TEST BANK for Fundamental Concepts and Skills for Nursing 6th Edition by Patricia A. Williams RN MSN by digitaldownload87

Chapter 01: Nursing and the Health Care System Williams: Fundamental Concepts and Skills for Nursing, 6th Edition MULTIPLE CHOICE 1. Florence Nightingale’s contributions to nursing practice and education: a. are historically important but have no validity for nursing today. b. were neither recognized nor appreciated in her own time. c. were a major factor in reducing the death rate in the Crimean War. d. were limited only to the care of severe traumatic wounds. ANS: C By improving sanitation, nutrition ventilation, and handwashing techniques, Florence Nightingale’s nurses dramatically reduced the death rate from injuries in the Crimean War. DIF: Cognitive Level: Knowledge TOP: Nursing History MSC: NCLEX: N/A

REF: p. 2 OBJ: Theory #1 KEY: Nursing Process Step: N/A

2. Early nursing education and care in the United States: a. were directed at community health. b. provided independence for women through education and employment. c. were an educational model based in institutions of higher learning. d. have continued to be entirely focused on hospital nursing. ANS: B Because of the influence of early nursing leaders, nursing education became more formalized through apprenticeships in Nightingale schools that offered independence to women through education and employment. DIF: Cognitive Level: Knowledge TOP: Nursing History MSC: NCLEX: N/A

REF: p. 2 OBJ: Theory #4 KEY: Nursing Process Step: N/A

3. In order to fulfill the common goals defined by nursing theorists (promote wellness, prevent illness, facilitate coping, and restore health), the LPN must take on the roles of: a. caregiver, educator, and collaborator. b. nursing assistant, delegator, and environmental specialist. c. medication dispenser, collaborator, and transporter. d. dietitian, manager, and housekeeper. ANS: A In order for the LPN to apply the common goals of nursing, he or she must assume the roles of caregiver, educator, collaborator, manager, and advocate. DIF: Cognitive Level: Comprehension TOP: Art and Science of Nursing MSC: NCLEX: N/A

REF: p. 3 OBJ: Theory #2 KEY: Nursing Process Step: N/A

4. Although nursing theories differ in their attempts to define nursing, all of them base their beliefs on common concepts concerning: a. self-actualization, fundamental needs, and belonging. b. stress reduction, self-care, and a systems model. c. curative care, restorative care, and terminal care. d. human relationships, the environment, and health. ANS: D Although nursing theories differ, they all base their beliefs on human relationships, the environment, and health. DIF: Cognitive Level: Comprehension TOP: Nursing Theories MSC: NCLEX: N/A

REF: p. 4 OBJ: Theory #2 KEY: Nursing Process Step: N/A

5. Standards of care for the nursing practice of the LPN are established by the: a. Boards of Nursing Examiners in each state. b. National Council of States Boards of Nursing (NCSBN). c. American Nurses Association (ANA). d. National Association of Licensed Practical Nurses. ANS: D The practical nurse follows standards written by the National Association of Licensed Practical Nurses to deliver safe, knowledgeable nursing care (Box 1.1, Appendix D) DIF: Cognitive Level: Comprehension TOP: Standards of Care MSC: NCLEX: N/A

REF: p. 6 OBJ: Theory #2 KEY: Nursing Process Step: N/A

6. The LPN demonstrates an evidence-based practice by: a. using a drug manual to check compatibility of drugs. b. using scientific information to guide decision making. c. using medical history of a patient to direct nursing interventions. d. basing nursing care on advice from an experienced nurse. ANS: B The use of scientific information from high-quality research to guide nursing decisions is reflective of the application of evidence-based practice. DIF: Cognitive Level: Knowledge TOP: Evidence-Based Practice MSC: NCLEX: N/A

REF: p. 4 OBJ: Theory #3 KEY: Nursing Process Step: N/A

7. Lillian Wald and Mary Brewster established the Henry Street Settlement Service in New York in 1893 in order to: a. offer a shelter to injured war veterans. b. found a nursing apprenticeship. c. provide health care to poor persons living in tenements. d. offer better housing to low-income families. ANS: C Henry Street Settlement Service brought the provision of community health care to the poor people living in tenements. DIF: Cognitive Level: Comprehension TOP: Growth of Nursing MSC: NCLEX: N/A

