Cooper: Foundations and Adult Health Nursing, 9th Edition - Answer Key to Study Guide by studymerit.com

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Answer Key CHAPTER 1—THE EVOLUTION OF NURSING Matching 1. b 2. d 3. e 4. a 5. f 6. h 7. c 8. g 9. j 10. i Multiple Choice 11. Answer 4: NAPNES would assist a nurse who is seeking information about LPN/LVN standards. The purposes of NAPNES and National Federation of Licensed Practical Nurses (NFLPN) are to: Set standards for practical/vocational nursing programs. Promote and protect practical/vocational nursing. Educate and inform the general public about practical/vocational nursing. For issues related to interpersonal conflict, the nurse would first attempt assertive communication with those who are bullying or harassing. If this is unsuccessful, it would be appropriate to go up the chain of command. Issues with nursing students can be reported to the nursing instructor or the education liaison. For job seeking, the nurse would use personal contacts, the Internet, or nurse recruiters. 12. Answer 4: Case management is a modified system to deliver care. The LPN/LVN assists the RN to achieve desired outcomes. The RN selects the clinical pathway and coordinates and plans patient care for individuals and groups of patients. Cross-training is another type of modified system of care. While cross-training is intended to expand the role of the employee, the LPN/LVN must not exceed scope of practice and cannot be expected to assume RN responsibilities. 13. Answer 2: Long-term care facilities employ the majority of LPN/LVNs; however, hospitals,

clinics, outpatient agencies, home health agencies, insurance companies, HCP offices, and the military services offer additional opportunities. 14. Answer 1, 2, 4, 5: The LPN/LVN communicates findings to members of the health care team, demonstrates caring and empathy by using therapeutic communication skills with patients, administers care according to professional standards and collects data from multiple sources. The LPN/LVN would collaborate with the RN but would not independently create the care plan for a newly admitted patient. 15. Answer 3: Reports indicate that challenges related to feelings of social isolation, stereotyping about men who choose nursing, nursing instructors’ inability to incorporate masculine styles of caring into the curriculum, and a lack of male role models in the profession may be to blame for the high attrition of male nursing students from nursing programs. 16. Answer 4: Advance directives could include a health care power of attorney that states who should make health care decisions if the person is unable to make them. A “living will” outlines wishes about end-of-life care. Ideally, everyone should carefully consider advance directives and have discussions with family members, caregivers, and the health care team. 17. Answer 2: One of the primary problems of early nineteenth-century hospitals was poor hygienic practice. Hospitals were dirty and overcrowded and care was mostly given by untrained persons. 18. Answer 4: The population is aging rapidly and people with chronic illness are living longer. There is an increased need for nursing services for this growing segment of the population. 19. Answer 3: “Nightingale Nurses” improved patient care and advanced the practice of nursing through good hygiene, sanitation, patient observation, accurate recordkeeping, nutritional improvement, and the introduction and use of new equipment. 20. Answer 1: The four major concepts are nurse, patient, health, and environment. 21. Answer 4: Poverty, homelessness, and unemployment are barriers to accessing health care.

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22. Answer 2: Physiologic needs, such as eating and oxygenation, are the first priority according to Maslow. 23. Answer 4: Adolescence is time when love and belonging to a peer group are very important. Being part of a team is the best way to help him meet this need. 24. Answer 1, 3, 5: Patient can participate in smoking cessation; stress, weight, and alcohol intake reduction; and control over own body and health. Giving information about technology, new medications, and costs may be of interest to the patient, but these topics are less useful in helping the patient take an active role in her own health. 25. Answer 4: Unlicensed assistive personnel (UAP) are trained to assist patients with activities of daily living. The unit secretary orders supplies using electronic or hardcopy requisition forms. While the UAP or unit secretary can direct visitors, extreme caution should be used in giving out patient information. (Note to student: Even acknowledging that a patient has been admitted to the hospital can be viewed as a violation of confidentiality.) Taking vital signs is acceptable; however, the pharmacist generally restocks medications. Validating and interpreting are nursing responsibilities. 26. Answer 2: Economical use of time and materials is the best way to contain costs for individual patients. Malpractice insurance does not help to contain costs. While it is appropriate to question the HCP about safety issues, it is not appropriate to question use of diagnostic testing. Diagnosis is an extremely complicated process, which requires an extensive knowledge about pathology. Referring patients to another clinic shifts the financial burden to another part of the health care system. 27. Answer 1: Orem’s theory is based on helping the patient to attain self-care. Nightingale’s theory uses manipulation of the environment (i.e., patient’s pillows). Benner and Wrubel demonstrate caring by assisting the patient to cope. Parse’s theory encourages the patient to participate in the health experience. 28. Answer 1, 2, 3, 4, 6: Under the terms of this document, patients are assured that they can expect high-quality hospital care, a clean and safe environment, involvement in their care and the decision-making process, protection of privacy, help when leaving the hospital, and help with billing concerns. Patients cannot

always expect to get a private room with all amenities. 29. Answer 3: Health care workers are entitled to respect from patients and also expect patients to be responsible for their own behavior. 30. Answer 3: LPN/LVNs never independently alter the plan of care without the supervision of an RN. 31. Answer 4: For primary prevention, the nurse would encourage wellness activities and preemptive screening programs such colonoscopy or glucose screening. Secondary prevention recognizes the presence of disease but seeks to reduce the impact of the condition by encouraging behaviors to promote health, such as dietary modification for recurrent hyperglycemia. Tertiary prevention is applied by managing care for those with serious health problems with the goal of improving the quality of life and reducing further loss of function. Critical Thinking Activities 32. :HOOQHVV +LJKHVW OHYHO RI RSWLPDO KHDOWK

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This patient has some health problems and some changes in her life, but she has a relatively high level of wellness. Her blood pressure is under control and she has adapted to a major change (retirement), by taking on a new challenge of volunteering. Her positive outlook on life allows her to find joy in the prospect of sharing time with a new generation. 33. a. Originally, the white pleated cap and the apron signified respectability, cleanliness, and servitude. Caps gradually became symbolic of office and achievement and were celebrated with capping ceremonies. Uniforms became more informal and nurses complained that caps interfered with care, caused hair loss, took too much time for washing and starching, and were a source of bacteria. Health care facilities and nursing schools typically have dress codes for style of uniform and/or color. Staff members are generally required to wear nametags and identification badges. Many nurses do not approve of mandatory dress codes. They argue that other health care professionals do not depend on uniforms for their authority.

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b. It is likely that as a nursing student and a soon-to-be nurse that looking professional is important to you. You may feel anxious to be rid of your current student uniform for a variety of reasons. Freedom of choice, unattractive style, and not being marked as a student are frequent reasons cited by students. From the patients’ point of view, they feel more comfortable and confident when they are easily able to distinguish nurses from other staff members. Next-Generation NCLEX™ (NGN) 34. a. Answer 1 d, 2 i, 3 e, 4 c, 5 f, 6 a, 7 b, 8 g, 9 h: Registered nurse (RN)—provides direct patient care in the hospital and an RN from a home health agency would also be involved in the care of this patient. LPN/LVN—works under the supervision of the RN in providing patient care. Physician or other HCPs—uses results of diagnostic testing and physical assessment to determine the medical diagnosis and prescribes treatment and medications. Social worker—provides counseling and referral to community resources. Physical therapist—teaches and monitors exercise and will assist this patient in learning techniques for safe ambulation, bending, and lifting. Dietitian—provides nutritional counseling. Respiratory therapist—supervises oxygen administration and performs pulmonary assessments. Unlicensed assistive personnel—assists the patient in the hospital and at home with bathing and other activities of daily living. Financial counselor—assists the patients in understanding the hospital bill and to make arrangements for paying out-ofpocket costs.

