CHAPTER 1 1. Which tasks would be appropriate for the nurse to delegate to unlicensed assistive personnel(UAP)? Standard Text: Select all that apply. 1. Taking vital signs 2. Measuring and recording intake and output 3. Postmortem care 4. Providing telephone advice 5. Weighing the client Correct Answer: 1,2,3,5 Rationale 1: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 2: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 3: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 4: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Rationale 5: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Global Rationale: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Telephone advice involves gathering data, analysis, and planning care, which would all be beyond the scope of
practice. Vital sign measurement, recording intake and output, providing postmortem care, and weighing the client are all appropriate tasks to delegate to the UAP. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation AACN Essential Competencies: II.1.Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care, health care team coordination, and the oversight and accountability for care delivery in a variety of settings NLN Competencies: Teamwork: Manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 19
2. Which procedure should the registered nurse delegate to unlicensed assistive personnel (UAP)? 1. Making a nursing diagnosis 2. Assisting a client to bedside commode 3. Performing assessments on client 4. Giving the client pain medication Correct Answer: 2 Rationale 1: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Formulating a nursing diagnosis is not a task that can be delegated to the UAP. Rationale 2: Assisting a client to a bedside commode is an activity that can be delegated to the UAP. Rationale 3: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Assessment is not a task that can be delegated to the UAP. Rationale 4: Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Administering pain medication is not an activity that can be delegated to the UAP. Global Rationale: Assisting a client to a bedside commode is an activity that can be delegated to the UAP. Tasks requiring advanced education such as assessment, interpretation of data, planning client care, or evaluating care are not delegated to the UAP. Formulating a nursing diagnosis, performing an assessment, and administering pain medications are activities that cannot be delegated to the UAP. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care
QSEN Competencies: II.B.5.Assume role of team member or leader based on the situation AACN Essential Competencies: II.1.Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care, health care team coordination, and the oversight and accountability for care delivery in a variety of settings NLN Competencies: Teamwork: Manage delegation effectively. Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 19 3. Which statement indicates that unlicensed assistive personnel (UAP) understand directions provided regarding client care? Standard Text: Select all that apply. 1. “I will bathe the client in room 402.” 2. “I am done with the assigned tasks for Mr. Wells.” 3. “I can give the medication for you.” 4. “I will note all orders.” 5. “I understand my assignment is to take and document the vital signs.” Correct Answer: 1,2,5 Rationale 1: Restating the task to the nurse indicates understanding and appropriate communication during delegation. Rationale 2: Telling the nurse that the assigned tasks are done indicates understanding and appropriate communication during delegation. Rationale 3: Medication administration cannot be delegated. Rationale 4: The UAP cannot note orders on the medical record. This activity must be done by the nurse. Rationale 5: Restating the task to the nurse indicates understanding and appropriate communication during delegation. Global Rationale: Restating the task to the nurse indicates understanding and appropriate communication during delegation. Telling the nurse that the assigned tasks are done indicates understanding and appropriate communication during delegation. Medication administration cannot be delegated. The UAP cannot note orders on the medical record. This activity must be done by the nurse. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation AACN Essential Competencies: II.1. Apply leadership concepts, skills and decision making in the provision of high quality nursing care, health care team coordination, and the oversight and accountability for care delivery in a variety of settings NLN Competencies: Teamwork: Manage delegation effectively.
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 19 4. The nurse observing the unlicensed assistive personnel (UAP) using alcohol-based rubs for hand hygiene would recognize that further teaching is required when the UAP performs which act? 1. Rubs palm against palm when washing hands. 2. Applies a palmful of product into cupped hands. 3. Interlaces fingers palm to palm. 4. Dries hands with clean paper towel. Correct Answer: 4 Rationale 1: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Rationale 2: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Rationale 3: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Rationale 4: When using an alcohol-based hand rub, the hNanUdR sS shIoNuG ldTnBo.tCbO e dM ried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Global Rationale: When using an alcohol-based hand rub, the hands should not be dried. Rubbing of hands palm to palm and interlacing fingers are continued until the product dries, which takes about 20–30 seconds. A palmful of product is generally required to coat all surfaces. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18 5. The nurse is working in a day care center where there recently has been an outbreak of viral conjunctivitis. What should the nurse instruct the staff to stop the spread of this infection?
1. Require all children with conjunctivitis to stay home until there is a reduction in drainage. 2. Require all children with an infection to be on otic antibiotics for at least 24 hours prior to returning to school. 3. Isolate all children with conjunctivitis in the same room away from those who are not infected. 4. Perform hand hygiene after providing personal care for all children. Correct Answer: 4 Rationale 1: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to keep children away from the day care center. Rationale 2: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to place a child with a viral illness on antibiotics. Rationale 3: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to isolate children with conjunctivitis. Rationale 4: The best way to reduce the spread of infection is through thorough hand hygiene. Global Rationale: The best way to reduce the spread of infection is through thorough hand hygiene. There would be no need to place a child with a viral illness on antibiotics, to isolate children with conjunctivitis, or to keep children away from the day care center. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use oNf U teR chSnIoNloGgT yB an.C dO staM ndardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18
6. For which situation should the nurse apply clean disposable gloves? 1. Providing denture care 2. Bathing a client 3. Applying antiemboli stockings 4. Assessing vital signs Correct Answer: 1
Rationale 1: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. When providing denture care, the nurse is in contact with mucous membranes and body secretions, so gloves would be required. Rationale 2: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. In most instances, unless the client has an open wound, gloves would not be required when bathing a client. Rationale 3: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. In most instances, unless the client has an open wound, gloves would not be required when applying stockings. Rationale 4: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. In most instances, unless the client has an open wound, gloves would not be required when assessing vital signs. Global Rationale: The purpose of gloves is to protect the hands when the nurse is likely to handle any potentially infective material. When providing denture care, the nurse is in contact with mucous membranes and body secretions, so gloves would be required. In most instances, unless the client has an open wound, gloves would not be required when bathing a client, applying stockings, or assessing vital signs. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues that involve individuals, families, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18 7. The nurse is caring for several clients during the shift. Which action demonstrates appropriate hand hygiene? 1. Putting on gloves 2. Washing hands with soap and water 3. Wiping hands off when entering room 4. Using the client’s soap on hands
Correct Answer: 2 Rationale 1: Putting on gloves does not demonstrate appropriate hand hygiene. Rationale 2: Washing hands with soap and water demonstrates appropriate hand hygiene. Rationale 3: Wiping hands off when entering the room does not demonstrate appropriate hand hygiene. Rationale 4: The use of the client’s soap on the hand is not appropriate when performing hand hygiene. Global Rationale: Washing hands with soap and water demonstrates appropriate hand hygiene. Putting on gloves and wiping hands off when entering the client’s room does not demonstrate appropriate hand hygiene. The use of the client’s soap on the hand is not appropriate when performing hand hygiene. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: II.5. Participate in quality and client safety initiatives, recognizing that these are complex system issues, that invN olvUeRinSdIiN viG duTaB ls.,CfaOmM ilies, groups, communities, populations, and other members of the health care team NLN Competencies: Context and Environment: Apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.19 Describe the steps of planning for client care. Page Number: 18 8. Which behavior indicates that the nurse is practicing as a professional? 1. Documenting that a client needs pain medication 2. Visiting with family of a client on another part of the care area 3. Telling a client to ask the next nurse for help getting out of bed 4. Directing unlicensed assistive personnel (UAP) to measure urine output Correct Answer: 4 Rationale 1: A professional nurse would assess the client’s pain level and provide medication. Documenting the need for pain medication does not demonstrate professionalism. Rationale 2: A professional nurse would not socialize with clients or family. Rationale 3: A professional nurse would meet the client’s needs at the time they are requested.
Rationale 4: A professional nurse appropriately delegates tasks to UAP. Global Rationale: A professional nurse appropriately delegates tasks to UAP. A professional nurse would address a client’s pain management needs, avoid socializing with clients and families, and meet the client’s needs at the time they are requested. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: VIII. 2. Assume accountability for personal and professional behaviors NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills Nursing/Integrated Concepts: Evaluation Learning Outcome: 1.1 Discuss what is meant by the concept “professional role of the nurse.” Page Number: 3 9. What actions should the nurse take to assist a client adapt to being hospitalized? Select all that apply. 1. Ensuring for the client’s comfort 2. Completing the admission assessment 3. Attempting to accommodate the client’s wishes 4. Communicating with the client as an individual 5. Accepting the client’s perception of the environment Correct Answer: 1, 3, 4, 5 Rationale 1: Ensuring for the client’s comfort is an action to assist a client adapt to being hospitalized. Rationale 2: Completing the admission assessment is not an approach to assist a client adapt to being hospitalized. Rationale 3: Attempting to accommodate the client’s wishes is an action to assist a client adapt to being hospitalized. Rationale 4: Communicating with the client as an individual is an action to assist a client adapt to being hospitalized. Rationale 5: Accepting the client’s perception of the environment is an action to assist a client adapt to being hospitalized.
