46 minute read
Chapter 02: Concepts of Health, Illness, Stress, and Health Promotion
from TEST BANK deWit’s Fundamental Concepts and Skills for Nursing, 5th Edition, Patricia Williams
by ACADEMIAMILL
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition
Multiple Choice
1. The nurse is aware that any description of health would include the concept that: a. health is the absence of illness, and illness is the presence of chronic disease. b. culture, education, and socioeconomic status influence one‘s definition of health or illness. c. illness is a biological malfunction, and health is biological soundness. d. lifestyle factors are the major determinants of health or illness.
ANS: B
The concept of health is influenced by culture, education, and socioeconomic factors.
DIF: Cognitive Level: Comprehension REF: p. 15
TOP: Views of Health and Illness
OBJ: Theory #1
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease
2. The nurse takes into consideration that the patient with an admitting diagnosis of Type 2 diabetes mellitus and influenza is described as having: a. two chronic illnesses. b. two acute illnesses. c. one chronic and one acute illness. d. one acute and one infectious illness.
ANS: C
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Chronic illnesses can be controlled but not cured, and are long-lasting. Acute illnesses develop suddenly and resolve in a short time. Type 2 diabetes mellitus would be considered chronic, whereas influenza would be considered acute.
DIF: Cognitive Level: Application REF: p. 15
TOP: Classification of Illnesses
OBJ: Theory #1
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease
3. The nurse explains that an idiopathic disease is one that: a. is caused by inherited characteristics. b. develops suddenly, related to new viruses. c. results from injury during labor or delivery. d. has an unknown cause.
ANS: D
Idiopathic disease is defined as disease whose cause is unknown.
DIF: Cognitive Level: Knowledge REF: p. 15
TOP: Classification of Illnesses
OBJ: Theory #1
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease
4. The nurse assesses a terminal illness in: a. a 76-year-old admitted to a nursing home with Alzheimer disease who is pacing and asking to go home. b. a 43-year-old with Lou Gehrig‘s disease who is refusing food and fluid. c. a 2-year-old child who burned her esophagus by drinking drain cleaner and who is being fed by a tube. d. a 52-year-old diagnosed with lung cancer who had part of one lung removed and has a closed chest drainage device in place.
ANS: B
A terminal illness is defined as one in which a person will live only a few months, weeks, or days. A person who refuses food and hydration will generally not live more than a few days.
DIF: Cognitive Level: Comprehension REF: p. 15 OBJ: Theory #1
TOP: Stages of Illness KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. The nurse clarifies to a patient who now has an abscess following a ruptured appendix that the abscess is considered to be: a. a secondary illness. b. a life-threatening complication. c. an expected event following any surgery. d. a disorder easily treated with antibiotics.
ANS: A
A secondary illness is an illness that arises from a primary disorder.
DIF: Cognitive Level: Comprehension REF: p. 15 OBJ: Theory #1
TOP: Views of Health and Illness KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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6. The nurse uses a diagram to demonstrate how Dunn‘s theory of health and illness can be compared with a: a. plant that grows from a seed, blossoms, wilts, and dies. b. continuum, with peak wellness and death at opposite ends; the person moves back and forth in a dynamic state of change. c. ladder; from birth to death the individual moves progressively downward a ladder to eventual death. d. state of mind dependent on the individual perception of their own health or illness.
ANS: B
Dunn‘s theory of a health continuum shows how an individual moves between peak wellness and death in a constant process.
DIF: Cognitive Level: Knowledge REF: p. 16
OBJ: Theory #1
TOP: Views of Health and Illness KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. A patient has been advised by the primary care provider to take medication for high cholesterol and to change eating habits after discharge home. The home health nurse discovered that the patient refused to follow the medical and nutritional directions. The nurse‘s best initial response to this situation is to: a. emphasize to the patient how important it is to follow the doctor‘s advice. b. determine whether any cultural, socioeconomic, or religious values conflict, thus interfering with the patient‘s compliance. c. explain that without diet and medication the condition will worsen and serious problems will develop. d. inform the primary care provider that the patient is unable to understand the instructions.
ANS: B
The patient may have cultural, socioeconomic, or religious values that cause conflicts that prevent her from following the doctor‘s instructions.
DIF: Cognitive Level: Application REF: p. 16
TOP: Concepts of Health and Illness, Cultural Influences
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychological Integrity: Coping and Adaptation
8. A nurse practicing a holistic approach to nursing care must:
OBJ: Theory #5 a. recognize that a change in one aspect of the person‘s life can alter the whole of that person‘s life. b. take responsibility for health care decisions. c. promote state of the art technology. d. discourage the use of more natural remedies and alternative methods of health care.
ANS: A
Holistic nursing requires that the nurse recognizes that a change in one aspect of the patient‘s life (biological, sociological, psychological, and spiritual) will bring about changes in that patient‘s whole life.
DIF: Cognitive Level: ComprehensNioUnRSINRGETFB:Cp OM19
OBJ: Theory #6
TOP: Holistic Approach to Caring KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
9. Included in Maslow‘s hierarchy, physiological needs are those that: a. nurture intimacy. b. foster independence. c. encourage social interaction. d. protect from harm.
ANS: D
Physiological needs are those that are essential to human life, such as oxygenation, nutrition, and elimination. Protection from physical harm, from a nursing standpoint, is often equivalent in importance to physical needs.
DIF: Cognitive Level: Application REF: p. 20
OBJ: Theory #7
TOP: Maslow‘s Hierarchy of Needs KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The factors involved in assessing the importance the patient attaches to the relief of a particular deficit include: a. needs that the nurse must assess to prioritize care, because they may be different from person to person. b. ordering needs according to Maslow‘s hierarchy, with lower level needs being least compelling. c. needs based on a hierarchy in which higher level needs are more prominent and demand attention before lower level needs. d. needs that are usually not known to the patient and that must be determined by the nurse.
ANS: A
A person‘s concern relative to a needs deficit must be assessed by the nurse to meet the needs of each patient. Needs are viewed differently from one person to the next.
DIF: Cognitive Level: Comprehension REF: p. 20
OBJ: Theory #7
TOP: Maslow‘s Hierarchy of Needs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. The nurse believes that patient teaching of how to give insulin and monitor blood glucose levels will improve the level of the patient‘s: a. physiological well-being. b. security, by providing psychological comfort. c. self-esteem, by promoting independence and learning. d. self-actualization, by seeking knowledge and truth.
ANS: C
Patient education activities that are to be used after discharge enhance independence and promote self-esteem.
DIF: Cognitive Level: Application REF: p. 27
OBJ: Theory #7
TOP: Maslow‘s Hierarchy of Needs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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12. Homeostasis can be described as: a. the unchanging steady condition of humans in a changing external environment. b. a tendency of biological systems toward stability of the internal environment by continuously adjusting to survive. c. biological wellness that comes from the ability of the body to change and respond to physical changes in the environment. d. a response to stress that results from a person‘s choice of coping mechanisms to deal with the stress.
ANS: B
Homeostasis results from the constant adjustment of the internal environment in response to change; it is mental, emotional, and biological, as well as conscious and unconscious.