CHAPTER 2—LEGAL AND ETHICAL ASPECTS OF NURSING Matching 1. c 2. e 3. a 4. b 5. d

Multiple Choice 6. Answer 4: The student has initiated the nursepatient relationship and therefore has the duty to act. All students are cardiopulmonary resuscitation (CPR)-certified so the student has to perform the duty in a reasonable and prudent manner as would other nursing students. All of the other options are also likely to be necessary. (Note to student: Discuss this situation with your clinical instructor for advice about visiting patients during the preclinical preparation time.) 7. Answer 4: A poor nurse-patient relationship increases the likelihood that the patient will seek legal action and harm has to occur for liability to be established. The family of the older patient could seek damages, but that is less likely if they understand that the nurse and facility will try their best to prevent falls but are unable to physically restrain patients for the purpose of preventing falls. The angry patient may report the nurse to the supervisor, but if no harm is sustained, then any legal action against the nurse will not be successful. The family who complained at 3:00 am may also be very angry. The nurse’s decision to wait must be based on comprehensive assessment of the patient to ascertain that there is nothing to warrant calling at 3:00 am. Careful documentation is necessary. Making an incident report in all of these situations would be a good idea. 8. Answer 1, 2, 3, 4, 6: In a health care–related case, items may include policies and procedures, standards of care, medical records, assignment sheets, personnel files, equipment maintenance records, birth certificates, marriage certificates, medical bills, and other documents pertinent to the issues at hand. The UAP’s personal health records are confidential and unrelated to the patient’s case. 9. Answer 2: Early discharge and high levels of patient acuity require excellent discharge teaching so patients can perform self-care and self-monitoring and are therefore less likely to suffer harm. Being able to take a limited number of high-acuity patients would be ideal, but high acuity is the current trend. Having malpractice coverage is good if litigation occurs; however, insurance payouts may actually be contributing to the problem. Ensuring accountability of others is not possible. 10. Answer 1: Assess knowledge and readiness to perform. Barriers may include knowledge

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deficit or feelings of anxiety or self-doubt. Going with her and observing performance and pulling her file would be appropriate after assessment. Directing someone to do a task that is beyond his or her ability and understanding is inappropriate supervision and the nurse would be liable for the UAP’s performance. 11. Answer 2: The first action is to locate the RN in charge so that the blood can be started. HCPs can supervise nurses and they know the potential adverse reactions of blood products; however, they are generally less familiar with the policies and procedures related to the actual administration. Explaining the policy is appropriate, but the priority is patient care. 12. Answer 1, 2, 3, 4: Do not include any information that identifies the patient. Information such as the room number or the HCP’s name may seem harmless but including those details could lead to speculation about the patient’s identity. A clinical report must include information such as vital signs and medical condition. If in doubt, the clinical instructor should be consulted. 13. Answer 1: Patients must be at least 18 years old to give consent. If younger than 18, the exceptions are marriage; court-approved emancipation; self-supporting and living apart from parents; military service; or for sexually transmitted infections, alcohol or drug abuse, sexual assault, or family planning. 14. Answer 3: Policies about giving patient information over the phone will vary. For example, some facilities may not allow acknowledging that the patient is or is not there. Other facilities require that the patient have a list of people who are allowed to call for information. Another variation is that selected callers are given a phone code to reach the patient. The nurse should be familiar with hospital policy, because the policies are designed to specifically comply with Health Insurance Portability and Accountability Act (HIPAA). 15. Answer 3: Alert the HCP so the child can be examined for occult injury. The other options may also be used to investigate the possibility of child abuse. 16. Answer 2: Good Samaritan laws offer limited liability, except in cases of gross negligence. A prudent nurse would know that moving a trauma victim could result in spinal cord injury. Initiating cardiopulmonary resuscitation, using available material to control bleeding

and calling for help first are appropriate emergency actions. 17. Answer 1: Being competent and compassionate are the best defenses. Knowing the legal definition may be helpful, but definitions are abstractions and the nurse’s day is full of realworld events. Obtaining malpractice insurance is likely to make the nurse feel better, but it does not decrease the chances of getting sued. Validating nursing actions with another nurse is always beneficial, but this is not a realistic option for minute-to-minute care. 18. Answer 2: The nurse is assessing the wound during the dressing change and documentation should reflect the nurse’s attention to the standard of care. Documenting the type of dressing may be necessary for continuity of care and also for reimbursement. The other options are incorrect. 19. Answer 4: Disciplinary defense insurance includes attorney; wage loss reimbursement; travel, food, and lodging expenses; and legal fees when the nurse has to go before the board of nursing for disciplinary action. The other types of insurance are for malpractice protection. 20. Answer 4: Regardless of years of experience, nurses should always seek instruction and supervision for any unfamiliar procedures or practices. Asking to be reassigned could be an option if there is no time or personnel available to supervise the new nurse. Reviewing the procedure might be an option if the nurse is confident that the information is sufficient to ensure safe performance. Giving feedback about orientation might be useful to improve the orientation program, but it is not possible to cover all skills and all patient situations during orientation. 21. Answer 1: First, assess the patient’s feelings by encouraging expression. The patient may not understand the advance directives or may have issues that were triggered by the discussion. The other options are also necessary. 22. Answer 2: The patient’s living will is the best protection, because it reflects the patient’s wishes. Policies and procedures and the Joint Commission may contain general guidance about giving excellent care to patients, but will not offer any specific help in this situation. The Patient Self-Determination Act supports the use of living wills to define the individual’s choices about care and treatment.

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23. Answer 4: The nurse, the 13-year-old girl, and the mother all have very strong feelings about this emotional situation. First, the nurse must reflect on and assess own values and responses. The other options are likely to be necessary, but this will be a difficult process and other health care team members such as a social worker, family counselor, spiritual advisor, legal counsel, or obstetrician are likely to be involved. 24. Answer 1, 2, 3, 5: If the nurse observes another nurse being rude to a patient, the ethical thing to do would be to follow up so that patients are respected. Texting should not be used as an additional method of passing gossip among staff. The other options demonstrate ethical professional behavior. 25. Answer 3: The supervisor should be presented with the facts. Theft is unethical and older residents are in an especially vulnerable position; thus, Nurse B is not giving good care. Talking to the residents or families will be part of the investigation that is conducted by the supervisor. The supervisor could recommend that both nurses seek assistance for values clarification. 26. Answer 3: First, Nursing Student Orange would give Apple the opportunity to take responsibility to discuss the incident with the instructor. Using social media in this manner is unethical. It is also a HIPAA violation that could result in dismissal from the nursing program or a lawsuit. Details of patient care should only be shared with other health care workers who are involved in the direct care of the patient. If Student Apple refuses to inform the instructor, then Student Orange is ethically obligated to report this misconduct. 27. Answer 4: The nurse should encourage the patient to express feelings and thoughts related to a situation without contributing personal opinions. The nurse must be aware of cultural differences and should avoid: (1) transferring personal expectations to patients; (2) making generalizations based on personal views; (3) assuming patients can understand what is being said just because they speak English; and (4) treating each patient the same. 28. Answer 4: Nonmaleficence means to do no harm. The nurse seeks to prevent harm from a high dose of medication by clarifying the prescription with the HCP. Providing care for all patients regardless of financial, social, or ethnic factors demonstrates the principle of justice. Advocating for the good of the patient

demonstrates beneficence. Encouraging independent decision-making exemplifies the principle of autonomy. 29. Answer 1, 2, 4, 5, 6: The nurse must know the signs and symptoms of abuse, which are often hidden or subtle. Declines in health or physical abilities and loss of support and independence cause feelings of helplessness. The older adult may be reluctant to report abuse for fear of reprisal or loss of caregiver support. Age of caregiver does not a predict abuse. 30. Answer 4: Careless handling of hard copies of notes, documents, charts, reports, etc., is a potential HIPAA violation because all patient information should be safeguarded. Only team members who are directly involved in a patient’s care should have access to information. The breakroom is for the nursing staff; however, there may be some people who are allowed to enter the breakroom (e.g., nursing students, housekeeping staff, friends or family of nursing staff) but are not involved in the direct care of the patient. 31. Answer 3: The nurse would offer to witness that the patient is signing the consent and is aware of the treatment, risks, alternatives, and consequences of accepting or rejecting care. The surgeon is required to disclose the risks or benefits involved with the treatment or procedure. Ideally, the nurse should accompany the surgeon during the explanation and the form should be signed at that time. If the surgeon is hostile or rejects the nurse’s offer of witnessing, the nurse would ask the charge nurse to clarify how nurses are dealing with the consent forms. It is possible that surgeons are explaining the procedures and the nurses are later assessing the patients’ understanding and contacting the surgeon if the patient has additional questions or needs clarification. If the patient has no questions, the nurse will then ask the patient to sign the form; however, this is not the best situation for the nurses. The nurse could also discuss the process with a nursing supervisor because the nurses may be at risk for practicing outside scope of practice. If a patient later claims misunderstanding, the involved nurse could be liable if the patient suffers harm from the procedure. 32. Answer 2: Battery is unlawfully touching another person without informed consent. The nurse who leaves a patient without giving handover report could be charged with abandonment, if the patient sustains harm.

