Test Bank for Basic Nursing Concepts, Skills & Reasoning by Leslie S. Treas, Judith M Wilkinson

TEST BANK FOR BASIC NURSING CONCEPTS SKILLS AND REASONING 1ST EDITION TREAS WILKINSON All chapters complete Question & Answers

Chapter 1. Nursing Past & Present Chapter 1. Nursing Past & Present Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. What is the most influential factor that has shaped the nursing profession?

1) Physicians need for handmaidens 2) Societal need for healthcare outside the home 3) Military demand for nurses in the field 4) Germ theory influence on sanitation ANS: 3 Throughout the centuries, stability of the government has been related to the success of the military to protect or extend its domain. As the survival and wellbeing of soldiers is critical, nurses provided healthcare to the sick and injured at the battle site. The physicians handmaiden was/is a nursing stereotype rather than an influence on nursing. Although there has been need for healthcare outside the home throughout history, this has more influence on the development of hospitals than on nursing; this need provided one more setting for nursing work. Germ theory and sanitation helped to improve healthcare but did not shape nursing.

PTS: 1 DIF: Moderate REF: pp. 910 KEY: Nursing process: N/A Client need: N/A | Cognitive level: Recall ____ 2. Which of the following is an example of an illness prevention activity? Select all that apply.

1) Encouraging the use of a food diary

2) Joining a cancer support group 3) Administering immunization for HPV 4) Teaching a diabetic patient about his diet ANS: 3 Administering immunization for HPV is an example of illness prevention. Although cancer is a disease, it is assumed that a person joining a support group would already have the disease; therefore, this is not disease prevention but treatment. Illness-prevention activities focus on avoiding a specific disease. A food diary is a health-promotion activity. Teaching a diabetic patient about diet is a treatment for diabetes; the patient already has diabetes, so it cannot prevent diabetes.

PTS: 1 DIF: Moderate REF: p. 18; high-level question, not directly stated in text KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Application ____ 3. Which of the following contributions of Florence Nightingale had an immediate impact on improving patients health?

1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) Establishing nursing as a distinct profession

ANS: 1 Improved sanitation (a clean environment) greatly and immediately reduced the rate of infection and mortality in hospitals. The other responses are all activities of Florence Nightingale that improved healthcare or nursing, but the impact is long range, not immediate.

PTS: 1 DIF: Easy REF: V1, p. 3; student must infer from content | V1, p. 10; student must infer from content KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application ____ 4. All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all the others?

1) Thinking and reasoning about the clients care 2) Providing hands-on client care 3) Carrying out physician orders 4) Delegating to assistive personnel ANS: 1 A substantial portion of the nursing role involves using clinical judgment, critical thinking, and problem solving, which directly affect the care the client will actually receive. Providing hands-on care is important; however, clinical judgment, critical thinking, and problem solving are essential to do it successfully. Carrying out physician orders is a small part of a nurses role; it, too, requires nursing assessment, planning, intervention, and evaluation. Many simple nursing tasks are being delegated to nursing assistive personnel; delegation requires careful analysis of patient status and the appropriateness of support personnel to deliver care. Another way to analyze this question is that none of the options of providing hands-on care, carrying out physician orders, and delegating

to assistive personnel is required for the nurse to think and reason about a clients care; so the answer must be 1.

PTS:1DIFifficultREF: p. 11 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis ____ 5. Which statement pertaining to Benners practice model for clinical competence is true?

1) Progression through the stages is constant, with most nurses reaching the proficient stage.

2) Progression through the stages involves continual development of thinking and technical skills.

3) The nurse must have experience in many areas before being considered an expert.

4) The nurses progress through the stages is determined by years of experience and skills.

ANS: 2 Movement through the stages is not constant. Benners model is based on integration of knowledge, technical skill, and intuition in the development of clinical wisdom. The model does not mention experience in many areas. The model does not mention years of experience.

PTS:1DIF:ModerateREF:p. 15 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall ____ 6. Which of the following best explains why it is difficult for the profession to develop a definition of nursing?

1) There are too many different and conflicting images of nurses.

2)

There are constant changes in healthcare and the activities of nurses.

3) There is disagreement among the different nursing organizations.

4) There are different education pathways and levels of practice.

ANS: 2 The conflicting images of nursing make it more important to develop a definition; they may also make it more difficult, but not to the extent that constant change does. Healthcare is constantly changing and with it come changes in where, how, and what nursing care is delivered. Constant changes make it difficult to develop a definition. Although different nursing organizations have different definitions, they are similar in most ways. The different education pathways affect entry into practice, not the definition of nursing.

PTS: 1 DIF: Moderate REF: p. 11; How Is Nursing Defined?

KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis ____ 7. Nurses have the potential to be very influential in shaping healthcare policy. Which of the following factors contributes most to nurses influence?

1) Nurses are the largest health professional group.

2) Nurses have a long history of serving the public.

3) Nurses have achieved some independence from physicians in recent years.

4) Political involvement has helped refute negative images portrayed in the media.

ANS: 1

Nurses are trusted professionals and the largest health professional group. As such, they have political power to effect changes. If nursing were a small group, there would be little potential for power in shaping policies, even if all the other answers were true. Serving the public, while positive, does not necessarily help nurses to be influential in establishing health policy. Independence from physicians, although positive, does not necessarily make nurses influential in establishing healthcare policy. Refuting negative media, although positive, does not necessarily make nurses influential in establishing healthcare policy.

PTS: 1 DIF: Moderate REF: p. 21 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis ____ 8. Nursing was described as a distinct occupation in the sacred books of which faith? 1) Buddhism 2) Christianity 3) Hinduism 4) Judaism ANS: 3 The Vedas, the sacred books of the Hindu faith, described Indian healthcare practices and were the earliest writings of a distinct nursing occupation.

PTS:1DIF:EasyREF:p. 7 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall ____ 9. The American Red Cross was established by 1) Louisa May Alcott

2) Clara Barton 3) Dorothea Dix 4) Harriet Tubman ANS: 2 Clara Barton was an American teacher, nurse, and humanitarian who organized the American Red Cross after the Civil War. Louisa May Alcott was an American novelist who wrote Little Women in 1868. Dorothea Dix was an American activist who acted on behalf of the indigent population with mental illness. She was credited for establishing the first psychiatric institution. Harriet Tubman was an African American abolitionist and Union spy during the Civil War. After escaping captivity, she set up a network of antislavery activists, known as the Underground Railroad.

PTS:1DIF:EasyREF:p. 10 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall ____ 10. Which of the following is the most important reason to develop a definition of nursing?

1) Recruit more informed people into the nursing profession 2) Evaluate the degree of role satisfaction 3) Dispel the stereotypical images of nurses and nursing 4) Differentiate nursing activities from those of other health professionals ANS: 4

Nursing organization leaders think it is important to develop a definition of nursing to bring value and understanding to the profession, differentiate nursing activities from those of other health professionals, and help student nurses understand what is expected of them. A definition of nursing would not be likely to increase the number of informed people recruited into nursing. A definition of nursing would do little to improve the nurses role satisfaction.

Although a definition of nursing might contribute to fighting stereotypes of nursing, other, more powerful influences (e.g., media portrayals) exist to counteract it.

PTS:1DIF:EasyREF:V1, pp. 1113; students must infer from content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall ____ 11. Which of the following provides evidence-based support for the contribution that advanced practice nurses (APNs) make within healthcare?

1) Reduced usage of diagnostics using advanced technology 2) Decreased number of unnecessary visits to the emergency department 3) Improved patient compliance with prescribed treatments 4) Increased usage of complementary alternative therapies ANS: 3 Studies demonstrate that APNs have improved patient outcomes over those of physicians, including increased patient understanding and cooperation with treatments and decreased need for hospitalizations. No well-known, scientific studies support APNs effect on the use of advanced technology. No well-known, scientific studies support APNs effect on the frequency of emergency department visits. No well-known, scientific studies support APNs effect on the use of alternative therapies.

PTS:1DIF:ModerateREF:p. 20

KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall ____ 12. Which of the following is an example of what traditional medicine and complementary and alternative medicine therapies have in common?

1) Both can produce adverse effects in some patients.

2) Both use prescription medications.

3) Both are usually reimbursed by insurance programs.

4) Both are regulated by the FDA. ANS: 1 Both traditional and complementary therapies can produce adverse effects in some patients. Many medications are derived from herbs, but the alternative treatments usually use the herbs, not prescription medication. Insurance programs do not necessarily reimburse alternative treatments, because many are not supported by sound scientific research methodology. Alternative medications are not regulated by the FDA. PTS:1DIF:ModerateREF:p. 20 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall ____ 13. Of the following, the biggest disadvantage of having nursing assistive personnel (NAP) help nurses is that the nurse 1) Must know what aspects of care can legally and safely be delegated to the NAP 2)

May rely too heavily on information gathered by the NAP when making patient care decisions

3) Is removed from many components of direct patient care that have been delegated to the NAP 4) Still maintains responsibility for the patient care given by the NAP ANS: 2 All of the options may be disadvantages to using NAPs, but making decisions based on anothers information is the greatest drawback because of the potential for negatively affecting patient care.

Treatment decisions based on incorrect information may cause harm to the patient.

PTS:1DIFifficultREF:p. 2021; students must conclude from content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Analysis ____ 14. An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration.

Which type of healthcare facility would be most appropriate for him?

1) Acute care facility 2) Ambulatory care facility 3) Extended care facility 4) Assisted living facility ANS: 4 Assisted living facilities are intended for those who are able to perform self-care activities but who require assistance with meals, housekeeping, or medications.

Acute care facilities focus on preventing illnesses and treating acute problems.

These facilities include physicians offices, clinics, and diagnostic centers. Ambulatory care facilities provide outpatient care. Clients live at home or in nonhospital settings and come to the site for care. Ambulatory care facilities include private health and medical offices, clinics, surgery centers, and outpatient therapy centers. Extended care facilities typically provide long-term care, rehabilitation, wound care, and ongoing monitoring of patient conditions.

PTS:1DIF:EasyREF:p. 18; ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, Where is Healthcare Provided?

KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application ____ 15. The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model can you infer that this nurse is following?

1) Functional 2) Primary 3) Case method 4) Team ANS: 3 The nurse is following the case method model of nursing care. In this model, one nurse cares for one patient during a single shift. When the functional nursing model is employed, care is compartmentalized, and each task is assigned to a staff member with the appropriate knowledge and skills. In primary nursing, one nurse plans the care for a group of patients round-the-clock. The primary nurse assesses the patient and develops the plan of care. When he or she is working, he or she provides care for those patients that he or she is responsible for. In his or her absence, the associate nurses deliver care. Although the nurse in this case could possibly be a primary nurse,

there are not enough data to confidently infer that. If the team nursing approach is utilized, a licensed nurse (RN or LVN) is paired with a nursing assistant. The pair is then assigned to a group of patients.

PTS:1DIF:ModerateREF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, What Models of Care Are Used to Provide Nursing Care?

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis ____ 16. Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors affecting healthcare?

1) Social worker 2) Occupational therapist 3) Physicians assistant 4) Technologist ANS: 1 The social worker coordinates services and counsels patients about financial, housing, marital, and family issues affecting healthcare. The occupational therapist helps patients regain function and independence for activities of daily living. Physicians assistants work under the physicians direction to diagnose certain diseases and injuries. Technologists provide a variety of specific functions in hospitals, diagnostic centers, and emergency care. For example, laboratory technologists aid in the diagnosis and treatment of patients by examining blood, urine, tissue, and body fluids. Radiology technologists perform x-rays and other diagnostic testing.

PTS:1DIF:ModerateREF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, What Healthcare Providers Will You Work With?

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension ____ 17. Which type of managed care allows patients the greatest choice of providers, medications, and medical devices?