Global Rationale: Actions to assist clients adapt to being hospitalized include ensuring for the client’s comfort, accommodating the client’s wishes if possible, communicating with the client as an individual, and accepting the client’s perception of the environment. Completing the admission assessment is not an approach to assist a client adapt to being hospitalized. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team AACN Essential Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment: Practice: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills Nursing/Integrated Concepts: Implementation Learning Outcome: 1.7 List three ways you can assist the client to assume and adapt to the client role. Page Number: 4 10. Which document should the nurse refer to ensure safe care is being provided to a client? 1. Core measure sets 2. Nurse practice act 3. Joint Commission standards 4. National patient safety goals (NPSGs) Correct Answer: 4 Rationale 1: Core measure sets were created as a quality improvement tool. Rationale 2: Nurse Practice acts ensure the nurse practices in a safe and legal manner. Rationale 3: Joint Commission standards are the basis of an objective evaluation process to help healthcare organizations measure, assess, and improve performance. Rationale 4: NPSGs identify focus areas for client safety. Global Rationale: NPSGs identify focus areas for client safety. Core measure sets were created as a quality improvement tool. Nurse Practice acts ensure the nurse practices in a safe and legal manner. Joint Commission standards are the basis of an objective evaluation process to help healthcare organizations measure, assess, and improve performance. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others
AACN Essential Competencies: II. 7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety: Ethical Comportment: Commit to a generative safety culture Nursing/Integrated Concepts: Planning Learning Outcome: 1.8 Describe Core Measures, the Joint Commission Standards, and National Patient Safety Goals and how they are developed and utilized in practice. Page Number: 5 11. The nurse is asked to perform a task that is beyond the scope of practice. What should the nurse use as a reason when refusing to complete the task? 1. “It is not a part of the National Patient Safety Goals.” 2. “The Joint Commission does not identify it as a nursing task.” 3. “It is not identified as permitted within the Nurse Practice Act.” 4. “The task can be delegated to unlicensed assistive personnel (UAP).” Correct Answer: 3 Rationale 1: The National Patient Safety Goals do not define nursing scope of practice. Rationale 2: The Joint Commission does not define nursing scope of practice. Rationale 3: The Nurse Practice Act defines nursing scope of practice and should be used as a reason to refuse a task. Rationale 4: Tasks that are beyond the nurse’s scope of practice cannot be delegated to UAP. Global Rationale: The Nurse Practice Act defines nursing scope of practice and should be used as a reason to refuse a task. The National Patient Safety Goals do not define nursing scope of practice. The Joint Commission does not define nursing scope of practice. Tasks that are beyond the nurse’s scope of practice cannot be delegated to UAP. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others AACN Essential Competencies: II. 7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety: Ethical Comportment: Commit to a generative safety culture Nursing/Integrated Concepts: Implementation Learning Outcome: 1.10 Discuss major sections of the Nurse Practice Act. Page Number: 5 12. For which reasons should a registered nurse contact the Board of Registered Nursing (BRN)? Select all that apply? 1. Renewing nursing license
2. Determining nursing standards 3. Identifying the date for a disciplinary hearing 4. Checking the dates for continuing education programs 5. Ascertaining when a nurse applicant became licensed Correct Answer: 1, 2, 3, 5 Rationale 1: A function of the BRN is to renew nursing licensure. Rationale 2: A function of the BRN is to determine nursing standards. Rationale 3: A function of the BRN is to investigate disciplinary actions. Rationale 4: The BRN is not responsible for continuing education programs. Rationale 5: A function of the BRN is to register nursing licenses. Global Rationale: Functions of the BRN include renewing nursing licensure, determining nursing standards, investigating disciplinary actions, and registering nursing licenses. The BRN is not responsible for continuing education programs. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: IV. C. 1. Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals AACN Essential Competencies: V. 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice NLN Competencies: Personal and Professional Development: Knowledge: Codes of ethics and regulatory and professional standards Nursing/Integrated Concepts: Implementation Learning Outcome: 1.12 State four functions of the Board of Registered Nursing. Page Number: 6 13. The nurse manager is contacting the Board of Registered Nursing (BRN) to report a staff member. Which action did the manager most likely observe the staff member perform? 1. Changing a client’s abdominal wound dressing 2. Instructed a client on self-administration of insulin 3. Assisting a client with ambulation to the bathroom 4. Informing a client to stop taking a prescribed medication Correct Answer: 4 Rationale 1: Changing an abdominal wound dressing is within the nurse’s scope of practice. Rationale 2: Medication teaching is within the nurse’s scope of practice.
Rationale 3: Providing direct client care is within the nurse’s scope of practice. Rationale 4: Practicing medicine without a license is an action that is identified as misconduct. Global Rationale: Practicing medicine without a license is an action that is identified as misconduct. Changing a dressing, providing medication teaching, and providing direct client care are all within the nurse’s scope of practice. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: V. B. 8. Use national patient safety resources for own professional development and to focus attention on safety in care settings AACN Essential Competencies: V. 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice NLN Competencies: Personal and Professional Development: Knowledge: Codes of ethics and regulatory and professional standards Nursing/Integrated Concepts: Assessment Learning Outcome: 1.13 Discuss four grounds for licensure revocation for professional misconduct. Page Number: 7 14. What action should the nurse take to ensure the safe adNmUinRisStrIaNtiG onToBf.pCrO esM cribed medications to a client? Select all that apply. 1. Validating the healthcare provider’s order 2. Checking two forms of client identification 3. Leaving a client’s medications at the bedside 4. Returning a mislabeled medication to the Pharmacy 5. Deciding to report a medication error later in the shift Correct Answer: 1, 2, 4 Rationale 1: Nurses must not administer any drug without a specific healthcare provider’s order. Rationale 2: Nurses must check two forms of client identification before administering medications. Rationale 3: Nurses must never leave prepared medicines unattended. Rationale 4: Nurses must send labeled bottles or packages that are unintelligible back to the pharmacist for relabeling. Rationale 5: Nurses must always report errors immediately. Global Rationale: Nurses must not administer any drug without a specific healthcare provider’s
order; check two forms of client identification before administering medications; and send labeled bottles or packages that are unintelligible back to the pharmacist for relabeling. Nurses must never leave prepared medicines unattended and always report errors immediately. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V. B. 8. Use national patient safety resources for own professional development and to focus attention on safety in care settings AACN Essential Competencies: V. 5. Describe state and national statues, rules and regulations that authorize and define professional nursing practice NLN Competencies: Personal and Professional Development: Knowledge: Codes of ethics and regulatory and professional standards Nursing/Integrated Concepts: Implementation Learning Outcome: 1.14 Explain the legal issues of drug administration. Page Number: 7 15. A client asks for a copy of the medical record to take home upon discharge. What action should the nurse take regarding this request? 1. Prepare the requested documentation 2. Tell the client that the record belongs to the hospital 3. Explain to the client that the record cannot be provided 4. Ask the health care provider if the medical record can be provided Correct Answer: 1 Rationale 1: Under the Health Insurance Portability and Accountability Act (HIPAA) a client can request copies of the medical record. Rationale 2: The record may be the hospital’s property however the client can have a copy of the record according to HIPAA. Rationale 3: The record can be provided. Rationale 4: The nurse does not need to ask the healthcare provider for permission to provide a copy of the record to the client. Global Rationale: Under the Health Insurance Portability and Accountability Act (HIPAA) a client can request copies of the medical record. The record may be the hospital’s property however the client can have a copy of the record according to HIPAA. The record can be provided. The nurse does not need to ask the healthcare provider for permission to provide a copy of the record to the client. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care
QSEN Competencies: VI. C. 3. Protect confidentiality of protected health information in electronic health records AACN Essential Competencies: VIII. 10. Protect patient privacy and confidentiality of patient records and other privileged communications NLN Competencies: Context and Environment; Knowledge: principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Implementation Learning Outcome: 1.15 Discuss the role of HIPAA in health care. Page Number: 8 16. What should the nurse include when reviewing the Patient Care Partnership brochure with a newly admitted client? 1. Visiting hours 2. Times for meals 3. Help with billing claims 4. How to avoid paying for medications Correct Answer: 3 Rationale 1: Visiting hours is not a part of the Patient Care Partnership brochure. Rationale 2: Times for meals are not a part of the Patient Care Partnership brochure. Rationale 3: Help with billing claims is a part of the PatienNt U CR arS e IPNarG tnTeB rs.hCipObM rochure. Rationale 4: How to avoid paying for medications is not a part of the Patient Care Partnership brochure. Global Rationale: Help with billing claims is a part of the Patient Care Partnership brochure. Visiting hours, times for meals and avoiding paying for medications are not a part of the Patient Care Partnership brochure. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: IV. C. 2. Value own and others' contributions to outcomes of care in local care settings AACN Essential Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient’s support network NLN Competencies: Context and Environment; Knowledge: principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Implementation Learning Outcome: 1.16 Describe what is meant by clients’ rights and the Patient Care Partnership brochure Page Number: 9