DIF: Cognitive Level: Comprehension REF: p. 22
TOP: Homeostasis KEY: Nursing Process Step: Assessment
OBJ: Theory #8
MSC: NCLEX: N/A
13. A patient admitted for diagnostic tests is frightened of hospital procedures and is nervous about the possible outcome of the tests. She states that her mouth is dry and her heart is pounding. Her blood pressure is 168/78 mm Hg (her usual blood pressure is 140/80 mm Hg), pulse is 112 beats/min, and respirations are 22 breaths/min. The nurse will recognize that these signs and symptoms are: a. indicative of serious, acute health problems and should be reported to the primary care provider immediately. b. most likely related to the disease for which the patient is admitted to the hospital. c. the effects of the parasympathetic nervous system and can be ignored. d. the effects of the sympathetic nervous system that can negatively affect the patient‘s health.
ANS: D
Fear stimulates the sympathetic nervous system to produce the symptoms identified in the question. If prolonged, they negatively affect a person‘s health.
DIF: Cognitive Level: Analysis REF: p. 26|Table 2-2
OBJ: Theory #10 TOP: Stress KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
14. According to Hans Selye‘s general adaptation syndrome (GAS), a person who has experienced excessive and prolonged stress is likely to: a. develop an illness or disease such as allergy, arthritis, or asthma. b. become resistant to biological methods of treatment. c. seek treatment for imagined illnesses and nonexistent symptoms. d. be admitted to the hospital during the alarm stage.
ANS: A
Many diseases are known to be caused or exacerbated by prolonged stress. Selye concluded that stress-induced illnesses respond to biological methods of treatment.
DIF: Cognitive Level: Comprehension REF: p. 26|Box 2-2
OBJ: Theory #10 TOP: Adaptation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
15. The nurse is aware that a stressor NasUeRxSpINerGieTnBcC edOMby an individual is usually perceived: a. as a negative event or stimulus that affects homeostasis in maladaptive ways. b. in different ways based on previous experience and personality traits. c. as an opportunity for growth and learning. d. in similar ways if age and education are similar.
ANS: B
Stressors are not perceived the same way by different people or even by the same person at different times. The experience of a stressor depends on previous experience and personality, as well as factors such as physical or emotional conditions, age, and education.
DIF: Cognitive Level: Comprehension REF: p. 26
OBJ: Theory #9
TOP: General Adaptation Syndrome KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychological Integrity: Psychosocial Adaptation
16. In 1946, the World Health Organization redefined health as the: a. absence of disease or infirmity. b. state of complete physical, mental, and social well-being. c. presence of disease or infirmity. d. state of incomplete physical, mental, and social well-being.
ANS: B
In 1946, the World Health Organization redefined health as ―the state of complete physical, mental, and social well–being, and not merely the absence of disease or infirmity.‖
DIF: Cognitive Level: Knowledge REF: p. 28
OBJ: Theory #1
TOP: Views of Health and Illness KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
17. The nurse assesses that a person is in the acceptance stage of illness when the patient: a. looks to home remedies to become well. b. reassumes usual responsibilities and roles. c. assumes the ―sick‖ role. d. rejects medical treatment.
ANS: C
When a person enters the acceptance stage of illness, he or she assumes the ―sick role‖ and withdraws from usual responsibilities and will frequently seek medical treatment at this time.
DIF: Cognitive Level: Comprehension REF: p. 15
OBJ: Theory #1
TOP: Acceptance Stage KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. The nurse instructs a patient that according to Selye‘s GAS theory, when stress is strong enough and occurs over a long enough period, the patient will enter the stage of: a. convalescence. b. alarm. c. transition. d. exhaustion.
ANS: D
The exhaustion stage in the GAS occurs when the stressor has been present for such a period that the patient will deplete the bo adaption.
DIF: Cognitive Level: Comprehension REF: p. 24
OBJ: Theory #1
TOP: Exhaustion Stage of GAS KEY: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
19. The nurse explains defense mechanisms as a patient‘s attempt to: a. justify the patient‘s assumption of the ―sick‖ role. b. reduce anxiety. c. problem solve. d. increase dependence.
ANS: B
Defense mechanisms are unconscious strategies to reduce anxiety.
DIF: Cognitive Level: Knowledge REF: p. 26
OBJ: Theory #9
TOP: Defense Mechanisms KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychological Integrity: Coping and Adaptation
20. In giving nursing care to persons of Asian origin, the nurse should: a. keep the room warm and free of drafts. b. look the patient directly in the eye. c. ask permission before touching the patient. d. warmly clasp the patient‘s hand in greeting.
ANS: C
Seek permission before touching persons of Asian extraction, because they may be sensitive to physical, personal contact.
DIF: Cognitive Level: Application REF: p. 18|Table 2-1
OBJ: Theory #4 TOP: Cultural Sensitivity
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychological Integrity: Coping and Adaptation
21. Sickle cell anemia is an example of a biological trait found primarily in: a. Asian populations. b. African populations. c. American Indian populations. d. Hispanic populations.
ANS: B
Sickle cell anemia is a biological variation found predominantly in people of African descent.
DIF: Cognitive Level: Knowledge REF: p. 18|Table 2-1
OBJ: Theory #5 TOP: Cultural Influences
MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A
22. When a young family man hospitalized after breaking his leg confides to the nurse that he is concerned about the well-being of his family and financial stress, the nurse can best support his sense of security by: a. reassuring him that his leg will heal quickly. b. actively listening to his concerns. c. encouraging family to make frequent visits. d. distracting him from his conce
ANS: B
A nurse‘s ability to use active listening will enhance the sense of security when patients feel that their needs are perceived accurately.
DIF: Cognitive Level: Application REF: p. 21
OBJ: Theory #7
TOP: Maslow‘s Hierarchy of Needs KEY: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
23. The nurse assesses successful adaptation in a post stroke patient when the patient: a. learns to walk and maintain balance with the aid of a walker. b. consistently takes antihypertensive drugs. c. attempts to get out of bed unassisted. d. refuses assistance with feeding.
ANS: A
Adaptation is a readjustment in habits to limitations and disabilities. Learning to walk and maintain balance with the aid of a walker is an example of this.
DIF: Cognitive Level: Application REF: p. 22
TOP: Adaptation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
OBJ: Theory #1
24. The nurse takes into consideration that in the stage of resistance in Selye‘s GAS, the patient: a. regresses to a dependent state. b. continues to battle for equilibrium. c. becomes maladaptive. d. begins to develop stress-related disorders.
ANS: B
The resistance stage is the second stage in the GAS when a patient is still attempting to find equilibrium.
DIF: Cognitive Level: Comprehension REF: p. 24 OBJ: Theory #10
TOP: Salye‘s GAS KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25. A patient states, ―I am not obese. My entire family is large.‖ The nurse assesses that the patient is using the defense mechanism of: a. sublimation. b. projection. c. denial. d. displacement.
ANS: C
Denial is a defense mechanism that allows a person to live as though an unwanted piece of information or reality does not exist. There is a persistent refusal to be swayed by the evidence.
DIF: Cognitive Level: Application REF: p. 27|Table 2-3
OBJ: Theory #8 TOP: Denial KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integri
26. A child who has just been scolded by her mother proceeds to hit her doll with a hairbrush. The nurse recognizes the child‘s actions are characteristics of: a. denial. b. displacement. c. rationalization. d. repression.