1) Health maintenance organization 2) Integrated delivery network 3) Preferred provider organization 4) Employment-based private insurance ANS: 3 Preferred provider organizations are a form of managed care that allows the patient a greater choice of providers, medications, and medical devices within the designated list. Health maintenance organizations allow the patient to choose a primary care provider within the organization to coordinate his care. This type of program will only reimburse medical care when the patient has first obtained a referral from the primary provider. Integrated delivery networks combine providers, healthcare facilities, pharmaceuticals, and services into one system, and the patient must remain within the system to receive care. Employment-based private insurance is not a managed care organization.

PTS:1DIF:EasyREF:ESG, Chapter 1, Healthcare Delivery Systems, Expanded Discussion, How Do Healthcare Policy and Reform Efforts Affect Care?

KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis ____ 18. A patient who underwent a total abdominal hysterectomy is assisted out of bed as soon as her vital signs are stable. This intervention is most likely being directed by a

1) Critical pathway 2) Nursing care plan 3) Case manager 4) Traditional care model ANS: 1 This patients care is most likely being directed by a critical pathway. A critical pathway is a multidisciplinary approach to care that sequences interventions over a length of stay for a given case type, such as total abdominal hysterectomy. Using this model, the patient can be assisted out of bed as soon as her vital signs are stable. Using the traditional model, the nurse would have to obtain a physicians order to assist the patient out of bed after surgery. The nursing care plan guides nursing care but cannot specify when the patient can get out of bed postoperatively without a physicians order. When case management is used, care is coordinated by the case manager across the healthcare setting, but the case manager does not direct each care intervention.

PTS:1DIF:ModerateREF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, Issues Related to Healthcare Reform KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application ____ 19. Which member of the healthcare team typically serves as the case manager?

1) Occupational therapist 2) Physician 3)

Physicians assistant 4) Registered nurse ANS: 4 Typically, registered nurses serve as case managers for patients with specific diagnoses. Their role is coordinator of care across the healthcare system. The occupational therapist, physician, and physicians assistant all serve on the healthcare team and take direction from the case manager.

PTS: 1 DIF: Easy REF: ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, What Healthcare Providers Will You Work With?

KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Recall ____ 20. Which of the following is considered a primary care service? 1)

Providing wound care 2) Administering childhood immunizations 3) Providing drug rehabilitation 4) Outpatient hernia repair ANS: 2 Primary care services focus on health promotion and disease prevention; administering childhood immunizations is one such service. Providing wound care and drug rehabilitation are examples of tertiary care services. Outpatient hernia repair surgery is an example of a secondary care service.

PTS:1DIF:ModerateREF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, Categories of Healthcare?

KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application ____ 21. Which of the following nursing activities represent direct care? Choose all that apply.

1) Bathing a patient 2) Administering a medication 3) Documenting an assessment 4) Making work assignments for the shift ANS: 1 B Direct care involves personal interaction between the nurse and clients (e.g., giving medications, dressing a wound, or teaching a client about medicines or care). Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing).

PTS:1DIF:EasyREF:p. 17 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension ____ 22. An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herself yet, and she will require lengthy physical therapy and further monitoring of

her medications and her physical and mental status. To which type of facility should she be transferred?

1) Nursing home 2) Rehabilitation center 3) Outpatient therapy center 4) None of these; she should receive home healthcare ANS: 2 A skilled nursing facility primarily provides skilled nursing care for patients who can be expected to improve with treatment. For example, a patient who no longer needs hospitalization may transfer to a skilled nursing facility to get skilled care until she is able to return home. A nursing home provides custodial care for people, like this patient, who cannot live on their own but who are not sick enough to require hospitalization. It provides a room, custodial care, and opportunity for recreation. This patient cannot ambulate or perform activities of daily living, so outpatient therapy and home care would not be appropriate. PTS:1DIF:ModerateREF:p. 18 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 1. Which of the following are examples of a health-promotion activity? Select all that apply.

1) Helping a client develop a plan for a low-fat, low-cholesterol diet 2)

Disinfecting an abraded knee after a child falls off a bicycle 3) Administering a tetanus vaccination after an injury from a car accident 4) Distributing educational brochures about the benefits of exercise ANS: 1, 4 Health promotion includes strategies that promote positive lifestyle changes.

Disinfecting an abraded knee is a treatment/intervention for an injury.

Administering a vaccination is a disease-prevention and treatment activity.

PTS: 1 DIF: Moderate REF: p. 18; high-level question, not directly stated in text KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Application Matching Match the nursing role listed on the left with the appropriate activity listed on the right. Each activity has only one correct answer.

1) Planning the units staffing schedule 2) Participating on a committee to develop a program to teach schoolchildren proper handwashing 3) Teaching the client about a scheduled test 4) Discussing new medication at a staff meeting 5) Discussing with the physician the clients reasons for not wanting the recommended surgery.

____ 1. Direct care provider ____ 2. Client advocate ____ 3. Manager ____ 4. Change agent 1.ANS:3PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 2.ANS:5PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 3.ANS:1PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application 4.ANS:2PTS:1DIF:Moderate REF:p. 13; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Application Match the event with the appropriate year. Each item has only one correct answer.

1) Nursing programs become affiliated with religious groups 2) Start of public health nursing with the founding of the Henry Street Settlement 3) First formal nursing education in United States 4)

First hospital 5) Establishment of the Army Nursing Service 6) Disassociation of nursing from religious orders 7) Florence Nightingale cared for the soldiers of the Crimean War ____ 5. 1st-century AD ____ 6. 15th to 19th century ____ 7. 1854 ____ 8. 1861 ____ 9. 1873 ____ 10. 1893 5.ANS:4PTS:1DIFifficult REF: pp. 611; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 6.ANS:6PTS:1DIFifficult REF: pp. 611; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 7.ANS:7PTS:1DIFifficult REF: pp. 611; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 8.ANS:5PTS:1DIFifficult

REF: pp. 611; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 9.ANS:3PTS:1DIFifficult REF: pp. 611; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 10.ANS:2PTS:1DIFifficult REF: pp. 611; must recognize examples not provided in content KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall Match the nursing organization with its function in the nursing profession. 1) Responsible for setting and maintaining nursing education standards 2) Developed Code for Nurses and the Standards of Clinical Nursing Practice 3) Responsible for publishing the journal, Image 4) Honor society for nursing 5) Represents nursing and promotes nursing leadership worldwide ____ 11. American Nurses Association (ANA) ____ 12. National Student Nurses Association (NSNA) ____ 13. National League for Nursing (NLN) ____ 14. International Council of Nursing (ICN) ____ 15. Sigma Theta Tau International (STTI)

11. ANS: 2 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 12. ANS: 3 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 13. ANS: 1 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 14. ANS: 5 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall 15. ANS: 4 PTS: 1 DIF: Moderate REF: p. 17 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall True/False Indicate whether the statement is true or false. ____ 1. The nurse caring for a patient undergoing minor surgery as an outpatient provides the same type of care as for a hospitalized patient undergoing the same procedure.

ANS: T The nurse caring for a patient receiving care after outpatient surgery provides the same type of care as with the hospitalized patient. The only difference is that the outpatient spends fewer than 24 hours in the facility.

PTS:1DIF:EasyREF:p. 18; students must draw conclusion from content KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Recall Completion Complete each statement.

1.

____________________ is a health program, administered by the state and funded by

federal and state governments to provide care for low-income people.

ANS:

Medicaid Medicaid is a health program run by the state and funded by the federal and state governments. It is intended to provide preventative and acute healthcare for individuals without ability to pay for services, particularly pregnant women and children.

PTS:1DIF:ModerateREF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, How Is Healthcare Financed?

KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall 2.

____________________ is a federal insurance-type program designed to fund healthcare

for people age 65 years and older, the disabled, and those with endstage renal disease from the high cost of healthcare.

ANS: Medicare Medicare is a federal insurance program created by Title XVIII of Social Security Act of 1965. This Act was designed to protect people age 65 years and older from the high cost of healthcare. In 1972, the program was expanded to cover disabled workers as well as people with end-stage renal disease.

PTS:1DIF:Moderate REF:ESG, Chapter 1, Healthcare Delivery SystemsExpanded Discussion, How Is Healthcare Financed?

KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall

Chapter 2. Critical Thinking & the Nursing Process Chapter 2. Critical Thinking & the Nursing Process Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking 1)

Requires reasoned thought 2) Asks the questions why? or how?

3) Is a hierarchical process 4) Demands specialized thinking skills ANS: 1 The definitions listed in the text as well as definitions in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor hierarchical. That means that the steps involved in critical thinking are not necessarily sequential, where mastery of one step is necessary to proceed to the next. Critical thinking is a purposeful, dynamic, analytic process that contributes to reasoned decisions and sound contextual judgments.

PTS:1DIF:ModerateREF: p. 25; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis ____ 2. A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to 1) Consider all the possible advantages and disadvantages 2) Maintain an open mind about the proposed change 3) Apply the nursing process to the situation 4)

Make a decision based on past experience with documentation ANS: 2 A critical attitude enables the person to think fairly and keep an open mind.

PTS:1DIF:ModerateREF:pp. 26 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Comprehension ____ 3. The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first?

1) Assessment 2) Diagnosis 3) Plan outcomes 4) Plan interventions ANS: 1 Assessment is the first step of the nursing process. The nursing diagnosis is derived from the data gathered during assessment, outcomes from the diagnosis, and interventions from the outcomes.

PTS:1DIF:EasyREF: p. 30-31 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application ____ 4. Which of the following is an example of theoretical knowledge?

1) A nurse uses sterile technique to catheterize a patient.

2) Room air has an oxygen concentration of 21%.

3) Glucose monitoring machines should be calibrated daily.

4) An irregular apical heart rate should be compared with the radial pulse.

ANS: 2 Theoretical knowledge consists of research findings, facts, principles, and theories. The oxygen concentration of room air is a scientific fact. The others are examples of practical knowledgewhat to do and how to do it.

PTS:1DIF:ModerateREF:p. 30; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application ____ 5. Which of the following is an example of practical knowledge? (Assume all are true.)

1) The tricuspid valve is between the right atrium and ventricle of the heart.

2) The pancreas does not produce enough insulin in type 1 diabetes.

3) When assessing the abdomen, you should auscultate before palpating.

4) Research shows pain medication given intravenously acts faster than by other routes.

ANS: 3 Practical knowledge is knowing what to do and how to do it, such as how to do an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), fact (type 1 diabetes), and research (IV pain medication).

PTS:1DIF:ModerateREF:p. 30; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application ____ 6. Which of the following is an example of self-knowledge? The nurse thinks, I know that I 1) Should take the clients apical pulse for 1 minute before giving digoxin 2) Should follow the clients wishes even though it is not what I would want 3) Have religious beliefs that may make it difficult to take care of some clients 4) Need to honor the clients request not to discuss his health concern with the family ANS: 3 Self-knowledge is being aware of your religious and cultural beliefs and values. Taking the pulse is an example of practical knowledge. Following client wishes and honoring client requests are examples of ethical knowledge.

PTS:1DIFifficultREF: p. 30; high-level question, answer not stated verbatim | V1, p. 32; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application ____ 7. Which of the following is the most important reason for nurses to be critical thinkers?

1) Nurses need to follow policies and procedures.

2) Nurses work with other healthcare team members.

3)

Nurses care for clients who have multiple health problems.

4) Nurses have to be flexible and work variable schedules.

ANS: 3 Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do not necessarily require critical thinking.

PTS:1DIF:ModerateREF: p. 26-27; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application ____ 8. The nurse administering pain medication every 4 hours is an example of which aspect of patient care?

1) Assessment data 2) Nursing diagnosis 3) Patient outcome 4) Nursing intervention ANS: 4 Interventions are activities that will help the patient achieve a goal, such as administering painrelieving medication. An example of assessment data might be, Patient reports pain is a 5 on a 1 to 10 scale. The nursing diagnosis would be Pain. The nurse might define the patient outcome in this scenario as, The patient will state the level of pain is less than 4.