17. A client refuses to complete an advance directive because he is not “ready to die.” What should the nurse respond to this statement? 1. “It’s best to be safe than sorry.” 2. “You are right – it is more appropriate for someone who has a terminal illness.” 3. “That’s fine. I’ll just document that you refuse to decide your medical treatment.” 4. “It is a document that allows you to make legal decisions about how you wish to receive future medical treatment.” Correct Answer: 4 Rationale 1: Saying that it is better to be safe than sorry does not explain the purpose of an advance directive. Rationale 2: Advance directives are appropriate for all clients and not just those with a terminal illness. Rationale 3: The client did not refuse to decide medical treatment. Rationale 4: An advance medical directive is a document that allows clients to make legal decisions about how they wish to receive future medical treatment. Global Rationale: An advance medical directive is a document that allows clients to make legal decisions about how they wish to receive future medical treatment. Saying that it is better to be safe than sorry does not explain the purpose of an advanceNdU irR ecStiIvN e.GATdB va.C n cOe M directives are appropriate for all clients and not just those with a terminal illness. The client did not refuse to decide medical treatment. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences, values AACN Essential Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Knowledge: principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Implementation Learning Outcome: 1.17 Explain what is meant by advance directives Page Number: 10
CHAPTER 2 1. The nurse is planning care for a newly admitted client. Which behavior indicates that the nurse is using critical thinking? 1. Recalls a similar client situation 2. Asks the healthcare provider for suggestions 3. Looks at a care plan written for another client 4. Expects the oncoming nurse to complete the care plan Correct Answer: 1 Rationale 1: An important aspect of critical thinking is the ability to use reflection and language properly. Reflection is the action of thinking back or recalling an earlier clinical situation, remembering nursing actions that worked or didn’t work, and determining whether this information is helpful in the current situation. Rationale 2: Asking a healthcare provider for suggestions when planning client care does not exemplify critical thinking. Rationale 3: Looking at a care plan written for another client does not exemplify critical thinking. Rationale 4: Expecting the oncoming nurse to complete the care plan does not exemplify critical thinking Global Rationale: An important aspect of critical thinking is the ability to use reflection and language properly. Reflection is the action of thinking back or recalling an earlier clinical situation, remembering nursing actions that worked or didn’t work, and determining whether this information is helpful in the current situation. Asking a healthcare provider for suggestions, looking at a care plan written for another client; and expecting the oncoming nurse to complete the care plan do not exemplify critical thinking. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.1 Define the term critical thinking. Page Number: 23
2. The nurse is assigned to care for a newly admitted client. Which approach should be used to address the client’s responses to the illness? 1. Best practices 2. Nursing process 3. Critical thinking 4. Evidence-based practice Correct Answer: 2 Rationale 1: Best practice is a generic or general phrase for a process of infusing nursing practice with research-based knowledge. Rationale 2: The nursing process is used to diagnose and treat human responses to health and illness. Rationale 3: Critical thinking involves the careful acquisition and interpretation of information and use of it to reach a well-justified conclusion. Rationale 4: Evidence-based nursing practice is defined as the application to clinical practice of the best available empirical evidence that applies recent research findings, in order to aid clinical decision making. Global Rationale: The nursing process is used to diagnose and treat human responses to health and illness. Best practice is a generic or gNeUnReSraINl G phTrBa.sCeOfM or a process of infusing nursing practice with research-based knowledge. Critical thinking involves the careful acquisition and interpretation of information and use of it to reach a well-justified conclusion. Evidence-based nursing practice is defined as the application to clinical practice of the best available empirical evidence that applies recent research findings, in order to aid clinical decision making. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.2 Define the term nursing process. Page Number: 24 3. The nurse is reviewing care provided to a client. Which behavior indicates that the nurse is using critical thinking? 1. Administers prescribed medications 2. Studies the results of diagnostic tests
3. Individually analyzes client problems 4. Documents responses to care provided Correct Answer: 3 Rationale 1: Administering prescribed medications is an action and would not be conducted when reviewing care. Rationale 2: Studying the results of diagnostic tests would be an action completed during the assessment phase of the nursing process. Rationale 3: The nursing process is a systematic, problem-solving approach that is considered a critical thinking competency that assists the nurse to intervene in client care. Rationale 4: Documentation is an action that would not be completed when reviewing care provided to a client. Global Rationale: The nursing process is a systematic, problem-solving approach that is considered a critical thinking competency that assists the nurse to intervene in client care. Administering prescribed medications is an action and would not be conducted when reviewing care. Studying the results of diagnostic tests would be an action completed during the assessment phase of the nursing process. Documentation is an action that would not be completed when reviewing care provided to a client. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3 Explain how critical thinking is used in each step of the nursing process. Page Number: 24 4. After receiving morning report the nurse categorizes an assigned client’s care according to priority needs. How does this behavior support the nursing process? 1. Organizes and structures care 2. Emphasizes client preferences 3. Follows Maslow’s hierarchy of needs 4. Considers time needs for each nursing action Correct Answer: 1
Rationale 1: The nursing process—assessment, analysis/nursing diagnosis, planning, implementation, and evaluation—provides an organized structure and framework for the delivery of nursing care in all settings. Rationale 2: Client preferences may or may not coincide with care priorities. Rationale 3: Maslow’s hierarchy of needs may or may not coincide with care priorities. Rationale 4: The time needed for nursing actions may or may not coincide with care priorities. Global Rationale: The nursing process—assessment, analysis/nursing diagnosis, planning, implementation, and evaluation—provides an organized structure and framework for the delivery of nursing care in all settings. Client preferences, Maslow’s hierarchy of needs, and time to complete nursing actions may or may not coincide with care priorities. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.4 Describe how the nursing process relates to nursing. Page Number: 24 5. The nurse collects data slowly and methodically from a new client. Why is the nurse using this approach during this phase of the nursing process? 1. Ensures accuracy of data 2. Identifies client outcomes 3. Establishes a rapport with the client 4. Highlights the importance of the therapeutic relationship Correct Answer: 1 Rationale 1: Assessment is a critical phase because all the other steps depend on the accuracy and reliability of the information obtained. Rationale 2: Client outcomes are not identified during the assessment phase. Rationale 3: Client rapport does become established during the assessment phase however this is not the reason for the nurse to collect data slowly and methodically.
Rationale 4: The therapeutic relationship is important however this is not the reason for the nurse to collect data slowly and methodically. Global Rationale: Assessment is a critical phase because all the other steps depend on the accuracy and reliability of the information obtained. Client outcomes are not identified during the assessment phase. Client rapport and the therapeutic relationship are important however these are not reasons for the nurse to collect data slowly and methodically. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.5 Discuss the term assessment, and describe how it influences the nursing process. Page Number: 24 6. The nurse is preparing to assess a client new to the out-patient care environment. Which actions should the nurse expect to complNeU teRdSuINriG nTgBth.CisOM phase of the nursing process? Select all that apply. 1. Complete a client interview 2. Conduct a physical examination 3. Analyze test results and findings 4. Categorize data into meaningful patterns 5. Identify pertinent family health history issues Correct Answer: 1, 2, 3, 5 Rationale 1: A client interview is a part of the assessment. Rationale 2: A physical examination is a part of the assessment. Rationale 3: Analyzing test results and findings is a part of the assessment. Rationale 4: Categorizing data into meaningful patterns is a part of the nursing diagnosis phase of the nursing process. Rationale 5: Identifying pertinent family health history issues is a part of the assessment. Global Rationale: Client interview, physical examination, analysis and findings of diagnostic tests, and family health history issues are all parts of the assessment phase of the nursing process.