ANS: B
Displacement is a defense mechanism that characterizes discharging intense feelings for one person onto an object or another person who is less threatening, thereby satisfying an impulse with a substitute object.
DIF: Cognitive Level: Application REF: p. 27|Table 2-3
OBJ: Theory #8 TOP: Defense Mechanisms
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
27. The nurse encourages a patient to participate in health maintenance by maintaining an ideal body weight as a method of: a. primary prevention. b. secondary prevention. c. tertiary prevention. d. simple prevention.
ANS: A
Primary prevention avoids or delays occurrence of a specific disease or disorder.
DIF: Cognitive Level: Comprehension REF: p. 27 OBJ: Theory #1
TOP: Primary Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
28. A nurse clarifies that methods of tertiary prevention are designed for: a. rehabilitation. b. delay of the development of a disorder. c. screening for early detection of disease. d. using an established protocol of therapy for a specific disease.
ANS: A
Tertiary prevention consists of rehabilitation measures after the disease or disorder has stabilized. Latent prevention does not exist.
DIF: Cognitive Level: Comprehension REF: p. 27
TOP: Tertiary Prevention
OBJ: Theory #1
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29. When a new admission to an extended care facility wanders about listlessly, eats only a small amount of each meal, and keeps himself isolated, the nurse can intervene by: a. assisting with feeding at each meal. b. reminding him that he is in a safe and secure area. c. socializing with him in the privacy of his room. d. supporting him to interact withNU
ANS: D oup.
The membership and social interaction in a group may provide a means for a sense of belonging.
DIF: Cognitive Level: Application REF: p. 27
OBJ: Theory #11
TOP: Love and Belonging KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
Multiple Response
1. When the brain perceives a situation as threatening, the sympathetic nervous system reacts by stimulating which of the following physiological functions? (Select all that apply.)
a. Constriction of the pupils b. Dilation of the bronchial tubes c. Decreased heart rate d. Dilation of the pupils
ANS: B, D
Activation of the sympathetic nervous system causes the pupils and bronchial tubes to dilate. It also causes the heart rate to increase.
DIF: Cognitive Level: Analysis REF: p. 23
OBJ: Theory #11
TOP: Sympathetic Nervous System KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A a. awareness of vague symptoms. b. denial of feeling ill. c. resorts to self-medication. d. withdrawal from roles and responsibilities. e. recovery from illness begins.
2. The nurse describes behaviors of the transition stage of illness, which are: (Select all that apply.)
ANS: A, B, C
The transition stage (onset) of illness is demonstrated by the patient‘s awareness of vague symptoms, denial of feeling ill, and initiation of self-medication; however, he or she still fulfills the roles and responsibilities of life.
DIF: Cognitive Level: Comprehension REF: p. 15
TOP: Stages of Illness
OBJ: Theory #1
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation a. The nurse‘s focus is specific to the disease or injury. b. The nurse realizes that each person has a responsibility for his or her own health. c. Health care providers are required to intervene on behalf of all persons to ensure that health goals are met. d. Providers combine traditional methods of health care with relaxation techniques forpain management. NURSINGTB.COM e. A change in one aspect of a person‘s life may or may not alter the person as a whole.
3. Which defines the holistic approach to caring for the sick and promoting wellness? (Select all that apply.)
ANS: B, C, D, E
The holistic approach to medicine treats the patient as a whole and may use a mix of traditional medicine and alternative medicine. Any change in one aspect of the whole may change the entire whole.
DIF: Cognitive Level: Comprehension REF: p. 19 OBJ: Theory #6
TOP: Holistic Approach
MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A a. slight increase in body temperature. b. substantial increase in energy. c. decreased appetite. d. hormones released for mobilization for defense. e. the body‘s adaptation abilities temporarily overreacting.
4. The responses during the alarm stage of the general adaptation syndrome as defined by Hans Selye include: (Select all that apply.)
ANS: A, C, D
The responses during the alarm stage according to the general adaptation syndrome include a slight rise in temperature, a loss of energy, decreased appetite, and a release of hormones that mobilizes the body‘s defenses.
DIF: Cognitive Level: Comprehension REF: p. 24
TOP: GAS KEY: Nursing Process Step: N/A
OBJ: Theory #10
MSC: NCLEX: N/A a. having met all other need levels. b. being certain of their beliefs and values. c. not being swayed by new ideas. d. having little need for creative self-expression. e. depending on significant others.
5. The nurse clarifies that a person who is self-actualized would have the characteristics of: (Select all that apply.)
ANS: A, B
A self-actualized person has been able to meet all other basic need levels and is certain of his or her beliefs and values. He or she is open to new ideas and finds many ways of creative self-expression.
DIF: Cognitive Level: Comprehension REF: p. 16
TOP: Self Actualization
OBJ: Theory #7
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychological Integrity: Coping and Adaptation
Completion
1. Exercise can reduce stress and anxiety by the release of
ANS: endorphins
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The release of endorphins induces a feeling of well-being and tranquility.
DIF: Cognitive Level: Knowledge REF: p. 26
OBJ: Theory #11
TOP: Views of Health and Illness KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. Adequate is necessary in the communication between nurse and patient in order to meet the higher basic needs of security, love, belonging, and self-esteem.
ANS: feedback
Adequate feedback and clarification are essential in assisting the patient meet the higher level needs.
DIF: Cognitive Level: Comprehension REF: p. 21
OBJ: Theory #7
TOP: Communication KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
Chapter 03: Legal and Ethical Aspects of Nursing
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition
Multiple Choice
1. A student nurse who is not yet licensed: a. may not perform nursing actions until he or she has passed the licensing examination. b. is not responsible for his or her actions as a student under the state licensing law. c. are held to the same standards as a licensed nurse. d. must apply for a temporary student nurse permit to practice as a student.
ANS: C
Student nurses are held to the same standards as a licensed nurse. This means that although a student nurse may not perform a task as quickly or as smoothly as the licensed nurse would, the student is expected to perform it as effectively. In other words, she must achieve the same outcome without harm to the patient. The student is legally responsible for her own actions or inaction, and many schools require the student to carry malpractice insurance.
DIF: Cognitive Level: Knowledge REF: p. 32
TOP: Practice Regulations for the Student Nurse
MSC: NCLEX: N/A
OBJ: Theory #1
KEY: Nursing Process Step: N/A
2. During an employment interview, the interviewer asks the nurse applicant about HIV status. The nurse applicant can legally reNspUoRnSdI:NGTB.COM a. ―No,‖ even though he or she has a positive HIV test. b. ―I don‘t know, but I would be willing to be tested.‖ c. ―I don‘t know, and I refuse to be tested.‖ d. ―You do not have a right to ask me that question.‖
ANS: D
In employment practice, it is illegal to discriminate against people with certain diseases or conditions. Asking a question about health status, especially HIV or AIDS infection, is illegal.
DIF: Cognitive Level: Application REF: p. 34
OBJ: Clinical Practice #1
TOP: Discrimination KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. An example of a violation of criminal law by a nurse is: a. taking a controlled substance from agency supply for personal use. b. accidentally administering a drug to the wrong patient, who then has a serious reaction. c. advising a patient to sue the doctor for a supposed mistake the doctor made. d. writing a letter to the newspaper outlining questionable or unsafe hospital practices.
ANS: A
Theft of a controlled substance is a federal crime and consequently a crime against society.