PTS:1DIF:ModerateREF:p. 31; high-level question, answer not stated verbatim KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application ____ 9. How does nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is 1) Terminology for the clients disease or injury 2) A part of the clients medical diagnosis 3) The clients presenting signs and symptoms 4) A clients response to a health problem ANS: 4 A nursing diagnosis is the clients response to actual or potential health problems.

PTS:1DIF:ModerateREF: p. 31 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall ____ 10. Which statement about the nursing process is correct?

1) It was developed from the ANA Standards of Care.

2) It is a problem-solving method to guide nursing activities.

3) It is a linear process with separate, distinct steps.

4) It involves care that only the nurse will give.

ANS: 2 The nursing process is a problem-solving process that guides nursing actions. The ANA organizes its Standards of Care around the nursing process, but the process was not developed from the standards. The nursing process is cyclical and involves care the nurses give or delegate to other members of the healthcare team.

PTS:1DIF:EasyREF: p. 31 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall ____ 11. What do critical thinking and the nursing process have in common?

1) They are both linear processes used to guide ones thinking.

2) They are both thinking methods used to solve a problem.

3) They both use specific steps to solve a problem.

4) They both use similar steps to solve a problem.

ANS: 2 Critical thinking and the nursing process are ways of thinking that can be used in problem solving (although critical thinking can be used beyond problemsolving applications). Neither method of thinking is linear. The nursing process has specific steps; critical thinking does not.

PTS:1DIFifficultREF: p. 31 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

____ 12. A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now 1) Analyze the assessment data 2) Consult standards of care 3) Decide which interventions are appropriate 4) Ask the clients perceptions of her health problem ANS: 1 The basis of the nursing diagnosis is the assessment data. Standards of care are referred to when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment.

PTS: 1 DIF: Moderate REF: p. 31 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application ____ 13. The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patients position every 2 hours. In the evaluation phase of the nursing process, which of the following would the nurse do first?

1) Determine whether she has gathered enough assessment data.

2) Judge whether the interventions achieved the stated outcomes.

3)

Follow up to verify that care for the nursing diagnosis was given.

4) Decide whether the nursing diagnosis was accurate for the patients condition.

ANS: 2 The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the nursing process steps and revising the care plan.

PTS:1DIF:ModerateREF: p. 31 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis ____ 14. In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. These activities are best described as 1) Full-spectrum nursing 2) Critical thinking 3) Nursing process 4) Nursing knowledge ANS: 1 Full-spectrum nursing (1) involves the use of critical thinking, nursing knowledge, nursing process, and patient situation. Although the other answers are important for planning and delivering nursing care, they do not reflect all the nurse has demonstrated.

PTS:1DIFifficultREF:pp. 32-33; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Analysis ____ 15. The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient is obese. The nurse has been overweight at one time and works very hard now to maintain a healthy weight. She immediately thinks, I know I tend to feel negatively about obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult that is and be very careful not to be judgmental of this patient. This best illustrates 1) Theoretical knowledge 2) Self-knowledge 3) Using reliable resources 4) Use of the nursing process ANS: 2 Self-knowledge is self-understandingawareness of ones beliefs, values, biases, and so on. That best describes the nurses awareness that her bias can affect her patient care. Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena. Using reliable resources is a critical thinking skill. The nursing process is a problem-solving process consisting of the steps of assessing, diagnosing, planning outcomes, planning interventions, implementing, and evaluating. The nurse has not yet met this patient, so she could not have begun the nursing process.

PTS:1DIFifficultREF:pp. 30; high-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: PHSI | Cognitive level: Comprehension

Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 1. Which aspects of healthcare are affected by a clients culture? Select all that apply.

1) How the clients views healthcare 2) How the client views illness 3) How the client will pay for healthcare services 4) The types of treatments the client will accept 5) When the client will seek healthcare services 6) The environment where the healthcare services are provided 7) The ease of accessibility of healthcare services ANS: 1, 2, 4, 5 Culture affects clients view of health and healthcare. It influences how they will define illness, when they will seek healthcare, and what treatments are acceptable in their culture. How services are paid for is related to economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services.

PTS:1DIF:ModerateREF:p. 27 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall

Matching Match the critical thinking attitude on the left with the appropriate example on the right.

1) Reading the instruction manual of a new glucose monitoring machine 2) Asking for help with a procedure because you have not done it before 3) Obtaining the latest research about a new diagnostic procedure even though the articles are difficult to find 4) Questioning the reason for a new staffing policy 5) Realizing your feelings about alternative medicine may interfere with the careyou give a patient 6) Asking a patients feelings about his cancer diagnosis 7) Questioning your feelings when a patients family requests withholding nutrition for a terminally ill client ____ 1. Independent thinking ____ 2. Intellectual curiosity ____ 3. Intellectual humility ____ 4. Intellectual empathy ____ 5. Intellectual courage ____ 6. Intellectual perseverance 1. ANS: 4 PTS: 1 DIF: Difficult REF: p. 26 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 2. ANS: 1 PTS: 1 DIF: Difficult REF: p. 26 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 3. ANS: 2 PTS: 1 DIF: Difficult REF: p. 26 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 4. ANS: 6 PTS: 1 DIF: Difficult REF: p. 26

KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 5. ANS: 7 PTS: 1 DIF: Difficult REF: p. 26 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application 6. ANS: 3 PTS: 1 DIF: Difficult REF: p. 26 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Application Match the terms from the critical thinking model in your text with the correct example.

1) I wonder if my values about quality of life have affected my thinking.

2) What should I have done differently?

3) I need to talk with the client to make sure the family gave me the correct information.

4) I have been through a situation like this before.

5) There are several interventions that would work in this situation.

6) I need to follow the steps in the procedure manual. ____ 7. Contextual awareness ____ 8. Inquiry ____ 9. Considering alternatives ____ 10. Analyzing assumptions ____ 11. Reflecting skeptically 7.ANS:4PTS:1DIFifficult REF: p. 28-29; High-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 8.ANS:3PTS:1DIFifficult REF: p. 28-29; High-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

9.ANS:5PTS:1DIFifficult REF: p. 28-29; High-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 10.ANS:1PTS:1DIFifficult REF: p. 28-29; High-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis 11.ANS:2PTS:1DIFifficult REF: p. 28-29; High-level question, answer not stated verbatim KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis

Chapter 3. Nursing Process: Assessment Chapter 3. Nursing Process: Assessment Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. What is the role of the Joint Commission in regard to patient assessment?

The Joint Commission 1) States what assessments are collected by individuals with different credentials 2) Regulates the time frames for when assessments should be completed 3) Identifies how data are to be collected and documented 4) Sets standards for what and when to assess the patient ANS: 4

The Joint Commission sets detailed standards regarding what and when to assess but does not address credentials. Nurse practice acts specify what data are collected and by whom. Agency policy may set time frames for when assessments should be done and how they should be documented. Nursing knowledge identifies how data are to be collected.

PTS:1DIF:ModerateREF:p. 39 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall ____ 2. Which of the following is an example of data that should be validated? 1)

The clients weight measures 185 lb at the clinic.

2) The clients liver function test results are elevated.

3) The clients blood pressure is 160/94 mm Hg; he states that that is typical for him. 4) The client states she eats a low-sodium diet and reports eating processed food.

ANS: 4 Validation should be done when the clients statements are inconsistent (processed foods are generally high in sodium). Validation is not necessary for laboratory data when you suspect an error has been made in the results. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale.

PTS:1DIF:ModerateREF: p. 47 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 3. Which of the following examples includes both objective and subjective data?

1) The clients blood pressure is 132/68 and her heart rate is 88.

2)

The clients cholesterol is elevated, and he states he likes fried food.

3) The client states she has trouble sleeping and that she drinks coffee in the evening.

4) The client states he gets frequent headaches and that he takes aspirin for the pain.

ANS: 2 Elevated cholesterol is objective, and states he likes fried food is subjective. Objective data can be observed by someone other than the patient (e.g., from physical assessments or lab and diagnostic tests). Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective. States . . . trouble sleeping and . . . drinks coffee . . . are both subjective. States . . . frequent headaches and . . . takes aspirin . . . are both subjective.

PTS:1DIF:ModerateREF:pp. 40 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis ____ 4. The Joint Commission requires which type of assessment to be performed on all patients?

1) Functional ability 2) Pain 3) Cultural 4) Wellness ANS: 2 The Joint Commission requires that pain and nutrition assessment be performed on all patients.

Other special needs assessments should be performed when cues indicate there are risk factors.

PTS:1DIF:ModerateREF:p. 39 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis ____ 5. Which of the following is an example of an ongoing assessment?

1) Taking the patients temperature 1 hour after giving acetaminophen (Tylenol) 2) Examining the patients mouth at the time she complains of a sore throat 3) Requesting the patient to rate intensity on a pain scale with the first perception of pain 4) Asking the patient in detail how he will return to his normal exercise activities ANS: 1 An ongoing assessment occurs when a previously identified problem is being reassessedfor example, taking an hourly temperature when a patient has a fever. Examining the mouth is a focused assessment to explore the patients complaint of sore throat. Asking for a pain rating is a focused assessment at the first complaint of pain. A detailed interview about exercise is a special needs assessment; there is no way to know if it is initial or ongoing.

PTS:1DIF:ModerateREF: p. 41 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 6. When should the nurse make systematic observations about a patient?

1) When the patient has specific complaints 2) With the first assessment of the shift 3) Each time the nurse gives medications to the patient

4) Each time the nurse interacts with the patient ANS: 4 The nurse should make observations about the patient each time she enters the room or interacts with the patient to gain ongoing data about the patient.

PTS:1DIF:EasyREF:p. 41-42 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application ____ 7. Which of the following is an example of an open-ended question?

1) Have you had surgery before?

2) When was your last menstrual period?

3) What happens when you have a headache?

4) Do you have a family history of heart disease?

ANS: 3 Open-ended questions such as What happens when you have a headache? are broad so as to encourage the patient to elaborate. The questions about surgery, menstrual period, and family history can all be answered with a yes, no, or short, specific answer (a date).

PTS:1DIF:ModerateREF:pp. 45 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application ____ 8. Of the following recommended interviewing techniques, which one is the most basic?

(That is, without that intervention, the others will all be less effective.)

1) Beginning with neutral topics 2) Individualizing your approach 3) Minimizing note taking 4) Using active listening ANS: 4 All are important techniques, but active listening focuses the attention on the patient and lets her know you are trying to understand her needs. The interviewer is more likely to get the patient to open up. Patients will forgive you for most errors in technique, but if they think you are not listening, that can negatively affect your relationship.

PTS:1DIFifficultREF:47 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 9. Which of the following is an example of the most basic motivation in Maslows hierarchy of needs?

1) Experiencing loving relationships 2) Having adequate housing 3) Receiving education 4)

Living in a crime-free neighborhood ANS: 2 The most basic needs are centered on physiological survivalshelter (housing), food, and water. All other options are for higher needs. The order from most basic to highest level is physiologic, safety and security, love and belonging, esteem, and self-actualization. Loving relationships fall under the love and belonging category. Education is a form of self-actualization. Living in a crimefree neighborhood meets the need for safety and security.

PTS:1DIF:ModerateREF:p. 48 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 10. What makes a nursing history different from a medical history?

1) A nursing history focuses on the patients responses to the health problem.

2) The same information is gathered; the difference is in who obtains the information.

3) A nursing history is gathered using a specific format.

4) A medical history collects more in-depth information.

ANS: 1 A medical history focuses on the patients current and past medical/surgical problems. A nursing history focuses on the patients responses to and perception of the illness/injury or health problem, his coping ability, and resources and support. Nursing history formats vary depending on the patient, the agency, and the patients needs. Both nursing and medical histories typically use a specific format. A medical history does not necessarily contain more in-depth information. A nursing history can be in-depth, covering a wide range of topics, including biographical data, reason(s) patient is seeking healthcare, history of present illness, patients perception of health

status and expectations for care, past medical history, use of complementary modalities, and review of functional ability associated with activities of daily living. Other topics might deal with nutrition, psychosocial needs, pain assessment, or other special needs topics.