Categorizing data into meaningful patterns is a part of the nursing diagnosis phase of the nursing process. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.6 List the components of the assessment step. Page Number: 24 7. After completing an assessment the nurse analyzes all data collected. What is the significance of the nurse performing this analysis? 1. Confirms observations 2. Identifies client outcomes 3. Establishes a foundation for the client’s care 4. Prioritizes interventions according to client needs Correct Answer: 3 Rationale 1: Confirming observations occurs during the assessment phase. Rationale 2: Identifying client outcomes occurs during the planning phase. Rationale 3: Analysis which occurs during the nursing diagnosis phase provides the foundation for each individual client’s therapeutic plan of care. Rationale 4: Prioritizing interventions occurs during the implementation phase. Global Rationale: Analysis which occurs during the nursing diagnosis phase provides the foundation for each individual client’s therapeutic plan of care. Confirming observations occurs during the assessment phase. Identifying client outcomes occurs during the planning phase. Prioritizing interventions occurs during the implementation phase. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 2.7 Describe the primary purpose of the analysis phase of the nursing process. Page Number: 25 8. The instructor is preparing a lecture on the nursing process. Which statement should the instructor use that best describes nursing diagnosis? 1. It is an educated judgment about a client’s potential or actual health problems 2. It refers to the priority nursing actions or interventions performed to accomplish a specified goal 3. It involves the careful acquisition and interpretation and use of information to reach a conclusion 4. It is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn’t work, and determining if this information is helpful in the current situation Correct Answer: 1 Rationale 1: Nursing diagnosis is an educated judgment about potential or actual health problem or problems of a client. Rationale 2: The implementation phase of the nursing process refers to the priority nursing actions or interventions performed to accNoUmRpSlIiNshGTaBs.pCeOcM ified goal. Rationale 3: Critical thinking involves the careful acquisition and interpretation and use of information to reach a conclusion. Rationale 4: Reflection is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn’t work, and determining if this information is helpful in the current situation. Global Rationale: Nursing diagnosis is an educated judgment about potential or actual health problem or problems of a client. The implementation phase of the nursing process refers to the priority nursing actions or interventions performed to accomplish a specified goal. Critical thinking involves the careful acquisition and interpretation and use of information to reach a conclusion. Reflection is the action of thinking back about an earlier clinical situation, recalling actions that worked or didn’t work, and determining if this information is helpful in the current situation. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 2.8 Define the term nursing diagnosis. Page Number: 25 9. The nurse is completing the planning phase of the nursing process with a client. Which should the nurse perform during this phase? Select all that apply. 1. Identify short- and long-term goals 2. Strategize approaches for goal outcomes 3. List nursing measures when delivering care 4. Create outcomes that are measurable and realistic 5. Organize defining characteristics of data into meaningful patterns Correct Answer: 1, 2, 3, 4 Rationale 1: Identification of short- and long-term goals occurs during the planning phase. Rationale 2: Strategizing approaches for goal outcomes occurs during the planning phase. Rationale 3: Listing nursing measures when delivering care occurs during the planning phase. Rationale 4: Creating outcomes that are measurable, realistic in addition to being time-specific and quantifiable occurs during the planning phase. Rationale 5: Organizing defining characteristics of data into meaningful patterns occurs during the nursing diagnosis phase. Global Rationale: Actions performed during the planning phase include identifying short- and long-term goals, strategizing approaches for goal outcomes, listing nursing measures when delivering care, and creating outcomes that are measureable and realistic in addition to being time-specific and quantifiable. Organizing defining characteristics of data into meaningful patterns occurs during the nursing diagnosis phase. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2.9 Define outcome planning and identification, and give an example of this step in the nursing process. Page Number: 25 10. The nurse is implementing a client’s plan of care. Which action should the nurse perform at this time? 1. Record relevant information 2. Motivate and maintain optimum wellness 3. Coordinate care and community resources 4. Anticipate needs of client and family based on priorities Correct Answer: 2 Rationale 1: Recording relevant information occurs during the planning phase. Rationale 2: Motivating and maintaining optimum wellness occurs during the implementation phase. Rationale 3: Coordinating care and community resources occurs during the planning phase. Rationale 4: Anticipating the needs of the client and the family based on priorities occurs during the planning phase. OMwellness occurs during the Global Rationale: Motivating and maintaNiU niRnSgINoG ptTiB m.uCm implementation phase. Recording relevant information occurs during the planning phase. Coordinating care and community resources occurs during the planning phase. Anticipating the needs of the client and the family based on priorities occurs during the planning phase.
Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.10 Define what is meant by the implementation phase of the nursing process. Page Number: 26 11. A client is being prepared for discharge. What should the nurse perform when evaluating this client’s care? Select all that apply. 1. Reassess care plan 2. Record client responses
3. Determine effects of nursing actions 4. Communicate to client and client’s family 5. Examine appropriateness of nursing actions Correct Answer: 1, 2, 3, 5 Rationale 1: Reassessing the care plan is performed during the evaluation phase. Rationale 2: Recording client responses is performed during the evaluation phase. Rationale 3: Determining the effectiveness of nursing actions is performed during the evaluation phase. Rationale 4: Communicating to the client and family occurs during the implementation phase. Rationale 5: Examining appropriateness of nursing actions occurs during the evaluation phase. Global Rationale: Actions completed during the evaluation phase include reassessing the care plan, recording client responses, determining the effectiveness of nursing actions, and examining appropriateness of nursing actions. Communicating to the client and family occurs during the implementation phase. Cognitive Level: Applying Client Need: Safe and Effective Care EnNvU irR onSImNeGnTtB.COM Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.11 Explain evaluation and include your understanding of why it is an important step in the nursing process. Page Number: 27 12. The nurse is explaining nursing diagnoses to a group of first-year nursing students. What should the nurse include in this explanation? Select all that apply. 1. Focuses on client responses 2. Focuses on injury, illness, or disease 3. Requires physician orders to address 4. Remains the same until client discharge 5. Changes according to the client’s needs Correct Answer: 1, 5
Rationale 1: Nursing diagnoses focus on client responses. Rationale 2: Medical diagnoses focus on injury, illness, or disease. Rationale 3: Medical diagnoses require physician orders to address. Rationale 4: Medical diagnoses remain the same until client discharge. Rationale 5: Nursing diagnoses change according to the client’s needs. Global Rationale: Nursing diagnoses focus on client responses and change according to the client’s needs. Medical diagnoses focus on injury, illness, or disease, require physician orders to address, and remain the same until the client is discharged. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy GT Nursing/Integrated Concepts: Nursing PrNoUcResSsI:NN uB rs.iCnOgMDiagnosis Learning Outcome: 2.12 Differentiate nursing diagnosis from medical diagnosis. Page Number: 27 13. The nurse is researching nursing interventions appropriate for a particular nursing diagnosis. Which classification system should the nurse use when researching this information? 1. NIC 2. PES 3. NOC 4. NANDA Correct Answer: 1 Rationale 1: The nursing interventions classification (NIC) is a system that provides uniformity to nursing actions because each intervention has a label name and a set of activities that are identified as steps to carry it out. Rationale 2: PES or problem, etiology, and signs and symptoms is an approach used to create a nursing diagnosis statement. Rationale 3: The nursing outcomes classification (NOC) is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of interventions provided by nurses or other healthcare professionals.
Rationale 4: The North America Nursing Diagnosis Association (NANDA) is an organization that studies and approves nursing diagnostic statements. Global Rationale: The nursing interventions classification (NIC) is a system that provides uniformity to nursing actions because each intervention has a label name and a set of activities that are identified as steps to carry it out. PES or problem, etiology, and signs and symptoms is an approach used to create a nursing diagnosis statement. The nursing outcomes classification (NOC) is a comprehensive, standardized classification of client outcomes developed to evaluate the effects of interventions provided by nurses or other healthcare professionals. The North America Nursing Diagnosis Association (NANDA) is an organization that studies and approves nursing diagnostic statements. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning UR Learning Outcome: 2.13 Define NIC andNN OSCINaGnTdBt.hCeOiM r role in standardizing nursing language. Page Number: 23 14. The nurse is identifying nursing diagnoses appropriate for a client’s health issues. Which information should the nurse include when creating a three-part diagnostic statement? 1. Interventions 2. Learning needs 3. Expected outcomes 4. Signs and symptoms Correct Answer: 4 Rationale 1: A three-part nursing diagnostic statement does not include interventions. Rationale 2: Learning needs is not included in a three-part nursing diagnostic statement. Rationale 3: Expected outcomes are not included in a three-part nursing diagnostic statement. Rationale 4: Signs and symptoms are included in a three-part nursing diagnostic statement. Global Rationale: Signs and symptoms are included in a three-part nursing diagnostic statement. Interventions, learning needs, and expected outcomes are not included in a three-part nursing diagnostic statement.
Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 2.14 Compare and contrast the two-part and three-part Nursing Diagnosis Statement. Page Number: 29 15. The manager is reviewing care plans created for newly admitted clients. Which nursing diagnostic statement should the manager review with the nurse as needing to be amended? 1. Risk for injury related to left sided paralysis 2. Fluid volume overload related to congestive heart failure 3. Impaired coping related to recent death of spouse and son 4. Imbalanced nutrition: Less than body requirements related to mouth and throat ulcers Correct Answer: 2 Rationale 1: This is a correctly written two-part nursing diagnostic statement. Rationale 2: A nursing diagnosis statement does not include a medical diagnosis. Rationale 3: This is a correctly written two-part nursing diagnostic statement. Rationale 4: This is a correctly written two-part nursing diagnostic statement. Global Rationale: A nursing diagnosis statement does not include a medical diagnosis. Risk for injury, impaired coping, and imbalanced nutrition are all correctly written nursing diagnostic statements. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis
Learning Outcome: 2.15 State two examples of nursing diagnoses. Page Number: 28 16. The nurse is explaining evidence-based practice to a group of new nursing students. Which statement should the nurse use during this explanation? 1. “Evidence-based nursing practice generates new knowledge.” 2. “Evidence-based nursing practice applies knowledge to practice.” 3. “Evidence-based nursing practice is measurable, time specific, quantifiable, and realistic.” 4. “Evidence-based nursing practice is based on the best evidence available from nursing research.” Correct Answer: 2 Rationale 1: Research generates new knowledge. Rationale 2: Evidence-based nursing practice applies knowledge to practice. Rationale 3: Outcomes are measurable, time specific, quantifiable and realistic. Rationale 4: Best practices are based on the best evidence available from nursing research. Global Rationale: Evidence-based nursing practice applies knowledge to practice. Research generates new knowledge. Outcomes are measurable, time specific, quantifiable and realistic. Best practices are based on the best evidN enUcReSaIN vaGiTlaBb.C leOfM rom nursing research. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.16 Define evidence-based nursing practice. Page Number: 30 17. The nurse manager determines that a staff nurse uses critical thinking when planning the outcomes for a client’s care. What did the manager observe to come to this conclusion? 1. Prioritized client problems 2. Critically analyzed all client outcomes 3. Clustered data to determine relationships 4. Used a systematic approach to collect data
Correct Answer: 1 Rationale 1: Prioritizing client problems demonstrates critical thinking during the planning phase. Rationale 2: Critically analyzing all client outcomes demonstrates critical thinking during the evaluation phase. Rationale 3: Clustering data to determine relationships demonstrates critical thinking during the nursing diagnosis phase. Rationale 4: Using a systematic approach to collect data demonstrates critical thinking during the assessment phase. Global Rationale: Prioritizing client problems demonstrates critical thinking during the planning phase. Critically analyzing all client outcomes demonstrates critical thinking during the evaluation phase. Clustering data to determine relationships demonstrates critical thinking during the nursing diagnosis phase. Using a systematic approach to collect data demonstrates critical thinking during the assessment phase. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate uNnU dR erSsItNaG ndTiBn.gCO ofMmultiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.3 Explain how critical thinking is used in each step of the nursing process. Page Number: 26
CHAPTER 3 1. A newly admitted client says desires to have surgery to replace a knee and then return home as soon as possible to resume living. On which part of the care plan should the nurse document this information? 1. Client problems 2. Short-term goals 3. Assessment data 4. Nursing interventions Correct Answer: 2 Rationale 1: A client problem is an unmet need. Rationale 2: Goals or expected outcomes are statements that address the client problems. For this situation, the client has stated the goal of having knee replacement surgery in order to return home and resume living. Rationale 3: Assessment data is not a part of the care plan. Rationale 4: Nursing interventions are actions taken to help achieve a client goal. Global Rationale: Goals or expected outcomes are statements that address the client problems. For this situation, the client has stated thN e UgRoSalINoGf ThBa.vCinOgMknee replacement surgery in order to return home and resume living. A client problem is an unmet need. Assessment data is not a part of the care plan. Nursing interventions are actions taken to help achieve a client goal. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.1 Describe the components of the client care plan. Page Number: 36 2. After report the nurse reviews a standardized care plan for an assigned client. Where should the nurse find the current active problems identified for the client? 1. Look at the problem list area on the Kardex 2. Read the notes written about specific problems 3. Ask the charge nurse where the problems are located 4. Identify the areas with check marks placed on the care plan
Correct Answer: 4 Rationale 1: The Kardex is not used to identify current problems identified on a standardized care plan. Rationale 2: Reading the notes written about the client’s problems would be time-consuming and potentially inaccurate. Rationale 3: It is not the charge nurse’s responsibility to know where active problems are documented. Rationale 4: On a standardized care plan the problems with check marks are those which are the most current and active for a client. Global Rationale: On a standardized care plan the problems with check marks are those which are the most current and active for a client. The Kardex is not used to identify current problems identified on a standardized care plan. Reading the notes written about the client’s problems would be time-consuming and potentially inaccurate. It is not the charge nurse’s responsibility to know where active problems are documented. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.2 Explain the method for individualizing the care plan when a standard care plan is used. Page Number: 36 3. The nurse is reviewing data collected during a client assessment. Which information should the nurse identify as a client need? Select all that apply. 1. Desires to walk without a cane 2. License to drive has been suspended 3. Attends religious services every Sunday 4. Spends time with family every winter in Florida 5. Experiences shortness of breath with ambulation Correct Answer: 1, 2, 5
Rationale 1: A client problem is identified as any unmet need. Desiring to walk without a cane is an unmet need. Rationale 2: A client problem is identified as any unmet need. Having a suspended driver’s license will cause many needs to be unmet. Rationale 3: A client problem is identified as any unmet need. Attending religious services is having a spiritual need met. Rationale 4: A client problem is identified as any unmet need. Visiting with family is meeting a psychosocial need. Rationale 5: A client problem is identified as any unmet need. Shortness of breath with ambulation is an unmet need for oxygenation. Global Rationale: A client problem is identified as any unmet need. Desiring to walk without a cane, unable to drive, and having shortness of breath with ambulation are all unmet needs. Attending religious services and visiting with family indicate needs that are being met. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.3 Define the term client problem or need. Page Number: 36 4. The nurse identifies problems for a specific client. What action should the nurse perform next when planning this client’s care? 1. Identify outcomes for care 2. Determine resources needed for care 3. Translate the needs into nursing diagnoses 4. Select appropriate interventions to address the needs Correct Answer: 3 Rationale 1: Outcomes for care occurs after nursing diagnoses are identified. Rationale 2: Resource needs are identified at the time of providing care. Rationale 3: When an individualized care plan is being generated, the nurse translates client
needs into nursing diagnoses. Rationale 4: Interventions are selected after nursing diagnoses are identified. Global Rationale: When an individualized care plan is being generated, the nurse translates client needs into nursing diagnoses. Outcomes and interventions are selected after nursing diagnoses are identified. Resource needs are identified at the time of providing care. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.4 State the most important reason for using nursing diagnoses in care planning. Page Number: 36 5. The nurse notes that a client intervention has a deadline occurring in 3 days. What should this information indicate to the nurse? 1. The action should be observed every 3 days 2. The action should be completed every 3 days 3. The action should be documented every 3 days 4. The action will no longer be necessary in 3 days Correct Answer: 4 Rationale 1: The checkpoint indicates how often the action or intervention should be observed. Rationale 2: The checkpoint indicates how often the action or intervention should be carried out. Rationale 3: The checkpoint indicates how often the action or intervention should be charted. Rationale 4: The deadline indicates the time when the goal should be met or the action is no longer necessary. Global Rationale: The deadline indicates the time when the goal should be met or the action is no longer necessary. The checkpoint indicates how often the action or intervention should be checked, observed, or carried out and therefore how often it should be charted. Cognitive Level: Applying Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.5 Define the use of deadlines and checkpoints in the client care plan. Page Number: 36 6. The nurse is meeting with physical therapist and a dietitian to review care for a client recovering from a stroke. Which tool is the nurse most likely using to coordinate this client’s care? 1. Critical pathway 2. Variance analysis 3. Standardized care plan 4. Individualized care plan Correct Answer: 1 Rationale 1: A critical path, or clinical pathway, is a standardized multidisciplinary plan of care developed for clients with common or prevalent conditions. Rationale 2: A variance analysis is completed if a client does not achieve an expected outcome in the time specified on the critical pathway. Rationale 3: A standardized care plan is one that can address a large portion of a client’s needs. Rationale 4: An individualized care plan is written to meet a client’s special needs. Global Rationale: A critical path, or clinical pathway, is a standardized multidisciplinary plan of care developed for clients with common or prevalent conditions. A variance analysis is completed if a client does not achieve an expected outcome in the time specified on the critical pathway. A standardized care plan is one that can address a large portion of a client’s needs. An individualized care plan is written to meet a client’s special needs. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.6 Compare and contrast a clinical pathway and a client care plan. Page Number: 39 7. After providing medications and changing a dressing the nurse accesses the client’s computerized medical record and enters the information about the care provided. Why is the nurse documenting at this time? Select all that apply. 1. Evaluates individual performance 2. Helps determine the staffing needs of the care area 3. Estimates the amount of time required to provide care 4. Communicates information to other members of the team 5. Provides a permanent record of the care provided to the client Correct Answer: 1, 2, 4, 5 Rationale 1: Documentation assists supervisory personnel to evaluate the staff’s performance on a day-by-day basis for specific clients. Rationale 2: Documentation helps management to establish an acuity system to maintain adequate staff levels based on client acuity. Rationale 3: Documentation is not completed to estimate the amount of time required to provide care. Rationale 4: Documentation communicates information to other members of the client’s healthcare team. Rationale 5: Documentation provides a permanent record for future reference that may become a legal document in the event of litigation or prosecution. Global Rationale: Documentation assists supervisory personnel to evaluate the staff’s performance on a day-by-day basis for specific clients, helps management to establish an acuity system to maintain adequate staff levels based on client acuity, communicates information to other members of the client’s healthcare team, and provides a permanent record for future reference that may become a legal document in the event of litigation or prosecution. Documentation is not completed to estimate the amount of time required to provide care. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.7 Explain at least three purposes of charting. Page Number: 40 8. The nurse is preparing to make an entry into a client’s medical record after completing morning care and providing medications. What should the nurse ensure when completing this documentation? Select all that apply. 1. Time care was provided 2. Client’s response to care provided 3. Time medications were administered 4. Estimated date for goals to be achieved 5. Client’s reaction to medications provided Correct Answer: 1, 2, 3, 5 Rationale 1: To ensure accurate documentation the time that care was provided should be included. Rationale 2: To ensure accurate documentation the client’s response to care should be included. Rationale 3: To ensure accurate documentation the time medications were administered should be included. Rationale 4: The estimated time for goalN sU toRbSIeNaGcThBie.CvO edMis documented on the care plan. Rationale 5: To ensure accurate documentation the client’s response to medications should be included. Global Rationale: To ensure accurate documentation the time that care was provided, the client’s response to care, the time medications were administered, and the client’s response to medications should be included. The estimated time for goals to be achieved is documented on the care plan. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.8 Describe at least three major components of accurate charting. Page Number: 41
9. An organization uses the SOAP documentation format. In which area should the nurse document the appearance of a client’s abdominal wound? 1. Plan 2. Objective 3. Subjective 4. Assessment Correct Answer: 2 Rationale 1: The plan includes the next steps determined for the client’s care. Rationale 2: Objective identifies information that can be observed or objectively measured. Rationale 3: Subjective identifies information that the client states. Rationale 4: Assessment is the area where a conclusion is drawn from the information collected through subjective and objective findings. Global Rationale: Objective identifies information that can be observed or objectively measured. The plan includes the next steps determined for the client’s care. Subjective identifies information that the client states. Assessment is the area where a conclusion is drawn from the information collected through subjective and objective findings. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.9 Complete a charting exercise in any of the charting systems using a simulated situation. Page Number: 45 10. The preceptor is reviewing the content of a new graduate’s documentation of client care. What areas should the preceptor easily identify in this notation? Select all that apply. 1. Questions asked by the family 2. Changes in the client’s condition 3. Teaching and the client’s response 4. Reactions to non-routine medications 5. Assessment made at the beginning of the shift
Correct Answer: 2, 3, 4, 5 Rationale 1: Questions asked by a client’s family are not an integral part of nursing documentation. Rationale 2: Documentation should include changes in the client’s emotional, medical, or mental condition. Rationale 3: Client teaching and the client’s response to teaching are important to document. Rationale 4: Reactions to any unscheduled or prn medications must be documented. Rationale 5: Documentation should include the assessment completed at the beginning of the shift. Global Rationale: Documentation should include changes in the client’s emotional, medical, or mental condition, client teaching and the client’s response to teaching, reactions to any unscheduled or prn medications, and the assessment completed at the beginning of the shift. Questions asked by a client’s family are not an integral part of nursing documentation. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate uNnU dR erSsItNaG ndTiBn.gCO ofMmultiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.10 List the four items that should be charted for every client. Page Number: 42 11. During morning care a client states that pain medication has been ineffective and wants to talk with the healthcare provider. How should the nurse categorize this information? 1. A variance 2. A complaint 3. Adverse effect 4. Subjective data Correct Answer: 4 Rationale 1: A variance is an unexpected or unachieved outcome. Rationale 2: A complaint is something that a client states regarding dissatisfaction with care.
