knowledge-focused trigger d.Expectations-focused trigger ANS: C A knowledge-focused trigger is a question that arises as a result of new information available on the topic. For example, What is the current evidence for the best way to educate patients with low health literacy? A problem- focused trigger is one you face while caring for patients or a trend you see on a nursing unit. Titler et al. (2001) suggest using problem- and knowledge-focused triggers to think critically about clinical and operational nursing- unit issues. It does not include measurement or expectation focuses. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 91-92 OBJ: Describe the steps of evidence-based practice. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 8.A nurses manager has suggested that a nurse formulate a PICO question to clarify the topic before doing a literature review. When the nurse asks what the acronym PICO stands for, how should the nurse manager respond? a.Policy, information, comparison, outcome b.Patient, information, collection, outcome c.Patient, intervention, comparison, outcome d.Policy, intervention, communication, outcome ANS: C P: Patient population of interest. Identify patients by age, gender, ethnicity, disease, or health problem. I: Intervention of interest. Which intervention do you want to use in practice (e.g., a treatment, diagnostic test, educational approach)? C: Comparison of interest. What is the usual standard of care or current intervention that you now use in practice? O: Outcome. What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, patient perception)? Policy, information, comparison, collection, and communication are not included in PICO. PTS:1DIF:Cognitive Level: Applying (Application) REF:92OBJevelop a PICO or PICOT question. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 9.A nurse working on a PICO question has found a large amount of literature available on the topic with multiple studies that have been published. Which type of study should have the best evidence? a.Meta-analysis of randomized control trials b.Opinion of an expert committee c.One well-designed randomized control trial d.Systematic review of descriptive and qualitative studies ANS: A Systematic reviews or meta-analyses are state-of-the-science summaries from an individual researcher or panel of experts and are on the highest level of the hierarchy. These research summaries are the perfect answers to PICO(T) questions because the researchers have rigorously summarized all current evidence on the question. A single RCT is not as conclusive as a review of several RCTs on the same question. Opinion of an expert committee is on the lowest level of the hierarchy of evidence. Systematic review is above opinions but is below meta-analysis on the hierarchy of evidence. PTS:1DIF:Cognitive Level: Applying (Application) REF: 93-94 OBJ: Discuss the levels of evidence in the literature. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 10.A registered nurse is concerned about the patients perceptions and feelings about the quality of life that they experience after a diagnosis of liver cancer. Which is the most appropriate type of research study the nurse should use to gather information about this situation? a.Quantitative study b.Randomized trial c.Qualitative study REF: 96-97 OBJ: Identify ways to sustain knowledge in evidence-based practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 15. The nursing unit staff has used evidence-based practice to implement a practice change. What is the next step in the process the nursing staff should implement? a.R eview literature. b.Engage companies. c.Measure outcomes. d.Ask a clinical question. ANS: C After implementing the change, the practice decision or change should be evaluated by using outcome or process measurements. Remember the O in your PICO(T) question. It represents the outcomes you choose to measure as you integrate the evidence. These outcomes tell you how well the evidence-based intervention works. Reviewing literature and asking a clinical question occurred before the change. Companies are not a part of this process. PTS:1DIF:Cognitive Level: Applying (Application) REF: 91 | 97 OBJ: Describe the steps of evidence-based practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 16. At a health care organization, patients are turned every 2 hours to help prevent pressure ulcers. Because of this nursing intervention, patients exhibit far fewer pressure ulcers than the national average. Which term should the nurse use to describe this finding? a.S entinel event b.Qualitative research c.Manuscript narrative d.Nursing-sensitive outcome ANS: D A nursing-sensitive outcome focuses on how patients and their health care problems are affected by nursing interventions (ONS, 2012). Nursing-sensitive outcomes look at the effects of interventions within the scope of nursing practice. Sometimes a problem is presented to a committee in the form of a sentinel event, an unexpected occurrence involving death or serious physical or psychological injury of a patient. Qualitative research is analysis of interviews, observations, and/or surveys to measure peoples perceptions, feelings, or views of phenomena about which little is known. Manuscript narrative is the middle section or narrative of a manuscript that differs according to the type of evidence-based article it is. PTS:1DIF:Cognitive Level: Applying (Application) REF:98 OBJ: Discuss ways to measure outcomes for an evidence-based practice change. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 17. The quality improvement or performance improvement (QI/PI) process should begin at which level of nursing? a.Staff nurse b.Nurse manager c.Nurse administrator d.Advanced practice registered nurse ANS: A The QI/PI process begins at the staff level, where all disciplines become involved in identifying quality problems. Although all those listed can do QI/PI, the process begins at the staff level. PTS:1DIF:Cognitive Level: Applying (Application) REF:100 OBJ: Explain the relationship among nursing research, evidence-based practice, and quality improvement. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.The nurse is investigating an area of practice in which no research evidence is available. What types of non- research information should the nurse consider? (Select all that apply.) a.Performance improvement and risk management data b.International, national and local standards of care c.Study with pre- and post-test design d.Benchmarking e.Retrospective or concurrent chart reviews ANS: A, B, D, E Other sources of information from non-research evidence include: performance improvement and risk management data, international, national and local standards of care, infection control data, benchmarking, clinicians expertise, and retrospective or concurrent chart reviews. Study with a pre- and post-test design is a research study. The question asked for non-research information. PTS:1DIF:Cognitive Level: Applying (Application) REF: 91 OBJ: Discuss the levels of evidence in the literature. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 2.A nurse is describing types of performance improvement models. Which information should the nurse include? (Select all that apply.) a.Six Sigma b.Balanced scorecard c.Plan-Do-Study-Act d.Root cause analysis e.Human subjects committee ANS: A, B, C, D Performance improvement models include Six Sigma, balanced scorecard, Plan-Do-Study-Act, and root cause analysis. Research studies must be approved by an institutional review board (IRB), also called a human subjects committee , which is not involved with performance improvement models but with research. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:101 OBJ: Discuss the relationship between evidence-based practice and the improvement of the safety and quality of nursing practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity ANS: A The fourth component of the critical thinking model is attitudes. Paul (1993) identifies 11 attitudes that are central features of a critical thinker of which risk taking, creativity, and integrity are examples. Kataoka-Yahiro and Saylor (1994) describe critical thinking competencies as the cognitive processes a nurse uses to make judgments about the clinical care of patients. There are three competencies: general critical thinking (scientific method, problem solving, and decision making), specific critical thinking in clinical situations (clinical inference, diagnostic reasoning, and clinical decision making), and specific critical thinking in nursing (nursing process). The standards for critical thinking include intellectual standards and professional standards. The nursing process is a five-step approach that incorporates diagnostic reasoning and clinical decision making. PTS:1DIF:Cognitive Level: Applying (Application) REF:115-116 OBJ: Discuss the critical thinking attitudes used in clinical decision making TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 6.A nurse is using the scientific method to solve a patient situation. Which action should the nurse take first ? a.Collect data. b.Identify a problem. c.Formulate a question. d.Evaluate the results. ANS: B Identifying the problem is the first step in the scientific method. The steps of the scientific method are as follows: Identify the problem; Collect data; Form a question or hypothesis; Test the question or hypothesis; Evaluate results of the study. Collect data is the second step. Formulate a question is the third step. Evaluate the results is the last step. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 110 OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 7.A registered nurse is explaining a procedure to a patient who speaks another language. Which action by the nurse reflects critical thinking? a.Teach with unfamiliar explanations. b.Explain using medical jargon. c.Use vague descriptions. d.Obtain an interpreter. ANS: D Critical thinkers use language precisely and clearly. If you do not obtain a professional interpreter when communicating with patients who speak a different language, you are taking the risk of miscommunicating important information. When you use incorrect terminology, jargon, or terminology with which a patient is unfamiliar, or vague descriptions, communication is ineffective. PTS:1DIF:Cognitive Level: Applying (Application) REF: 108 OBJ: Discuss the nurses responsibility in making clinical decisions. OBJ: Explain the relationship between clinical experience and critical thinking. 8.A patient receiving blood after an abdominal surgery notified the nurse that the IV pump was alarming. The nurse checked the pump and determined that the tubing was kinked. The tubing was straightened out and the nurse left the room. Five minutes later the IV pump again alarmed. The nurse returned to find the tubing was again kinked. On further investigation, the nurse discovered that the IV tubing had become twisted. This is an example of which behavior on the part of the nurse? a.Effective problem solving b.Diagnostic reasoning c.Scientific method d.Commitment level of critical thinking ANS: A Effective problem solving involves evaluating the solution over time to be sure that it is still effective and if a problem occurs you try different options, which the nurse did in this scenario. In commitment, you anticipate the need to make choices without assistance from others. The nurse did not anticipate the need as evidenced by the fact the nurse did not fully investigate until the second time. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. In diagnostic reasoning, the information a nurse collects and analyzes leads to a diagnosis of a patients condition. Nurses do not make medical diagnoses; they make nursing diagnoses, which is a part of diagnostic reasoning. This scenario deals with an equipment problem, not a patient health problem (diagnostic reasoning). PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 111 OBJ: Discuss the nurses responsibility in making clinical decisions. TOP:Nursing Process: Implementation MSC: NCLEX: Pharmacological and Parenteral Therapies 9.A patient on a pediatric unit who underwent an appendectomy for a ruptured appendix 3 days ago complains of acute pain and has a high fever. The nurse is concerned that the patient may have an infection and notifies the primary health care provider of the change in the patients condition. This concern is based on the nurses experience as a pediatric nurse. The nurses ability to make a tentative conclusion regarding this patients situation based on observed data is known as what? a.Scientific method b.Clinical inference c.Effective problem solving d.Data collection ANS: B The nurse used clinical inference because of previous experience as a pediatric nurse and pieces of evidence of acute pain and a high fever. Clinical inference is the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a nursing diagnosis. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Effective problem solving involves evaluating the solution over time to be sure that it is still effective and if a problem occurs you try different options. Data collection is a component of assessment in the nursing process. In diagnostic reasoning you use patient data that you gather or collect to logically identify a problem. The nurse in this scenario is past data collection and is making a tentative conclusion. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:111 TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 10.A patient with cancer is undergoing outpatient chemotherapy. The clinic nurse notes that the patients white blood cell count is very low and has little energy. The plan of care is based upon the nursing diagnosis Risk for Infection . The nurse provides patient teaching in order to reduce the risk for infection. The nurse is using which skill in this situation? a.Medical diagnosis b.Scientific method c.Diagnostic reasoning d.Data collection ANS: C The nurse used diagnostic reasoning by using data (low white blood cells and little energy) to arrive at a patients health problem/nursing diagnosis ( Risk for Infection ). Diagnostic reasoning is the analytical process for determining a patients health problems. It requires you to assign meaning to the behaviors and physical signs and symptoms presented by a patient. Nurses do not make medical diagnoses; they make nursing diagnoses. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Data collection is a component of assessment in the nursing process. In diagnostic reasoning you use patient data that you gather or collect to logically identify a problem. The nurse in this scenario is past data collection and has made a nursing diagnosis: Risk for Infection. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 111 OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Evaluation MSC: NCLEX: Safety and Infection Control 11.A nurse is caring for an elderly lady who recently experienced a stroke and who coughs/chokes after eating or drinking. The nurse knew that the patient was at risk for aspiration because of the stroke and was concerned that the patient may have impaired swallowing. The nurse develops a care plan based on the nursing diagnosis Impaired Swallowing . Which skill is the nurse using to make this nursing diagnosis? a.Medical diagnosis b.Scientific method c.Diagnostic reasoning d.Data collection ANS: C The nurse used diagnostic reasoning to arrive at a nursing diagnosis. During diagnostic reasoning, the information a nurse collects and analyzes leads to a diagnosis of a patients condition. Nurses do not make medical diagnoses; they make nursing diagnoses. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Data collection is a component of assessment in the nursing process. In diagnostic reasoning you use patient data that you gather or collect to logically identify a problem. The nurse in this scenario is past data collection and has made a nursing diagnosis: Impaired Swallowing. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 111 OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Evaluation MSC: NCLEX: Reduction of Risk Potential 12.Which situation represents a nurse using clinical decision-making skills? REF:115-116 OBJ: Discuss the critical thinking attitudes used in clinical decision making. TOP: Nursing Process: Evaluation MSC: NCLEX: Basic Care and Comfort 17.A student nurse in the last semester of nursing school found that keeping a journal of clinical experiences helped the student nurse understand why certain actions were taken and to evaluate whether there was a better way of approaching the task. The student nurse has found that this has helped strengthen critical thinking skills. Which skill for developing critical thinking did the student nurse use? a.Professional standards b.Nursing process c.Concept mapping d.Purposeful reflection ANS: D Purposeful reflection leads to a deeper understanding of issues and the development of judgment and skill. One activity that will help a nurse develop into a critical thinker is reflective journaling. A concept map is a visual representation of meaningful relationships between concepts (e.g., patient problems or nursing diagnoses and interventions), which then form propositions. The primary purpose of a concept map is to synthesize relevant data about a patient such as assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. The nursing process is a systematic process that incorporates diagnostic reasoning and clinical decision making through five steps: assessment, diagnosis, planning, implementation, and evaluation. Professional standards for critical thinking refer to ethical criteria for nursing judgments (e.g., advocacy, patient autonomy, and beneficence), evidence-based criteria used for assessment and evaluation, and criteria for professional responsibility. PTS:1DIF:Cognitive Level: Applying (Application) REF: 118 OBJ: Describe how reflection improves clinical decision making. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 18.A new nurse who has just begun working for an oncology unit is frustrated with trying to figure out the relationships between a patients problems and appropriate nursing interventions. What is the best tool that the nurse can use to synthesize data into meaningful information? a.Concept map b.Reflective journal c.Plan of care d.Intellectual standards ANS: A A concept map is a visual representation of meaningful relationships between concepts (e.g., patient problems or nursing diagnoses and interventions), which then form propositions. Concept maps are visual road maps that highlight the meanings of these relationships. The primary purpose of a concept map is to synthesize relevant data about a patient such as assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. Reflective writing requires you to record your clinical experiences in your own words in a personal journal. In the nursing process, a plan of care is written to guide nursing care, but it does not show relationships as well as does a concept map. Paul (1993) identified 14 intellectual standards universal for critical thinking. An intellectual standard is a guideline or principle for rational thought, but it does not show relationships like a concept map does. PTS:1DIF:Cognitive Level: Applying (Application) REF: 118 OBJ: Discuss the nurses responsibility in making clinical decisions. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 19.A nurse walks into a room and finds a patient to be severely confused. The nurse examines and observes the patient closely and thinks about other situations with severely confused patients before making a nursing diagnosis. Which skill is the nurse using? a.Clinical inferences b.Reflective journaling c.Accountability d.Intuition ANS: A Part of diagnostic reasoning is clinical inference, the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a nursing diagnosis. Reflective writing requires you to record your clinical experiences in your own words in a personal journal. Intuition is an inner sensing or gut feeling about something. Accountability refers to being answerable for ones actions. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 111 OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Assessment MSC: NCLEX: Safety and Infection Control 20.A nurse is using scientific knowledge and experience to choose strategies to use in the care of a patient. Which critical thinking skill is the nurse using? a.Analysis b.Evaluation c.Explanation d.Self-regulation ANS: C Scientific knowledge and experience to choose strategies you use in the care of patient is explanation; it supports your findings and conclusions. Analysis is being open-minded as you look at information about a patient. Do not make careless assumptions in analysis. Evaluation is looking at all situations objectively and systematically and using criteria to determine results of nursing actions. Self-regulation is reflecting on your experiences and identifying ways you can improve your own performance. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 107 OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 21.A nurse is alert to potentially problematic situations in a patient and is using evidence-based knowledge. Which concept for a critical thinker is the nurse using? a.Maturity b.Analyticity c.Systematicity d.Inquisitiveness ANS: B Analyticity is being alert to potentially problematic situations and using evidence-based knowledge. Maturity is reflecting on your own judgments and realizing multiple solutions are acceptable. Systematicity is being organized, focusing, and working hard in any inquiry. Inquisitiveness is being eager to acquire knowledge and learning explanations even when applications of the knowledge are not immediately clear and to value learning for learnings sake. PTS:1DIF:Cognitive Level: Applying (Application) REF:107OBJescribe characteristics of a critical thinker. TOP: Nursing Process: Assessment MSC: NCLEX: Reduction of Risk Potential 22.A surgical unit uses Betadine to prep the skin before surgery. A nurse is using the scientific method to decide if soap and water is better than Betadine for preparing the skin for surgery. A nurse washes one group of patients with soap and water and washes another group of patients with Betadine. Which step did the nurse implement? a.Identifying the problem b.Forming the question or hypothesis c.Answering the question or hypothesis d.Evaluating the results of the test or study ANS: C When the nurse washes one group with soap and water and the other with Betadine, the nurse is answering the question or hypothesis. Identifying the problem would be an increase in infections or adverse reactions from Betadine. Forming the question or hypothesis would be, Does soap and water vs Betadine reduce the incidence of infections or adverse reactions? Evaluating the results would occur when the nurse compared the incidence of infection or adverse reactions for each of the two groups. PTS:1DIF:Cognitive Level: Applying (Application) REF: 110 OBJ: Discuss critical thinking skills used in nursing practice. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 23.Which patient situation indicates the nurse used fairness? a.The nurse used original thinking to find solutions outside the standard routine. b.The nurse asked why the interventions were used to help the patient. c.The nurse did not allow personal attitudes to influence delivery of care. d.The nurse followed the six rights when giving medication to a patient. ANS: C Fairness means the nurse deals with situations justly. This means that bias or prejudice does not enter into a decision. For example, regardless of how you feel about obesity, you do not allow personal attitudes to influence the way you deliver care to patients who are overweight. Creativity involves original thinking. This means you find solutions outside of the standard routines of care while still following standards of practice. A critical thinkers favorite question is, Why? and represents curiosity. Following the six rights is being responsible and accountable. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:115-116 OBJ: Discuss the critical thinking attitudes used in clinical decision making. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 24. Which information indicates the nurse has a correct understanding of critical thinking? a. It is a continuous process characterized by open-mindedness. b. It is the same thing as the nursing process. Chapter 09: Nursing Process Potter: Essentials for Nursing Practice, 9th Edition MULTIPLE CHOICE 1.A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process? a.Assessment b.Implementation c.Evaluation d.Diagnosing ANS: A Assessment is the deliberate and systematic collection of data about a patient. The data will reveal a patients current and past health status, functional status, and present and past coping patterns. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Implementation is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care. Evaluation is crucial to deciding whether, after interventions have been delivered, a patients condition or well-being improves. PTS:1DIF:Cognitive Level: Applying (Application) REF:124OBJescribe each step of the nursing process. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 2. The nurse is admitting a patient to the unit and asks the patient about the health history. The nurse is engaged in which component of the nursing process? a. Evaluation b.Diagnosis c.Assessment d.Planning ANS: C The nurse is in the assessment phase. An assessment database includes a patients comprehensive health history, which includes information about a patients physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system. The database also includes physical examination findings and a summary of results from laboratory and diagnostic testing. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Evaluation is crucial to deciding whether, after interventions have been delivered, a patients condition or well-being improves. Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions. PTS:1DIF:Cognitive Level: Applying (Application) REF: 124 OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 3.A postoperative patient is continuing to have incisional pain. As part of the nurses assessment, the nurse notes that the patient is grimacing when he or she changes position. The patients grimace can be useful in the assessment and can be described as which of the following? a.Cue b.Inference c.Diagnosis d.Health pattern ANS: A Grimacing is a cue. A cue is information that a nurse obtains through use of the senses. An inference is your judgment or interpretation of these cues. Gordons functional health patterns are a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. PTS:1DIF:Cognitive Level: Applying (Application) REF: 125 OBJ: Explain the type of conclusions that result from data analysis. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 4.A postoperative patient has denied the need for pain medication. The nurse has noted that the patient describes the pain as a 1 on a 0 to 10 scale. The nurse also notes that the patient grimaces when he or she changes position and guards the incision. The nurse believes that the patient is experiencing pain based on the information gathered in the assessment. What is this phenomenon known as? a.Cue b.Inference c.Diagnosis d.Health pattern ANS: B The nurse made a judgment, which is an inference, that the patient is experiencing pain. An inference is a nurses judgment or interpretation of a cue. A cue is information that you obtain through use of the senses. Gordons functional health patterns are a type of database format to obtain a comprehensive assessment. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat such as impaired tissue perfusion. PTS:1DIF:Cognitive Level: Applying (Application) REF: 125 OBJ: Explain the type of conclusions that result from data analysis. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 5.A nurse is collecting data during the assessment of a patient. During the assessment, the nurse collects both subjective and objective data. Which information should the nurse consider as subjective data? a.Heart rate of 96 b.Incisional erythema c.Emesis of 150 mL d.Sharp, burning pain ANS: D Sharp, burning pain is subjective. Subjective data are patients verbal descriptions of their health problems. Only patients provide subjective data. Heart rate, incisions, and emesis are all objective data. Objective data are observations or measurements of a patients health status. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 126 OBJ: Differentiate between subjective and objective data. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 6.The nurse has just completed an assessment on a patient with a fractured right femur. Which data will the nurse categorize as objective? a.The patients toes of right foot are warm and pink. b.The patient reports a dull ache in the right hip. c.The patient says feels tired all the time. d.The patient is concerned about insurance coverage. ANS: A Toes pink and warm are objective data. Objective data are observations or measurements of a patients health status. Subjective data are patients verbal descriptions of their health problems. Only patients provide subjective data. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 126 OBJ: Differentiate between subjective and objective data. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 7.A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse. As the student nurse charts the interaction, which statement is the best way to document what happened? a.Appears to be in pain as evidenced by grouchy behavior b.Behavior is inappropriate, requests registered nurse do the assessment c.States, I want a registered nurse to do my assessment d.Is grumpy, registered nurse notified ANS: C When a nurse collects objective data, he or she should apply critical thinking intellectual standards (e.g., clear, precise, and consistent). Nurses do not include personal interpretive statements. The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. If you do not report or record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient. Grouchy, inappropriate, and grumpy are personal interpretive statements and should be avoided. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:126 | 131 OBJ: Explain the relationship between critical thinking and steps of the nursing process. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 8.A mother of five children is admitted to the hospital for abdominal pain. The nurse asks a series of questions before performing a physical assessment. The patient answers the questions. When asking the patient some other questions, the patients spouse starts to answer. As the admission process progresses and the nurse gathers subjective data, the nurse requests that the patient answer the next questions. What is the rationale for the nurses behavior? a.The patient is exhibiting confusion. b.The spouse is being obnoxious. c.The patient is the best source of information. d.The spouse is too controlling. ANS: C A patient is usually the best source of information. A patient who is alert and answers questions appropriately a.What made you choose this hospital? b.How long did the seizure last? c.Tell me how the seizure disorder has affected the family. d.Tell me why you brought your spouse to the hospital today. ANS: B How long did the seizure last? is the question that will quickly focus on the patients symptoms. Once patients tell their story, use a problem-seeking interview technique. This approach takes the information provided in the patients story and then more fully describes and identifies specific problem areas. For example, focus on the symptoms the patient identifies and ask closed-ended questions that limit the patients answers to one or two words such as yes or no or a number or frequency of a symptom. What made you choose this hospital does not focus on the seizure. Tell me will not get information quickly as these are open-ended. PTS:1DIF:Cognitive Level: Applying (Application) REF: 129 OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Implementation MSC: NCLEX: Safety and Infection Control 15.A patient is admitted to the hospital after a motorcycle accident. The nurse in the emergency room is assessing vital signs, general appearance and behavior, and performing a head-to-toe examination of all body systems. What is the nurse doing? a.Making a medical diagnosis b.Performing a physical examination c.Making an evaluation d.Performing data validation ANS: B A physical examination involves use of the techniques of inspection, palpation, percussion, auscultation, and smell. A complete examination includes a patients height, weight, vital signs, general appearance and behavior, and a head-to-toe examination of all body systems. Nurses make nursing diagnoses, not medical diagnoses, after assessment of data. Evaluation is the last step of the nursing process. Evaluation is crucial to deciding whether, after interventions have been delivered, a patients condition or well-being improves. Validation of assessment data is the comparison of data with another source to confirm accuracy. PTS:1DIF:Cognitive Level: Applying (Application) REF: 129 OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 16.When admitting a patient to the hospital, the nurse asks if has problems eating since the patient had a stroke. The patient denies any problems and states that does not require assistance. After lunch, the nurse notes that the patient has not eaten most of the food and has spilled much of the food. These cues lead the nurse to believe that the patient is not functioning at the level indicated upon admission. The nurse is using which type of information to make this deduction? a.Verbal behavior b.Physical assessment c.Nursing diagnosis d.Nonverbal behavior ANS: D Observation of the level of function is different from what a nurse learns about function during the interview. A nurse observes what the patient does, such as self-feeding or making a decision, rather than what the patient says he or she can do. The level of function involves a persons ability to perform during everyday activities. Observation of the patients behavior for level of function differs from a physical assessment. The hands-on physical examination measures the extent of function through measures such as range of motion and muscle strength. Verbal behavior is what the patient says. A nursing diagnosis would be self-care deficit. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 129-130 OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 17.A 67-year-old male patient of French heritage is admitted to the hospital. The patient is interviewed by a nurse from a Korean family. The nurse did not make eye contact with the patient while conducting the interview. This disturbed the patient because the patient thought that the nurse might be trying to hide something. Which factor most likely influenced the behavior of the nurse and patient? a.Culture b.Validation c.Collaborative problem d.Defining characteristics ANS: A Communication and culture are interrelated in the way individuals express feelings verbally and nonverbally. When a nurse learns the variations in how people of different cultures communicate, he or she will likely gather more accurate information from patients. Validation of assessment data is the comparison of data with another source to confirm accuracy. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patients status. Defining characteristics are the clinical criteria or assessment findings that support an actual nursing diagnosis. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 130 OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 18.A nurse wants to provide patient-centered care to a patient of another culture. Which question is the most culturally sensitive when talking about a patients illness? a.What do you call your problem? b.How long has your child had the runs? c.When did you last void today? d.Has anyone else in your family had diarrhea? ANS: A To start an assessment, Seidel and others (2011) offer useful questions to begin to explore a patients illness or health care problem in context of the patients culture: What do you call your problem? A different culture may not know what the runs means. Most people do not know what void (urinate) means. Has anyone else in your family had diarrhea is not as culturally sensitive as finding out what the problem is according to the patients culture. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 130 OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 19.Which action by the nurse is the final step in a complete assessment? a.Forming diagnostic conclusions b.Documentation of findings c.Auscultation d.Palpation ANS: B Communication of assessment findings, either verbally or through documentation, is the last step of a complete assessment. The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. The techniques of a physical examination include inspection, palpation, percussion, auscultation, and smell. After reviewing and validating a patients assessment, the next step of the nursing process is to form diagnostic conclusions. PTS:1DIF:Cognitive Level: Applying (Application) REF:131OBJescribe each step of the nursing process. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care 20.A patient with bilateral pneumonia is admitted to the intensive care unit. The nurse who initially prepared the plan of care identified that the patient had the collaborative problem of Potential complications: hypoxemia . What made the nurse classify this as a collaborative problem? a. It requires ensuring adequate hydration. b. It requires monitoring for signs of acid-base imbalance. c. It requires evaluating the effects of positioning on oxygenation. d. It requires both nursing and physician-prescribed interventions. ANS: D A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patients status. When collaborative problems develop, nurses collaborate with personnel from other health care disciplines, such as social workers and dietitians and physicians. Adequate hydration, acid-base imbalance, and oxygenation do not make a collaborative problem. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 131 OBJ: Explain the type of conclusions that result from data analysis. TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Adaptation 21.A patient states, Im burning up, and I have a fever. The nurse takes the patients temperature, observes the skin for flushing, and feels the skin temperature. This is an example of subjective data. a.validating b.clustering c.reviewing d.documenting ANS: A Validation of assessment data is the comparison of data with another source to confirm accuracy. The nurse reviews data to validate that measurable, objective physical findings support subjective data. A data cluster is a set of signs or symptoms that are grouped in a logical order. When a nurse reviews a patients subjective data, the nurse is examining the patients own interpretation of his or her condition. Documenting information includes the written details of the assessment. PTS:1DIF:Cognitive Level: Analyzing (Analysis) 27.A nurse is writing a care plan for a newly admitted patient. Which outcome statement did the nurse correctly write? a.The patient will eat 80% of all meals. b.The nursing assistant will set up the patient for a bath every day. c.The nursing assistant will ambulate the patient three times a day by May 30. d.The patient will identify the need to increase dietary intake of fiber by July 4. ANS: D The patient will identify the need to increase dietary intake of fiber by July 4 is measurable, reliable, valid, and focuses on the patient. Expected outcomes are measurable criteria to evaluate goal achievement. These measurable effects relate to a change in a patients physical condition or behavior that results from individualized nursing interventions. Outcomes should be measurable, reliable, valid, suited to the patient, and sensitive to change. Eat 80% of meals has no time frame. The nursing assistant is not the focus the patient is. Also, the nursing assistant will ambulate the patient or set the patient for a bath are interventions, not outcomes. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:141 OBJiscuss the difference between a goal and an expected outcome. TOP: Nursing Process: Planning MSC: NCLEX: Management of Care 28.A home health nurse is providing care to a patient. Which action by the nurse is a physical care technique? a.Dressing a patient b.Assisting a patient to learn how to shop c.Performing range-of-motion exercises d.Administering cardiopulmonary resuscitation ANS: C Physical care techniques involve the safe and competent administration of nursing procedures (e.g., inserting a urinary catheter, performing range-of-motion exercises). Dressing a patient is an activity of daily living. Shopping is an instrumental activity of daily living. Cardiopulmonary resuscitation is a lifesaving measure. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 154 OBJ: Discuss the process of selecting nursing interventions. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 29.A nurse is delegating care of patients to the nursing assistant personnel (NAP) and a licensed practical nurse (LPN). Which situation indicates the nurse needs more instruction on delegation? a. LPN to change a sterile dressing b. NAP to provide skin care c. NAP to insert an indwelling catheter d. LPN to administer an enema ANS: C The question indicates the nurse made an incorrect delegation assignment. An NAP cannot insert indwelling catheter, an LPN or RN can do that skill. Noninvasive and frequently repetitive interventions such as skin care, ambulation, grooming, and hygiene measures are examples of activities that you assign to NAP such as certified nurse assistants. Licensed practical nurses perform these measures in addition to medication administration and many invasive tasks (e.g., dressing care and catheterization). It is appropriate for an RN to delegate, a sterile dressing change and enema to an LPN. It is appropriate for an RN to delegate skin care to an NAP. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF: 155 OBJ: Discuss the process of selecting nursing interventions. TOP: Nursing Process: Evaluation MSC: NCLEX: Management of Care 30.A patient has an outcome of ambulating three times a day. The patient does not ambulate the entire day. What should the nurse do next? a.Walk the patient. b.Reassess the patient. c.Change the goal for the patient. d.Continue with the plan for the patient. ANS: B When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs. A complete reassessment of all patient factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. The plan cannot continue because the goal was not met. The goal cannot be changed and walking the patient cannot occur until reassessment has been completed. PTS:1DIF:Cognitive Level: Applying (Application) REF:157 OBJ: Describe how to evaluate nursing interventions selected for a patient. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 31.A patient has met the goals and outcomes mutually agreed upon for improvement of ventilatory status. What should the nurse do next? a.Modify the care plan. b.Discontinue the care plan. c.Create a nursing diagnosis that states goals have been met. d.Reassess the patients response to care and evaluate interventions. ANS: B After a nurse determines that expected outcomes and goals have been met and evaluation confirms it, the nurse discontinues that portion of the care plan. The nurse modifies a care plan when goals are not met. Create a nursing diagnosis occurs after assessment, not during evaluation. Reassessing the patient occurs if the goals are not met. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:157OBJescribe each step of the nursing process. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care 32.A nurse is evaluating care for a patient. Which action should the nurse take? a.Compares patient findings with the goals and outcomes b.Determines if interventions were completed c.Develops a nursing diagnosis d.Writes a care plan ANS: A During evaluation you compare your findings with the goals and expected outcomes set for your patient. You conduct an evaluation to determine if expected outcomes are met, not if nursing interventions were completed. Develops a nursing diagnosis is the second step of the nursing process (diagnosis), not the last (evaluation). Writes a care plan occurs in the planning phase. PTS:1DIF:Cognitive Level: Analyzing (Analysis) REF:156OBJescribe each step of the nursing process. TOP: Nursing Process: Implementation MSC: NCLEX: Management of Care MULTIPLE RESPONSE 1.The nurse is beginning an assessment of a newly admitted patient. What are some recommended comprehensive assessment approaches the nurses can use? (Select all that apply.) a.Functional Health Patterns b.Nursing Diagnosis c.Problem-Focused Approach d.Nursing Intervention Classification e.Nursing Outcome Classification ANS: A, C There are two approaches for a comprehensive assessment. Gordons Functional Health Patterns involves use of a structured database format, based upon an accepted theoretical framework or practice standard. Another approach for conducting a comprehensive assessment is the problem-focused approach. The nurse should focus on the patients situation and begin with problematic areas. By using Nursing Intervention Classification nurses learn the common interventions recommended for the various NANDA-I nursing diagnoses. The Nursing Outcome Classification system is a classification system of nursing-sensitive outcomes. One of its purposes is to identify, label, validate, and classify nursing-sensitive patient outcomes. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat and occurs after assessment. PTS:1DIF:Cognitive Level: Applying (Application) REF: 125 OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care