REF: p. 2 OBJ: Theory #4 KEY: Nursing Process Step: N/A

8. An educational pathway for an LPN/LVN refers to an LPN/LVN: a. learning on the job and being promoted to a higher level of responsibility. b. moving from a maternity unit to a more complicated surgical unit. c. obtaining additional education to move from one level of nursing to another. d. learning that advancement requires consistent work and commitment. ANS: C By broadening the educational base, an LPN/LVN may advance and build a nursing career. DIF: Cognitive Level: Knowledge TOP: Nursing Education Pathways MSC: NCLEX: N/A

REF: p. 7 OBJ: Theory #7 KEY: Nursing Process Step: N/A

9. When diagnosis-related groups (DRGs) were established by Medicare in 1983, the purpose was to: a. put patients with the same diagnosis on the same unit. b. attempt to contain the costs of health care. c. increase the availability of medical care to older adults. d. identify a patient’s condition more quickly. ANS: B The purpose of instituting DRGs was to contain skyrocketing costs of health care. DIF: Cognitive Level: Knowledge TOP: Health Care Delivery MSC: NCLEX: N/A

REF: p. 10 OBJ: Theory #10 KEY: Nursing Process Step: N/A

10. The advent of diagnosis-related groups (DRGs) required that nurses working in health care agencies: a. record supportive documentation to confirm a patient’s need for care in order to qualify for reimbursement. b. use the DRG rather than their own observations for patient assessment. c. be aware of the specific drugs related to the diagnosis. d. acquire cross-training to make staffing more flexible. ANS: A DRGs required that nurses provide more supportive documentation of their assessments and identified patient’s needs to qualify the facility for Medicare reimbursement. Observant assessment might also indicate another DRG classification and consequently more reimbursement for the facility. DIF: Cognitive Level: Comprehension TOP: Managed Care MSC: NCLEX: N/A

REF: p. 10 OBJ: Theory #10 KEY: Nursing Process Step: N/A

11. If a member of a health maintenance organization (HMO) is having respiratory problems such as fever, cough, and fatigue for several days and wants to see a specialist, the person is required to go: a. directly to an emergency room for treatment. b. to any general practitioner of choice. c. directly to a respiratory specialist. d. to a primary care provider for a referral. ANS: D Participants in an HMO must see their primary provider to receive a referral for a specialist in order for the HMO to pay for the care. DIF: Cognitive Level: Comprehension TOP: Managed Care MSC: NCLEX: N/A

REF: p. 10 OBJ: Theory #11 KEY: Nursing Process Step: N/A

12. An advantage of preferred provider organizations (PPOs) is that: a. they make insurance coverage of employees less expensive to employers. b. there are fewer physicians to choose from than in an HMO. c. long-term relationships with physicians are more likely. d. patients may go directly to a specialist for care. ANS: A The use of PPOs allows insurance companies to keep their premiums low and in turn makes insurance coverage less expensive for the employers. There are usually more physicians from which to choose than from an HMO, but long-term relationships between physician and patient cannot be established easily. Patients still must see their primary physician before being referred to other specialties. DIF: Cognitive Level: Knowledge TOP: Preferred Provider Organizations MSC: NCLEX: N/A

REF: p. 11 OBJ: Theory #11 KEY: Nursing Process Step: N/A

13. After passing the National Council Licensure Examination for Practical Nurses (NCLEX PN), the nurse is qualified to take an additional certification in the field of: a. pharmacology. b. care of infants and children. c. operating room technology. d. community health. ANS: A After becoming an LPN, the nurse may apply for additional certification in pharmacology, long-term care, and/or IV therapy. DIF: Cognitive Level: Knowledge TOP: Educational Opportunities MSC: NCLEX: N/A