PTS:1DIF:ModerateREF:pp. 44-45 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension ____ 11. Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies?

1) To determine what type of therapies are acceptable to the client 2) To identify whether the client has a nutrition deficiency 3) To help you to understand cultural and spiritual beliefs 4) To identify potential interaction with prescribed medication and therapies ANS: 4 Herbs and nutritional supplements can interact with prescription medications, and complementary and alternative treatments can interfere with conventional therapies. Physical assessment and laboratory tests are needed to assess a nutritional deficiency. To identify cultural and spiritual beliefs and well as what therapies are acceptable to the client, you need more than just information about nutritional and herbal supplements.

PTS:1DIFifficultREF: p. 45 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Application ____ 12. What do the nursing assessment models have in common?

1)

They assess and cluster data into model categories.

2) They organize assessment data according to body systems.

3) They specify use of the nursing process to collect data.

4) They are based on the ANA Standards of Care.

ANS: 1 All the models categorize or cluster data into functional health patterns, domains, or categories.

None of the assessment models clusters data according to body system. Assessment is the first step of the nursing process; the nurse does not use the entire nursing process in data collection. The ANA Standards of Care describe a competent level of clinical nursing practice based on the nursing process; nursing models are not based on the ANA Standards of Care.

PTS:1DIFifficultREF:pp. 48 KEY: Nursing process: Assessment | Client need: SACE | Cognitive level: Analysis ____ 13. Nondirective interviewing is a useful technique because it 1) Allows the nurse to have control of the interview 2) Is an efficient way to interview a patient 3) Facilitates open communication 4) Helps focus patients who are anxious

ANS: 3 Nondirective interviewing helps build rapport and facilitates open communication. Because it puts the patient in control, it can be very timeconsuming (inefficient) and produce information that is not relevant. Directive interviewing should be used to focus anxious patients.

PTS:1DIF:EasyREF:p. 45 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall ____ 14. A nursing instructor is guiding nursing students on best practices for interviewing patients.

Which of the following comments by a student would indicate the need for further instruction?

1) My patient is a young adult, so I plan to talk to her without her parents in the room.

2) Because my patient is old enough to be my grandfather, I will call him Mr. 3) When reading my patients health record, I thought of a few questions to ask.

4) When I give my patient his pain medication, I will have time to ask questions.

ANS: 4 A patient should be comfortable when interviewing. The pain medication should have time to work before considering interviewing the patient, so asking questions when giving the medication is not a good idea. It is appropriate to interview patients without family/friends around. In nearly every culture, calling a patient Mr. or Mrs. shows respect and is therefore correct. Reading the patients health record is appropriate preparation for an interview.

PTS:1DIF:ModerateREF:p. 46 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application ____ 15. A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform?

1) Comprehensive 2) Ongoing 3) Initial focused 4) Special needs ANS: 3 An initial focused assessment is performed during a first exam for specific abnormal findings. A comprehensive assessment is holistic and is usually done upon admission to a healthcare facility. An ongoing assessment follows up after an initial database is completed or a problem is identified. A special needs assessment is performed when there are cues that more in-depth assessment is needed.

PTS:1DIF:ModerateREF: pp. 4243 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application ____ 16. A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would it be most important to perform?

1) Family 2) Functional 3) Community 4)

Psychosocial ANS: 2 A functional assessment is most important because of discharge needs (e.g., self-care ability at home) and patient safety. A family and community assessment would be helpful to evaluate support systems, and a psychosocial assessment would be helpful to evaluate a patients understanding of and coping with his recent stroke. Remember that special needs assessments are lengthy and time-consuming, so they should be used only when in-depth information is needed about a topic.

PTS:1DIF:ModerateREF:pp. 43 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Analysis ____ 17. The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is highly anxious and cannot seem to focus on what the nurse is saying. Which of the following questions would be best for the nurse to use to begin gathering data about the headaches?

1) When did your migraines begin?

2) Tell me about your family history of migraines.

3) What are the types of things that trigger your headaches?

4) Describe what your headaches feel like.

ANS: 1 For someone who is anxious, it is best to use closed questions. (When did your migraines begin?) A closed question can be answered in one or very few words and has a very specific answer. The other questions are open-ended questions.

PTS:1DIF:ModerateREF:p. 45

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application ____ 18. Which of the following is an example of an active listening behavior?

1) Taking frequent notes 2) Asking for more details 3) Leaning toward the patient 4) Sitting with legs crossed ANS: 3 Active listening behaviors include leaning toward the patient; facing the patient; open, relaxed posture without crossing arms or legs; and maintaining eye contact. Taking frequent notes makes it difficult to keep eye contact. Asking for more details may seem like idle curiosity. Sitting with legs crossed may indicate to the patient that you are not open to her.

PTS:1DIF:EasyREF:p. 47 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension ____ 19. A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching?

1) I find it difficult to avoid using phrases like, The patient tolerated the procedure well.

2) Its confusing to have to remember which abbreviations this hospital allows.

3)

I need to work on charting assessments and interventions right after they are done.

4) My patient was really quiet and didnt say much, so I charted that he acted depressed.

ANS: 4 When charting data, chart only what was observed, not what it meant.

Inferences should not be made about a patients behavior during data collection (he acted depressed); so that response reflects the students lack of knowledge and need for teaching. Chart specific data, not vague phrases; the student is acknowledging the importance of this. There are no universally accepted phrases, just agency-approved abbreviations; the student is acknowledging the need to use agency-approved abbreviations. The student is correct that charting should be completed as soon after data collection as possible.

PTS:1DIF:ModerateREF:p. 50 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application ____ 20. For which of the following purposes is a graphic flow sheet superior to other methods of recording data?

1) Easy documentation of routine vital signs 2) Seeing the patterns of a patients fever 3) Describing the symptoms accompanying a rising temperature 4) Checking to make sure vital signs were taken ANS: 2

All are benefits of the graphic flow sheet, but to easily and graphically see trends over time, the graphic flow sheet is superior to other methods of documentation. For the other options, other kinds of flow sheets would be equally effective.

PTS:1DIF:ModerateREF:p. 50 KEY: Nursing process: N/A | Client need: SECE | Cognitive level: Analysis ____ 21. The most obvious reason for using a framework when assessing a patient is to 1) Prioritize assessment data 2) Organize and cluster data 3) Separate subjective and objective data 4) Identify primary from secondary data ANS: 2 A framework is used to organize and cluster data to find patterns. During the assessment phase, the nurse is collecting and recording data, not prioritizing the data. A framework includes subjective and objective data as well as primary and secondary data; it does not help you to separate them.

PTS:1DIF:EasyREF:p. 48 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall ____ 22. Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television?

The woman is alert and oriented.

1) Provide enough chairs so the family and you are able to sit facing the client.

2) Introduce yourself and ask, Dear, what name do you prefer to go by? before asking any questions.

3) After the family leaves, ask the client if she is comfortable and willing to answer a few questions.

4) Ask the client if you can talk with her while her family is watching the television.

ANS: 3 The interview should be done when the client is comfortable and there are no distractions.

Endearing terms are inappropriate unless the client prefers them. Family members may offer information that may or may not be pertinent and may distract from the interview. The presence of family members may also inhibit full disclosure of information by the client.

PTS:1DIFifficultREF:p. 46-47 KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 23. Which of the following questions would be effective for obtaining information from a patient? Choose all that apply.

1) How did this happen to you?

2) What was your first symptom?

3) Why didnt you seek healthcare earlier?

4) When did you start having symptoms?

ANS: 1, 2, 4 How, what, and when are acceptable lines of questioning. Asking why can put the patient on the defensive and may suggest disapproval, limiting the amount of information the patient is willing give.

PTS:1DIF:ModerateREF:p. 45-46 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application ____ 24. A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) or a registered nurse (RN). To which sources should the nurse turn for the answer to his question?

Choose all that are appropriate.

1) The nurse practice act of his state 2) The American Medical Association guidelines 3) The Code of Ethics for Nurses 4) The American Nurses Associations Scope and Standards of Practice ANS: 1, 4 State nurse practice acts specify which portions of the assessment can legally be completed by individuals with different credentials. The ANA Scope and Standards of Practice provide a guide for who is ultimately responsible and qualified to collect assessment data. The American Medical Association provides guidelines and standards for physicians, not nurses. The Code of Ethics for Nurses says merely that the nurse should delegate tasks appropriately; it does not speak to credentials of personnel.

PTS:1DIF:ModerateREF:p. 40 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension ____ 25. Which of the following are cues rather than inferences? Choose all correct answers.

1) Ate 50% of his meal 2) Patient feels better today 3) States, I slept well 4) White blood cell count 15,000/mm3 ANS: 1, 3, 4 Cues are what the client says and what you observe. Just the facts. The only inference in the list is slept well. What did the nurse observe to tell her the client slept well? Those would be cues. If the client states, I slept well it is a cue, because it is a factthat is what the client stated.

PTS:1DIF:EasyREF:p. 50 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension Matching 26. Match the assessment technique to the data that should be collected. There may be more than one technique used to collect the data.

1) Auscultation 2)

Inspection 3) Palpation 4) Percussion ____ 1. Skin pink, warm, and dry ____ 2. Lung sounds clear ____ 3. Abdomen is tympanic ____ 4. Abdomen soft and nontender 1. ANS: 2 PTS: 1 DIF: Moderate REF: p. 42 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 2. ANS: 1 PTS: 1 DIF: Moderate REF: p. 42 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 3. ANS: 4 PTS: 1 DIF: Moderate REF: p. 42 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 4. ANS: 3 PTS: 1 DIF: Moderate REF: p. 42 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application 27. Match the type of special needs assessment with the correct example.

1) Do you perform monthly breast self-exams?

2) Do you live near any industrial manufacturing plants?

3)

Who can you talk to when you feel sad?

4) Who do you live with?

5) What is your understanding of your diet?

6) Since you had your stroke, have you had any problems dressing yourself?

7) Do you have a religious preference? ____ 5. Community ____ 6. Family ____ 7. Functional ability ____ 8. Nutrition ____ 9. Psychosocial ____ 10. Wellness ____ 11. Spiritual 5.

ANS: 2 PTS: 1 DIF: Easy REF: pp. 4344

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 6.

ANS: 4 PTS: 1 DIF: Easy REF: pp. 4344

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 7.

ANS: 6 PTS: 1 DIF: Easy REF: pp. 4344

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 8.

ANS: 5 PTS: 1 DIF: Easy REF: pp. 4344

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 9.

ANS: 3 PTS: 1 DIF: Easy REF: pp. 4344

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 10. ANS: 1 PTS: 1 DIF: Easy REF: pp. 4344 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application 11. ANS: 7 PTS: 1 DIF: Moderate REF: pp. 43-44 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 28. Match the assessment model with the intended use for that model.

1) Categorizes nursing diagnoses, client outcomes, and nursing interventions 2) Assesses the clients ability to achieve balance (homeostasis) 3) Identifies deficits in activities of daily living that require nursing assistance 4) Formulates a model for nursing assessment and diagnosis but is not a theory 5) Categorizes nursing diagnoses ____ 12. Gordons Functional Health Patterns ____ 13. NANDA Nursing Diagnosis Taxonomy II ____14.Taxonomy of Nursing Practice ____ 15. Roys Adaptation model ____ 16. Orems Self-Care model

12. ANS: 4 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 13. ANS: 5 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 14. ANS: 1 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 15. ANS: 2 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall 16. ANS: 3 PTS: 1 DIF: Moderate REF: p. 49 KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Recall

Chapter 4. Nursing Process: Diagnosis Chapter 4. Nursing Process: Diagnosis Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. Which of the following is an example of a problem that nurses can treat independently?

1) Hemorrhage 2) Nausea 3) Fracture 4) Infection

ANS: 2 A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems.

PTS:1DIF:ModerateREF: pp. 57 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application ____ 2. Which of the following is an example of a cluster of related cues?