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Falsifying documentation could be used by the plaintiff in a malpractice suit. Gossiping that results in ruining a person’s reputation is defamation. Critical Thinking Activities 33. a. Further assessment is needed to determine the underlying motivation for the action of these two nurses. It appears that Nurse A is reluctant to care for “those kinds of people” and the code specifies that the nurse should provide care without discrimination. Assessment of Nurse A’s behavior may reveal that she lacks the confidence or skills to care for AIDS patients; thus, additional training is needed. Possibly, the death of a close friend from AIDS may have created an emotional barrier and thus she may need grief counseling. Nurse B is attempting to help Nurse A, which is a laudable action; however, to maintain a high degree of personal and professional behavior, which is also part of the code of ethics, Nurse B should talk to Nurse A about the comment, rather than ignoring it. b. Nurse B should initiate the process of values clarification, either by herself or with assistance from a counselor or supervisor. This process includes thinking about a belief or behavior, deciding its value, and incorporating the value into a response. Nurse B could talk directly to Nurse A to see if Nurse A is actually discriminating against a certain type of patient or if there is some other problem such as knowledge/ skills deficit. Nurse B may also decide to report Nurse A’s unethical behavior by following the appropriate chain of command, explaining the facts clearly, and documenting the incident objectively and accurately. 34. a. First, the nurse needs to involve other members of the health care team, such as the HCP and the psychiatric social worker. Physical causes for depression or changes in cognition should be investigated, as well as psychological causes of depression. A psychiatrist or psychiatric clinical nurse specialist should assess the patient for signs of suicide. If the patient is deemed of sound mind, then he has the right to refuse care. The Patient Self-Determination Act requires that institutions maintain written policies and procedures regarding advance directives (including the use of life support if the

patient is incapacitated), the right to accept or refuse treatment, and the right to participate fully in health care–related decisions. b. When a patient refuses care, the nurse may experience a personal feeling of rejection. The nurse has to recognize that refusal of treatment is not a refusal of interaction or compassion. It may be difficult, but the nurse should continue to check on the patient as before and to spend as much time as before, but the focus may shift from task orientation to therapeutic communication. And of course, the patient always has the option to change his mind and accept selected elements of care. c. For nurses, this is an ethical dilemma. The refusal of heroic measures is often easier to accept because many nurses themselves do not want to be kept “alive by machines.” However, it seems cruel and inhuman if basic needs like food or hygiene are not provided. Nurses have worked for centuries trying to prevent pressure injuries and to improve patient outcomes. Nurses may also believe that immunization is partially for the protection of the individual, but also for “herd immunity.” Nurses are trained to be problem-solvers and doers. Doing nothing for the patient may seem difficult but remember that supporting the patient emotionally and psychologically is also a nursing function. 35. The nurse has gone up the chain of command and reported her concerns to the supervisor; however, the nurse could still be involved in a legal action if there is an occurrence where a patient is harmed. The nurse could report the conditions to the state board of nursing, but change is likely to come slowly, if at all. The nurse may opt to make personal notes or incident reports related to working conditions or discussions with supervisors. The ethical implications are that the nurse is employed in a situation that is constantly putting the patients at risk; however, in some ways, if the nurse opts to quit and seek another job, then the patients have lost an advocate and a caregiver. In addition, this scenario is not uncommon and could occur in other facilities. If the nurse opts to stay, then teamwork is especially important under these conditions and watching out for each other and all of the patients becomes more important when everyone is tired and stressed.

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Next-Generation NCLEX™ (NGN) 36.

Actions and Events

Duty

7:00 RN assigns LPN/LVN to monitor an IV potassium infusion prescribed to infuse over 4 hours.

7:45 Patient reports pain (1/10) at the site. LPN/LVN assesses the site and says, “Potassium is irritating to the veins, some discomfort is expected.”

8:30 Patient reports that pain (5/10) is increasing. LPN/ LVN observes redness around insertion site, flushes IV with normal saline and notices that slight swelling occurs during flushing. Warm pack applied and nurse says, “Everything is fine. The warmth will relieve the pain.”

Breach of Duty

Harm

10:00 Patient reports severe pain (9/10). Redness and swelling are markedly increased. LPN/LVN stops infusion and notifies the RN. Several days later, extensive necrotic tissue damage is noted. The HCP informs the nurse manager that there may be permanent scarring or nerve damage.

Proximate Cause

The LPN/LVN agrees to accept the task and duty is established. At 7:45, duty is met. The nurse performs the assessment and gives accurate information (potassium infusions can be irritating and uncomfortable) and the patient’s discomfort is minimal. At 8:30, a breach of duty occurs. The nurse observes redness and then flushes the IV with normal saline. Swelling after flushing indicates a problem; the saline is getting pushed into the tissue rather than flowing through the vein. Pain has increased and redness suggests tissue irritation. At this point, the LPN/LVN should have reported findings to the RN and referred to a procedure manual or talked to the RN before applying a warm pack (warm packs are used for some infiltrations but depending on the drug or fluid, a warm pack may worsen the damage). At 10:00, the nurse recognizes and reports the problem, but tissue damage has occurred as a result of the IV infiltration. Several days later, permanent harm is obvious; thus, all four criteria for liability are present.

CHAPTER 3—DOCUMENTATION Matching 1. d 2. i 3. f 4. j 5. g 6. h 7. b 8. c 9. a 10. e Short Answer 11. Home health care and long-term care documentation are directly related to

reimbursement because patients’ eligibility and services provided by the nurses must be documented to justify payment by Medicare, Medicaid, or private insurance companies. The charting is not usually done on the same time schedule or with the same frequency as that of the acute care facility. An interdisciplinary approach must be documented in the notes along with evidence of compliance with state and federal regulations. For home health care, nurses carry written records with them or use a laptop computer to maintain patient documentation. Table Activity 12. See Table 3.1, Essential Elements of Documentation.

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Multiple Choice 13. Answer 4: When making a late entry, the nurse would note it as a late entry and then proceed with the notation; for example, “Late entry _______________,” or as dictated by facility policy. 14. Answer 2: In charting by exception, complete physical assessments, observations, vital signs, intravenous (IV) site and rate, and other pertinent data are charted at the beginning of each shift. During the shift, the only notes the nurse will make will be for additional treatments done or planned treatments withheld, changes in patient condition, and new concerns. Focus charting uses the nursing process and the focus is sometimes a current patient concern or behavior, and sometimes a significant change in patient status or behavior, or a significant event in the patient’s therapy. DARE (data [D], action [A], response and evaluation [R], and [E] education and patient teaching) is one acronym that is used in focus charting. Narrative charting is an abbreviated story form of patient care. It is used for both computerized and noncomputerized nurse’s notes and includes subjective and/or objective data, consultations, care and treatments, and response to therapy. Some facilities require a minimum of three entries and a flow sheet for narrative charting. In acute care facilities (e.g., hospitals) taking vital signs every 4 hours and increasing frequency as needed is common practice regardless of the documentation system that is used. 15. Answer 1, 2, 3, 4: The five basic purposes for accurate and complete patient records are: (1) documented communication, (2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5) research and data collection. The nurse would not interpret or discuss the HCP’s notes with the patient. If the patient does not understand the medical diagnosis, the nurse would assist the patient to formulate a list of questions and then contact the HCP to talk directly with the patient. 16. Answer 1: A peer review is an appraisal by professional coworkers of equal status. Peer review appraises the way an individual nurse conducts practice, education, or research. Journal articles frequently undergo peer review. Queries or clarification of orders or prescriptions should always occur if the nurse has a question. This is standard practice and nurse would not anticipate any type of review.