REF: p. 7 OBJ: Theory #6 KEY: Nursing Process Step: N/A

14. Nursing interventions are best defined as activities that: a. are taken to improve the patient’s health. b. involve researching methods to maintain asepsis. c. include the family in nursing care. d. review guidelines for handling infectious wastes. ANS: A Interventions are actions taken to improve, maintain, or restore health. DIF: Cognitive Level: Comprehension REF: p. 3 OBJ: Theory #2 TOP: Art and Science of Nursing KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. Nurse Practice Acts define the legal scope of an LPN’s practice, which are written and enforced by: a. American Nurses Association. b. National Council Licensure Examiners. c. each state. d. each health care agency. ANS: C Each state writes and enforces the Nurse Practice Act, which defines the legal scope of nursing practice. DIF: Cognitive Level: Comprehension TOP: Nurse Practice Act MSC: NCLEX: N/A

REF: p. 6 OBJ: Theory #3 KEY: Nursing Process Step: N/A

16. Women volunteers were organized to give nursing care to the wounded soldiers during the Civil War by: a. Florence Nightingale. b. Dorothea Dix. c. Clara Barton. d. Lillian Wald. ANS: B The Union government appointed Dorothea Dix, a social worker, to organize women volunteers to provide nursing care for the soldiers during the Civil War. DIF: Cognitive Level: Knowledge TOP: Nursing History MSC: NCLEX: N/A

REF: p. 2 OBJ: Theory #4 KEY: Nursing Process Step: N/A

17. The nursing theory presented by Sister Calista Roy is based on: a. reduction of stress. b. achievement of maximum level of wellness. c. relief of self-care deficit. d. adaptation modes. ANS: D Adaptation modes (physiological, psychological, sociological, and independence) are the basis of the nursing theory of Sister Calista Roy. DIF: Cognitive Level: Knowledge REF: p. 5|Table 1-1 OBJ: Theory #2 TOP: Nursing Theories KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 18. The founding of the Red Cross is attributed to: a. Lillian Wald. b. Dorothea Dix. c. Florence Nightingale. d. Clara Barton. ANS: D Clara Barton founded the Red Cross. DIF: Cognitive Level: Knowledge TOP: Nursing History MSC: NCLEX: N/A

REF: p. 2 OBJ: Theory #4 KEY: Nursing Process Step: N/A

19. The nursing theorist whose practice framework is based on 14 fundamental needs is: a. Dorothy Johnson. b. Jean Watson. c. Virginia Henderson. d. Martha Rogers. ANS: C Virginia Henderson’s nursing theory framework is based on 14 fundamental needs. DIF: Cognitive Level: Knowledge REF: p. 5|Table 1-1 OBJ: Theory #2 TOP: Nursing Theories KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. The nursing theory that uses seven behavioral subsystems in an adaptation model is: a. Betty Neumann. b. Sister Calista Roy. c. Dorothy Johnson. d. Patricia Benner. ANS: C Dorothy Johnson’s practice framework is based on seven behavioral subsystems in an adaptation model. DIF: Cognitive Level: Knowledge REF: p. 5|Table 1-1 OBJ: Theory #2 TOP: Nursing Theories KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. The Standards of Nursing Practice are designed to direct LPNs to: a. advance their nursing career. b. seek a scientific basis for their interventions. c. deliver safe, knowledgeable care. d. a leadership role. ANS: C The Standards of Nursing Practice are designed to guide the LPN to deliver safe, knowledgeable care. DIF: Cognitive Level: Knowledge REF: p. 6 OBJ: Theory #2 TOP: Nursing Standards KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment

22. A state’s Nurse Practice Act is designed to protect the: a. physician. b. nurse. c. public. d. hospital. ANS: C Nurse Practice Acts are designed to protect the public. DIF: Cognitive Level: Knowledge TOP: Nurse Practice Act MSC: NCLEX: N/A

REF: p. 6 OBJ: Theory #5 KEY: Nursing Process Step: N/A

23. It is appropriate for practical nurses to provide direct patient care to persons in a hospital under the supervision of a: a. medical assistant. b. registered nurse on the unit. c. supervising nurse who is responsible for care on several units. d. more experienced LPN on the unit. ANS: B Practical nurses provide direct patient care under the direct supervision of a registered nurse, physician, or dentist. DIF: Cognitive Level: Knowledge TOP: Scope of Practice MSC: NCLEX: N/A

REF: p. 7 OBJ: Theory #9 KEY: Nursing Process Step: N/A

24. An example of tertiary health care is: a. hospice care. b. restorative care. c. emergency care. d. home health care. ANS: A Tertiary health care includes extended care, chronic disease management, medical homes, in-home personal care, and hospice care. DIF: Cognitive Level: Comprehension REF: p. 11|Box 1-2 OBJ: Theory #8 TOP: Health Care Services KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