1) Complains of nausea and stomach pain after eating 2) Has a productive cough and states stools are loose 3) Has a daily bowel movement and eats a high-fiber diet 4) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 ANS: 1 A cue is an unhealthy response; a cluster of cues consists of cues related to each other. Productive cough and loose stools are abnormal findings but are not obviously or usually related to each other.

Daily bowel movement and high-fiber diet are related but normal responses. The vital signs are also within normal limits.

PTS:1DIFifficultREF: pp. 62 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis ____ 3. Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology 1)

Is the cause of the problem 2) Cannot always be observed 3) Directs nursing care 4) Is an inference ANS: 3 The etiology directs nursing interventions. If the incorrect etiology is given, the nursing care would not be appropriate for the client. The other statements are true but not a reason for the importance of the etiology being correct.

PTS:1DIFifficultREF:pp. 63 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis ____ 4. How does a risk nursing diagnosis differ from a possible nursing diagnosis?

1) A risk diagnosis is based on data about the patient.

2) A possible diagnosis is based on partial (or incomplete) data.

3) Nurses collect the data to support risk diagnoses.

4) A possible diagnosis becomes an actual diagnosis when symptoms develop.

ANS: 2

A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and does not have enough data to support it; it is based on incomplete data. A risk diagnosis describes a problem that may develop in a vulnerable client if nursing care is not initiated to prevent it; it is made when risk factors are present in the data. Nurses collect data to support both risk and possible diagnoses; therefore, this statement does not differentiate them. A risk diagnosis becomes an actual diagnosis when symptoms develop.

PTS:1DIF:ModerateREF:p. 60 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis ____ 5. Which of the following describes the difference between a collaborative problem and a medical diagnosis?

1) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem.

2) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care.

3) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes.

4) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

ANS: 4 Collaborative problems are physiological complications a client may be at risk for due to her medical diagnosis, medical treatment, or diagnostic studies. A collaborative problem requires monitoring by the nurse and intervention by a physician. A medical diagnosis requires interventions

(medications, treatments) by the physician. Medical diagnoses do not direct all nursing care.

Collaborative problems have the potential to become medical, not nursing, diagnoses.

PTS:1DIF:ModerateREF: pp. 5859 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis ____ 6. Which of the following is the best approach to validate a clinical inference?

1) Have another nurse evaluate it.

2) Have the physician evaluate it.

3) Have sufficient supportive data.

4) Have the clients family confirm it.

ANS: 3 All clinical inferences should be well supported by data. The more reliable data you gather, the more certain you can be that your inference is accurate. Because inferences are nursing diagnoses, it would be inappropriate to have a physician evaluate them. Although another experienced nurse could evaluate the inference, it still needs to be supported by sound and sufficient data. Even clients can validate clinical inferences in some situations, but adequate supporting data are still needed. Keep in mind that the clients data might or might not be sufficient to prove the inference.

PTS: 1 DIF: Easy REF: p. 63 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall ____ 7. What is wrong with the following diagnostic statement? Impaired Physical Mobility related to laziness and not having appropriate shoes. The statement is 1) Judgmental

2) Too complex 3) Legally questionable 4) Without supportive data ANS: 1 Lazy implies criticism of the client and therefore is judgmental. There need to be several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum amount of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose lack of data as the best answer because all the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use A.M.B. and include defining characteristics).

PTS:1DIF:ModerateREF:p. 74 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis ____ 8. When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose?

1) Etiology 2) Related factors 3) Diagnostic label 4)

Defining characteristics ANS: 4 The defining characteristics are the signs and symptoms that must be present to support any given nursing diagnosis. The etiology and related factors are the causes or contributing factors to the problem. The diagnostic label is the name NANDA-I has given the problem; it is chosen based on the presence of defining characteristics.

PTS:1DIF:EasyREF:p. 68 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall ____ 9. Based only on Maslows hierarchy of needs, which nursing diagnosis should have the highest priority?

1) Self-care Deficit 2) Risk for Aspiration 3) Impaired Physical Mobility 4) Disturbed Sensory Perception ANS: 2 Highest priority is given to problems that are life threatening or that could be destructive to the client. Safety is most basic in Maslows hierarchy. Even though Risk for Aspiration is not an actual problem, it poses the most immediate lifethreatening risk to the client, and nursing interventions must be performed to prevent it from becoming an actual problem.

PTS:1DIF:ModerateREF:pp. 6465 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

____ 10. Which of the following describes the most important use of nursing diagnosis? (All statements are true.)

1) Differentiates the nurses role from that of the physician 2) Identifies a body of knowledge unique to nursing 3) Helps nursing develop a more professional image 4) Describes the clients needs for nursing care ANS: 4 Benefits to nurses and nursing are that nursing diagnoses differentiate the nurses role, they identify a unique body of nursing knowledge, and some think they help nursing to develop a more professional image. However, the primary goal of nursing is to serve the good of the patient.

Therefore, the most important use of a diagnosis is to specifically identify the clients needs for quality nursing care.

PTS: 1 DIF: Moderate REF: p. 56 KEY: Nursing process: Diagnosis | Client need: Safe-care environment | Cognitive level: Analysis ____ 11. Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I? 1) There is little research to support nursing diagnoses labels.

2) A perfect nursing diagnosis must be written for it to be useful.

3)

They are not included in all states nurse practice acts.

4) Other professions do not recognize nursing diagnoses.

ANS: 1 Best practice is evidence-based practice; that is, it is developed through sound, scientific research.

Research is currently being conducted, but many of the diagnoses are not research based. A perfect nursing diagnosis is impossible to write, so that is not an issue. Having standardized nursing diagnoses recognized in state practice acts or by other professions has nothing to do with the value of the NANDA-I taxonomy.

PTS:1DIFifficultREF: p. 57 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall ____ 12. Which of the following most accurately describes nursing diagnoses? A nursing diagnosis 1) Supports the nurses diagnostic reasoning 2) Supports the clients medical diagnosis 3) Identifies a clients response to a health problem 4) Identifies a clients health problem ANS: 3 Nursing diagnoses are statements that nurses use to describe a clients physical, mental, emotional, spiritual, and social response to disease, injury, or other stressor. Diagnostic reasoning is used to identify the appropriate nursing diagnosis; it is not meant to support the diagnosis. A health problem is a condition that requires intervention to promote wellness or prevent illness; it is sometimes, but not always, a nursing diagnosis. Nursing diagnoses are not medical diagnoses.

PTS:1DIF:ModerateREF: p. 57 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis ____ 13. The diagnostic label, or patient problem, is used primarily to suggest 1) Client goals 2) Cue clusters 3) Interventions 4) Etiology ANS: 1 As a general rule, the problem suggests goals for client outcomes. The etiology suggests interventions. Cue clusters support whether the correct nursing diagnosis has been identified.

PTS: 1 DIF: Moderate REF: p. 73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Recall ____ 14. Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy?

1) Bowel Obstruction related to recent abdominal surgery A.M.B. nausea, vomiting, and abdominal pain 2) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight

3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area 4) Caregiver Role Strain related to alienation from family and friends A.M.B 24-hour care responsibilities ANS: 3 The components of NANDA-I nursing diagnosis might include the following four parts: diagnostic label, defining characteristics, related factors, and risk factors. Impaired Skin Integrity . . . has the problem statement, etiology, and symptoms. For Bowel Obstruction . . . the problem is a medical diagnosis. The cause-andeffect order of Inability to Ingest Food . . . is incorrect; it starts with the etiology.

The etiology and symptoms (A.M.B.) of Caregiver Role Strain . . . are reversed (alienation from family and friends are the symptoms that support the diagnosis).

PTS: 1 DIF: Difficult REF: pp. 7071 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application ____ 15. What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. statement that When Im busy, I cant always take the time to go to the bathroom.

1) Possible nursing diagnoses do not have signs and symptoms.

2) A nursing diagnosis is either a possible risk or a risk, not both.

3) Constipation is a medical diagnosis.

4) The etiology is actually a defining characteristic.

ANS: 2 If there are risk factors, it is not a possible diagnosis, it is a risk diagnosis. It is possible to have a possible risk for diagnosis. The patient with possible diagnoses may have symptoms, just not enough to support the diagnosis. Constipation is a nursing diagnosis, and the etiology is a defining characteristic for a risk diagnosis because it contributes to the problem. In risk diagnoses, the etiology consists of the risk factors.

PTS: 1 DIF: Moderate REF: pp. 60 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis ____ 16. Which nursing diagnosis is written in the correct format?

1) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight 2) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm 3) Impaired Swallowing related to absent gag reflex 4) Excess Fluid Volume related to 3 lb weight gain in 24 hours ANS: 3 The etiology should describe what is causing or contributing to the problem. The etiologies for Ineffective Airway Clearance, Impaired Airway Swallowing, and Excess Fluid Volume describe signs or symptoms rather than causal factors.

PTS: 1 DIF: Difficult REF: V1, p. 64 | pp. 70-73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis

____ 17. The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis?

1) Ask a more experienced nurse to confirm it.

2) Have a social worker interview the patient.

3) Ask the patient to confirm the diagnosis.

4) Read about Decisional Conflict in the NANDA-I handbook.

ANS: 3 After identifying problems and etiologies (which this nurse has done), the nurse should verify them with the patient to help ensure that her conclusions are accurate. If the patient does not agree that he has Decisional Conflict, the nurse might interview him more to clarify the meaning of the data.

Certainly the nurse could ask another nurses opinion, but that is not essential. It would make no sense to have a social worker interview the patient unless the situation remains unclear even after confirming with the client. If the nurse did have adequate theoretical knowledge of Decisional Conflict for this patient, she should have been informed by reading the NANDA-I handbook before making the diagnosis. If the patient does not confirm the diagnosis, and the nurse concludes the diagnosis is in error, she might then reread the NANDA-I guide.

PTS: 1 DIF: Moderate REF: V1, p. 56 | p. 63 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application ____ 18. The clients weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I dont like to

take supplements, and I think I could really improve my nutrition. Which of the following nursing diagnoses should the nurse use?

1) Balanced Nutrition 2) Possible Imbalanced Nutrition: Less Than Body Requirements 3) Risk for Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition ANS: 4 You will use a wellness diagnosis when a persons present level of wellness is effective and when the person wants to move to a higher level of wellnessin this case, a higher level of nutrition. The format for a wellness diagnosis is Readiness for Enhanced . . . Use a possible diagnosis when you have enough data to suspect a problem but need more data to support a diagnosis. Use a risk diagnosis when there are risk factors for a problem.

PTS: 1 DIF: Moderate REF: p. 72 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application ____ 19. The patient verbalizes an overwhelming lack of energy. He says, I still feel exhausted even after I sleep. I feel guilty when I cant keep up with my usual daily activities or sleep during the day.

Ive been a little depressed lately, too.

The patient seems to have difficulty concentrating but has no apparent physical problems. Which of the following diagnoses best describes his health status?

1) Fatigue related to depression

2) Fatigue related to difficulty concentrating 3) Guilt related to lack of energy 4) Chronic confusion related to lack of energy ANS: 1 The diagnosis that best describes the overall health status is Fatigue. The only cue that might cause Fatigue is depression. You cannot use depression as the problem because it is a medical diagnosis, and it is not a NANDA-I label. The other cues (difficulty concentrating, inability to perform ADLs, and guilt) are symptoms of Fatigue, not etiologies. These diagnoses would lead the nurse to focus on dealing with guilt and confusion, so the source of the Fatigue would not be addressed.

PTS: 1 DIF: Difficult REF: pp. 70-73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application ____ 20. Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them.

1) Readiness for Enhanced Nutrition 2) Pain related to stating, On a scale of 1 to 5, its a 5.

3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever ANS: 1

Wellness diagnoses (e.g., Readiness for Enhanced . . .) are usually one-part statements. A pain ranking of 5 is a symptom of pain, not an etiology, so it should be preceded by A.M.B. or as manifested by. Hip fracture is a medical diagnosis that is causing an etiology of pain; therefore, it should be preceded by secondary to. Risk diagnoses do not have symptoms, so it is not correct to put anything after A.M.B. PTS: 1 DIF: Moderate REF: pp. 70-73 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 1. Which of the following are cues? Select all that apply.