DIF: Cognitive Level: Application REF: p. 32
OBJ: Theory #2
TOP: Criminal Law KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A a. Toilet the residents every 2 hours and as needed. b. Feed breakfast to one of the residents who needs assistance. c. Give medications to the residents at the prescribed times. d. Transport the residents to the physical therapy department.
4. The LPN (LVN) assigns part of the care for her patients to a nursing assistant. The LPN is legally required to perform which of the following for the residents assigned to the assistant?
ANS: C
Toileting, feeding, and transporting residents or patients are tasks that can be legally assigned to a nurse‘s aide. Administering medications is a nursing act that can be performed only by a licensed nurse or by a student nurse under the supervision of a licensed nurse.
DIF: Cognitive Level: Application REF: p. 33 OBJ: Theory #3
TOP: Delegation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
5. If a nurse is reported to a state board of nursing for repeatedly making medication errors, it is most likely that: a. the nurse will immediately have his or her license revoked. b. the nurse will have to take the licensing examination again. c. a course in legal aspects of nursing care will be required. d. there will be a hearing to determine whether the charges are true.
ANS: D
The nurse may have his or her liceNnU sR eS rIeNvGok Te BdCoOrMbe required to take a refresher course, but this would be based on the evidence presented at a hearing. The licensing examination is not usually required as a correction of the situation as described.
DIF: Cognitive Level: Knowledge REF: p. 33 OBJ: Theory #3
TOP: Professional Discipline KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
6. A nurse co-worker arrives at work 30 minutes late, smelling strongly of alcohol. The fellow nurses‘ legal course of action is to: a. have the nurse lie down in the nurses‘ lounge and sleep while others do the work. b. state that, if this happens again, it will be reported. c. report the condition of the nurse to the nursing supervisor. d. offer a breath mint and instruct the nurse co-worker to work.
ANS: C
Nurses must report the condition. It is a nurse‘s legal and ethical duty to protect patients from impaired or incompetent workers. Allowing the impaired nurse to sleep enables the impaired nurse to avoid the consequences of his or her actions and to continue the risky behavior. Threatening to report ―the next time‖ continues to place patients at risk, as does masking the signs of impairment with breath mints.
DIF: Cognitive Level: Application REF: p. 33
OBJ: Theory #3
TOP: Professional Discipline KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
7. When a student nurse performs a nursing skill, it is expected that the student: a. performs the skill as quickly as the licensed nurse. b. achieves the same result as the licensed nurse. c. not be held to the same standard as the licensed nurse. d. always be directly supervised by an instructor.
ANS: B
Students are not expected to perform skills as quickly or as smoothly as experienced nurses, but students must achieve the same result in a safe manner.
DIF: Cognitive Level: Comprehension REF: p. 33
TOP: Practice Regulations for the Student Nurse
MSC: NCLEX: N/A
OBJ: Theory #1
KEY: Nursing Process Step: N/A
8. If a nurse receives unwelcome sexual advances from a nursing supervisor, the first step the nurse should take is to: a. send an anonymous letter to the nursing administration to alert them to the situation. b. tell the nursing supervisor that she is uncomfortable with the sexual advances and ask the supervisor to refrain from this behavior. c. report the nursing supervisor to the state board for nursing. d. resign and seek employment in a more comfortable environment.
ANS: B
The first step in dealing with sexual harassment in the workplace is to indicate to the person that the actions or conversations are offensive and ask the person to stop. If the actions continue, then reporting the occurNre or the offender‘s supervisor is indicated.
DIF: Cognitive Level: Application REF: p. 34
OBJ: Clinical Practice #1
TOP: Sexual Harassment KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
9. A person who has been brought to the emergency room after being struck by a car insists on leaving, although the doctor has advised him to be hospitalized overnight. The nurse caring for this patient should: a. have him sign a Leave Against Medical Advice (AMA) form. b. tell him that he cannot leave until the doctor releases him. c. immediately begin the process of involuntary committal. d. contact the person‘s health care proxy to assist in the decision-making process.
ANS: A
A person has the right to refuse medical care, and agencies use the Leave AMA to document the medical advice given and the patient‘s informed choice to leave against that advice.
DIF: Cognitive Level: Application REF: p. 39
OBJ: Clinical Practice #3
TOP: Patient Rights KEY: Nursing Process Step: Implementation
MSC: NCLEX: N/A
10. The information in a patient‘s medical record may legally be: a. copied by students for use in school reports or case studies. b. provided to lawyers or insurers without the patient‘s permission. c. shared with other health care providers at the patient‘s request. d. withheld from the patient, because it is the property of the doctor or agency.
ANS: C
A release or consent is required to provide information from a patient‘s medical record to anyone not directly caring for that patient. The patient must provide consent to provide information to insurers, lawyers, or other health care agencies or providers. The patient has the right to access the information in his or her medical record (copies), but the agency or doctor retains ownership of the document.
DIF: Cognitive Level: Application REF: p. 39 OBJ: Theory #5
TOP: Legal Documents KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
11. If a patient indicates that he is unsure if he needs the surgery he is scheduled for later that morning, the nurse would best reply: a. ―Your doctor explained all of that yesterday when you signed the consent.‖ b. ―Your doctor is in the operating room; she can‘t talk to you now.‖ c. ―You should have the surgery; your doctor recommended that you have it.‖ d. ―I will call the doctor to speak with you before you go to the operating room.‖
ANS: D
A consent can be withdrawn at any time before the treatment or procedure has been started. The primary care provider should be notified by the supervising nursing staff of the unit.
DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #4
TOP: Informed Consent NURSINKGETY B:CN OMursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. A 16-year-old boy is admitted to the emergency room after fracturing his arm from falling off his bike while visiting with his stepfather who is not the custodial parent. The nurse is preparing him to go to the operating room but must obtain a valid informed consent by: a. having the patient sign the consent for surgery. b. obtaining the signature of his stepfather for the surgery. c. declaring the patient to be an emancipated minor. d. obtaining permission of the custodial parent for the surgery.
ANS: D
The patient is a minor and cannot legally sign his own consent unless he is an emancipated minor; the guardian for this patient is the custodial parent. A step parent is not a legal guardian for a minor unless the child has been adopted by the step parent. The hospital does not have the authority to declare the patient an emancipated minor.
DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3
TOP: Consent KEY: Nursing Process Step: Intervention
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
13. A patient has advance directives spelled out in a durable power of attorney, with the appointment of his daughter as his health care agent. The daughter will be responsible for: a. paying all the medical bills associated with the father‘s illness. b. making all informed consent decisions for her father. c. making all choices about her father‘s health care if the father is unable. d. paying only for those health care decisions based on the advance directives.
ANS: C
A health care agent makes decisions for the patient only when a patient is unable, according to the wishes made known by the patient in advance directives. A health care agent is not responsible for financial decisions or payments.
DIF: Cognitive Level: Application REF: p. 39 OBJ: Clinical Practice #5
TOP: Advance Directives KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
14. A patient has signed a do-not-resuscitate (DNR) order. If a nurse performs cardiopulmonary resuscitation (CPR) when the patient stops breathing and then successfully revives the patient, the: a. nurse could be found guilty of battery. b. patient would have no grounds for legal action. c. patient could charge the nurse with false imprisonment. d. nurse could be found guilty of assault.