Incident reports are reviewed by nurse managers and risk managers so errors can be identified and corrected. Routine charting can be randomly audited for quality assurance, assessment, and improvement. 17. Answer 4: Narrative notes should include a complete description of the patient’s response to any therapies. As a student, you write evaluation statements on a care plan, but in the hospital, it is unlikely that you will see the actual care plan format that you use in school. The Kardex is a tool that outlines therapies, orders, and activities, but there is no space for documentation of outcomes. Medication administration times are recorded on the medication administration record, but usually there is no space for additional notations. 18. Answer 3: Documentation can always be improved; however, it is particularly important to document patient condition on discharge and any follow-up instructions. If the patient goes home and immediately dies, the nurse, who is the last professional to see the patient, has made no note to indicate that the patient was stable on leaving the hospital. 19. Answer 2: In a large hospital, there could be many employees who would have a legitimate reason to look at the patient’s chart; however, for document security and patient confidentiality, the nurse is obligated to question any unfamiliar person. If the person identifies self and the nurse is still not sure if access is appropriate, the charge nurse or security could be contacted for advice. 20. Answer 4: Computer access and time for documentation can always be a problem, so making notes for personal use is an alternative. The student can always ask the instructor for advice, but there is nothing the instructor can do about lack of functional computers. Hardcopy charting is usually reserved for total system shutdown for prolonged periods of time. Waiting until the end of the shift is never the best option. 21. Answer 3: The nurse would meet the patient’s immediate need for the medication. Since the vital sign data are missing, the nurse applies nursing process and assesses the blood pressure (BP) and pulse before administering the medication. Then the nurse documents the BP and pulse and the administration of the medication. Next, the nurse would find the UAP and ask about the vital signs. (Ask about other patients too; the UAP should have finished and

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recorded all am vitals by 10:00 am.) Giving the medication without knowing the BP is an incorrect action. If the UAP recorded the vitals in the narrative notes, he/she may need additional training, because this is not the best place to document routine vital signs. 22. Answer 2: If the nurse is clear about the orders, it would be appropriate to carry them out. If there are questions, the nurse should call the HCP for clarification. Later, consult a supervisor about HCP’s response; ISBARR is a relatively new concept and some HCPs may need some additional instruction about the process. Documenting the HCP’s behavior in the patient’s chart is not appropriate. The nurse may opt to do so in an incident report because this is a potential safety problem. 23. Answer 3: The charge nurse can determine the corrective action, which may include referral to the nurse educator. Coworkers do not have time to teach basic spelling and grammar to other employees. All health care professionals are obligated to watch out for each other and the patients; therefore, doing nothing is incorrect. The nurse can correct (not change) his/her own documentation, but not the documentation of others. 24. Answer 3: Documenting the time that the patient is in radiology explains why the medication was not given on time. Consult the charge nurse because there are certain medications that should not be held for prolonged time periods. Interventions and therapies should be documented after they are completed, not before. Calling the pharmacy is okay, but the student will have to take additional steps after talking to the pharmacist. An incident report is not needed at this time if steps are taken to resolve the situation. (Note to student: Some facilities may require an incident report for any delay in medication administration.) 25. Answer 1: Clinical (critical) pathways allow staff from all disciplines to develop standardized, integrated care plans for projected length of stay for specific and predictable cases. Dayto-day elements of care such as activity and pain control are laid out. Unusual events with potential for harm or those that cause actual harm are usually documented in an incident report. The pathway is a multidisciplinary care plan. The LPN/LVN has a role in monitoring and documenting, but professional roles are not specifically written out in the pathway.

26. Answer 3: The nurse manager will have knowledge of policies related to medical records and leaving the hospital prior to discharge. The records are hospital property, but this explanation is likely to cause the patient to become more upset. Contacting the HCP may be appropriate to address the patient’s desire to leave the hospital, but the HCP is not the best resource to contact for requesting records. Copying the chart for the patient is incorrect because policies need to be reviewed and followed. 27. Answer 4: Contact the nursing instructor for guidance. Immediately shredding the Kardex copy or checking for patient identifiers at this point does not address the problem. Apologizing and explaining may seem like the best route, but the student should seek out the instructor first. This is a serious HIPAA violation that could result in disciplinary action or even a lawsuit for the student and the instructor. 28. Answer 1: For paper charting, draw a line through the error and initial it. Generally, there is no need to report this type of error to the charge nurse unless there is some unusual occurrence. Using correction fluid is incorrect. Discarding the page is a possibility if the nurse is the first and only person to make an entry on that page. 29. Answer 1, 2, 3, 4: Failure to completely document allergies puts the patient at risk for severe allergic reactions that could result in death. Using patient quotes may be appropriate for describing symptoms or conditions, but complaints about care or caregivers would be documented in an incident report. Documenting medication that is not given is falsification. Failure to document assessment of the IV site indicates low quality of care (even if there was no actual problem with the IV site). Clustering information is a common and acceptable method of documentation. It would be better if the generic and brand names are written in prescriptions; however, if the meaning is clear, legible, and accurate, the recording is acceptable. 30. Answer 2: If the computer monitor is left open, anyone who walks by can look at the information. In addition, an active login allows anyone to go into the system under the nurse’s password. The other actions are acceptable ways to pass information to other health care team members. 31. Answer 3: First, the nurse would call for clarification of the abbreviation. Then the nurse could correct the prescription by rewriting;

Answer Key

noting that it is a phone order. The pharmacy can then be called to deliver the medication. If the HCP repeatedly continues to use inappropriate abbreviations, the nurse may decide to report the behavior to the charge nurse. 32. Answer 2: First, the nurse would observe for adverse effects and then notify the prescribing HCP. An incident report is also required. After contacting the HCP, the nurse may also use the other options. 33. Answer 4: The LPN/LVN would consult with the charge nurse. Acuity level 1 is the highest acuity and this type of patient is generally assigned to an RN. There may be an issue with staffing shortages, or the charge nurse may feel confident that the LPN/LVN can manage the patient. However, the LPN/LVN has the responsibility to voice concerns if the assignment exceeds abilities or scope of practice. 34. Answer 1, 2, 4, 5: Sharing passwords, leaving a computer terminal unattended, allowing visitors to view a monitor and taking hard copies of patient data are violations of guidelines for safe computer use. If an entry is made on the wrong chart, the charge nurse can give guidance about how to correct the error. Critical Thinking Activities 35. Sample #1: Day of month and time of entry are missing. “Good night” and “status unchanged” are empty, general phrases. There is one spelling error: escendially should be corrected to essentially. Rather than charting diamond ring and gold watch, use descriptive adjectives, such as clear, white, or yellow. Also, documenting that expensive items are being stored in the bedside table creates liability for theft or loss. Patient’s condition, the time, and the method of transportation to the cafeteria are missing. Sample #2: Generally charting for another nurse is not done. (Note to student: Charting the actions of another team member could potentially be done in an emergency situation where many tasks are simultaneously being performed and one nurse is the designated recorder.) “SSE” and “CC” are not approved abbreviations. There are two spelling errors: adominal distencion should be corrected to abdominal distention. Sample #3: Time of entry is missing. Full assessment of pain is missing. Statement indicating blame, “HCP made error,” should not be used. Inappropriate follow-up action is recorded (i.e., the appropriate follow-up is to call

the HCP for clarification). Patient’s complaint about care and quoted remark should not appear in nurses’ notes (this type of information is documented in an incident report). Time of pain medication is missing and there is no note about response to medication. Signature of nurse is missing. 36. The electronic health record and hardcopy systems provide a permanent legal record of past and current medical and nursing problems, plans for care, care given, and the patient’s responses to various treatments. Both are used for cost reimbursement and quality assurance and improvement. EHR eliminates repetitive entries and it is easier to locate and retrieve the data. Generally, EHR increases efficiency, consistency, accuracy, and legibility and decreases cost. EHR has created new issues related to safeguarding patient confidentiality and additional training is needed for new employees and whenever the software is upgraded. Access to functional computers can also be an issue. Hardcopy charting is less common, especially in large hospital settings; however, hardcopy can be easier to read than a computer screen. The hardcopy system can also be easier to navigate when documenting the atypical situation (i.e., patient’s situation or the event does not seem to fit into the computer’s checkbox style of organization). Next-Generation NCLEX™ (NGN) 37. Answer a, c, d, e, f, h: Nurses must document all their services for payment (e.g., direct skilled care, patient instructions, skilled observations, and evaluation visits). The nurse must document in detail any procedures, treatments, or medications administered and response to these interventions. Patient education and demonstration of learning must be documented. Documentation must also reflect coordination of services by all members of the health care team and evidence of compliance with regulations. Comments made by the patient or daughter about the care or specific team members can be discussed by the team but would not be recorded to meet the requirements for Medicare, Medicaid, or other insurance. The daughter’s request for vacation coverage is understandable, but the family may have to pay out-of-pocket if the patient is ineligible for Medicare, Medicaid, or other insurance

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Answer Key

coverage. The patient’s eligibility for home care must be thoroughly assessed and documented.