1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms ANS: 2, 3, 5 Cues are a deviation from norms, such as changes in usual health behavior, indications of delayed growth and development, changes in behaviors, or nonproductive or dysfunctional behavior.

PTS:1DIF:ModerateREF:p. 61-62 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

____ 2. Using Maslows hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis.

1) Anxiety 2) Risk for infection 3) Disturbed body image 4) Sleep deprivation ANS: 4, 2, 1, 3 In Maslows hierarchy, physiologic needs and safety are the highest priority. Sleep is a basic physiologic need. Infection can threaten physical health. In this question, infection is not present; therefore, there is just a risk for it. Sleep Deprivation is an immediate problem that affects general physical, mental, and emotional health. Neither Anxiety nor Disturbed Body image is a physiologic or safety need. Anxiety is a more immediate need than Disturbed Body Image, so it probably deserves a higher ranking. Remind students that the ranking would depend on the severity of each problem, which is not known by the labels alone.

PTS:1DIFifficultREF:pp. 64 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Analysis Matching Using problem urgency as your framework, rank the following nursing diagnoses as low, medium, or high priority.

1) low 2) medium

3) high ____ 1. Risk for Spiritual Distress ____ 2. Decreased Cardiac Output ____ 3. Chronic Confusion 1. ANS: 1 PTS: 1 DIF: Moderate REF: pp. 64 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 2. ANS: 3 PTS: 1 DIF: Moderate REF: pp. 64 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 3. ANS: 2 PTS: 1 DIF: Moderate REF: pp. 64 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application Label the parts of the following nursing diagnosis statement: Activity Intolerance related to prolonged bedrest A.M.B. increased heart rate, decreased blood pressure with activity, statements of weakness, and dyspnea with exertion.

1)

diagnostic label or problem

2)

etiology 3) cues or defining

characteristics ____ 4. Activity Intolerance ____ 5. Prolonged bedrest ____ 6. Increased heart rate, decreased blood pressure with activity, statements of weakness, dyspnea with exertion 4. ANS: 1 PTS: 1 DIF: Moderate REF: p. 70. 72 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application 5. ANS: 2 PTS: 1 DIF: Moderate REF: p. 70-72 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

6. ANS: 3 PTS: 1 DIF: Moderate REF: p. 70-72 KEY: Nursing process: Diagnosis | Client need: SECE | Cognitive level: Application

Chapter 5. Nursing Process: Planning Outcomes Chapter 5. Nursing Process: Planning Outcomes Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. For which patient would it be most important to perform a comprehensive discharge plan?

1) A teen who is a first-time mother, single, and lives with her parents 2) An older adult who has had a stroke affecting the left side of his body and lives alone 3) A middle-aged man who has had outpatient surgery on his knee and requires crutches 4) A young woman who was admitted to the hospital for observation following an accident ANS: 2 A comprehensive discharge plan should be developed for older adults and anyone who has complex needs, including self-care deficits. The other patients do not have the complex needs of the older adult patient who has had a stroke that affects body function.

PTS:1DIF:ModerateREF:p. 83 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis

____ 2. The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful?

1) Start planning at admission.

2) Involve the family members.

3) Get patient input when making the plan.

4) Involve the multidisciplinary team.

ANS: 3 The discharge plan may be developed in a timely manner and involve the family and a multidisciplinary team, but if the patient does not agree with the plan, it will not be successful.

PTS: 1 DIF: Moderate REF: pp. 83| p. 87 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 3. What do initial, ongoing, and discharge planning have in common?

1) They are based on assessment and diagnosis.

2) They focus on the patients perception of his needs.

3) They require input from a multidisciplinary team.

4)

They have specific timelines in which to be completed.

ANS: 1 All planning is based on nursing assessment data and identified nursing diagnoses. The patient should have input, but the planning is based on the nursing assessment. The different types of planning are intertwined and may or may not be done at distinct, separate times. Discharge planning often requires a multidisciplinary team, but initial and ongoing planning may not. Initial planning is usually begun after the first patient contact, but there is no specified time for completion; ongoing planning is more or less continuous and is done as the need arises; discharge planning must be done before discharge.

PTS:1DIF:ModerateREF: p. 81-82 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 4. Which client has the greatest need for comprehensive discharge planning?

1) A woman who has just given birth to her second child and lives with her husband and 18-month-old daughter 2) A man who has been readmitted for exacerbation of his chronic obstructive pulmonary disease 3) A 12-year-old boy who had outpatient surgery on his knee and lives with his mother 4) A woman who was just diagnosed with renal failure and has started peritoneal dialysis ANS: 4 Comprehensive discharge planning should be done for patients who have a newly diagnosed chronic disease or have complex needs. The other patients may require discharge planning but not as comprehensive as someone with a new diagnosis with complex treatment.

PTS:1DIFifficultREF: p. 83

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 5. Which of the following is a benefit of standardized care plans, as defined in your text?

Standardized care plans 1) Apply to every patient on a particular unit 2) Include both medical and nursing orders 3) Specify patient outcomes for each day 4) Help ensure that important interventions are not overlooked ANS: 4 Standardized care plans help promote consistency of care and ensure that important interventions are not forgotten. They are not likely to apply to every patient on a unit because they are usually single-problem plans or are used with a particular medical diagnosis. Unlike protocols, they do not include medical orders. Unlike critical pathways, they do not specify predicted patient outcomes for each day.

PTS:1DIF:ModerateREF: p. 86 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Recall ____ 6. How are standardized (model) care plans similar to unit standards of care? Standardized (model) care plans 1) Describe the care needed by patients in defined situations 2) Include specific goals and nursing orders

3) Become a part of the patients comprehensive care plan 4) Usually describe ideal nursing care ANS: 1 All of the statements are true for standardized care plans, but only 1 is true of both standardized care plans and unit standards of care. Both describe care needed by patients in defined situations, although unit standards usually describe care for groups of patients (e.g., all women admitted to a labor unit), and standardized care plans are often organized around a particular or all nursing diagnoses commonly occurring with a particular medical diagnosis. Unit standards are more general and do not have goals for each patient. Unit standards are kept on file in a central place on the unit and do not become a part of the care plan. Unit standards describe minimal, not ideal, care.

PTS: 1 DIF: Difficult REF: p. 87; requires analysis of text discussion.

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 7. The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient?

1) Validate conflicting data with the patient.

2) Transcribe medical orders.

3) State the frequency for ambulation.

4) Perform a comprehensive assessment.

ANS: 3 Individualizing the care plan means identifying specific problems, outcomes, and interventions and the frequency of those interventions to meet the patients needs. Validating data ensures your assessment is accurate. Transcribing orders is a part of developing and implementing the care plan but not of individualizing the plan. Performing an assessment is the beginning step to developing a care plan. Assessment helps you to know the ways in which a standardized plan needs to be individualized.

PTS:1DIF:ModerateREF: p. 90 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application ____ 8. Which of the following is the best example of an outcome statement? The patient will 1) Use the incentive spirometer when awake 2) Walk two times during day and evening shifts 3) Maintain oxygen saturation above 92% while performing ADLs each morning 4) Tolerate 10 sets of range-of-motion exercises with physical therapy ANS: 3 Outcome statements should have specific performance criteria and a target time; maintain oxygen saturation is the only one that meets those criteria. The incentive spirometer goal should say how many times the incentive spirometer should be used each hour as well as the volume. The walking goal should state how far the patient should walk. In the range-of-motion goal, tolerate is a vague word and is difficult to measure, and the outcome needs to specify how often.

PTS:1DIF:ModerateREF: p. 91-92 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 9. How are critical pathways and standardized nursing care plans similar? Both

1) Specify daily, or even hourly, outcomes and interventions 2) Prescribe minimal care needed to meet recommended lengths of stay 3) Describe care common to all patients with a certain condition or situation 4) Emphasize medical problems and interventions ANS: 3 Both critical pathways and standardized care plans are preplanned documents; they describe care common to all patients who have a certain condition (e.g., all patients who have a heart attack need some of the same interventions). The other statements are true of critical pathways but not of standardized nursing care plans.

PTS:1DIFifficultREF: pp. 8687; high-level question, answer not given verbatim KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 10. How is NOC different from the Omaha System?

1) NOC can be used to write health restoration outcomes.

2) NOC can be used in all specialty and practice areas.

3) NOC can be used for individuals, families, or groups.

4) NOC formulates goals based on nursing diagnoses.

ANS: 2 NOC was developed for all specialty and practice areas. The Omaha System was developed for community health nursing. Both address health restoration and can be used for individuals, family, or groups (community). Both base goals on nursing diagnoses, although Omaha does not use the NANDA-I taxonomy.

PTS:1DIF:ModerateREF: p. 95; answer based on analysis of text discussion | V1, p. 98; answer based on analysis of text discussion KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 11. How are short-term goals different from long-term goals? Short-term goals 1) Can be met within a few hours or a few days 2) Are developed from the problem side of the nursing diagnosis 3) Must have target times/dates 4) Specify desired client responses to interventions ANS: 1 Short-term goals may be accomplished in hours or days; long-term goals usually are achieved over weeks, months, or even years. The other statements are true for both short-term and long-term goals.

PTS:1DIF:ModerateREF: p. 91 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 12. What do standardized nursing care plans and individualized care plans have in common?

They both

1) Reflect critical thinking for a specific patient 2) Are preprinted to apply to needs common to a group of patients 3) Address a patients individual needs 4) Provide detailed nursing interventions ANS: 4 They both provide detailed nursing interventions, although the individualized care plan is more specific to the patients needs and reflects critical thinking, whereas standardized plans do not. It is not true of individual nursing care plans that they are preprinted and apply to a group.

PTS: 1 DIF: Moderate REF: pp. 87 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 13. The nurse is individualizing Mr. Wus plan of care by writing a plan for his nursing diagnosis of Anxiety. Why does the nurse need to write goals/outcomes on the plan of care? Because outcomes describe 1) Desired changes in the patients health status 2) Specific patient responses to medical interventions 3) Specific nursing behaviors to improve a patients health 4)

Criteria to evaluate the appropriateness of a nursing diagnosis ANS: 1 Outcomes describe changes in the patients health status in response to nursing, rather than medical, interventions. Outcomes relate to patient behavior, not nursing behaviors. Outcomes are a measure of the effectiveness of nursing care for a specific nursing diagnosis, not whether the nursing diagnosis is appropriate.

PTS:1DIF:ModerateREF: p. 91 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension ____ 14. Which of the following outcome statements contains the best example of performance criteria? The patient will 1) Turn herself in bed frequently while awake 2) Understand how to use crutches by day 2 3) State that pain is decreased after being medicated 4) Eat 75% of each meal without complaint of nausea ANS: 4 Performance criteria should be specific and measurable. 75% of each meal is specific and measurable. Frequently is vague. You cannot observe whether someone understands. Decreased is vague; a numerical pain rating would be better.

PTS:1DIF:ModerateREF: p. 92 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

____ 15. Which of the following is true for goals/outcomes for collaborative problems?

1) They are monitored only by other disciplines.

2) They are usually sensitive to nursing interventions.

3) They state that a complication will not occur.

4) They state only broad performance criteria.

ANS: 3 The goal for a collaborative problem is always that the complication will not occur. Other disciplines may be involved in helping to prevent the problem, but nurses still monitor for the complication.

The outcomes to collaborative problems are not affected by nursing interventions alone. Goals for collaborative problems are specific to the medical condition/treatment.

PTS:1DIF:ModerateREF: pp. 93 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 16. How are NANDA-I problem labels and NOC outcome labels alike? Both describe 1) Health status in terms of human responses 2) Patient response before interventions are done 3) Patient response in positive terms 4)

A pattern of related cues ANS: 1 Both NANDA-I and NOC labels are stated as human responses. A NOC label can be used to describe patient responses both before and after interventionNANDAI before. NOC statements are neutral to allow for positive, negative, or no change in health status; NANDA-I diagnoses describe both problem responses and positive responses (wellness labels). NANDA-I labels are based on patterns of related cues; NOC labels are based on (linked to) NANDA-I labels.