ANS: A
A nurse who attempts CPR on a patient who had a doctor‘s order for a DNR could be found guilty of battery.
DIF: Cognitive Level: Comprehension REF: p. 39 OBJ: Clinical Practice #3
TOP: DNR KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
15. A patient refuses to take his medicNaUtiRoSnIsNoGrTtBoC eO atMhis breakfast. He is alert, mentally competent, and fairly comfortable. The nurse should: a. give the medications by injection if the patient will not take them orally. b. respect the patient‘s right to refuse medications or food, because he is competent. c. tell the patient that he must cooperate with his care. d. contact the doctor to insert a feeding tube to supply both medicine and food.
ANS: B
The competent patient has the right to refuse medicine, food, treatments, and procedures. Giving (or threatening to give) medications by injection over the patient‘s objections is considered battery. Threatening the patient or overriding the patient‘s wishes is a violation of the patient‘s bill of rights and constitutes assault or battery.
DIF: Cognitive Level: Application REF: p. 40 OBJ: Clinical Practice #3
TOP: Patient‘s Rights KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
16. A nurse remarks to several people that ―Dr. X must be getting senile because she makes so many mistakes.‖ If that remark results in some of Dr. X‘s patients changing to another doctor, Dr. X would have grounds to sue the nurse for: a. slander. b. libel. c. invasion of privacy d. negligence.
ANS: A
A person who makes untrue, malicious, or harmful remarks that damage a person‘s reputation and cause injury (loss of business) is guilty of defamation and slander. Libel is defamation that is written.
DIF: Cognitive Level: Application REF: p. 40
TOP: Defamation/Slander
MSC: NCLEX: N/A
OBJ: Clinical Practice #5
KEY: Nursing Process Step: N/A
17. A licensed nurse is liable for charges of malpractice when she: a. does not show up for work and fails to call to notify the agency. b. clocks in for another nurse to prevent that nurse from having pay docked. c. falsifies data, causing the patient to suffer problems resulting in death. d. assists in performing CPR that is unsuccessful, and the patient dies.
ANS: C
Malpractice is professional negligence or, in this case, doing (falsifying) something the reasonable and prudent nurse would not do. It is the proximate cause of the patient injury. This is a case of causation.
DIF: Cognitive Level: Application REF: p. 40|Box 3-6
OBJ: Theory #5 TOP: Negligence and Malpractice KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
18. A postoperative patient in the intensive care unit (ICU) is so confused and agitated that staff have not been able to safely care for him. He has pulled out his central line once, and he slides to the bottom of the bed, where he attempts to climb out, pulling and disrupting the various tubes and monitors. The nurse‘s b tion is to: a. place him in a protective vest device. b. use a sheet to tie him in a chair at the nurses‘ station. c. request that the doctor write an order for a protective device and/or medication. d. call a family member to stay with the patient.
ANS: C
A protective device may not be used (except in an emergency) without a doctor‘s order, and it is used only when other less restrictive means do not provide safety for the patient.
DIF: Cognitive Level: Application REF: p. 41
OBJ: Clinical Practice #3
TOP: False Imprisonment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
19. An elderly, slightly confused patient sustains an injury from a heating pad that was wrongly applied by the nurse. The nurse should: a. pretend to be unaware of the injury to the patient. b. report the incident to the risk management team via an incident report. c. document in the patient‘s medical record that an incident report was filled out. d. not document anything about the injury in the patient‘s medical record.
ANS: B
When an incident occurs that has potential for a future lawsuit, the risk management team should be aware of it as soon as possible. An incident report should be filled out, and the patient medical record should be documented to describe the injury. No mention of the incident report is usually made in the patient medical record. Honesty and a forthright explanation to the patient reduce the risk of lawsuits.
DIF: Cognitive Level: Application REF: p. 43
TOP: Incident Reports
MSC: NCLEX: N/A
OBJ: Theory #5
KEY: Nursing Process Step: N/A
20. Nursing liability insurance is a policy purchased and put into effect by the nurse for the purpose of: a. providing protection against being sued. b. reducing the chance of litigation. c. paying attorney fees and any award won by the plaintiff. d. providing the hospital with added protection.
ANS: C
Nursing liability insurance pays attorney fees and any award won by the plaintiff.
DIF: Cognitive Level: Comprehension REF: p. 43
TOP: Nursing Ethics
MSC: NCLEX: N/A
OBJ: Theory #5
KEY: Nursing Process Step: N/A
21. Ethics and law are different from each other in that ethics: a. bear a penalty if violated. b. are voluntary. c. rarelychange.
NURSINGTB.COM d. can always direct all decisions.
ANS: B
Ethics are voluntary and are based on values. Ethics may change as parameters of health care change. There is no penalty for violation.
DIF: Cognitive Level: Analysis REF: p. 43
TOP: Nursing Ethics
MSC: NCLEX: N/A
OBJ: Theory #6
KEY: Nursing Process Step: N/A
22. To best protect himself or herself from being sued, the nurse should: a. continue to do procedures as taught in school. b. purchase malpractice insurance. c. maintain competency. d. use evidence-based practice.
ANS: C
Keeping up with continuing education, maintaining competency, and seeking to improve one‘s own practice by self-evaluation will best protect the nurse.
DIF: Cognitive Level: Comprehension REF: p. 42|Box 3-7
OBJ: Theory #5 TOP: Avoiding Lawsuits
MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A
23. The Health Insurance Portability and Accountability Act‘s (HIPAA) main focus is in keeping: a. patients safe from harm. b. patient information in a secure office area. c. medications in a locked area. d. hospital infections under control.
ANS: B
HIPAA regulates the way patient information is conveyed and stored.
DIF: Cognitive Level: Comprehension REF: p. 37|Box 3-4
OBJ: Clinical Practice #1 TOP: HIPAA KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A a. A nurse posts a poem about the qualities of a compassionate nurse on his or her social media page. b. A nurse‘s mother shares a ―selfie‖ of her daughter (a nurse) and a celebrity patient she is caring for on her social media page. c. A nurse posts a request for prayer for strength after a difficult day at work. d. A nurse posts a video of fellow nurse‘s lip syncing and dancing to a popular song, ―We are Strong.‖
24. Which of the following could place the nurse in a serious legal situation?
ANS: B
Legal and Ethical Considerations
Social Media and HIPAA
Health care agencies and institutions have had to become more diligent in protecting personal health information (PHI) as a result. It is imperative that no PHI be disseminated, either intentionally or unintentionally, ovNeUrRsSoIcN iG alTmB.eCdOiaM . Posting of pictures, discussions (even those that do not use patient or hospital names), and images of x-rays all violate HIPAA and place the nurse in a serious legal situation. It is generally best to separate one‘s personal and professional life when dealing with social media. The National Council of State Boards of Nursing (2011) provides guidelines and suggestions for nurses in dealing with social media and nursing practice.
DIF: Cognitive Level: Analysis REF: p. 37
OBJ: Clinical Practice #6
TOP: Social Media and HIPAA KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
25. When a patient asks a nurse to witness the signing of a will, the nurse should refer the request to the: a. nurse supervisor. b. hospital legal department. c. notary public for the hospital. d. nurse‘s attorney.
ANS: C
Although witnessing a legal document for a patient is not illegal, most agencies have a policy regarding the proper course of action by referring the patient to the notary public.