25. Which nursing care delivery systems have some nursing schools adopted as the foundation of their education programs? a. Relationship-based care b. Team nursing c. Patient-centered care d. Total patient care ANS: A Relationship-based care appeared in the early 2000s. It emphasizes three critical relationships: (1) the relationship between caregivers and the patients and families they serve; (2) the caregiver’s relationship with him- or herself; and (3) the relationship among health team members (Koloroutis & Abelson, 2017). The motivation behind relationship-based care was to promote a cultural transformation by improving relationships to foster care for the patient. Some schools of nursing have adopted relationship-based care as the foundation of their nursing education curriculum. DIF: Cognitive Level: Knowledge TOP: Delivery of Nursing Care MSC: NCLEX: N/A

REF: p. 9 OBJ: Theory #8 KEY: Nursing Process Step: N/A

26. Which nursing care delivery system has been fully embraced by the nursing community and is identified as one of the seven QSEN competencies? a. Relationship-based care b. Team nursing c. Patient-centered care d. Total patient care ANS: C Patient-centered care has been described since the 1950s, but it came to the forefront in 2001 when the Institute of Medicine (IOM) targeted six areas for improvement in the US health care system, including safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitableness (National Academies of Sciences, Engineering, and Medicine, 2018). Patient-centered care has been fully embraced by the nursing community, and it is identified as one of the seven QSEN competencies (QSEN.org, 2018). DIF: Cognitive Level: Knowledge TOP: Delivery of Nursing Care MSC: NCLEX: N/A

REF: p. 18 OBJ: Theory #8 KEY: Nursing Process Step: N/A

27. Which of the following is considered a positive aspect of the Affordable Care Act? a. A 38-year-old mother is penalized on her taxes for not purchasing health insurance. b. A 42-year-old laborer who has chronic kidney disease is denied insurance coverage. c. Jamie, age 24, cannot continue insurance coverage on his parent’s insurance since he has graduated from college. d. Maria, age 60, is able to obtain health insurance at a rate that is manageable on her income. ANS: D The Patient Protection and Affordable Care Act (the “Affordable Care Act,”) was signed into law in 2010 as was meant to be phased in over several years. It created health insurance exchanges, expanded eligibility for Medicaid, allowed young adults to remain on their parents’ insurance through age 26, and stopped insurance providers from denying coverage for pre-existing conditions. Uninsured people were required to purchase health insurance and were penalized on their income taxes if they did not. Since the Republican administration came to power in 2017, however, many aspects of the Affordable Care Act have either been defunded or repealed. For example, the penalty for not purchasing insurance has been removed, the enrollment period has been cut in half, and “navigators” (people employed to help those looking into buying insurance) have had their funding cut. Fortunately, enrollment hasn’t declined significantly so far, although the current administration has a goal to repeal and replace the Affordable Care Act. As coverage under the Affordable Care Act expanded, the national uninsured rate initially fell from 16% to 11% of people under age 65 (people over age 65 generally have universal coverage by Medicare), although with the weakening of the Affordable Care Act the uninsured rate has gone back up to nearly 16% (Collins 2018). DIF: Cognitive Level: Analysis REF: p. 12 OBJ: Theory #10 TOP: The Patient Protection and Affordable Care Act KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

MULTIPLE RESPONSE 1. Characteristics of primary nursing include: (Select all that apply.) a. elimination of fragmentation of care between shifts. b. evolved in the mid-1950s. c. planning and direction performed by one nurse. d. ancillary workers used to increase productivity. e. the care plan covering the entire day. f. associate nurses taking over care and planning when the primary nurse is off duty. ANS: A, C, D, E, F Primary care reduces fragmentation of care between shifts. Care is planned by one nurse to cover a 24-hour period using ancillary workers to increase the productivity. An associate nurse may take on direction of care in the absence of the primary nurse. DIF: Cognitive Level: Knowledge TOP: Nursing Care Delivery MSC: NCLEX: N/A