CHAPTER 4—COMMUNICATION Multiple Choice 1. Answer 2: The term “patient problem statement” (nursing diagnosis) is jargon of the nursing profession and it is used primarily in discussions about the care plan between nurses (or nursing students). The formal language of nursing diagnosis is rarely used during handoff report. Other members of the health care team (e.g., HCPs, pharmacists, technicians) may or may not understand the term. It best to avoid jargon when talking to patients and family. 2. Answer 3: Eye contact for 2 to 6 seconds is the best method. Extended eye contact may cause the patient to become anxious, especially during a discussion about sexuality. If the nurse looks downward when the patient uses profanity or slang terms, this may indicate rejection or disapproval to the patient. It is appropriate for the nurse to observe the patient’s behavior, but in this case, mimicking the patient’s pattern of eye contact (i.e., staring or refusal to look up) would not facilitate communication. 3. Answer 2, 3, 5, 6: Signals of inattention include attending to others, manipulating objects in the environment, and giving advice before the student has finished speaking. Ideally, the instructor should welcome the student, indicate time constraints, shut the door, and give the student full attention by appearing relaxed and asking open-ended questions. 4. Answer 4: The nurse would first try to use normal volume and a lower tone of voice. Talking to the spouse is an option if nothing else works, but there is an issue of privacy and the spouse is not able to describe the patient’s subjective experiences (e.g., pain). Directing speech toward the better ear is good strategy, but shouting should be avoided. Using simpler language and avoiding use of medical terminology is a general strategy that applies to all nurse-patient interactions, but it does not directly address the issue of hearing impairment. 5. Answer 2: The nurse must assess the patient for suicidal intent. Based on the assessment, the nurse would explain the obligation to report suicidal intent/behaviors. Thanking the patient for the trust is appropriate, but intent to

harm self or others must be reported. Staying with the patient is also appropriate, but direct questioning about intent is better than waiting and hoping for the patient to disclose. 6. Answer 2: The best method is to give report behind a closed door. Eliminating all passersby is almost impossible in busy care settings. Negative language should be eliminated from reports, but even positive reports should not be broadcast to anyone not directly involved in the patient’s care. Written notes do not guarantee confidentiality unless they are closely safeguarded and appropriately shredded. 7. Answer 4: Open-ended questions and twoway communication are the best ways to elicit feelings. Asking the patient if he is afraid is a closed question, this could also suggest to the patient that he should be afraid. Giving information or showing pictures creates a one-way information flow from nurse to patient and this doesn’t encourage the patient to speak out. 8. Answer 1: The nurse acknowledges the patient’s desire to go home, while providing an opportunity to assess (patient must also assess) ability to independently walk and function. The other options indicate that the nurse is agreeing with the patient’s verbal desire to go home and is ignoring the nonverbal grimace. 9. Answer 4: A notebook and a pen are typically associated with recording new material for later use. However, an optimistic nurse will remember that adolescents may demonstrate behaviors to get peer approval; thus, all of these students may be interested in the topic, and the cell phone or the bored expression may be less about the teacher or topic and more about the peer group. Use of the Internet is questionable. The adolescent may be searching for some information that will contribute to the class discussion; however, casually ‘surfing the net’ would be considered disrespectful to the instructor and to other students who are trying to participate. 10. Answer 4: The nurse checks to understand the patient’s concern. Option 1 is a closed question. Option 2 is about obtaining additional information. Option 3 is a validating response. 11. Answer 3: An open-ended question allows the patient to take the lead and provides an opportunity for the nurse to assess the patient’s worries. A closed question that directs the patient’s worries back toward the surgeon does not elicit explanation. The second-best response: the nurse makes a good guess about the patient’s

Answer Key

worries, but this is also a closed question. Offering to make the patient feel better is not realistic in this instance. 12. Answer 4: Use of closed questions is the best strategy for this type of patient interview. The other techniques will only prolong the discussion of irrelevant information. Focusing could also be used. 13. Answer 2: In expressive aphasia, the patient understands, but can’t verbally respond; therefore, eye blinks are an alternative. Encouraging the patient to speak is inappropriate at this time. Referring to family members is appropriate if they have knowledge of details that the patient cannot describe; however, do not leave the patient out of the communication loop. Hearing and understanding speech are not the issues. 14. Answer 1, 2, 3, 6: Method of addressing people, interpretation of time, touch, and eye contact are culturally based. Facial expressions and gestures such as hand-shaking and tone of voice also have a cultural context, so the nurse should investigate cultural norms before assuming that these are acceptable approaches. 15. Answer 2: Older adults may need additional time to process information or formulate a response. Speaking loudly and slowly is not necessary unless there is some hearing loss. Well-lit environments are preferred. Discouraging anecdotes or tangential communication may be necessary if there is an urgent need or if the nurse needs specific information. 16. Answer 3: The nurse paraphrases the patient’s statement. This indicates that nurse heard and interpreted the meaning. For the other behaviors/responses, the patient is not sure if the nurse understands what he/she is trying to say. 17. Answer 2: The nurse is reflecting patient’s feelings and then invites the patient to elaborate. Restating what the patient has said should be used sparingly; overuse sounds like parroting. Offering to review the instructions suggests that grasp of the knowledge will alleviate all problems. Suggesting that someone stay with the patient might be an option, but assessment of the patient’s circumstances would be done before offering advice. 18. Answer 1: Intimate space is from the face to 18 inches away; therefore, in assisting the patient to transfer, the nurse would have to touch the patient and should obtain permission first. Sitting in a chair would be within the personal

space of 18 inches to 4 feet. Speaking to the family or handling the patient’s belongings could also have cultural implications; however, these are less directly related to intimate space. 19. Answer 1: Asking about type of surgeries invites the patient to give an exact answer. “What kinds of problems?” and “How do you feel?” are very broad questions. The patient may be unsure what the nurse is asking about. “Are you having any pain?” is a closed question, which is okay, but requires several other follow-up questions to elicit relevant details. 20. Answer 2: The nurse should assess the underlying meaning of the patient’s comment (i.e., jokes might be hurtful, offensive, or inappropriate to the patient. Or the patient might like the UAP’s communication style.) Automatic superficial responses, making assumptions, or changing the subject are not therapeutic. 21. Answer 3: When talking to HCPs, the nurse uses assertive communication that conveys respect, but also communicates what is needed to safely care for the patient. The other responses are not in the best interest of the patient. Being aggressive toward the HCP may cause him/ her to hang up. Being nonassertive puts the nurse in the position of having no orders or guidelines to address the change in condition. 22. Answer 4: The nurse is acting like a physical bridge between the boy at the window and the two at the bedside. Using silence and being physically present are good interventions when a patient has died. Talking to the boy about feelings or directing him to come to the bedside may be premature. He may need a little time to process the death. At the same time, do not leave him isolated by grouping with the two at the bedside. 23. Answer 2: The nurse must do a quick assessment of her own feelings and decide whether she can be therapeutic with the patient. The patient’s nonchalance could mean many things and the young patient needs to feel that health care personnel are available to help. The nurse must care for a patient if there is no one else available but asking another nurse would be appropriate if the situation is not urgent and the nurse continues to feel hostile towards the patient. Expressing concern is a possibility, but the nurse and the patient must have a well-established trusting relationship, and when expressed, the concern should be patient-centered.