DIF: Cognitive Level: Application REF: p. 39
TOP: Witnessing Wills and Other Legal Documents
KEY: Nursing Process Step: Implementation
OBJ: Theory #1
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
26. Criteria that justify becoming an emancipated minor and able to sign a medical consent include all of the following except: a. independence established through a court order. b. service in the armed forces. c. a 14-year-old whose parents are dead. d. a 17-year-old pregnant female.
ANS: C
Criteria are that the minor be independent by court order, be a member of the military, be pregnant, or be married.
DIF: Cognitive Level: Application REF: p. 38
OBJ: Clinical Practice #3
TOP: Emancipated Minor KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
27. A written statement expressing the wishes of a patient regarding future consent for or refusal of treatment in case the patient is incapable of participating in decision making is an example of: a. a privileged relationship. b. a health care agent. c. an advance directive. d. witnessed will.
ANS: C
An advance directive makes the patient‘s wishes known regarding medical decisions and consent in the event that he or she
DIF: Cognitive Level: Knowledge REF: p. 39
TOP: Legal Terms KEY: Nursing Process Step: N/A in decision making.
OBJ: Clinical Practice #5
MSC: NCLEX: N/A
28. A nurse is caring for an unmarried 16-year-old patient who has just given birth to a baby boy. The nurse will get the consent to perform a circumcision on the patient‘s son from the: a. patient‘s father. b. patient‘s primary care provider. c. patient‘s mother. d. 16-year-old patient.
ANS: D
Pregnancy qualifies as the basis for the 16-year-old to be treated as an emancipated minor.
DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3
TOP: Patient Rights KEY: Nursing Process Step: Implementation
MSC: NCLEX: N/A
29. A 48-year-old man refuses to take a medication ordered for the control of his blood pressure. The nurse‘s most effective response would be: a. ―Your doctor expects you to be compliant.‖ b. ―You have the right to refuse. This medication keeps your blood pressure under control.‖ c. ―Fine. I will document that you are refusing this drug.‖ d. ―Are you aware that you could have a stroke?‖
ANS: B
Patients have the right to refuse medication, but it is the nurse‘s responsibility to explain the reason for the particular drug.
DIF: Cognitive Level: Application REF: p. 38
OBJ: Theory #1
TOP: Legal Standards KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30. The Occupational Safety and Health Act includes all of the following, except: a. regulations for handling infectious materials. b. radiation and electrical equipment safeguards. c. staffing ratios and delegation criteria. d. regulations for handling toxic materials.
ANS: C
The Occupational Safety and Health Act was passed in 1970 to improve the work environment in areas that affect workers‘ health or safety. It includes regulations for handling infectious or toxic materials, radiation safeguards, and the use of electrical equipment.
DIF: Cognitive Level: Comprehension REF: p. 34
TOP: OSHA KEY: Nursing Process Step: N/A
OBJ: N/A
MSC: NCLEX: N/A
31. The most frequently cited cause of a sentinel event by the Joint Commission is a problem in: a. applying physical restraints. b. methods of patient transportation. c. medication errors. d. inadequate communication.
ANS: D
NURSINGTB.COM
The most frequently cited cause of a sentinel event by the Joint Commission is communication. During ―handoff‖ communication, there is a risk that critical patient care information might be lost due to lack of communication.
DIF: Cognitive Level: Knowledge REF: p. 35
OBJ: Clinical Practice #2
TOP: Communication KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
32. The acronym SBAR is a method to communicate with a primary care provider that clarifies a situation that may result in litigation. The acronym stands for: a. situation, background, alterations, results. b. subjective, believable, actual, recommendation. c. situation, background, assessment, recommendation. d. situation, basis, assessment, recommendation.
ANS: C
SBAR is an acronym that stands for situation, background, assessment, and recommendation. This undetailed analysis clarifies the situation in a manner that is concise yet complete.
DIF: Cognitive Level: Knowledge REF: p. 35
OBJ: Theory #5
TOP: SBAR Reporting KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
33. The patient who cannot legally sign his or her own surgical consent is: a. a 17-year-old who is serving in the armed forces. b. a 16-year-old who is legally married. c. a 17-year-old emancipated minor. d. an 18-year-old who received a narcotic 30 minutes ago.
ANS: D
The person giving the consent must be able to take part in the decision making. A sedated person does not have this ability.
DIF: Cognitive Level: Application REF: p. 38
OBJ: Clinical Practice #3
TOP: Patient Rights KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
34. The nurse who may be liable for invasion of privacy would be the nurse who is: a. refusing to give patient information to a relative over the phone. b. firmly closing the door prior to bathing the patient. c. discussing her patients with a fellow nurse. d. reporting the patient as a possible victim of elder abuse.
ANS: C
Discussing a patient with anyone, even another health professional, who is not involved in the patient‘s care can put a nurse at risk for invasion of privacy.
DIF: Cognitive Level: Application REF: p. 38
OBJ: Clinical Practice #3
TOP: Patient Rights KEY: Nursing Process Step: Implementation
MSC: NCLEX: N/A
NURSINGTB.COM
35. A characteristic of an advance directive is that: a. advance directives do not expire. b. only some states recognize advance directives. c. advance directives can be nonverbal. d. advance directives from one state are recognized by another.
ANS: A
An advance directive is a written statement expressing the wishes of the patient regarding future consent for or refusal of treatment if the patient is incapable of participating in decision making, and they do not expire. All states recognize advance directives, but each state regulates advance directives differently, and an advance directive from one state may not be recognized in another.
DIF: Cognitive Level: Comprehension REF: p. 38 OBJ: Clinical Practice #5
TOP: Advance Directives KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
36. A patient who is refusing to take his medication is threatened that he will be held down and forced to take the dose. This is an example of: a. battery. b. defamation. c. assault. d. invasion of privacy.
ANS: C
Assault is the threat to harm another or even to touch another without that person‘s permission. The person being threatened must believe that the nurse has the ability to carry out the threat.
DIF: Cognitive Level: Comprehension REF: p. 40
TOP: Legal Terms KEY: Nursing Process Step: N/A
OBJ: Theory #3
MSC: NCLEX: N/A
37. The nurse explains that a sentinel event is a situation in which a patient: a. refuses care. b. is accidentally exposed. c. leaves the hospital against medical advice. d. comes to harm.
ANS: D
A sentinel event is an unexpected situation in which the patient comes to harm.
DIF: Cognitive Level: Comprehension REF: p. 35
TOP: Legal Terms KEY: Nursing Process Step: N/A
Multiple Response
1. Professional accountability includes: (Select all that apply.)
a. understanding theory.
b. adhering to the dress code of the facility.
OBJ: Theory #5
MSC: NCLEX: N/A c. asking for assistance when unsure of a procedure or primary care provider order. d. participating in continuing eduNcU aR tiS oInNcGlTasBsC esO . M e. meeting the health care needs of the patient. f. reporting patient health status changes to all family members.
ANS: A, C, D, E
Professional accountability is a nurse‘s responsibility to meet the health care needs of the patient in a safe and caring application of nursing skills and understanding of human needs.