REF: p. 9 OBJ: Theory #8 KEY: Nursing Process Step: N/A

2. In 1991, the American Nurses Association (ANA) published the Standards of Nursing Practice. These standards are designed to: (Select all that apply.) a. set standards for safe nursing care delivery. b. define the legal scope of practice. c. state legal requirements for clinical practice. d. protect the nurse, patient, and health care agency. e. regulate the nursing profession. f. define activities in which nurses may engage. ANS: A, D, F The Standards of Nursing Practice generally define activities in which nurses may engage, set standards for nursing care and delivery, and thereby protect the nurse, patient, and health care agency. DIF: Cognitive Level: Knowledge TOP: Nursing Practice MSC: NCLEX: N/A

REF: p. 6|Box 1-1 OBJ: Theory #2 KEY: Nursing Process Step: N/A

3. During the Civil War, nursing schools offered education to women both in England and in the United States. The schools in the United States differed from those in Europe because in US schools: (Select all that apply.) a. students worked without pay. b. the core curriculum was the same. c. instruction was presented by physicians at the bedside. d. the educational focus was on nursing care. e. classes were held separately from the clinical experience. ANS: A, C In the United States, the students staffed the hospital and worked without pay. There were no formal classes; education was achieved through work. There was no set curriculum, and content varied depending on the type of cases present in the hospital. Instruction was done at the bedside by the physician and therefore came from a medical viewpoint. DIF: Cognitive Level: Comprehension TOP: Early Nursing Education MSC: NCLEX: N/A

REF: p. 2 OBJ: Theory #4 KEY: Nursing Process Step: N/A

COMPLETION 1. Preferred provider organizations (PPOs) use ____________ to finance their services and pay the physical cost of the service. ANS: capitated cost The capitated cost is the set fee that is paid to the network for each patient enrolled to finance its services. DIF: Cognitive Level: Knowledge TOP: Capitated Cost MSC: NCLEX: N/A

REF: p. 11 OBJ: Theory #8 KEY: Nursing Process Step: N/A

2. In the United States, the Young Women’s Christian Association (YMCA) in New York opened The ____________ School, the first practical nursing school. ANS: Ballard In 1892, the YMCA opened The Ballard School, a 3-month course in practical nursing that was the first school of practical nursing. DIF: Cognitive Level: Knowledge TOP: Ballard School MSC: NCLEX: N/A

REF: p. 2 OBJ: Theory #4 KEY: Nursing Process Step: N/A

3. Such health services as surgical procedures, restorative care, and home health care would be classified as ________ care. ANS: secondary Surgical procedures, restorative care, and home health are part of the many services classified as secondary care. DIF: Cognitive Level: Comprehension REF: p. 11|Box 1-2 OBJ: Theory #10 TOP: Health Care Services KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

Chapter 02: Concepts of Health, Illness, Stress, and Health Promotion Williams: Fundamental Concepts and Skills for Nursing, 6th 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 OBJ: Theory #1 TOP: Views of Health and Illness KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early 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 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 OBJ: Theory #1 TOP: Classification of Illnesses KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early 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 OBJ: Theory #1 TOP: Classification of Illnesses KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early 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

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 OBJ: Theory #5 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: 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: Comprehension TOP: Holistic Approach to Caring MSC: NCLEX: N/A

REF: p. 18 OBJ: Theory #6 KEY: Nursing Process Step: Assessment

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. 21 OBJ: Theory #7 TOP: Maslow’s Hierarchy of Needs KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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 TOP: Homeostasis MSC: NCLEX: N/A

REF: p. 22 OBJ: Theory #8 KEY: Nursing Process Step: Assessment

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. 24|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. 25|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 as experienced by 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. 23 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 TOP: Views of Health and Illness MSC: NCLEX: N/A

REF: p. 28 OBJ: Theory #1 KEY: Nursing Process Step: 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 body’s resources for 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. 25 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. 19|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. 19|Table 2-1 OBJ: Theory #5 TOP: Cultural Influences KEY: Nursing Process Step: N/A MSC: NCLEX: 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 concerns by socialization. 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. 23 OBJ: Theory #1 TOP: Adaptation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 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 Integrity: Coping and Adaptation