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24. Answer 4: The nurse is newly graduated and wants to have good relationships with coworkers and to see that the patients get good care. Honest praise is a good way to establish trust in coworker relationships. Once trust is established, the nurse could be more confrontational with UAP. Role-modeling is one way to gently redirect behavior. Gaining more experience is good, but don’t mimic questionable behavior. Speaking to the RN is a possibility, but true disrespect may not be the issue, so assessment of behavior should precede going to the RN. Everyone may seem happy, but residents in long-term care facilities frequently feel that they have to get along because there is no other option. 25. Answer 2: First assess the patient to determine if there is an issue with social isolation. Also remember that hearing-impaired patients may have problems if there is excessive background noise, so he may actually hear better in his own room. Based on the assessment, the other options could be considered. 26. Answer 1: Commenting on the weather is a common topic; for the unresponsive patient, it serves to orient to time and season. The nurse would remind the silent UAP to assume that the unresponsive patient can hear, so care actions are explained. The other UAPs would be reminded that the patient is at the center of the communication, so discussion of work schedules or personal disclosures are inappropriate. 27. Answer 4: The nurse would assess the patient’s ability (e.g., cognitive level, literacy, visual acuity, consciousness level, primary language, gross motor skills, and fine motor skills). Based on the assessment, a method, such as a

communication board, computer, or a signal system for yes or no is selected. Critical Thinking Activities 28. Environment—the nurse is experiencing an overload of distraction from a variety of sources. The nurse’s posture and position (crossing the arms over the chest) and the space and territory (standing too far away and by the door) convey impatience. The message to the patient is “I do not want to communicate with you.” Any trust between the nurse and patient is destroyed. “Dear” is used less by younger people and possibly the nurse may view “dear” as condescending. The patient may be experiencing unresolved grief over the loss of husband (recall that she is a widow) or stress related to hospitalization. The patient could also be having a physiologic problem such as fever or an electrolyte imbalance, which has triggered confusion or hallucinations. Cultural differences and use of language could also be factors. For example, the patient may not be able to directly express fears and concerns, so repeatedly uses the call bell to get attention. 29. See Table 4.4. We all use responses that block communication, so do not judge yourself to be a poor communicator if you have numerous examples. On the other hand, if you cannot think of any examples where you used responses that blocked communication, you may need to increase awareness of what you are saying and how others are responding to you. Conscious use of communication responses and the effect that responses have on others allow us to intentionally improve our therapeutic communication.

Next-Generation NCLEX™ (NGN) 30. Action

Essential

Collaborate with an occupational therapist. Avoid patronizing phrases.

Nonessential

Contraindicated

Answer Key

Problems with communication create frustration for the patient. Assessment of cognitive level, literacy, visual acuity, consciousness level, primary language, gross motor skills, and fine motor skills would be the first step. Patient-centered care includes giving the patient time to understand, maintaining dignity, offering alternative methods, and considering the patient’s interests and readiness. A speech therapist would be consulted for speech problems. An occupational therapist could be consulted if alternative methods, such as computer-assisted devices are selected. Speaking loudly is not necessary if the patient has normal hearing. Comments would be directed toward the patient. If the patient is currently using “yes” and

“no” responses, support the behavior until he shows readiness to attempt speech.

CHAPTER 5—NURSING PROCESS AND CRITICAL THINKING Figure Labeling 1. a. Acute pain: Physiologic b. Insufficient cardiac output: Physiologic c. Situational low self-esteem: Esteem d. Potential for injury: Safety and security e. Ineffective relationship: Love and belongingness f. Hopelessness: Self-actualization

Table Activity 2. See Table 5.2 for additional examples of determination of significant cues. Determination of Significant Cues Patient Values

Normal Range

Conclusion

10-month-old child not babbling

Babbling usually starts at 9 months

Babbling delayed

38-year-old patient with potassium 6 mEq/L

3.5-5 mEq/L

Above normal limits (hyperkalemia)

45-year-old patient with Glasgow Coma Scale score of 15

15 is normal; score of <8 is severe brain injury

Brain functioning within normal limits

22-year-old patient with blood pressure 120/76 mm Hg

<120/80 mm Hg is normal

Within normal limits

Male adult with sodium of 130/ mEq/L

135-145 mEq/L

Below normal limits (hyponatremia)

Adult female patient with hemoglobin of 12 g/dL

12-16 g/dL

Within normal limits

65-year-old patient with 4+ pitting edema of lower legs

1+ is barely perceptible; 4+ severe

Severe edema

28-year-old female with pulse of 55

60-100 beats/min

Bradycardia

Shout or speak loudly.

Give the patient time to understand.

Offer pictures or a communication board.

Direct comments toward family. Speak about topics of interest to the patient.

X X

Suggest speaking, rather than relying on yes/no responses.

Short Answer 3. a. Uses patient or a part of the patient as the subject of the statement b. Uses a measurable verb c. Is specific for the patient’s problem d. Does not interfere with the medical plan of care e. Is realistic for the patient’s problem

f. 4.

a. b. c. d.

Includes a time frame for patient reevaluation Research Practice-generated data Clinical expertise Health care consumer values and preferences

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Multiple Choice 5. Answer 1: Performs is an action verb and twice a day is the parameter for measuring the performance. Knowing and understanding are internal processes for the patient. These goals must be revised so that the nurse can measure the knowledge and understanding. The nurse is performing the action and the patient is passive during “will be advised.” 6. Answer 4: The nurse makes an independent decision to gather data and to determine the schedule for bladder training. Nurse-prescribed interventions are actions that a nurse is legally able to order or begin independently. The other interventions are HCP-prescribed. 7. Answer 3: North American Nursing Diagnosis Association International (NANDA-I) uses standardized language that is recognized. It is used in all patient settings, including acute care hospitals, long-term care facilities, outpatient and ambulatory settings, rehabilitation facilities, and home care. Nursing Interventions Classification (NIC) lists interventions and activities. Nursing Outcomes Classification (NOC) includes scales to measure outcomes. Managed care and case management are systems that help with cost effectiveness. 8. Answer 1: Visual inspection is usually the first assessment and the nurse observes the dressing for blood or drainage. If the dressing is saturating through, the nurse would reinforce it because the surgeon usually removes the dressing for the first time. The nurse would check the blood pressure and pulse and assess the abdomen because postoperative patients have risk for hemorrhage or peritonitis. Ideally, the nurse would be monitoring the trends of the hematocrit and hemoglobin (H&H) to identify a problem before it occurs. (Note to student: slow bleeding will show progressive downward trend in H&H, whereas sudden acute bleeding would cause a sharp drop in H&H values.) 9. Answer 1: Chronic obstructive pulmonary disease is characterized by a lower-than-normal oxygen level, a higher-than-normal carbon dioxide level, chronic productive cough with thick secretions, fatigue, shortness of breath that worsens as disease progresses, and exertional dyspnea. Clubbing of the fingernails, barrel chest, wheezing, and dusky skin color may also be observed.

10. Answer 3: The HCP would prescribe diagnostic testing and medications and referrals for Alzheimer’s disease. The nurse would carry out the HCP’s prescriptions and use nursing interventions for the patient’s/family’s response to the disease process. The nurse will use nursing process/interventions to assist the other patients. 11. Answer 4: Nurse-prescribed interventions are actions that the nurse can independently determine and initiate. The other interventions require an HCP’s prescription. 12. Answer 2: If a patient does not achieve the projected outcome that is outlined in the clinical pathway, it is considered a variance. Variances are analyzed, and if there is a pattern of recurrence, the team will review the pathway and make revisions as needed. 13. Answer 4, 3, 1, 2, 5, 6: The six phases are assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. 14. Answer 1: Observing the patient’s abilities is an assessment that will guide the type of interventions that the nurse selects. Modifying a standardized plan is part of the planning phase. Taking the blood pressure after medication is evaluating the efficacy of the intervention. Assisting the patient to make a list of questions would be done during the intervention phase. 15. Answer 3: There are a number of conditions that could cause the patient to be pale, diaphoretic, and tachypneic. Based on the objective cues, the nurse would use critical thinking and conclude that respiratory (e.g., pulmonary emboli) and cardiac (e.g., myocardial infarction) causes would have priority over metabolic (e.g., hypoglycemia or infection) or renal (e.g., kidney stone) causes. Then the nurse will use a series of closed questions to try to determine the cause. In other words, chest pain suggests cardiac or respiratory problems. Fever and chills are related to infection. Difficulty sitting could be related to neurologic dysfunction, systemic weakness, or musculoskeletal problems. Asking about time of onset of symptoms helps to further clarify problem (e.g., onset after exertion). 16. Answer 3: Prioritize the problems/nursing diagnoses so that the patient’s health and safety are maintained; immediately intervene if necessary. The other actions are also part of a complete and comprehensive nursing care plan.