DIF: Cognitive Level: Analysis REF: p. 33
OBJ: Theory #3
TOP: Professional Accountability KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A a. Using two magazines and a bandana to splint a broken arm b. Applying a tourniquet to a lacerated leg while awaiting emergency personnel c. Pulling the individual from the surface of the highway d. Initiating an emergency tracheotomy when the individual goes into respiratory arrest e. Compressing a bleeding wound with a soiled shirt
2. A nurse arrives at the scene of a motor vehicle accident. A person in the vehicle mumbles incoherently when asked his name. Which actions are not covered by the Good Samaritan Law? (Select all that apply.)
ANS: D
The Good Samaritan Law covers care given in an emergency, but only within the scope of one‘s practice, and care that does not cause harm resulting from negligence.
DIF: Cognitive Level: Comprehension REF: p. 35
OBJ: Theory #5
TOP: Legal Scope of Practice KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment a. develop policies. b. address issues in their facility. c. modify the established codes of ethics as suits the situation. d. create a master plan for decision making to be followed in ethical dilemmas. e. help to find a better understanding of ethical dilemmas from different standpoints.
3. The Ethics Committee of a facility has the responsibility to: (Select all that apply.)
ANS: A, B, E
An Ethics Committee of an institution has representatives from various fields to formulate, address, and help clarify ethical problems that present themselves in their facility.
DIF: Cognitive Level: Comprehension REF: p. 45
TOP: Ethics KEY: Nursing Process Step: N/A
OBJ: Theory #6
MSC: NCLEX: N/A a. commitment to continuing education. b. respect for human dignity. c. maintenance of competence. d. requirement for membership in a national organization. e. preserving the confidentiality of the nurse-patient relationship. NURSINGTB.COM
4. The commonalities of The Codes of Ethics of the National Association for Practical Education and Service (NAPNES) and The National Federation of Licensed Practical Nurses (NFLPN) include: (Select all that apply.)
ANS: A, B, C, E
Both Codes of Ethics support maintenance of competency, preservation of confidentiality of the nurse patient relationship, commitment to continuing education, and respect for human dignity.
DIF: Cognitive Level: Application REF: p. 43
TOP: Ethics KEY: Nursing Process Step: N/A
Completion
OBJ: Theory #6
MSC: NCLEX: N/A
1. In 2003, the Patients‘ Bill of Rights was revised to become the : Understanding Expectations, Rights, and Responsibilities.
ANS: Patient Care Partnership
The Patient Care Partnership addresses patient rights and the responsibility of health care facilities.
DIF: Cognitive Level: Knowledge REF: p. 33
OBJ: Clinical Practice #3
TOP: Patient Rights KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. CAPTA, passed in 1973, is a law regarding the safety of minors. It is the and
ANS: Child Abuse Prevention; Treatment Act
This is a law that requires mandated reporting and defines who is a mandated reporter.
DIF: Cognitive Level: Knowledge REF: p. 34 OBJ: Theory #1
TOP: Professional Accountability KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
NURSINGTB.COM
Chapter 04: The Nursing Process and Critical Thinking
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition
Multiple Choice
1. The nurse who uses the nursing process will: a. help reduce the obvious signs of discomfort. b. help the patient adhere to the primary care provider‘s treatment protocol. c. approach the patient‘s disorder in a step-by-step method. d. make all significant nursing care decisions involving patient care.
ANS: C
The nursing process is a collaborative process used throughout the patient‘s stay. It is an organized method for identifying and meeting patient needs in a step-by-step manner.
DIF: Cognitive Level: Knowledge REF: p. 48 OBJ: Theory #1
TOP: Nursing Process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. A nurse will arrive at a nursing diagnosis through the nursing process step of: a. planning. b. evaluation. c. research. d. assessment.
ANS: D
As a result of the nursing assessmNenUtR , S aINnuGrT sB in.C gOdMiagnosis is established.
DIF: Cognitive Level: Comprehension REF: p. 50|Table 4-2
OBJ: Theory #2 TOP: Nursing Diagnosis KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is to: a. collect data of health status. b. select a nursing diagnosis. c. organize data to help the RN evaluate patient progress. d. prioritize nursing diagnoses for more effective care.
ANS: A
The LPN/LVN collects data of the patient‘s health status to assist the RN in selecting a nursing diagnosis.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #2 TOP: Critical Thinking KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
4. The participants of the planning stage of the nursing process during which the health goals are defined include: a. the RN. b. the health team led by the RN. https://www.coursehero.com/file/62123929/c4pdf/ c. the health team, the patient, and the patient‘s family. d. the health team as directed by the physician.
ANS: C
The planning stage during which the health goals are defined are best shared by the entire health team, the patient, and the patient‘s family for the optimum outcome.
DIF: Cognitive Level: Comprehension REF: p. 48 OBJ: Theory #1
TOP: Nursing Process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
5. When a resident in the nursing home complains of constipation, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an example of: a. implementation. b. nursing diagnosis. c. assessment. d. evaluation.
ANS: C
The examination to confirm and affirm the complaint of constipation is an assessment.
DIF: Cognitive Level: Application REF: p. 48|Table 4-1
OBJ: Theory #1 TOP: Nursing Process
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. The nurse completing morning assessments on a patient who is sitting up in bed is told by the patient, ―I‘m having trouble breath to get enough air.‖ The best nursing response is to: a. notify the doctor as soon as he or she comes in later in the morning. b. finish the vital signs for the assigned patients, and then notify the charge nurse. c. reassure the patient, if his blood pressure and pulse are normal. d. notify the charge nurse immediately of the patient‘s statement.
ANS: B
The nurse should finish the assessment in order to confirm the complaint and inform the charge nurse.
DIF: Cognitive Level: Analysis REF: p. 50|Table 4-2
OBJ: Theory #1 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. The order in which the nursing process is approached is: a. planning, assessment, implementation, nursing diagnosis, evaluation. b. nursing diagnosis, evaluation, assessment, implementation, planning. c. assessment, nursing diagnosis, planning, implementation, evaluation. d. evaluation, nursing diagnosis, planning, implementation, assessment.
ANS: C
The order of assessment nursing diagnosis, planning, implementation, and evaluation sets up a basis for an organized approach to nursing care.
DIF: Cognitive Level: Knowledge REF: p. 49|Box 4-1 https://www.coursehero.com/file/62123929/c4pdf/
OBJ: Theory #1 TOP: Nursing Process
MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A
8. Once the nursing plan has been initiated, the nursing care plan will: a. stay in place until all nursing goals have been met. b. change as the patient‘s condition changes. c. remain on the patient record to show progress. d. be given to the patient for final approval.
ANS: B
The nursing care plan is always a work in progress and will change as the patient condition changes.
DIF: Cognitive Level: Comprehension REF: p. 50
OBJ: Theory #2
TOP: Nursing Process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
9. When a patient states, ―I can‘t walk very well,‖ the first problem-solving step would be to: a. consider alternatives such as a wheelchair or walker. b. find out what the problem is, such as weakness or poor balance. c. choose the alternative with the best chance of success. d. consider the outcomes of the choices, such as danger of falling with a walker.
ANS: B
Defining the problem clearly assists in the interventions to reduce the problem.
DIF: Cognitive Level: Analysis REF: p. 50 OBJ: Theory #5
TOP: Problem Solving NURSINKGETY B: .CN OMursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
10. A student nurse can begin to develop critical thinking skills by means of: a. working with a more experienced nurse. b. questioning every statement made by instructors to be sure of its correctness. c. memorizing class notes for tests and studying all night for big tests. d. listening attentively and focusing on the speaker‘s words and meaning.