Rationale 3: An adverse effect is an unexpected response to a medication or treatment. Rationale 4: Subjective data is what the client feels or says. Global Rationale: Subjective data is what the client feels or says. A variance is an unexpected or unachieved outcome. A complaint is something that a client states regarding dissatisfaction with care. An adverse effect is an unexpected response to a medication or treatment. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.11 Define the terms subjective data and objective data in SOAP and other documentation. Page Number: 35 12. The nurse manager notes that documentation in the medical record about a client’s fall does not match the information identified on tNhU e RoScIcNuGrrTeBn.cCeOrM eport. What could be the potential outcome of this inconsistency? 1. A court case would not occur 2. Valuable information would be forgotten 3. Client’s hospitalization could be prolonged 4. Termination of the nurse completing the occurrence form Correct Answer: 2 Rationale 1: Eliminating information from an occurrence report would not stop a court case from occurring. Rationale 2: When completing an unusual occurrence form with possible legal implications, it is very important to document all details of the incident. Frequently, lawsuits are not filed for months or even years after an incident, when it will not be easy to recall details of care. It is essential to document important details promptly on the form. Rationale 3: Eliminating information from an occurrence report would not necessarily prolong the client’s hospitalization. Rationale 4: Eliminating information from an occurrence report would not necessarily cause the nurse to be terminated.
Global Rationale: When completing an unusual occurrence form with possible legal implications, it is very important to document all details of the incident. Frequently, lawsuits are not filed for months or even years after an incident, when it will not be easy to recall details of care. It is essential to document important details promptly on the form. Eliminating information from an occurrence report would not stop a court case from occurring. Eliminating information from an occurrence report would not necessarily prolong the client’s hospitalization or cause the nurse to be terminated. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.12 Describe the legal ramifications for completing unusual occurrence reports. Page Number: 48 13. The nurse is preparing a consent form for a client’s signature. For which reason is this form most likely needed? 1. Chest x-ray 2. Drawing a blood sample 3. Measuring blood pressure 4. Biopsy of an abdominal mass Correct Answer: 4 Rationale 1: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form. A chest x-ray would be routine care. Rationale 2: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form. Drawing a blood sample would be routine care. Rationale 3: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form. Measuring blood pressure would be routine care. Rationale 4: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form. A biopsy would not be routine care and would need a consent form. Global Rationale: Routine nursing care is “consented to” when the client signs the “conditions of admissions” form. Routine care would include a chest x-ray, drawing a blood sample, and measuring blood pressure. A biopsy would not be routine care and would need a consent form.
Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.13 Discuss specific client activities requiring consent forms. Page Number: 48 14. The nurse is preparing to electronically enter data in a client’s medical record. For which reason could a legal issue occur? 1. Obtains password taped under keyboard 2. Logs out of the record before leaving the terminal 3. Shreds laboratory reports after using them during report 4. Turns off the monitor when approached by a family member Correct Answer: 1 Rationale 1: Personal passwords should N noUtRbSeINsG haTrBe.dCOorMgiven to anyone. Taping a password under a keyboard would be sharing. Rationale 2: Logging out of the record before leaving the terminal would not cause a legal issue. Rationale 3: Shredding laboratory reports would ensure client confidentiality and not cause a legal issue. Rationale 4: Protecting health information by turning off a monitor when approached by a family member would not cause a legal issue. Global Rationale: Personal passwords should not be shared or given to anyone. Taping a password under a keyboard would be sharing. Logging out of the record before leaving the terminal, shredding laboratory reports, and turning off a monitor when approached by a family member would not cause legal issues. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality AACN Essential Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality and clients’ right to privacy
NLN Competencies: Quality and Safety; Practice; Carefully maintain and use electronic and/or written health records Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.14 Discuss the legal risks of computer charting. Page Number: 47 15. After delegating an aspect of care to unlicensed assistive personnel (UAP) the nurse answers any questions and is available while the care is being provided. Which “right of delegation” is this nurse performing? 1. Person 2. Direction 3. Supervision 4. Circumstances Correct answer: 3 Rationale 1: Right Person occurs when the nurse delegates the right task to a person who can legally perform the task. Rationale 2: Right Direction occurs when the person delegating the task has described the task clearly, including directions, special steps of the task, and the expected outcomes. Rationale 3: Right Supervision occurs when the nurse delegating the activity answers the UAP’s questions and is available to problem solNvU e,RiSfInNeGcTeBss.CarOyM. Rationale 4: Right Circumstances occurs when the UAP understands the elements of the task and the nurse is assured that the UAP can perform the procedure safely in an appropriate setting. Global Rationale: Right Supervision occurs when the nurse delegating the activity answers the UAP’s questions and is available to problem solve, if necessary. Right Person occurs when the nurse delegates the right task to a person who can legally perform the task. Right Direction occurs when the person delegating the task has described the task clearly, including directions, special steps of the task, and the expected outcomes. Right Circumstances occurs when the UAP understands the elements of the task and the nurse is assured that the UAP can perform the procedure safely in an appropriate setting. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: V. C. 3. Value own role in preventing errors AACN Essential Competencies: IX. 14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the health care team NLN Competencies: Teamwork; Practice; manage delegation effectively Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.15 Discuss the RN’s role in delegating client care. Page Number: 53
16. The nursing student is using a data collection tool while researching a client assignment before clinical the next day. In which category should the student document the client’s use of oxygen? 1. Medications 2. Biographical data 3. Nursing interventions 4. Physical assessment findings Correct Answer: 1 Rationale 1: To assist students with client care planning prior to and during the clinical experience, many nursing programs have developed student clinical preparation forms. Oxygen is prescribed and would be categorized as a medication. Rationale 2: To assist students with client care planning prior to and during the clinical experience, many nursing programs have developed student clinical preparation forms. Biographical data would be the client’s name and age. Rationale 3: To assist students with client care planning prior to and during the clinical experience, many nursing programs have developed student clinical preparation forms. Nursing interventions would be actions that the nurse would perform while providing care. Rationale 4: To assist students with clienNt UcRarSeINpGlaTnBn.iCnOgMprior to and during the clinical experience, many nursing programs have developed student clinical preparation forms. Physical assessment findings would be data collected while completing an examination. Global Rationale: To assist students with client care planning prior to and during the clinical experience, many nursing programs have developed student clinical preparation forms. Oxygen is prescribed and would be categorized as a medication. Biographical data would be the client’s name and age. Nursing interventions would be actions that the nurse would perform while providing care. Physical assessment findings would be data collected while completing an examination. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.16 Complete a data collection tool based on a clinical situation. Page Number: 53
17. The nurse is completing a tool to help coordinate care needed for several clients. What should the nurse identify as a task that must be completed at a specific time for a client? 1. Evaluating the amount of food a client ingested after lunch 2. Providing intravenous medication before a peak blood level is drawn 3. Measuring urine in a collection bag before attending afternoon report 4. Checking the results of laboratory tests before documenting end of shift care Correct Answer: 2 Rationale 1: Evaluating the amount of food a client ingested after lunch can occur any time before the trays are removed from the bedside. Rationale 2: Providing intravenous medication before a peak blood level is drawn would be time dependent. Rationale 3: Measuring urine in a collection bag can occur any time before attending afternoon report. Rationale 4: Checking the results of laboratory tests can occur any time before documenting end of shift care. Global Rationale: Providing intravenous medication before a peak blood level is drawn would be time dependent. Evaluating the amount oNfUfRoSoIdNiGnTgBes.CteOdM , urine output, and laboratory results can occur at any time. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.17 Develop a time-management worksheet for client care. Page Number: 53
CHAPTER 4 1. The nurse is caring for a group of clients. Which nursing behaviors exemplify communication about these clients’ care? Select all that apply. 1. Making a check mark on a care tracking sheet 2. Initialing and dating an entry in the medical record 3. Volunteering to participate in an upcoming seminar 4. Reading the results of laboratory and diagnostic tests 5. Discussing a client’s response to pain medication with the care provider Correct Answer: 1, 2, 4, 5 Rationale 1: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Making a check mark on a care tracking sheet is communicating care provided. Rationale 2: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Initialing and dating an entry in the medical record is communicating care provided. Rationale 3: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Volunteering to participate in an upcoming seminar is not communicating care provided to the clients. Rationale 4: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Reading the results of laboratory and diagnostic tests is receiving communication. Rationale 5: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Discussing a client’s response to pain medication with the care provider is communicating the result of care provided. Global Rationale: Communication is the process of sending and receiving messages by means of symbols, words, signs, gestures, or other actions. Making a check mark on a care tracking sheet and initialing and dating an entry in the medical record is communicating care provided. Reading the results of laboratory and diagnostic tests is receiving communication. Discussing a client’s response to pain medication with the care provider is communicating the result of care provided. Volunteering to participate in an upcoming seminar is not communicating care provided to the clients. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication
AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 4.1 Define the term communication. Page Number: 60 2. The nurse educator is preparing an inservice presentation about communication. What should the nurse emphasize during this training? 1. Communication is an optional task 2. Communication is a sense of self-pride 3. Communication is an essential part of nursing care 4. Communication ensures the provision of quality nursing care Correct Answer: 4 Rationale 1: Communication is a vital element in nursing. It is not an option task. Rationale 2: Self-esteem is a sense of self-pride. Rationale 3: Communication is a vital element in nursing. Rationale 4: Communication does not ensure the quality of nursing care provided. Global Rationale: Communication is a vital element in nursing. It is not an option task. Selfesteem is a sense of self-pride. Communication does not ensure the quality of nursing care provided. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 4.2 Explain why communication is an important concept in nursing. Page Number: 60 3. A visitor asks the nurse questions about a client’s health status. What should the nurse respond to this individual? 1. “I can tell you that the client is not doing very well.”
2. “That information cannot be shared without the client’s permission.” 3. “Please keep this to yourself. The client needs to go on hospice soon.” 4. “Since you are a visitor I can tell you that the client will be here for a few more days.” Correct Answer: 2 Rationale 1: Clients are protected by law against unauthorized release of personal clinical data such as diagnoses. The nurse is telling a stranger that the client is not doing very well which is a violation of the client’s privacy. Rationale 2: Confidential information may be released with the consent of the client. Rationale 3: Clients are protected by law against unauthorized release of personal clinical data such as diagnoses. The nurse is telling a visitor that the client needs to go on hospice which is a violation of the client’s privacy. Rationale 4: Clients are protected by law against unauthorized release of personal clinical data such as diagnoses. The nurse violates the client’s privacy by telling the visitor about the length of the client’s hospitalization. Global Rationale: Confidential information may be released with the consent of the client. Clients are protected by law against unauthorized release of personal clinical data such as diagnoses. The nurse is telling a stranger that the client is not doing very well, saying that the client needs to go on hospice, and sayingNtUhRatSItN heGTcB lie.CnOt M needs to remain hospitalized are all violations of the client’s privacy. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.C. 3. Protect confidentiality of protected health information in electronic health records AACN Essential Competencies: VIII. 10. Protect patient privacy and confidentiality of patient records and other privileged communications NLN Competencies: Context and Environment; Knowledge; principles of informed consent, confidentiality, patient self-determination. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.3 Describe what is meant by the term confidentiality. Page Number: 60 4. During an assessment a client answers no questions and tells the nurse to talk with the spouse who is due to arrive later in the day. What can occur with this situation? 1. Noncompliance 2. Enhanced rapport 3. Situational awareness 4. Dysfunctional communication
Correct Answer: 4 Rationale 1: Noncompliance is the failure or refusal to go along with a plan or program. Rationale 2: Rapport is a feeling of mutual trust experienced by individuals in a satisfactory relationship. Rationale 3: Situational awareness is the ability to gather the right information, analyze it, and make projections as it relates to client care. Rationale 4: Dysfunctional communication results from failing to learn to communicate properly and leaving the responsibility for communicating to others. Global Rationale: Dysfunctional communication results from failing to learn to communicate properly and leaving the responsibility for communicating to others. Noncompliance is the failure or refusal to go along with a plan or program. Rapport is a feeling of mutual trust experienced by individuals in a satisfactory relationship. Situational awareness is the ability to gather the right information, analyze it, and make projections as it relates to client care. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication Uo RnSsIN AACN Essential Competencies: II. 2. DeNm trG atTeBl.eCaOdM ership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 4.4 Discuss four factors that affect communication. Page Number: 61 5. The nurse is reviewing data collected during a health history. Which statement should the nurse use to clarify information? 1. “I hear what you’re saying.” 2. “When you say that, it makes me feel uncomfortable.” 3. “I don’t understand. Can you say it in a different way?” 4. “You were telling me how hard it is to talk to your spouse.” Correct Answer: 3 Rationale 1: “I hear what you’re saying” demonstrates the technique of acknowledgement. Rationale 2: “When you say that, it makes me feel uncomfortable” demonstrates the technique of feedback.
Rationale 3: “I don’t understand. Can you say it in a different way?” demonstrates the technique of clarifying. Rationale 4: “You were telling me how hard it is to talk to your spouse” demonstrates the technique of focus. Global Rationale: “I don’t understand. Can you say it in a different way?” demonstrates the technique of clarifying. “I hear what you’re saying” demonstrates the technique of acknowledgement. “When you say that, it makes me feel uncomfortable” demonstrates the technique of feedback. “You were telling me how hard it is to talk to your spouse” demonstrates the technique of focus. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 4.5 List five examples of therapeutic communication. Page Number: 63 6. The nurse manager is observing a new graduate provide client care. Which statements should the manager identify as being barriers to communication? Select all that apply. 1. “What a beautiful day! I love bright sunshine!” 2. “If it were me I would take the new medication.” 3. “You gave yourself the insulin injection very well.” 4. “You shouldn’t worry so much about your surgery.” 5. “I think it was right for you to delay having the surgery.” Correct Answer: 1, 2, 4, 5 Rationale 1: “What a beautiful day! I love bright sunshine!” demonstrates the barrier of a social response. Rationale 2: “If it were me I would take the new medication” demonstrates the barrier of giving advice. Rationale 3: “You gave yourself the insulin injection very well” demonstrates the communication technique of giving feedback. Rationale 4: “You shouldn’t worry so much about your surgery” demonstrates the barrier of false reassurance.
Rationale 5: “I think it was right for you to delay having the surgery” demonstrates the barrier of value judgment. Global Rationale: “What a beautiful day! I love bright sunshine!” demonstrates the barrier of a social response. “If it were me I would take the new medication” demonstrates the barrier of giving advice. “You shouldn’t worry so much about your surgery” demonstrates the barrier of false reassurance. “I think it was right for you to delay having the surgery” demonstrates the barrier of value judgment. “You gave yourself the insulin injection very well” demonstrates the communication technique of giving feedback. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 4.6 List five examples of barriers to communication. Page Number: 64 7. The nurse asks to attend a seminar on cultural diversity. What was the primary reason for the nurse making this request? 1. Improve ability to care for pediatric clients 2. Decide if a home care position should be accepted 3. Recognize the special needs of an aging population 4. Understand care issues of non-English speaking clients Correct Answer: 4 Rationale 1: Cultural diversity would not improve the nurse’s ability to care for pediatric clients. Rationale 2: Cultural diversity would not help the nurse decide to accept a home care position. Rationale 3: Cultural diversity would not help the nurse recognize the special needs of an aging population. Rationale 4: Cultural diversity implies the range of differences in values, beliefs, customs, folklore, traditions, language, and patterns of behavior for the various cultural groups. This would help with understanding care issues of non-English speaking clients. Global Rationale: Cultural diversity implies the range of differences in values, beliefs, customs, folklore, traditions, language, and patterns of behavior for the various cultural groups. This
would help with understanding care issues of non-English speaking clients. Cultural diversity would not improve the nurse’s ability to care for pediatric clients. Cultural diversity would not help the nurse decide to accept a home care position. Cultural diversity would not help the nurse recognize the special needs of an aging population. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values AACN Essential Competencies: I. 5. Apply knowledge of social and cultural factors to the care of diverse populations NLN Competencies: Context and Environment; Practice: conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.7 Explain why multicultural health care is important and discuss the term cultural diversity. Page Number: 65 8. The nurse is preparing to assess a client who has lived in the United States for 6 months. What should the nurse include to ensure cultural sensitivity? Select all that apply. 1. Education 2. Nutrition practices 3. Family relationships 4. Cultural background 5. Access to a computer Correct Answer: 1, 2, 3, 4 Rationale 1: When completing a total assessment on a client it is important to include the cultural component of education. Rationale 2: When completing a total assessment on a client it is important to include the cultural component of nutrition practices. Rationale 3: When completing a total assessment on a client it is important to include the cultural component of family relationships. Rationale 4: When completing a total assessment on a client it is important to include the cultural component of cultural background. Rationale 5: Access to a computer is not a component of a cultural assessment. Global Rationale: When completing a total assessment on a client it is important to include the cultural components of education, nutritional practices, family relationships, and cultural background. Access to a computer is not a component of a cultural assessment.
Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values AACN Essential Competencies: I. 5. Apply knowledge of social and cultural factors to the care of diverse populations NLN Competencies: Context and Environment; Practice: conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.8 List three components of a cultural sensitivity assessment. Page Number: 65 9. The nurse is completing a spiritual assessment as part of a health history with a newly admitted client. Which question should the nurse use to learn more about this client’s spirituality? Select all that apply. 1. “Do you like your religion?” 2. “How often do you attend religious services?” 3. “Do you follow any particular religious practices?” 4. “Isn’t it difficult to have to go to church every Sunday?” 5. “How can I ensure that your religious practices are followed in the event of a health crisis? Correct Answer: 3, 4 Rationale 1: Asking if the client likes their religion would not help the nurse learn more about the client’s spirituality. Rationale 2: Asking how often the client attends religious services would not help the nurse learn more about the client’s spirituality. Rationale 3: Asking if the client follows any particular religious practices would help the nurse learn more about the client’s spirituality. Rationale 4: Asking if it is difficult to attend church every Sunday would not help the nurse learn more about the client’s spirituality. Rationale 5: Asking for ways to ensure the client’s religious practices are followed in the event of a health crisis would help the nurse learn more about the client’s spirituality. Global Rationale: Asking if the client follows any particular religious practices and asking for ways to ensure the client’s religious practices are followed in the event of a health crisis would help the nurse learn more about the client’s spirituality. Asking if the client likes their religion, how often the client attends religious services, and if it is difficult to attend church every Sunday would not help the nurse learn more about the client’s spirituality.
Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values AACN Essential Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals’ spiritual beliefs and values and how those beliefs and values impact health care NLN Competencies: Context and Environment; Practice: conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.9 List two questions that would elicit information about the client’s spiritual issues. Page Number: 66 10. The nurse is preparing to meet a newly admitted client. What should the nurse do first? 1. Ask the client for feedback 2. Introduce herself to the client 3. Ask if the client has any questions 4. Check client ID with two forms of identification Correct answer: 4 Rationale 1: Asking the client for feedback occurs at the end of the conversation. Rationale 2: Introducing self to the client occurs after identifying the client. Rationale 3: Asking if the client has any question occurs after explaining the purpose of the communication. Rationale 4: Checking the client ID with two forms of identification should be done first. Global Rationale: Checking the client ID with two forms of identification should be done first. Asking the client for feedback occurs at the end of the conversation. Introducing self to the client occurs after identifying the client. Asking if the client has any question occurs after explaining the purpose of the communication. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Planning/Communication and Documentation
Learning Outcome: 4.10 Demonstrate the steps for beginning a client interaction. Page Number: 69 11. The nurse is caring for a client newly diagnosed with heart failure. Which nursing statement encourages the client to express thoughts and feelings? 1. “Please tell me how I can help you learn to manage this health problem.” 2. “Oftentimes heart failure can be prevented with proper diet and exercise.” 3. “Many of my clients have your same health problem and they are doing very well.” 4. “Would you mind holding any questions until I review your healthcare provider’s care orders?” Correct Answer: 1 Rationale 1: Asking the client to say how the nurse can help the client with the health problem best encourages the client to express thoughts and feelings. Rationale 2: There is no evidence that proper diet and exercise will prevent all episodes of heart failure. This statement also assumes that the client did not eat a proper diet or exercise. Rationale 3: Saying that other clients with the same health problem are doing very well minimizes the impact of the health problem on this client. Rationale 4: Asking the client to hold any questions until orders are reviewed communicates that the nurse does not have time to talk withNtU heRScIlN ieGnTt.B.COM Global Rationale: Asking the client to say how the nurse can help the client with the health problem best encourages the client to express thoughts and feelings. There is no evidence that proper diet and exercise will prevent all episodes of heart failure. This statement also assumes that the client did not eat a proper diet or exercise. Saying that other clients with the same health problem are doing very well minimizes the impact of the health problem on this client. Asking the client to hold any questions until orders are reviewed communicates that the nurse does not have time to talk with the client. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A. 9. Discuss principles of effective communication AACN Essential Competencies: II. 2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 4.11 Explain why it is therapeutic to encourage the client to express feelings and thoughts.
Page Number: 67 12. The nurse is engaged in a relationship with a client. Which action should the nurse take when in the continuation phase of this relationship? 1. Identify major problems 2. Anticipate issues once discharged 3. Teach how to self-administer insulin 4. Recognize barriers to communication Correct Answer: 3 Rationale 1: Identifying major problems occurs in the orientation phase. Rationale 2: Anticipating issues once discharged occurs in the termination phase. Rationale 3: Teaching self-care occurs during the continuation phase. Rationale 4: Recognizing barriers to communication occurs in the orientation phase. Global Rationale: Teaching self-care occurs during the continuation phase. Identifying major problems and recognizing barriers to communication occurs in the orientation phase. Anticipating issues once discharged occurs in the termination phase. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 11. Recognize the boundaries of therapeutic relationships AACN Essential Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 4.12 Describe the phases of a nurse–client relationship. Page Number: 67 13. The nurse is having difficulty maintaining rapport with a client. What should the nurse do to facilitate this relationship? 1. Establish mutual goals 2. Demonstrate consistent behavior 3. Use a warm, accepting manner during interactions 4. Accept client as having value and worth as an individual Correct Answer: 4 Rationale 1: Establishing mutual goals occurs during the orientation phase of the relationship.
Rationale 2: Demonstrating consistent behavior occurs during the orientation phase of the relationship. Rationale 3: Using a warm accepting manner during interactions occurs during the orientation phase of the relationship. Rationale 4: Accepting the client as having value and worth as an individual is a fundamental prerequisite of a relationship and helps facilitate the nurse-client relationship. Global Rationale: Accepting the client as having value and worth as an individual is a fundamental prerequisite of a relationship and helps facilitate the nurse-client relationship. Establishing mutual goals, demonstrating consistent behavior, and using a warm accepting manner during interactions occur during the orientation phase of the relationship. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 11. Recognize the boundaries of therapeutic relationships AACN Essential Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively OM Nursing/Integrated Concepts: Nursing PrNoUcResSsI:NIGmTpBl.eCm entation/Communication and Documentation Learning Outcome: 4.13 List three components for maintaining a nurse–client relationship. Page Number: 75 14. During the orientation phase of a new relationship the nurse explains the activities that need to be accomplished before the client is discharged back to home. Why should the nurse do this at this time? 1. Identifies coping mechanisms 2. Establishes trust between the nurse and client 3. Prevents the client from being placed on the defensive 4. Promotes independence and increases sense of self-esteem Correct Answer: 4 Rationale 1: Identifying coping mechanisms helps facilitate an ongoing nurse-client relationship. Rationale 2: Having consistent behavior and only making realistic promises helps establish trust. Rationale 3: Avoiding asking “why” questions helps prevent placing the client on the defensive. Rationale 4: Working closely with the client in discharge planning and in planning the termination of the relationship from its beginning promotes the client’s independence and
increases his or her sense of self-esteem. Global Rationale: Working closely with the client in discharge planning and in planning the termination of the relationship from its beginning promotes the client’s independence and increases his or her sense of self-esteem. Identifying coping mechanisms helps facilitate an ongoing nurse-client relationship. Having consistent behavior and only making realistic promises helps establish trust. Avoiding asking “why” questions helps prevent placing the client on the defensive. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B. 11. Recognize the boundaries of therapeutic relationships AACN Essential Competencies: IX. 21. Engage in caring and healing techniques that promote a therapeutic nurse-patient relationship NLN Competencies: Relationship Centered Care; Practice; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 4.14 Describe the rationale for discussing termination at the beginning of the relationship. Page Number: 76 GT 15. A client says that the health care provNiUdRerSIaNlw ayBs.CsOeM ems to be in a hurry which causes confusion with care expectations. What should the nurse recommend to this client? 1. Write questions to ask when the health care provider makes rounds 2. Suggest telephoning the healthcare provider’s office and speak to the staff 3. Volunteer to discuss the client’s concerns with the provider later in the day 4. Remind that if the healthcare provider does not mention something it probably is not an issue
Correct Answer: 1 Rationale 1: It is a good idea to recommend for clients to keep a notepad and a list of the things they want to mention when they see their provider. This way, all their concerns can be addressed. Rationale 2: Suggesting telephoning the healthcare provider’s office and speak to the staff might be appropriate once the client is discharged. Rationale 3: Volunteering to talk with the healthcare provider for the client enhances dependence and may make the termination phase of the nurse-client relationship more difficult. Rationale 4: The client’s concerns may not be the same as the healthcare provider’s concerns. The client’s concerns should be addressed, regardless of what they may be. Global Rationale: It is a good idea to recommend for clients to keep a notepad and a list of the things they want to mention when they see their provider. This way, all their concerns can be