Answer Key

17. Answer 4: The decision to use an as-needed (PRN) medication is based on nursing assessment; therefore, the nurse would obtain a baseline assessment at the beginning of the shift and frequently reassess. The patient should also be instructed on how/when to use the call bell and the signs or symptoms of asthma that indicate the need for the inhaler. The nurse could ask the charge nurse if the prescription could be revised; for example, “use inhaler for respiratory rate > 30/min with subjective feelings of air hunger.” However, the charge nurse might also point out that all nurses should be familiar with asthma symptoms. Asking the patient about what triggers the asthma gives a clue as to when the inhaler might be needed. Leaving the inhaler at the bedside could be a strategy if the patient is very familiar with the onset of asthma and how to use the inhaler, but this option leaves the decision-making up to the patient. This patient is newly diagnosed and therefore needs more guidance and supervision. 18. Answer 1, 2, 4, 5, 6: All subjective, objective, historical (Note to student: opioid medication can cause constipation), and functional data related to bowel function are relevant for the problem of constipation. Flat, brown lesion near umbilicus is noted during physical assessment, but does not apply to bowel function. 19. Answer 2, 3, 5, 6: A focused assessment is advisable when the patient is critically ill or unable to respond. A focused assessment is also used to gather information about a specific health problem or a patient’s report of a sign or a symptom. A complete assessment must be done on all newly admitted patients and it involves a review and physical examination of all body systems and cognitive, psychosocial, emotional, cultural, and spiritual components and is appropriate for a patient who is stable and not in acute distress. Physical examination for a job should include all body systems. 20. Answer 3: Biographic data assists the health care team to identify potential risk factors. For example, the average 85-year-old man has different health issues than the average 3-year-old child. The other options are also true. 21. Answer 2: The nurse must gather and analyze data to make clinical judgments and determine appropriate nursing diagnoses/patient problem statements. In the past, nurses were not encouraged to make judgments, but rather were expected to follow the HCP’s orders/

prescriptions without question. HCPs identify disease and illness. Standardized care plans did evolve from the use of nursing diagnoses; however, standardized plans must be carefully evaluated to make sure that they are appropriate to the individual patient. Nursing diagnoses/patient problem statements are not intended to limit, but rather to reflect, the types of problems that the nurse can treat. 22. Answer 4: Being underweight and having difficulty with independent position changes puts the patient at risk for developing problems with the skin. In the other options, a problem with the skin already exists; therefore, skin integrity is impaired and requires additional interventions. 23. Answer 1: Edema would be a collaborative problem, because the HCP would identify the medical diagnosis that is causing or contributing to the edema and then prescribe medication or other therapies. The nurse would identify a patient problem statement such as fluid overload, and design interventions such as position change, review dietary aspects, and reinforce medication compliance. Assisting the patient with self-esteem, social isolation, and coping would be nursing responsibilities. 24. Answer 3: At discharge, patients should be given a copy of the medication reconciliation form. If the patient does not have the form, the nurse should obtain a copy from the discharging hospital for the patient. Because of confidentiality, the family should not have this form unless the patient gives permission. HCPs and pharmacists will also rely on the medication reconciliation form. 25. Answer 2: Palpating the abdomen to locate any rigidity or rebound tenderness would be part of the focused physical assessment related to the patient’s report of abdominal pain. The other assessments are appropriate for the headto-toe assessment that would be done at the beginning of each shift. 26. Answer 2, 3, 4, 5: Patients with Alzheimer’s disease will have many problems. Acute confusion should not apply, unless the patient has delirium or a new injury/insult to the neurologic system. Chronic confusion would more accurately describe the patient’s baseline behavior. Patients with cognitive disorders have an increased risk for dehydration because of lack of access or difficulty remembering to drink fluids.

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27. Answer 3: All phases of the nursing process are linked together. However, for this patient the problem is straightforward and the solution seems simple, but careful planning is essential because assisting this patient to the bathroom will be very time-consuming. Older people may move slowly, require help to stand, ambulate, sit, undo clothing, clean perineal area, and wash hands. It is likely that the nurse will make a short-term plan that includes assigning unlicensed personnel to assist the patient and an order should be obtained for a bedside commode. Also, some time must be allocated to teach the patient to call for help. This patient will also need more frequent skin assessments. Long-term, the plan may include bowel/bladder training, or possibly a physical therapy consult to help the patient gain more independent movement. 28. Answer 4: If the goals are not being met, then the nurse should evaluate the situation to determine why they are not being met. After that, the nurse may opt to revise the goal or change interventions. Documentation of interventions, results, and any revisions to the plan are always essential. 29. Answer 2: Evidence-based practice is a scholarly and systematic problem-solving paradigm that draws from research, practice-generated data, clinical expertise, and health care consumer values and preferences. The committee will draw on many sources to create an evidence-based practice policy and procedure manual, because it guides the employees of an institution in the delivery of high-quality care. Directly applying research results to the clinical setting is rarely done. While this is a criticism of research, results generally have to be replicated many times with large numbers of subjects. The Internet is a tool, but sources and information must be validated. Asking for advice from clinical experts is one of many sources used to build evidence-based practice. 30. Answer 4: The nurse applied critical thinking skills and used assessment findings, knowledge of pathophysiology, and knowledge of equipment used for monitoring to identify the irregular pattern of heart rhythm. Possibly, the nurse might visually identify patient risk factors such as being overweight, smoking, or shortness of breath. In this case, the nurse would use questions to gather more data (e.g., “Do you ever have chest pain?” and “Do you have a personal or family history for heart

problems?”). A head-to-toe assessment and a complete evaluation can always give beneficial information; however, because of time constraints, these assessments are not always practical. 31. Answer 1, 2, 3, 4: Mentally rehearsing is a way to think about a problem before it happens. Formulating questions is a way of actively engaging the mind while receiving information. Knowing how others are making decisions can guide the learner to understand the linkage of events. Advocating for more clinical time is a reasonable suggestion, but most nursing programs are already providing the maximum number of clinical hours and are constrained by availability of clinical space and faculty. Scanning nursing information is useful to gather more information, but critical thinking requires active application and practice. Critical Thinking Activities 32. a. See Box 5.2. b. The RN is responsible for identifying and prioritizing nursing diagnoses/patient problem statements; however, patient care is a collaborative effort and the goal is to provide quality care for the patient. If the LPN/LVN feels that an error has been made, he/she has a responsibility to point out the error to protect the patient. When there is a disagreement, use a diplomatic approach. Organize information, opinions, and rationales in a clear and concise manner. Focus on the patient and avoid making comments that are personal or defensive. If two people cannot resolve their differences, it would be appropriate to discuss the situation with a supervisor; this is very important when patient safety and wellbeing are involved. 33. On a daily basis, nurses must make decisions about how to spend their time with patients. Critical thinking is essential for prioritizing the needs of many patients versus the needs of one patient. The nurse can use Maslow’s hierarchy as a framework to prioritize the needs of the assigned patients. Have the basic needs of my patients been met? The nurse can also use the ABCs (airway, breathing, circulation). Are any of my patients at risk for respiratory problems or hemorrhage? Facility policy must be considered; for example, do any of my patients need scheduled medications? (Note to student: some facilities may require incident

Answer Key

reports if medications are late.) Other health care employees also have tasks to complete; for example, do any of my patients require preparation before they go to other departments for diagnostic testing or for treatments? The nurse must also consider the patient who needs to talk. Does the patient need 5 minutes or 45 minutes to complete the discussion? Is the patient able to wait? “You seem upset. I can come back in about an hour and then we can talk.” Or is the need urgent? “You seem upset. Is something wrong?” Next-Generation NCLEX™ (NGN) 34. Answer: During assessment, the nurse recognizes that assessment finding in need of immediate attention is the report of severe pain (9/10). First, the nurse will do a focused assessment on the problem area. Interventions are then used to address the immediate needs. To evaluate the efficacy of nursing actions, the patient is the primary source of information. Postoperative abdominal pain must be investigated for potential complications such as hemorrhage, infection, or ileus. In addition, nurses strive to address pain as soon as possible. Desire to see family is expected and the patient would be reassured that they will be welcomed as soon as possible. A positional IV is changed if the patient is unable or unwilling to maintain the straight arm position. Small amounts of light pink staining are expected; however, the nurse would frequently check the dressing for increased bleeding or drainage. A slightly increased temperature is not unusual because of mild dehydration related to being NPO (nothing by mouth) prior to the procedure. Also, surgical incisions can create an inflammatory response. The nurse would give fluids as ordered and monitor the temperature. An increased pulse, respiratory rate, and blood pressure can be related to pain or stress. The nurse would check baseline vital signs and monitor for changes. A focused assessment of the pain is the first action. Assessment findings guide the nurse’s actions. If the nurse suspects that there is a problem, such hemorrhage, the nurse would repeat the vital signs and call the HCP. The nurse would use clinical judgment about administering medication. The nurse can reassure the patient that every effort will be made to meet needs. Policy and procedure manuals are not likely to address the nurse’s specific

concerns for this patient. The patient is always the primary source of information when pain is the problem.