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. 26 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. 26 OBJ: Theory #1 TOP: Tertiary Prevention 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 with an exercise group. ANS: D 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 TOP: Sympathetic Nervous System MSC: NCLEX: N/A

REF: p. 23 OBJ: Theory #11 KEY: Nursing Process Step: N/A

2. The nurse describes behaviors of the transition stage of illness, which are: (Select all that apply.) 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. 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 OBJ: Theory #1 TOP: Stages of Illness KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. Which defines the holistic approach to caring for the sick and promoting wellness? (Select all that apply.) 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 for pain management. e. A change in one aspect of a person’s life may or may not alter the person as a whole. 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 TOP: Holistic Approach MSC: NCLEX: N/A

REF: p. 18 OBJ: Theory #6 KEY: Nursing Process Step: N/A

4. The responses during the alarm stage of the general adaptation syndrome as defined by Hans Selye include: (Select all that apply.) 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. 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

5. The nurse clarifies that a person who is self-actualized would have the characteristics of: (Select all that apply.) 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. 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 OBJ: Theory #7 TOP: Self Actualization 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 The release of endorphins induces a feeling of well-being and tranquility. DIF: Cognitive Level: Knowledge TOP: Views of Health and Illness MSC: NCLEX: N/A

REF: p. 25 OBJ: Theory #11 KEY: Nursing Process Step: 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 TOP: Communication MSC: NCLEX: N/A

REF: p. 21 OBJ: Theory #7 KEY: Nursing Process Step: N/A

Chapter 03: Legal and Ethical Aspects of Nursing Williams: Fundamental Concepts and Skills for Nursing, 6th 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. 33 OBJ: Theory #1 TOP: Practice Regulations for the Student Nurse KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. During an employment interview, the interviewer asks the nurse applicant about HIV status. The nurse applicant can legally respond: 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 OBJ: Clinical Practice #1 KEY: Nursing Process Step: N/A

REF: p. 35 TOP: Discrimination 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 TOP: Criminal Law MSC: NCLEX: N/A

REF: p. 33 OBJ: Theory #2 KEY: Nursing Process Step: N/A

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? 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. 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. 34 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 license revoked or be 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 TOP: Professional Discipline MSC: NCLEX: N/A

REF: p. 34 OBJ: Theory #3 KEY: Nursing Process Step: 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 TOP: Professional Discipline MSC: NCLEX: N/A

REF: p. 34 OBJ: Theory #3 KEY: Nursing Process Step: 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 OBJ: Theory #1 TOP: Practice Regulations for the Student Nurse KEY: Nursing Process Step: N/A MSC: NCLEX: 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 occurrence to the supervisor or the offender’s supervisor is indicated. DIF: Cognitive Level: Application OBJ: Clinical Practice #1 KEY: Nursing Process Step: N/A

REF: p. 36 TOP: Sexual Harassment 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. 40 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 TOP: Legal Documents MSC: NCLEX: N/A

REF: p. 39 OBJ: Theory #5 KEY: Nursing Process Step: 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. 39 OBJ: Clinical Practice #4 TOP: Informed Consent KEY: Nursing 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. 39 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 OBJ: Clinical Practice #5 KEY: Nursing Process Step: N/A

REF: p. 40 TOP: Advance Directives 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 OBJ: Clinical Practice #3 KEY: Nursing Process Step: N/A

REF: p. 40 TOP: DNR MSC: NCLEX: N/A

15. A patient refuses to take his medications or to eat his 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 OBJ: Clinical Practice #3 KEY: Nursing Process Step: N/A

REF: p. 39 TOP: Patient Rights 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 OBJ: Clinical Practice #5 KEY: Nursing Process Step: N/A

REF: p. 41 TOP: Defamation/Slander MSC: NCLEX: 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. 41|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 best course of action 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. 42 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 TOP: Incident Reports MSC: NCLEX: N/A

REF: p. 44 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 TOP: Nursing Ethics MSC: NCLEX: N/A

REF: p. 44 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. rarely change. 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 TOP: Nursing Ethics MSC: NCLEX: N/A

REF: p. 44 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. 43|Box 3-7 OBJ: Theory #5 TOP: Avoiding Lawsuits KEY: Nursing Process Step: N/A MSC: NCLEX: 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 OBJ: Clinical Practice #1 KEY: Nursing Process Step: N/A