PTS: 1 DIF: Difficult REF: pp. 94; also information about NANDA-I diagnoses from Chapter 4 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 17. The nursing diagnosis is Impaired Memory related to fluid and electrolyte imbalances A.M.B. inability to recall recent events. Which of the following goals/outcomes must be included on the care plan?

1) Checks current medications for mind-altering side effects 2) Demonstrates use of techniques to help with memory loss 3) Drinks at least 1500 cc of fluid per day 4) Takes electrolyte supplements with meals ANS: 2 The essential goal/outcome is aimed at the problem response Impaired Memory. The other goals in this question address the etiology.

PTS:1DIF:ModerateREF: p. 93-94 KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

____ 18. A client arrives in the emergency department, pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that are needed. This scenario demonstrates 1) Formal planning 2) Informal planning 3) Ongoing planning 4) Initial planning ANS: 2 Informal planning is performed while doing other nursing process steps and is not written; this nurse is forming a plan in her mind. The end product of formal planning is a holistic plan of care that addresses the patients unique problems and strengths; this nurse has no time to create a holistic plan of care. Ongoing planning refers to changes made in the plan as you evaluate the patients responses to care; no care has been given at this point. Initial planning does indeed begin with the first patient contact. However, it refers to the development of the initial comprehensive plan or care; this nurse does not have enough data for a comprehensive plan, nor does she have time to make such a plan at the moment.

PTS:1DIF:EasyREF:p. 81 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 1. A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Choose all that apply.

1) Developing culturally appropriate outcomes 2) Using the outcomes preprinted on the clinical pathway 3) Choosing the best outcome for the patient, regardless of the costs involved in bringing it about 4) Involving the patient and family in formulating the outcomes ANS: 1, 4 ANA standard 3 includes derives culturally appropriate expected outcomes from the diagnosis and involves the patient, family . . . in formulating expected outcomes. . . . It is acceptable for the nurse to use outcomes on a clinical pathway, but these are not individualized; ANA standard 3 says that the nurse identifies . . . outcomes for a plan individualized to the patient. . . . The standard also says that the nurse should consider associated risks, benefits, and costs. . . .

PTS:1DIF:ModerateREF: p. 82 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension

Chapter 6. Nursing Process: Planning Interventions Chapter 6. Nursing Process: Planning Interventions Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. Which of the following nursing interventions is an indirect-care intervention?

1)

Emotional support 2) Teaching 3) Consulting 4) Physical care ANS: 3 An indirect-care intervention is an activity performed away from the client on behalf of the client.

Indirect-care interventions include consulting with other healthcare team members, making referrals, advocacy, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care.

PTS:1DIF:EasyREF:pp. 103 KEY: Nursing process: Implementation | Client need: SASE | Cognitive level: Recall ____ 2. Which nursing intervention is considered an independent intervention?

1) Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour 2) Encouraging the postoperative client to perform coughing and deep breathing exercises 3) Explaining his diet to the client; then communicating the teaching with the dietitian 4) Administering morphine sulfate 2 mg IV to the client with postoperative pain ANS: 2

Encouraging the postoperative client to perform coughing and deep breathing exercises is an independent nursing intervention. An independent intervention is one that nurses are licensed to prescribe, perform, or delegate based on their skills and knowledge. Administering IV fluid or morphine sulfate are dependent interventions; they require an order from a physician or advanced practice nurse but are carried out by the nurse. Explaining to the client how sodium intake affects his heart failure and then communicating the teaching with the dietitian is an interdependent intervention, one that is carried out in collaboration with other healthcare team members.

PTS:1DIF:ModerateREF: p. 103 KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application ____ 3. A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write?

1) Collaborative 2) Interdependent 3) Dependent 4) Independent ANS: 4 Writing an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physicians order. The nurse is licensed to prescribe, perform, or delegate the intervention based on her knowledge and skills. A collaborative or interdependent intervention is one that is carried out in collaboration with other health team members, such as providing the client with a sodium-restricted diet. A dependent intervention is

prescribed by a physician or advanced practice nurse; for example, administer oxygen at 2 L/min via nasal cannula.

PTS:1DIF:ModerateREF: p. 103 KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application ____ 4. The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not currently have any respiratory problems. The nurses teaching plan includes coughing and deep breathing exercises. Which type of nursing intervention is the nurse performing?

1) Health promotion 2) Treatment 3) Prevention 4) Assessment ANS: 3 The nurse is teaching the client coughing and deep breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is utilizing a prevention intervention. Prevention interventions are used to help prevent complications, such as postoperative pneumonia. Healthpromotion interventions promote a clients efforts to achieve a higher level of wellness. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. Assessment interventions detect changes in the clients condition and detect potential problems.

PTS:1DIF:ModerateREF: p. 106 KEY: Nursing process: Interventions | Client need: Physiological integrity |

Cognitive level: Application ____ 5. Which standardized intervention vocabulary was designed specifically for community health nurses?

1) Omaha System 2) Clinical Care Classification 3) Nursing Interventions Classification 4) International Classification for Nursing Practice ANS: 1 The Omaha System was designed specifically for community health nurses to use in caring for individuals, families, community groups, or entire communities. The Clinical Care Classification was developed for home healthcare. The Nursing Interventions Classification system is applicable in all settings, including home health and community nursing. The International Classification for Nursing Practice system was designed to describe nursing practice of individuals, families, and communities worldwide.

PTS:1DIF:EasyREF: p. 110 KEY: Nursing process: Planning | Client need: SASE | Cognitive level: Recall ____ 6. A 55-year-old patient returned to the medical-surgical unit after undergoing a right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an appropriate, correctly written nursing order for this patient?

1) 7/12/13 Encourage use of the incentive spirometer every hour while the client is awakeD. Goodman, RN

2) By 7/12/13, uses incentive spirometer 10 times every hour while awake to 1000 mL 3) Incentive spirometer hourly while awake 4) Offer incentive spirometer to the clientJ. Smith, RN ANS: 1 The option beginning with a date and ending with the RNs signature contains necessary information. It contains the date the order was written along with specific instruction for the nurse that is written in terms of nursing behavior. Uses incentive spirometer 10 times . . . is an example of an expected outcome. Incentive spirometer hourly . . . is an example of a medical order. Plus, the date and nurses signature are missing. Offer incentive spirometer . . . does not provide the nurse with enough detailed instruction. Therefore, it is a poorly written nursing order.

PTS:1DIF:ModerateREF:pp. 111-112 KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level: Application ____ 7. A client newly diagnosed with diabetes is admitted to the hospital because her diabetes is out of control. Which of the following is an appropriate direct-care intervention for this client during her stay?

1) Consulting the diabetic nurse educator for help with a teaching plan 2) Making arrangements for the client to join a diabetic support group 3) Demonstrating blood glucose monitoring and insulin administration to the client 4) Consulting with the dietician about the clients dietary concerns

ANS: 3 Demonstrating blood glucose monitoring and insulin administration is an appropriate direct-care intervention for this client. Direct-care interventions are performed through intervention with the client and include interventions such as physical care, emotional support, and client teaching.

Indirect-care activities include consulting the diabetic nurse educator, making arrangements for the client to join a diabetic support group, and consulting with the dietitian about the clients dietary concerns. Indirect-care activities are performed away from but on behalf of the client.

PTS:1DIF:ModerateREF:p. 103 KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Application ____ 8. Which definition best describes a critical pathway?

1) Standardized plan of care for frequently occurring conditions 2) Systematically developed statement to assist practitioners and patients in making decisions 3) Systematic review of clinical evidence for an intervention 4) Set of interrelated concepts that describes or explains something ANS: 1 Critical pathways are standardized plans of care for commonly occurring health conditions (e.g., myocardial infarction) for which similar outcomes and interventions are appropriate for the majority of patients with the condition. Clinical practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure. Evidence reports are systematic reviews on clinical topics for the purpose of providing evidence for guidelines, quality improvement, quality measures, and

insurance coverage decisions. A theory is a set of interrelated concepts that describe or explain something.

PTS:1DIF:EasyREF: p. 104 KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall ____ 9. A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan?

1) Determine airway adequacy hourly and as needed.

2) Administer oxygen as needed.

3) Monitor arterial blood gas values.

4) Place the client in a high Fowlers position.

ANS: 1 For any acute respiratory problem, prior to implementing interventions, the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventions should be listed according to priority. Airway always takes precedence, as ventilation, oxygenation, and positioning will be ineffective without a patent airway.

PTS: 1 DIF: Difficult REF: p. 107 KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level: Analysis ____ 10. Who is the primary decision maker when caring for healthy adult clients? 1) Physician

2) Family 3) Client 4) Nurse ANS: 3 The client is the primary decision maker in the care of healthy clients. The nurse functions as a teacher and health counselor. The physician plays a role in health promotion and screening. The family may give input, but the client is the decision maker.

PTS:1DIF:EasyREF: p. 110 KEY: Nursing process: Planning | Client need: Health promotion | Cognitive level: Comprehension ____ 11. A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the nurse do first?

1) Identify several interventions likely to achieve the desired outcomes.

2) Review the problem and etiology of the nursing diagnosis.

3) Choose the best interventions for the patient.

4) Review the goals she has written.

ANS: 2

The process of choosing interventions is review the nursing diagnosis, review the desired outcomes, identify several interventions or actions, choose the best interventions for the patient, and then individualize standardized interventions to meet the patients unique needs.

PTS:1DIF:ModerateREF: p. 106-107 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis ____ 12. The nurse is using electronic care planning. He enters the patients nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions the program generates, he sees that none of them fit this patients individual needs. What should the nurse do?

1) Reject them all and type in appropriate interventions.

2) Select the interventions from the program that are most suitable.

3) Ask another nurse to assess the patient and give her recommendation.

4) Restart the computer; it is probably a program malfunction.

ANS: 1 The nurse can reject all the suggested interventions if they do not address patient needs. Nearly all computer programs have a screen that allows you to type in interventions and nursing orders. It is the nurses responsibility to choose interventions: He cannot abdicate this responsibility and let the computer choose. As a professional, this nurse has already validated the data, nursing diagnosis, and goals, so he can feel reasonably certain that there is nothing wrong with the plan to that point.

Although consultation with other nurses can be wise and prudent at times, the nurse caring for the patient would likely have the most familiarity with the healthcare needs and is in a better position to make sound judgments than another nurse who does not know the patient. Therefore, it might not be productive or efficient to consult another nurse or restart the computer.

PTS:1DIF:ModerateREF:p. 108-109 KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis Multiple Response Identify one or more choices that best complete the statement or answer the question. ____ 1. Which statement(s) about nursing interventions is/are true? Select all that apply.

1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. 2) The best nursing interventions are based on tradition.

3) Nursing interventions should be individualized and culturally sensitive.

4) Standardized nursing interventions improve care for a specific client.

ANS: 1, 3 Some nursing interventions and activities can be delegated to the LPN/LVN or nursing assistive personnel (NAP); however, writing nursing orders is the responsibility of the registered nurse.

Nursing interventions should always be individualized and culturally sensitive. Whenever possible, nursing interventions should be based on scientific evidence, not tradition. Standardized interventions are not customized to improve care for a specific client.

PTS:1DIF:ModerateREF: pp. 103104 KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application ____ 2. An 80-year-old resident in a long-term-care facility comes to the emergency department with dehydration. The nurse writes a diagnosis of Deficient Fluid Volume related to excessive fluid loss. An individualized nursing goal identified for this client is The client will maintain urine output of at least 30 mL/hour. Which nursing interventions would directly help achieve or evaluate the stated goal? Choose all that are correct.

1) Measure and record urine output every hour; report an output of less than 30 mL/hour.

2) Monitor skin turgor and moistness of mucous membranes every shift.

3) Administer IV fluids as prescribed.

4) Keep oral fluids within the patients reach, and encourage the patient to drink.

ANS: 1, 3, 4 Measuring and recording urine output allow for direct evaluation of the goal urine output 30 mL/hour. Administering IV fluids adds fluid to correct dehydration, improve blood flow through the kidneys, and increase urine production. Intake of oral fluids has the same effect. Monitoring skin turgor and mucous membranes are ways to assess for dehydration, but it does not directly apply to the goal of maintaining urine output. It is an intervention aimed at the etiology of this nursing diagnosis, rather than the problem.

PTS:1DIF:ModerateREF:p. 106-107; high-level question; answer not given verbatim KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive level: Analysis

Chapter 7. Implementation & Evaluation Chapter 7. Implementation & Evaluation Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. A physician prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed?

1) Administer the medication as prescribed.

2) Hold the medication and notify the prescriber.

3) Consult with a pharmacist before administering it.

4) Ask the patients nurse for information about the medication.

ANS: 3 The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice. Administering the medication as prescribed, without knowing its expected actions and side effects, at the least prevents adequate reassessment; at the most, it is dangerous. Holding the medication and notifying the prescriber prevents the client from receiving timely treatmentmany drugs are less effective if a consistent schedule is not maintained. Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication.

PTS:1DIF:ModerateREF:p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis ____ 2. Which task can be delegated to nursing assistive personnel (NAP)?

1) Turn and reposition the client every 2 hours.

2) Assess the clients skin condition.

3) Change pressure ulcer dressings every shift.

4) Apply hydrocolloid dressing to the pressure ulcer.

ANS: 1 The nurse can delegate turning the client every 2 hours to the NAP. Assessing the clients skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.

PTS:1DIF:ModerateREF:pp. 122124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application ____ 3. The nurse has just finished documenting that he removed a patients nasogastric tube.

Which is the next logical step in the nursing process?

1) Assessment 2) Planning 3) Evaluation 4) Diagnosis ANS: 3 The implementation phase ends when you document nursing actions on the clients chart.

Implementation evolves into the evaluation step when you document the clients response to your interventions. As a general rule, the steps in order are as follows: assessment diagnosis, planning outcomes, planning interventions, implementation, and evaluation.

PTS:1DIF:EasyREF:p. 125 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Comprehension ____ 4. Which nursing intervention is best individualized to meet the needs of a specific client?

1) Suction the client every 2 hours per unit policy.

2) Use incentive spirometry every hour while awake per postoperative protocols.

3) Institute swallowing precautions.

4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner.

ANS: 4 Positioning the client in the chair for meals considers the clients desire to be out of bed for dinner, so it is obviously individualized. An intervention performed according to unit policy or protocols is not necessarily individualized. Institute swallowing precautions does not provide instructions for the specific actions needed to do that for this particular client.

PTS:1DIF:ModerateREF:p. 118; high-level question, answer not given verbatim KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Application ____ 5. The primary provider prescribes an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed?

1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone.

2) Gather the equipment and prepare it before informing the client about the procedure.

3) Obtain an order to restrain the client before inserting the urinary catheter.

4) Inform the provider that the nurse cannot perform the procedure because the client is confused.

ANS: 1 Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance.

PTS:1DIF:ModerateREF:p. 118 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis ____ 6. A patient underwent surgery 3 days ago for colorectal cancer. The patients critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed?

1) Postpone the teaching session until the patient is more receptive.

2) Follow the critical pathway for patient teaching about ostomy care.

3) Administer a prescribed antidepressant and notify the physician.

4)

Explain to the patient the importance of skin care around the ostomy site.

ANS: 1 A depressed affect and poor eye contact likely indicate that the client is having difficulty coping with the new colostomy. At this time, the client would not be physically and psychologically ready to obtain the most benefit from teaching pertaining to ostomy care. Therefore, the nurse should postpone the teaching session for this client until the client is receptive to receiving the information. The nurse should not perform the teaching session simply because the critical pathway indicates it is appropriate. Simply administering an antidepressant does not address the clients readiness to participate in a teaching session and ultimately self-care of the ostomy. The nurse should encourage the client to verbalize his feelings. Client education is not effective unless the client is receptive to the information. Readiness to learn is important. Proceeding with teaching when the client is struggling with coping is not sensitive to the clients individual needs.

PTS:1DIF:ModerateREF:p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Application ____ 7. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?

1) Psychomotor 2) Interpersonal 3) Cognitive 4) Critical thinking ANS: 2

Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills.

Assessing whether there is an indication for the nasogastric tube requires critical thinking skills.

PTS:1DIF:ModerateREF: p. 120 KEY: Nursing process: Implementation | Client need: PHI | Cognitive level: Comprehension ____ 8. Which intervention depends almost entirely on the clients adhering to the therapy?

1) Inserting an IV catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet ANS: 4 Instituting and adhering to a low-fat, low-calorie diet is an intervention that depends almost entirely on the clients adhering to the therapy. Client cooperation is necessary for performing the other interventions, but the interventions do not depend on the client to the same extent.

PTS:1DIF:EasyREF: p. 122 KEY: Nursing process: Planning interventions | Client need: SECE | Cognitive level: Analysis ____ 9. The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus.

Which intervention by the nurse best promotes client cooperation with the treatment plan?

1) Teaching the client that he must lose weight to control his blood sugar

2) Informing the client he must exercise at least three times per week 3) Explaining to the client that he must come to the diabetic clinic weekly 4) Determining the clients main concerns about his diabetes ANS: 4 Determining the clients main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the clients support systems and resources, not just tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior.

PTS:1DIF:ModerateREF: p. 122 KEY: Nursing process: Planning interventions | Client need: PHSI | Cognitive level: Analysis ____ 10. Which statement accurately describes delegation?

1) Transferring authority to another person to perform a task in a selected situation 2) Collaborating with other caregivers to make decisions and plan care 3) Scheduling treatments and activities with other departments 4) Performing a planned intervention from a critical pathway

ANS: 1 Delegation is the transfer to another person of the authority to perform a task in a selected situationthe person delegating retains accountability for the outcome of the activity. Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions.

Coordination of care involves scheduling treatments and activities with other departments.

Implementation is the process of performing planned interventions.

PTS:1DIF:EasyREF: p. 122 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Knowledge ____ 11. Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task?

1) Record how much the patient drinks today, please.

2) Take the patients vital signs every 2 hours today.

3) Take the patients temperature every 4 hours; notify me if it is greater than 100.5F (38.1C).

4) Assist the patient with all of her meals.

ANS: 3 Clear communication about a task (such as Take the patients temperature . . . ) tells the NAP exactly what the task is, the specific time it needs to be done, and the method for reporting the results to the registered nurse. The other options are vague and leave room for misinterpretation.

PTS:1DIF:ModerateREF:p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

____ 12. Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)?

1) Nurse who delegated the task 2) Licensed practical nurse working with the NAP 3) Unit nurse manager 4) Charge nurse for the shift ANS: 1 The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse manager, or charge nurse, can answer questions and provide help, if necessary.

PTS:1DIF:EasyREF: p. 124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Recall ____ 13. Which criterion might be used in structure evaluation?

1) Staff refrains from sharing computer password.

2) Healthcare provider washes hands with each client contact.

3) A defibrillator is accessible on each client care area.

4)

Nurse verifies client identification before initiating care.

ANS: 3 The criterion that states a defibrillator is present on each client care area is associated with structure evaluation. Refrains from sharing computer password, washes hands before each client contact, and verifies client identification before initiating care are criteria associated with process evaluation.

PTS:1DIF:ModerateREF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Analysis ____ 14. Which of the following is a client outcome criterion?

1) Central venous catheter site infection does not occur (90% of cases).

2) Client will sit out of bed in a chair for 20 minutes three times per day.

3) Postoperative phlebitis does not occur (95% of cases).

4) Falls will decrease by 2% between January 1 and March 30.

ANS: 2 A client outcome criterion states the client health status or behaviors one wishes to effect. Client will sit out of bed . . . is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution.

PTS:1DIF:ModerateREF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application ____ 15. When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour?

1) At the end of the shift 2) Every 24 hours 3) Every 4 hours 4) Every hour ANS: 4 The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patients urine output every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient.

PTS:1DIF:EasyREF: pp. 127-128 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application ____ 16. Which type of client-centered evaluation is performed at specific, scheduled times?

1) Intermittent 2) Ongoing 3) Terminal 4) Process ANS: 1

Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the clients health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation.

PTS:1DIF:EasyREF: p. 127 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Recall ____ 17. Which of the following is the most valid criterion for determining the status of a patients anxiety at discharge? The patient 1) Has a relaxed facial expression 2) States that he feels more relaxed today 3) Shows no physiological signs of anxiety (e.g., pallor) 4) Has no further questions about home care ANS: 2 A criterion is considered valid when it measures what it is intended to measure. Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it.

A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety. All of the options except what the patient states could be measuring something other than anxiety.

PTS: 1 DIF: Difficult REF: p. 127 KEY: Nursing process: Evaluation | Client need: PSI | Cognitive level: Application ____ 18. The nurse works with the respiratory therapist to administer a patients breathing treatments. He reports the patients breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of 1) Delegation 2) Collaboration 3) Coordination of care 4) Supervision of care ANS: 2 Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain the big picture. Supervision is the process of directing, guiding, and influencing the outcome of an individuals performance of an activity or task.

PTS:1DIF:ModerateREF: pp. 122 KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Application Multiple Response Identify one or more choices that best complete the statement or answer the question.

____ 1. The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply.

1) 75-year-old patient newly admitted to the hospital with dehydration 2) 65-year-old patient hospitalized for a stroke, whose blood pressure is 188/90 mm Hg 3) 92-year-old patient with stable vital signs who was admitted with a urinary tract infection 4) 56-year-old patient with chronic renal failure who has vital signs within his normal range ANS: 1, 3, 4 The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration, the client admitted with a urinary tract infection, or the client with chronic renal failure. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse.

PTS: 1 DIF: Difficult REF: pp. 122124 KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

Chapter 8. Nursing Theory & Research M Chapter 8. Nursing Theory & Research

Multiple Choice Identify the choice that best completes the statement or answers the question. ____ 1. Which commonly accepted practice came out of the Framingham study?

Use of 1) Mammography in breast cancer screening 2) Colonoscopy in colon cancer screening 3) Pap testing in cervical cancer screening 4) Digital rectal examination in prostate cancer screening ANS: 1 One commonly accepted practice that came out of the Framingham study is the link between mammography and breast cancer. Before the Framingham study, mammography was considered an unreliable tool in breast cancer screening.

PTS:1DIF:EasyREF:p. 137 KEY:Nursing process: N/A | Client need: HPM | Cognitive level: Recall ____ 2. Which theorist developed the nursing theory known as the science of human caring?

1) Florence Nightingale 2) Patricia Benner 3)

Jean Watson 4) Nola Pender ANS: 3 Dr. Jean Watson developed the nursing theory known as the science of human caring. Her theory describes caring from a nursing perspective. Florence Nightingale developed the theory that stated that a clean environment would improve the health of patients. By changing the care environment, she dramatically reduced the death rate of soldiers. Dr. Patricia Benners theory described the progression of a beginning nurse who learns to be an expert nurse. Nola Penders theory on health promotion became the basis for most health-promotion teaching done by nurses.

PTS: 1 DIF: Easy REF: p. 137 KEY: Nursing process: N/A | Client need: N/A | Cognitive level: Recall ____ 3. A patient complains of pain after undergoing surgery. The nurse forms a mental image of pain based on her own experiences with pain. This mental image is known as a(n) 1) Phenomenon 2) Concept 3) Assumption 4) Definition ANS: 2 A concept is a mental image of a phenomenon, an aspect of reality that you can observe and experience. In the scenario above, the nurse forms a mental image of pain because of her past experiences with pain. Phenomena are the subject matter of a discipline. They mark the boundaries