ANS: D
Critical thinking involves foundation skills such as effective reading and writing and attentive listening.
DIF: Cognitive Level: Comprehension REF: p. 50 OBJ: Theory #7
TOP: Critical Thinking KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
11. When a nurse prioritizes the patient care, consideration is given to: a. completing assessments before mid-shift. b. considering situations that may result in an alteration of health. c. assuming all health care activities for a group of patients. d. identifying who can assist with the aspect of care.
ANS: B https://www.coursehero.com/file/62123929/c4pdf/
Priority setting includes addressing health endangering situations and physiological needs first.
DIF: Cognitive Level: Comprehension REF: p. 53 OBJ: Theory #9
TOP: Priority Setting KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
12. When the nurse checks to see whether a patient has had relief 45 minutes after administering pain medication, the nurse is performing a(n): a. nursing diagnosis. b. implementation. c. assessment. d. evaluation.
ANS: D
Evaluation is the step in which the nurse determines whether the plan and interventions are effective or need to be modified.
DIF: Cognitive Level: Comprehension REF: p. 49|Box 4-1
OBJ: Theory #2 TOP: Nursing Process
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
13. The activity that is an implementation in the nursing care is: a. checking the assigned patient‘s blood pressure, pulse, and respiration. b. changing the patient‘s surgical dressing. c. asking the patient to demonstrate how to give himself medication after teaching him. d. discussing the patient with other team members to establish a care plan. NURSINGTB.COM
ANS: B
Changing a dressing that is soiled is a nursing intervention performed to meet a patient‘s need. Checking vital signs is assessment. Demonstrating medication administration is evaluation. Discussing the patient with other team members is planning.
DIF: Cognitive Level: Comprehension REF: p. 49|Box 4-1
OBJ: Theory #2 TOP: Implementation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
14. Constant nursing assessments and evaluations of the patient will most likely result in: a. the nursing care plan changing to reflect appropriate priorities. b. small changes in the patient condition being overlooked. c. cluttered and confusing documentation. d. impeded problem solving.
ANS: A
Continued assessment and evaluation are necessary; reprioritizing and reorganizing activities occur in response to the patient‘s changing condition.
DIF: Cognitive Level: Application REF: p. 50 OBJ: Theory #1
TOP: Nursing Process KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A https://www.coursehero.com/file/62123929/c4pdf/
15. The effect of using a scientific problem-solving approach in nursing care will cause decision making to be: a. slowed down considerably by the multiple steps. b. rigid and nonpatient oriented. c. improved nursing care outcomes. d. unrelated to the nursing process.
ANS: C
A scientific problem-solving approach is most likely to result in positive patient outcomes.
DIF: Cognitive Level: Comprehension REF: p. 50
OBJ: Theory #3
TOP: Problem Solving KEY: Nursing Process Step: Planning
MSC: NCLEX: N/A
16. An emergency room nurse will give first priority to the patient with the most critical need, which is the patient who: a. is bleeding from a chin laceration. b. complains of a productive cough. c. has a fever of 102F. d. complains of severe chest pain.
ANS: D
Because the chance of a bad outcome is highest for the patient with chest pain, it is most appropriate to assess this patient first.
DIF: Cognitive Level: Analysis REF: p. 53
OBJ: Theory #8
TOP: Critical Thinking KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
Multiple Response
NURSINGTB.COM a. documentation of care given. b. assembly of supplies. c. analysis of data gathered. d. modification of aspects of the plan. e. evaluation of the patient response.
1. Activities considered to be aspects of the implementation step of the nursing process are: (Select all that apply.)
ANS: A, B
Documentation of care and assembly of supplies are nursing interventions performed during the implementation step of the nursing process.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #2 TOP: Nursing Process
MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A a. determination of potential health problems. b. clustering of related assessments. https://www.coursehero.com/file/62123929/c4pdf/ c. sharing of information with the patient and physician. d. determination of desired outcomes. e. evaluation of probable outcomes.
2. Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select all that apply.)
ANS: A, B
During the nursing diagnosis step, assessment data are analyzed and clustered to determine health problems, and appropriate nursing diagnoses are selected.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #1 TOP: Nursing Process
MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A a. Collect data. b. Perform nursing interventions. c. Initiate the plan of care. d. Assist the RN with evaluation of the patient‘s response to nursing interventions. e. Document nursing care.
3. Which of the following items could be the responsibility of the LPN/LVN for a patient‘s plan of care? (Select all that apply.)
ANS: A, B, D
Registered nurses are officially responsible for the initiation of nursing care plans for each patient, but the LPN/LVN assists with each part of the care plan. The LPN/LVN is often responsible for data collection to assist the RN with the assessment phase.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #2 TOP: Nursing Process
MSC: NCLEX: N/A
Completion
NURSINGTB.COM
KEY: Nursing Process Step: N/A
1. When the nurse constructs a nursing approach after careful judgment and sound reasoning, the nurse has used a system of
ANS: critical thinking
Critical thinking is a concept in which decisions are made using solidly based judgments and reasoning.
DIF: Cognitive Level: Knowledge REF: p. 50 OBJ: Theory #2
TOP: Critical Thinking KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. Clinical thinking is considered to be the keystone and foundation of the development of
ANS: clinical judgment https://www.coursehero.com/file/62123929/c4pdf/
Clinical judgment is built on the ability to think critically.
DIF: Cognitive Level: Knowledge REF: p. 50 OBJ: Theory #2
TOP: Critical Thinking KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. The tasks of synthesizing data and linking nursing interventions with patient health problems are enhanced by the process of
ANS: concept mapping
Concept mapping is a method to promote critical thinking by visualizing relationships between patient health problems and effective intervention.
DIF: Cognitive Level: Knowledge REF: p. 51 OBJ: Theory #3
TOP: Concept Mapping KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
Ordering
1. A nurse begins rounds on a medical-surgical nursing unit. Review the following patients on her assignment. Prioritize the order in which the patients should be assessed, based on their descriptions.
a. A 22-year-old patient who is awakening from neck surgery.
b. An 82-year-old patient who is blind and needs discharge instructions.
c. A 44-year-old patient with dehydration from vomiting and diarrhea, who was admitted 3 days ago and who has an IV infusNioUnRoSfINflGuTidBs .. COM d. A 35-year-old patient admitted for an injury to his left femoral artery, which required surgical repair 8 hours ago following an ice skating accident.
ANS: A, D, C, B
Nursing priorities need to address patients with life-threatening concerns first. A patient just awakening from neck surgery needs to be assessed first because of the concerns of tracheal swelling. A patient with a compromised limb is the next priority. The patient on IV fluids for dehydration is next. The patient for discharge is the last priority.
DIF: Cognitive Level: Analysis REF: p. 53 OBJ: Theory #9
TOP: Prioritizing KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. Place the steps of the problem-solving approach in the appropriate order: a. Predict the likelihood of each outcome occurring. b. Choose the alternative with the best chance of success. c. Consider all possible alternatives as the solution to the problem. d. Identify the problem. e. Examine possible outcomes of each alternative.
ANS: https://www.coursehero.com/file/62123929/c4pdf/