CHAPTER 6—CULTURAL AND ETHNIC CONSIDERATIONS 1. Crossword Puzzle Across 5. ethnicity 7. race 8. disparities 10. transcultural Down 1. mores 2. subculture 3. culture 4. cultural bias 6. society 9. ableism Multiple Choice 2. Answer 4: Talk to the UAP first. This will initiate the process of values clarification. Help him understand that some patients may not interpret the gesture as friendly or positive. The charge nurse or supervisor could talk to the UAP and the patients if there is a problem or complaint. 3. Answer 3: Lack of or limitations in transportation options is a social issue for persons (or patients) with limited funds or support. Ideally, the student should have talked to the instructor at the beginning of the semester. Once the nursing instructor is aware of the transportation issue, the student can be assisted to locate resources and make alternate plans. 4. Answer 4: Health promotion behaviors indicate a future time orientation. Patient who uses previous family history to make medical decisions is relying on the past. Actions that address acute conditions or immediate situations demonstrate present time orientation. 5. Answer 1: In a patriarchal family structure, a male (usually the oldest) will assume leadership for family decision-making. 6. Answer 2: Persons of American Indian ancestry have a higher incidence of diabetes. 7. Answer 2: People who speak a little English are more likely to understand simple language; brevity is also important because communicating in a second language is very tiring.

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Speaking loudly may be interpreted as aggression and cause withdrawal or irritation. Use of an interpreter is necessary when obtaining an initial history or getting informed consent; however, getting an interpreter for every interaction is not possible. Providing detailed directions is not usually a good strategy even for patients who speak English, because details are frequently forgotten or become overwhelming. 8. Answer 1, 2, 4, 5: While it is important to approach all patients as individuals, older adults are generally less tolerant of other cultures, they belong to a group that shares historical experiences and they often rely on home remedies. Those with cognitive impairments may make thoughtless or hurtful comments. Older age is not directly related to educational background. 9. Answer 2: Discuss the alternatives (e.g., nonblood plasma expanders, surgical techniques to decrease blood loss, autologous transfusions, or autotransfusion) to blood transfusion with the surgeon and then perhaps the surgeon can make a plan that will incorporate an acceptable alternative. Supporting the patient and documenting are also appropriate after alternatives have been fully explored. The risk manager can advise about problems that might occur if the patient feels coerced but trying to change the patient’s mind about a blood transfusion is not appropriate. 10. Answer 3: Keep her head, arms, and legs covered as much as possible. Ideally, an all-female health care team is preferred. Patients who are Muslim may desire to pray at scheduled times each day. Patient may prefer that family is present for support and decision-making. 11. Answer 1, 3, 6: Self-assessment and understanding of self along with keeping an open mind will help the nurse. Trying to match beliefs is not reasonable, because the nurse is also influenced by his/her own culture. If the nurse tries to act the same toward everyone or ignores the differences, the nurse is not giving care based on individual needs. 12. Answer 2: Respect and protection of the soul were indicated by all study participants. Prayers at the bedside may be appropriate for some, but not all; assess before making suggestions. Religious beliefs can assist with coping, but those who have no religious preferences may have alternative coping methods. Rituals and ceremonies should be allowed as long as there is no harm to patient or others.

13. Answer 3: First the nurse controls own behavior; this helps the family decrease excitement and anxiety. Identifying the leader is important because the leader can control the family and the information flow. If the leader does not speak the best English, then the nurse can ask him/her to identify the member to speak. Taking the patient to a private room may be counterproductive if the patient relies on family for support or translation. Physically assessing the patient would be appropriate if the patient arrives unresponsive or is in apparent distress. 14. Answer 3: Talk with the UAP first to assess the circumstances and the UAP’s behavior. After assessing, the nurse can go back to the patient and apologize or explain as appropriate. There is a chance that the patient did something that made the UAP feel uncomfortable, in which case the nurse can support the UAP to be professional and problem-solve in difficult situations. Also, the UAP may be exhibiting behavior that would be considered normal or respectful of an older person but giving feedback about how patients are interpreting her behavior can help her to work in cross-cultural situations. 15. Answer 2: If a nurse has strong beliefs or has certain behaviors that are very natural, finding a work environment that matches personal strengths can be a better solution than trying to modify behavior for every patient situation. For example, pediatrics may be a good match for this nurse, whereas a clinic that serves older multicultural patients may not be a good match. Assessing and understanding behavior is always a good start but understanding origin of behavior does not ensure change. Learning about other cultures broadens perspective, but patients still need to be assessed and treated as individuals. Requesting certain types of patients is not ethical or fair to staff or patients. 16. Answer 3: In group settings, people will normally gravitate to preferred areas with preferred company; thereafter the same seat/ area is chosen over and over again. (Watch how a group of students enters and sits in a classroom.) Assigning seats is demeaning for adults and may inhibit natural development of relationships. Asking every resident for seating preference at every meal is impractical for time management. (Some residents may be confused or hard of hearing and others may answer but decide and move very slowly.) Encouraging conversation with a variety of people is not a

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bad idea, but this might be a better strategy during other social activities. 17. Answer 1: To prevent delay for all the patients, leave this patient to the end. If there is a medication that cannot be delayed, giving a 15-minute warning might work. Assessing the preoccupation may be useful; however, the patient may just have a number of rituals/behaviors that always fill the morning hours. Starting at 8:00 am is impractical, there are many things at the beginning of the shift that the nurse must attend to. 18. Answer 1: Present orientation is action that is guided by patient’s “feeling okay” in the moment. “What should I do if…?” indicates future thinking and readiness to make contingency plans. “Can we share the pills?” is possibly present-oriented, but also there is no understanding of even basic safety concepts. “Would you take…?” suggests that the patient is ready to align himself with the future thinking of the nursing student. 19. Answer 3: Use of herbal tea should be investigated. Many herbs can interact with prescribed medications or will be contraindicated in certain disease conditions. The HCP should be informed and the pharmacist can be consulted. The other practices should be allowed, because they may be effective or ineffective, but are not harmful. 20. Answer 4: First gather more information about what the wife is feeding the husband, then this information can be shared with the nutritionist. Revising the goal is necessary. The dietary plan can be changed, but the change should incorporate compromises that support the patient’s health and meet the cultural preferences. 21. Answer 2, 3, 4, 5: These questions are designed to elicit what the patient thinks or believes about what is happening to the body. Asking about onset of symptoms is a standard assessment question used to clarify and identify the problem. Critical Thinking Activities 22. The nurses have tried to go up the chain of command and this has not been successful so far. Approaching the nurse manager again would be appropriate because one person’s behavior is affecting other staff members and potentially patient care is being delayed. Talking to the nurse is another good attempt, but the day-shift nurse’s comment suggests that her time orientation is not the same as the other

nurses on the staff. There are many factors that may contribute to the nurse’s being late. Culture is one factor, but family responsibilities, transportation problems, or health problems may also contribute. The nurse who is late also needs to hear feedback from coworkers about how her behavior affects them. Respect has to be extended both ways. The nurse manager should be involved to help all of the nurses make a personal and unit-wide action plan for the safe and efficient function of the unit. 23. a. Answers will vary widely because the U.S. is a large country and Americans are frequently influenced by worldwide ancestral backgrounds; however, American nursing students frequently share a belief in equal access to health care and education. As a nursing student, you are likely to place a high value on education, achievement, and scientific principles. Nurses are also known as having high standards of moral and ethical behavior and being champions of human rights. It is also likely that you aspire to be a responsible citizen who is willing to be happy on a modest income. You may also identify strongly with one or several other American subcultures. b. As a nursing student who is originally from another country, you are likely to share many of the values that American nursing students hold. If you are not originally from the United States, the impact of being in the American culture may be (or perhaps used to be) very stressful for you. Even if you are relatively comfortable in your job/school, have friends, and speak English very well, it is likely that there are many things about your country that you miss very much. Sometimes you may feel isolated, angry, or just exhausted because of the challenges of being in a country that seems so different. In addition to adapting to American culture, it is also likely that as a nursing student, you will meet many patients from other countries. Next-Generation NCLEX™ (NGN) 24. Answer 2, 4, 5, 8, 9: The disadvantages are that family members may or may not be able to accurately convey the nurse’s meaning to the patient or may intentionally or unintentionally withhold information from the nurse or the patient. Potentially, there is a violation of confidentiality; the patient has less opportunity to

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