REF: p. 38|Box 3-4 TOP: HIPAA MSC: NCLEX: N/A

24. Which of the following could place the nurse in a serious legal situation? 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.” ANS: B Legal and Ethical Considerations Social Media and HIPAA Social media use has increased greatly since the implementation of 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, over social media. 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 (2018) provides guidelines and suggestions for nurses in dealing with social media and nursing practice. DIF: Cognitive Level: Analysis OBJ: Clinical Practice #6 KEY: Nursing Process Step: N/A

REF: p. 38 TOP: Social Media and HIPAA 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. 40 OBJ: Theory #1 TOP: Witnessing Wills and Other Legal Documents KEY: Nursing Process Step: Implementation 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 OBJ: Clinical Practice #3 KEY: Nursing Process Step: N/A

REF: p. 40 TOP: Emancipated Minor 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 is unable to participate in decision making. DIF: Cognitive Level: Knowledge OBJ: Clinical Practice #5 KEY: Nursing Process Step: N/A

REF: p. 40 TOP: Legal Terms 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. 39 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. 39 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 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 OBJ: Clinical Practice #2 KEY: Nursing Process Step: N/A

REF: p. 36 TOP: Communication 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 TOP: SBAR Reporting MSC: NCLEX: N/A

REF: p. 36 OBJ: Theory #5 KEY: Nursing Process Step: 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 OBJ: Clinical Practice #3 KEY: Nursing Process Step: N/A

REF: p. 39 TOP: Patient Rights 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

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 OBJ: Clinical Practice #5 KEY: Nursing Process Step: N/A

REF: p. 40 TOP: Advance Directives 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. 41 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. 36 TOP: Legal Terms KEY: Nursing Process Step: N/A

OBJ: Theory #5 MSC: NCLEX: N/A

MULTIPLE RESPONSE 1. Professional accountability includes: (Select all that apply.) a. understanding theory. b. adhering to the dress code of the facility. c. asking for assistance when unsure of a procedure or primary care provider order. d. participating in continuing education classes. 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 TOP: Professional Accountability MSC: NCLEX: N/A

REF: p. 34 OBJ: Theory #3 KEY: Nursing Process Step: N/A

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.) 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 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. 36 OBJ: Theory #5 TOP: Legal Scope of Practice KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment

3. The Ethics Committee of a facility has the responsibility to: (Select all that apply.) 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. 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. 46 TOP: Ethics KEY: Nursing Process Step: N/A

OBJ: Theory #6 MSC: NCLEX: N/A

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.) 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. 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. 46 TOP: Ethics KEY: Nursing Process Step: N/A

OBJ: Theory #6 MSC: NCLEX: N/A

COMPLETION 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 OBJ: Clinical Practice #3 KEY: Nursing Process Step: N/A

REF: p. 34 TOP: Patient Rights 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 Child Abuse Prevention, Treatment Act Child Abuse Prevention Treatment Act This is a law that requires mandated reporting and defines who is a mandated reporter. DIF: Cognitive Level: Knowledge TOP: Professional Accountability MSC: NCLEX: N/A

REF: p. 35 OBJ: Theory #1 KEY: Nursing Process Step: N/A

Chapter 04: The Nursing Process, Critical Thinking and Clinical Judgment Williams: Fundamental Concepts and Skills for Nursing, 6th 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 TOP: Nursing Process MSC: NCLEX: N/A

REF: p. 49 OBJ: Theory #1 KEY: Nursing Process Step: 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 assessment, a nursing diagnosis is established. DIF: Cognitive Level: Comprehension REF: p. 53|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. 52|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. 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. 51 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. 52|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 breathing—I can’t seem 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. 53|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. 51|Box 4-1 OBJ: Theory #1 TOP: Nursing Process KEY: Nursing Process Step: N/A MSC: NCLEX: 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. 51 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. 52 OBJ: Theory #5 TOP: Problem Solving KEY: Nursing 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. 52 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

Priority setting includes addressing health endangering situations and physiological needs first. DIF: Cognitive Level: Comprehension REF: p. 55 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. 51|Box 4-1 OBJ: Theory #2 TOP: Nursing Process KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort