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Test Bank Fundamental Nursing 8th Edition, Taylor
Chapter 1: Introduction to Nursing
1. An oncology nurse with 15 years of experience, certification in the area of oncology nursing, and a masters degree is considered to be an expert in her area of practice and works on an oncology unit in a large teaching hospital. Based upon this description, which of the following career roles best describes this nurses role, taking into account her qualifications and experience?
A) Clinical nurse specialist
B) Nurse entrepreneur
C) Nurse practitioner
D) Nurse educator
2. What guidelines do nurses follow to identify the patients health care needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes?
A) Nursing process
B) ANA Standards of Professional Performance
C) Evidence-based practice guidelines
D) Nurse Practice Acts
3. Which of the following organizations is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice?
A) American Nurses Association (ANA)
B) American Association of Colleges in Nursing (AACN)
C) National League for Nursing (NLN)
D) International Council of Nurses (ICN)
4. Who is considered to be the founder of professional nursing?
A) Dorothea Dix
B) Lillian Wald
C) Florence Nightingale
D) Clara Barton
5. Which of the following nursing pioneers established the Red Cross in the United States in 1882?
A) Florence Nightingale
B) Clara Barton
C) Dorothea Dix
D) Jane Addams
6. A nurse practitioner is caring for a couple who are the parents of an infant diagnosed with Down Syndrome. The nurse makes referrals for a parent support group for the family. This is an example of which nursing role?
7. A nurse is providing nursing care in a neighborhood clinic to single, pregnant teens. Which of the following actions is the best example of using the counselor role as a nurse?
A) Discussing the legal aspects of adoption for teens wishing to place their infants with a family
B) Searching the Internet for information on child care for the teens who wish to return to school
C) Conducting a client interview and documenting the information on the clients chart
D) Referring a teen who admits having suicidal thoughts to a mental health care specialist
8. A nurse instructor explains the concept of health to her students. Which of the following statements accurately describes this state of being?
A) Health is a state of optimal functioning.
B) Health is an absence of illness.
C) Health is always an objective state.
D) Health is not determined by the patient.
9. A nurse incorporates the health promotion guidelines established by the U.S. Department of Health document: Healthy People 2010. Which of the following is a health indicator discussed in this document?
10. Which of the following is a criteria that defines nursing as profession?
A) an undefined body of knowledge
B) a dependence on the medical profession
C) an ability to diagnose medical problems
D) a strong service orientation
Chapter 2: Theory, Research, and Evidence-Based Practice
1. After reviewing several research articles, the clinical nurse specialist on a medical surgical unit rewrites the procedure on assessing placement of a nasogastric tube. What source of nursing knowledge did the nurse use in this situation?
A) Scientific knowledge
B) Traditional knowledge
C) Authoritative knowledge
D) Philosophical knowledge
2. Which of the following theories emphasizes the relationships between the whole and the parts, and describes how parts function and behave?
A) General systems theory
B) Nursing theory
C) Adaptation theory
D) Developmental theory
3. A nurse researcher is studying perceptions of vocational rehabilitation for clients after a spinal cord injury. What type of research method will be used to study the perceptions of this group of individuals?
A) Qualitative research
B) Quantitative research
C) Basic research
D) Applied research
4. A staff development nurse is asking a group of new staff nurses to read and be prepared to discuss a qualitative study that focuses on nursing events of the past. This is done in an attempt to increase understanding of the nursing profession today. What method of qualitative research is used in this article?
C) Grounded theory
5. In understanding the historical influences on nursing knowledge, nursing as a profession struggled for years to establish its own identify and to receive recognition for its contributions to health care. Why?
A) The conceptual and theoretical basis for nursing practice came from outside the profession.
B) Nurses were too busy working in practice to increase the public awareness associated with the role of the nurse.
C) Nurses spent most of their time in laboratory settings conducting research.
D) Women were independent and refused to work collectively.
6. An obstetrical nurse wishes to identify whether clients perceptions of a high level of support from their partner is associated with a decreased length of the second stage of labor. Which type of quantitative research is most appropriate for this research question?
A) Correlational research
B) Descriptive research
C) Quasi-experimental research
D) Experimental research
7. Nurse researchers have predicted that a newly created mentorship program will result in decreased absenteeism, increased retention, and decreased attrition among a hospitals nursing staff. Which of the following does this predicted relationship represent?
B) Dependent variable
8. The practice of changing patients bedclothes each day in acute care settings is an example of what type of knowledge?
9. A student nurse learns how to give injections from the nurse manager. This is an example of the acquisition of what type of knowledge?
10. A client undergoing chemotherapy for a brain tumor believes that having a good attitude will help in the healing process. This is an example of what type of knowledge?
Chapter 3: Health, Illness, and Disparities
1. The nurse is preparing a care plan for an African American man age 68 years who was recently diagnosed with hypertension. Age, race, gender, and genetic inheritance are examples of what human dimension?
2. The mother of a toddler with asthma seeks support from the parents of other children with asthma. The nurse recognizes that seeking and utilizing support systems is an example of which human dimension?
A) Sociocultural dimension
B) Physical dimension
C) Environmental dimension
D) Intellectual and spiritual dimension
3. A nurse educator uses models of health and illness when teaching. Which model of health and illness places high-level health and death on opposite ends of a graduated scale?
A) Health-Illness Continuum
B) Agent-Host-Environment Model
C) Health Belief Model
D) Health Promotion Model
4. A homeless client has been brought to the emergency department (ED) by ambulance after being found unresponsive outside a mall. The client is known to the ED staff as having bipolar disorder, and assessment reveals likely cellulitis on his left ankle. He is febrile with a productive cough, and the care team suspects pneumonia. A sputum culture for tuberculosis has been obtained and sent to the laboratory. Which of the following aspects of the clients medical condition would be considered a chronic condition?
A) Bipolar disorder
5. Which of the following activities related to respiratory health is an example of tertiary health promotion and illness prevention?
A) Administering a nebulized bronchodilator to a client who is short of breath
B) Assisting with lung function testing of a client to help determine a diagnosis
C) Teaching a client that light cigarettes do not prevent lung disease
D) Advocating politically for more explicit warning labels on cigarette packages
6. An elderly resident of a long-term care facility has developed diarrhea and dehydration as a result of exposure to clostridium difficile during a recent outbreak. The residents primary care provider has consequently prescribed the antibiotic metronidazole (Flagyl). Which model of health promotion and illness prevention is most clearly evident in these events?
A) The Agent-Host-Environment Model
B) The Health-Illness Continuum
C) The Health Promotion Model
D) The Health Belief Model
7. The nurse is performing a routine assessment of a male client who has an artificial arm as a result of a small plane crash many years earlier. How should the nurse best understand this clients health?
A) Despite the loss of his limb, the client may consider himself to be healthy.
B) The client may be well, but his loss of limb means that he is unhealthy.
C) The loss of his limb prevents the client from achieving wellness, though he may be healthy.
D) Because the clients injury is far in the past, it does not have a bearing on his health or wellness.
8. What phrase best describes health?
A) Individually defined by each person
B) Experienced by each person in exactly the same way
C) The opposite of illness
D) The absence of disease
9. Which of the following most accurately defines illness?
A) The inability to carry out normal activities of living
B) A pathologic change in mind or body structure or function
C) The response of a person to a disease
D) Achieving maximum potential and quality of life
10. Which of the following statements accurately describes the concepts of disease and illness?
A) A disease is traditionally diagnosed and treated by a nurse.
B) The focus of nurses is the person with an illness.
C) A person with an illness cannot be considered healthy.
D) Illness is a normal process that affects level of functioning.
Chapter 4: Health of the Individual, Family, and Community
1. The nurse who is caring for a child admitted after an automobile accident recognizes the importance of including the childs family in the plan of care. Inclusion of the family meets which of Maslows basic human needs?
A) Love and belonging
2. The community health nurse is creating a plan of care for a client with Parkinsons disease. The clients spouse has provided care to the client for the past five years and the clients care needs are increasing. What is an appropriate nursing diagnosis for the client and family?
A) Risk for Caregiver Role Strain.
B) Health Seeking Behaviors.
C) Parental Role Conflict.
D) Readiness for Enhanced Family Processes.
3. During the course of assessing the family structure and behaviors of a pediatric patients family, the nurse has identified a number of highly significant risk factors. Which of the following actions should the nurse prioritize when addressing these risk factors?
A) Engage in appropriate health promotion activities.
B) Validate the familys unique way of being.
C) Enlist the help of community and social support.
D) Introduce the family to another family that possesses fewer risk factors.
4. According to Maslows basic human needs hierarchy, which needs are the most basic?
B) Safety and security
C) Love and belonging
5. Which of the following is a tenant of Maslows basic human needs hierarchy?
A) A need that is unmet prompts a person to seek a higher level of wellness.
B) A person feels ambivalence when a need is successfully met.
C) Certain needs are more basic than others and must be met first.
D) People have many needs and should strive to meet them simultaneously.
6. An woman 80 years of age states, I have successfully raised my family and had a good life. This statement illustrates meeting which basic human need?
A) Safety and security
B) Love and belonging
7. A boy age 2 years arrives at the emergency department of a local hospital with difficulty breathing from an asthmatic attack. Which of the following would be the priority nursing intervention?
A) Giving him his favorite stuffed animal to hold
B) Assessing respirations and administering oxygen
C) Raising the side rails and restraining his arms
D) Asking his mother what are his favorite foods
8. A man 75 years of age is being discharged to his home following a fall in his kitchen that resulted in a fractured pelvis. The home health nurse makes a home assessment that will be used to design interventions to meet which priority need?
A) Sleep and rest
B) Support from family members
C) Protection from potential harm
D) Feeling a sense of accomplishment
9. A nurse caring for a client in a long-term health care facility measures his intake and output and weighs him to assess water balance. These actions help to meet which of Maslows hierarchy of needs?
B) Safety and security
C) Love and belonging
10. What action by a nurse will help a client meet self-esteem needs?
A) Verbally negate the clients negative self-perceptions
B) Freely give compliments to increase positive self-regard
C) Independently establish goals to improve self-esteem
D) Respect the clients values and belief systems
Chapter 5: Cultural Diversity
1. A nursing instructor has assigned a student to care for a client of Asian descent. The instructor reminds the student that personal space considerations vary among cultures. What personal space preferences are important for the student to consider when caring for this client?
A) People of Asian descent prefer some distance between themselves and others.
B) People of Asian descent commonly stand close to one another when talking.
C) People of Asian descent touch one another when sitting next to a familiar person.
D) People of Asian descent prefer direct eye contact when communicating.
2. When providing nursing care to an African American individual, which of the following cultural factors should the nurse consider?
A) Values and beliefs are often present oriented.
B) Families are usually patriarchal.
C) They possess weak religious affiliations.
D) Families are highly competitive.
3. The nurse is obtaining a health history from a patient of Puerto Rican descent. Which of the following is most likely to be a health problem that has a cultural connection for this patient?
A) Lactose enzyme deficiency
C) Sickle cell anemia
4. Despite the presence of a large number of elderly residents of Asian heritage, a long-term care facility has not integrated the Asian concepts of hot and cold into meal planning. Which of the following should the nurses at the facility recognize this as an example of?
A) Cultural blindness
C) Cultural assimilation
D) Cultural imposition
5. When providing care on an Indian reservation, the nurse has prioritized assessments for diabetes and fetal alcohol syndrome when working with residents of the reservation. How should this nurses practice be best understood?
A) The nurse is correct in assessing for health problems that have a higher incidence and prevalence among this population.
B) The nurse is stereotyping American Indians as leading unhealthy lifestyles and abusing alcohol.
C) The nurse is performing cultural imposition of the majority American culture, and the accompanying beliefs around diabetes and alcohol use.
D) The nurse should seek specific permission from each client before proceeding with these assessments.
6. A Mexican immigrant who migrated to the United States and lives in a Spanish-speaking community with other relatives is taken to the ER following a fall at work. He is admitted to the hospital for observation. The nurse is aware tht this client is at risk for:
A) Cultural assimilation
B) Cultural shock
C) Cultural imposition
D) Cultural blindness
7. A nurse walks by a clients room and observes a Shaman performing a healing ritual for the client. The nurse then remarks to a coworker that the ritual is a waste of time and disruptive to the other clients on the floor. What feelings is this nurse displaying?
A) Culture conflict
B) Cultural blindness
D) Cultural shock
8. A nurse is caring for a client from Taiwan who constantly requests pain medication. What should the nurse consider when assessing the clients pain?
A) Most people react to pain in the same way.
B) Pain in adults in less intense than pain in children.
C) The client has a low pain tolerance.
D) Pain is what the client says it is.
9. A father, mother, grandmother, and three school-aged children have immigrated to the United States from Thailand. Which member(s) of the family are likely to learn to speak English more rapidly?
A) Unemployed father
B) Stay-at-home mother
10. A 40-year-old nurse is taking a health history from a Hispanic man aged 20 years. The nurse notes that he looks down at the floor when he answers questions. What should the nurse understand about this behavior?
A) The client is embarrassed by the questions.
B) This is culturally appropriate behavior.
C) The client dislikes the nurse.
D) The client does not understand what is being asked.
Chapter 6: Values, Ethics, and Advocacy
1. A nurse in a physicians office has noted on several occasions that one of the physicians frequently obtains controlled-drug prescription forms for prescription writing. The physician reports that his wife has chronic back pain and requires pain medication. One day the nurse enters the physicians office and sees him take a pill out of a bottle. The doctor mentions that he suffers from migraines and that his wifes pain medication alleviates the pain. What type of nurse-physician ethical situation is illustrated in this scenario?
A) Unprofessional, incompetent, unethical, or illegal physician practice
B) Disagreements about the proposed medical regimen
C) Conflicts regarding the scope of the nurses role
D) Claims of loyalty
2. The client was diagnosed with diabetes three years ago, but has failed to integrate regular blood glucose monitoring or dietary modifications into his lifestyle. He has been admitted to the hospital for treatment of acute renal failure secondary to diabetic nephropathy, an event that has prompted the client to reassess his values. Which of the following actions most clearly demonstrates that this client is engaging in the step of prizing within his valuing process?
A) The client expresses pride that he now has the knowledge and skills to take control of his diabetes management.
B) The client states that he will now begin to check his blood glucose before each meal and at bedtime.
C) The client is now able to explain how his choices have contributed to his renal failure.
D) The client expresses remorse at how his failure to take make lifestyle changes has adversely affected his health.
3. The children of a female client 78 years of age with a recent diagnosis of early-stage Alzheimers disease are attempting to convince their mother to move into an assisted living facility, a move to which the client is vehemently opposed. Both the client and her children have expressed to the nurse how they are entrenched in their position. Which of the following statements expresses a utilitarian approach to this dilemma?
A) The decision should be made in light of consequences.
B) The clients autonomy and independence are the priority considerations.
C) Benefits and burdens should be evenly distributed between the children and the client.
D) The client has a right to self-determination.
4. A group of nurse researchers has proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence?
A) The nurses are taking every reasonable measure to ensure that no participants experience impaired wound healing as a result of the study intervention.
B) The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible.
C) The nurses have given multiple opportunities for potential participants to ask questions, and have been following the informed consent process systematically.
D) The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time.
5. A client with a diagnosis of colorectal cancer has been presented with her treatment options, but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the clients culture. By which of the following is the clients right to self-determination best protected?
A) Respecting the clients desire to have the uncle make choices on her behalf
B) Revisiting the decision when the uncle is not present at the bedside
C) Teaching the client about her right to autonomy
D) Holding a family meeting and encouraging the client to speak on her own behalf
6. A male client age 56 years is experiencing withdrawal from alcohol and is placing himself at risk for falls by repeatedly attempting to scale his bedrails. Benzodiazepines have failed to alleviate his agitation and the nurse is considering obtaining an order for physical restraints to ensure his safety. The nurse should recognize that this measure may constitute what?
7. A mother always thanks clerks at the grocery store. Her daughter age 6 years echoes her thank you. The child is demonstrating what mode of value transmission?
C) Reward and punishment
D) Responsible choice
8. Which of the following modes of value transmission is most likely to lead to confusion and conflict?
D) Responsible choice
9. A nurse in a womens health clinic values abstinence as the best method of birth control. However, she offers compassionate care to unmarried pregnant adolescents. What is the nurse demonstrating?
A) modeling of value transmission
B) conflict in values acceptance
C) nonjudgmental value neutral care
D) values conflict that may lead to stress
10. While at lunch, a nurse heard other nurses at a nearby table talking about a client they did not like. When they asked him what he thought, he politely refused to join in the conversation. What value was the nurse demonstrating?
A) The importance of food in meeting a basic human need
B) Basic respect for human dignity
C) Men do not gossip with women
D) A low value on collegiality and friendship
Chapter 7: Legal Dimensions of Nursing Practice
1. Which of the following aspects of nursing would be most likely defined by legislation at a state level?
A) The differences in the scope of practice between registered nurses (RNs) and licensed practical nurses (LPNs).
B) The criteria that a nurse must consider when delegating tasks to unlicensed care providers.
C) The criteria that clients must meet in order to qualify for Medicare or Medicaid.
D) The process that nurses must follow when handling and administering medications.
2. During a clinical placement on a subacute, geriatric medicine unit, a student nurse fed a stroke client some beef broth, despite the fact that the clients diet was restricted to thickened fluids. As a result, the client aspirated and developed pneumonia. Which of the following statements underlies the students potential liability in this situation?
A) The same standards of care that apply to a registered nurse apply to the student.
B) The student and the nursing instructor share liability for this lapse in care.
C) The patients primary nurse is liable for failing to ensure that delegated care was appropriate.
D) The students potential liability is likely negated by the insurance carried by the school of nursing.
3. A nurse is arrested for possession of illegal drugs. What kind of law is involved with this type of activity?
4. A lawyer quotes a precedent for punishment of a crime committed by the defendant in a trial. What is court-made law known as?
A) Public law
B) Statutory law
C) Common law
D) Administrative law
5. A client is suing a nurse for malpractice. What is the term for the person bringing suit?
6. A nurse is providing client care in a hospital setting. Who has full legal responsibility and accountability for the nurses actions?
A) The nurse
B) The head nurse
C) The physician
D) The hospital
7. What type of law regulates the practice of nursing?
A) Common law
B) Public law
C) Civil law
D) Criminal law
8. What is the legal source of rules of conduct for nurses?
A) Agency policies and protocols
B) Constitution of the United States
C) American Nurses Association
D) Nurse Practice Acts
9. A nurse moves from Ohio to Missouri. Where can a copy of the Nurse Practice Act in Missouri be obtained?
A) Ohio State Board of Nursing
B) Missouri State Board of Nursing
C) Federal government nursing guidelines
D) National League for Nursing
10. Which of the following best describes voluntary standards?
A) Voluntary standards are guidelines for peer review, guided by the publics expectation of nursing.
B) Voluntary standards set requirements for licensure and nursing education.
C) Voluntary standards meet criteria for recognition, specified area of practice.
D) Voluntary standards determine violations for discipline and who may practice.
Chapter 8: The Health Care Delivery System
1. Which of the following clients is the most appropriate candidate for receiving outpatient care?
A) A client whose complaints of irregular bowel movements have necessitated a colonoscopy
B) A woman who has previously borne two children and is entering the second stage of labor
C) A man who is receiving treatment for sepsis after his blood cultures came back positive
D) A client with a history of depression who is currently expressing suicidal ideation
2. After many years of advanced practice nursing, a nurse has recently enrolled in a nurse practitioner program. This nurse has been attracted to the program by the potential to provide primary care for clients after graduation, an opportunity that is most likely to exist in which of the following settings?
A) A rural health center
B) A long-term care facility
C) A university hospital
D) A community hospital
3. Which of the following phrases best describes hospitals today?
A) Focus on chronic illnesses
B) Focus on acute care needs
C) Primary care centers
D) Voluntary agencies
4. A man is scheduled for hospital outpatient surgery. He tells the nurse, I dont know what that word, outpatient, means. How would the nurse respond?
A) It means you will have surgery in the hospital and stay for 2 days.
B) It means the surgeon will come to your home to do the surgery.
C) Why would you ask such a question? Dont worry about it.
D) You will have surgery and go home that same day.
5. A nurse in a walk-in health care setting provides technical services (e.g., administering medications), determines the priority of care needs, and provides client teaching on all aspects of care. Which of the following terms best describes this type of health care setting?
B) Physicians office
C) Ambulatory center
D) Long-term care
6. Nurses who are employed in home care have a variety of responsibilities. Which of the following is one of those responsibilities?
A) Provide all care and services
B) Maintain a clean home environment
C) Advise clients on financial matters
D) Collaborate with other care providers
7. Which of the following is true of long-term care facilities?
A) They provide care only to older adults.
B) They provide care for homeless adults.
C) They provide care to people of any age.
D) They provide care only for people with dementia.
8. A grade school is preparing a series of classes on the dangers of smoking. Who would be most likely to teach the classes?
A) A community health nurse
B) An outside consultant
C) A teacher
D) The school nurse
9. An elderly woman has total care of her husband, who suffers from debilitative rheumatoid arthritis. The couple voices concern over the pain and stress associated with the condition. What type of care might the nurse suggest to help the couple?
A) Primary care
B) Respite care
C) Bereavement care
D) Palliative care
10. What population do hospice nurses provide with care?
A) Those requiring care to improve health
B) Children with chronic illnesses
C) Dying persons and their loved ones
D) Older adults requiring long-term care
Chapter 9: Care Coordination and Continuity
1. A client asks a nurse, How does ergotamine (Ergostat) relieve migraine headaches? The nurse should respond that it:
A) dilates cerebral blood vessels.
B) constricts cerebral blood vessels.
C) decreases peripheral vascular resistance.
D) decreases the stimulation of baroreceptors.
2. What role will the nurse play in transferring a client to a long-term care facility?
A) Provide a verbal report to the nurse at the long-term care facility on the client, the hospital care, and the clients current condition.
B) Assure that the clients original chart accompanies the client.
C) Arrange for the clients belongings to remain at the hospital until discharge from the long-term care facility.
D) Inform the client that transferring should be a stress-free situation.
3. The nurse recognizes that the goals established for a clients discharge are more likely to be accomplished when
A) the client assists in developing the goals.
B) the physician develops the goals.
C) the nurse develops the goals.
D) the multidisciplinary team develops the goals.
4. Which of the following phrases best describes continuity of care?
A) Focusing on acute care in the hospital
B) Serving the needs of children
C) Facilitating transition between settings
D) Providing single-episode care services
5. Which of the following nursing diagnoses would be appropriate for almost all clients entering a health care setting?
A) Impaired Elimination
B) Dysfunctional Grieving
6. A nurse is admitting an older woman (Grace Staples) to a long-term care facility. How should the nurse address the woman?
A) We will just call you Grace while you live here. Okay?
B) I know you have lots of grandchildren, Grandma.
C) What name do you want us to use for you?
D) I think you will enjoy living here, Sweetie.
7. Which of the following is the major goal of ambulatory care facilities?
A) To save money by not paying hospital rates
B) To provide care to clients capable of self-care at home
C) To perform major surgery in a community setting
D) To perform tests prior to being admitted to the hospital
8. According to established standards, which health care provider should conduct a holistic assessment for all clients admitted to the hospital?
B) Admission clerk
C) Licensed practical nurse
D) Registered nurse
9. Which health care provider is responsible for ensuring the room is prepared for admission and that the client is welcomed?
A) Nursing assistant
B) Admitting room clerk
C) Social worker
10. A client has suddenly become very ill, and a nurse is transferring him to the intensive care unit (ICU). How does the nurse provide information to ensure continuity of care?
A) By giving a verbal report to nurses in the ICU
B) By ensuring that the chart and all belongings are moved
C) By delegating a nursing assistant to provide information
D) By asking the family to provide the information
Chapter 10: Blended Competencies
1. The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill?
A) Cognitive skill
B) Technical skill
C) Interpersonal skill
D) Ethical/legal skill
2. A nurse has come on day shift and is assessing the clients intravenous setup. The nurse notes that there is a mini-bag of the clients antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patients medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following?
A) Ethical/legal skills
B) Technical skills
C) Interpersonal skills
D) Cognitive skills
3. A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurses execution of this order demonstrates technical skill?
A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing
B) Understanding the Rh system that underlies the clients blood type
C) Ensuring that informed consent has been obtained and properly filed in the clients chart
D) Explaining the process that will be involved in preparing and administering the transfusion
4. In which of the following situations would the nurse be most justified in implementing trial-and-error problem solving?
A) The nurse is attempting to landmark an obese clients apical pulse.
B) The nurse is attempting to determine the range of motion of a clients hip joint following hip surgery.
C) The nurse is attempting to determine which PRN (as needed) analgesic to offer a client who is in pain.
D) The nurse is attempting to determine whether a poststroke client has a swallowing deficit.
5. What nursing organization first legitimized the use of the nursing process?
A) National League for Nursing
B) American Nurses Association
C) International Council of Nursing
D) State Board of Nursing
6. A client comes to the emergency department complaining of severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?
7. A nurse is examining a child two years of age. Based on her findings, she initiates a care plan for a potential problem with normal growth and development. Which step of the nursing process identifies actual and potential problems?
8. A home health nurse reviews the nursing care with the client and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?
9. Based on an established plan of care, a nurse turns a client every two hours. What part of the nursing process is the nurse using?
10. What name is given to standardized plans of care?
A) Critical pathways
B) Computer databases
C) Nursing problems
D) Care plan templates
Chapter 11: Assessing
1. Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?
A) Assessment data about the client should be collected continuously.
B) Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses.
C) Assess your client at least hourly if the clients vital signs are unstable, and every two hours if the vital signs are stable.
D) Assessment data should be collected prior to the physician rounding on the unit.
2. The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?
A) Human Needs (Maslow) model
B) Functional Health Patterns model
C) Human Response Patterns model
D) Body System model
3. A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation?
A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward.
B) Encourage the novice nurse to develop his or her own tool for data collection.
C) Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation.
D) Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.
4. When documenting subjective data, the nurse should do which of the following?
A) Use the clients own words placed in quotation marks.
B) Paraphrase the information stated by the client.
C) Validate the information with the clients family prior to documentation.
D) Record the information using nonspecific words.
5. The nurse has entered a clients room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
A) Measure the clients oral temperature.
B) Ask a colleague for assistance.
C) Give the client a clean gown and warm blankets.
D) Obtain an order for blood cultures.
6. The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?
A) To gather data about a specific and current health problem
B) To identify life-threatening problems that require immediate attention
C) To compare and contrast current health status to baseline data
D) To establish a database to identify problems and strengths
7. A client comes to her health care providers office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?
A) Initial assessment
B) Focused assessment
C) Emergency assessment
D) Time-lapsed assessment
8. A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the residents ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
A) To identify a life-threatening problem
B) To establish a database for medical care
C) To practice respiratory assessment skills
D) To facilitate the residents ability to breathe
9. A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
10. Of the following information collected during a nursing assessment, which are subjective data?
A) vomiting, pulse 96
B) respirations 22, blood pressure 130/80
C) nausea, abdominal pain
D) pale skin, thick toenails
Chapter 12: Diagnosing
1. Which of the following is a correct guideline to follow when composing a nursing diagnosis statement?
A) Place defining characteristics after the etiology and link them by the phrase as evidenced by.
B) Phrase the nursing diagnosis as a client need.
C) Place the etiology prior to the client problem and linked by the phrase related to.
D) Incorporate subjective and judgmental terminology.
2. In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?
A) Ineffective airway clearance as evidenced by inability to clear secretions
B) Ineffective health maintenance as evidenced by unhealthy habits
C) Ineffective breathing pattern related to pneumonia
D) Ineffective therapeutic regimen management due to smoking
3. The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following?
A) The client is more vulnerable to certain problems than other individuals would be.
B) The diagnoses present significant risks for the development of medical diagnoses.
C) The data necessary to make a definitive nursing diagnosis is absent.
D) The diagnosis has yet to be confirmed by another practitioner.
4. A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented Noncompliance related hostility on the clients chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis?
A) Presuming to know the factors contributing to the problem
B) Identifying a problem that cannot be changed
C) Identifying a problem without corroborating evidence in the statement
D) Neglecting to identify potential complications related to the problem
5. The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis?
A) Validate the nursing diagnosis
B) Identify potential complications
C) Cross-reference the nursing diagnosis with medical diagnoses
D) Modify interventions based on the diagnosis
6. Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis?
A) A cluster of several significant cues of data that suggest a particular health problem
B) A single, definitive cue that is closely associated with a common diagnosis
C) A cue that can be verified by objective, medical data
D) A group of related nursing diagnoses that exist within the same NANDA-approved domain
7. In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?
A) To collect information about subjective and objective data
B) To correlate nursing and medical diagnostic criteria
C) To identify etiologies of health problems
D) To evaluate mutually developed expected outcomes
8. Which of the following client care concerns is clearly a nursing responsibility?
A) Prescribing medications
B) Monitoring health status changes
C) Ordering diagnostic examinations
D) Performing surgical procedures
9. After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used?
A) Selecting nursing interventions to meet expected outcomes
B) Establishing a database of information for future comparison
C) Mutually establishing desired outcomes of the plan of care
D) Evaluating the effectiveness of the established plan of care
10. Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client?
A) The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client.
B) The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the client.
C) The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it.
D) The health care facility directs the nursing diagnosis in order to receive payment for services performed.
Chapter 13: Outcome Identification and Planning
1. The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal?
A) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.
B) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma.
C) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased.
D) Within 72 hours of admission, the clients respiratory rate returns to normal and retractions disappear.
2. Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes?
A) The nurse expresses the client outcome as a nursing intervention.
B) The nurse develops measurable outcomes using verbs that are observable.
C) The nurse develops a target time when the client is expected to achieve that outcome.
D) The outcome should include a subject, verb, conditions, performance criteria, and target time.
3. Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following?
A) Reduction in the time spent on care planning
B) Increased autonomy related to the nursing care planning process
C) Enhanced individualization of a care plan
D) Increased nursing expertise in care planning
4. The nurse is planning the care of a male client who is receiving treatment for acute renal failure and who has begun dialysis three times weekly. The nurse has identified the following outcome: Client will demonstrate the appropriate care of his arteriovenous fistula. This outcome is classified as which of the following?
5. The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the clients plan of care this morning was: Client will demonstrate correct technique for self-injecting insulin. The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation?
A) Record an evaluative statement in the clients plan of care.
B) Remove the outcome from the clients care plan.
C) Ask the nurse who wrote the plan of care to document this development.
D) Reassess the clients psychomotor skills at dinner time.
6. A male client is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: After attending an educational session, client will demonstrate correct technique for applying his prosthesis. Which of this clients following statements would signal a need to amend this outcome?
A) Im not interested one bit in wearing an artificial hand.
B) Im worried that Im going to get some really strange looks when I wear this thing.
C) I dont have a clue how this thing goes on and comes off.
D) I dont understand the technology thats used in this artificial hand.
7. What is the primary purpose of the outcome identification and planning step of the nursing process?
A) To collect and analyze data to establish a database
B) To interpret and analyze data so as to identify health problems
C) To write appropriate client-centered nursing diagnoses
D) To design a plan of care for and with the client
8. Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning?
A) How do I best cluster these data and cues to identify problems?
B) What problems require my immediate attention or that of the team?
C) What major defining characteristics are present for a nursing diagnosis?
D) How do I document care accurately and legally?
9. A nurse is discharging a client from the hospital. When should discharge planning be initiated?
A) At the time of discharge from an acute health care setting
B) At the time of admission to an acute health care setting
C) Before admission to an acute health care setting
D) When the client is at home after acute care
10. The nursing diagnosis Impaired Gas Exchange, prioritized by Maslows hierarchy of basic human needs, is appropriate for what level of needs?
C) Love and belonging
Chapter 14: Implementing
1. A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the clients discharge needs. This interaction is an example of which professional nursing relationship?
A) Nurse-health care team
2. A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care?
A) Research findings
C) Current standards of care
D) Ethical and legal guides to practice
3. The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice?
A) The registered nurse
B) The American Nurses Association
C) The nurse manager
D) The units medical director
4. An older adult client is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist dont seem to be on the same page and that everyone has their own plan for me. How can the nurse best respond to the clients frustration?
A) Facilitate communication between the different professionals and attempt to coordinate care.
B) Educate the client about the unique scope and focus of each member of the healthvcare team.
C) Modify the clients plan of care to better reflect the commonalities between the different disciplines.
D) Arrange for each professional to perform bedside assessments and interventions simultaneously rather than individually.
5. A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurses best intervention in this clients care?
A) Educate the client about the benefits of early mobilization and offer to assist him.
B) Respect the clients wishes to remain in his bed and ask him when he would like to begin mobilizing.
C) Show the client the expected outcomes on his clinical pathway that relate to mobilization.
D) Document the clients noncompliance and reiterate the consequences of delaying mobilization.
6. Many of the homeless clients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the clients state that the clinic is difficult to find and in an intimidating environment. This demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed?
A) Psychosocial background of clients
B) Developmental stage of clients
C) Ethical and legal considerations
7. A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other clients can hear her. The nurse should respond by modifying which of the following resources?
D) Patient and visitors
8. What is the unique focus of nursing implementation?
A) Client response to health and illness
B) Client response to nursing diagnosis
C) Client compliance with treatment regimen
D) Client interview and physical assessment
9. The researchers developing classifications for interventions are also committed to developing a classification of which of the following?
D) Data clusters
10. What activity is carried out during the implementing step of the nursing process?
A) Assessments are made to identify human responses to health problems.
B) Mutual goals are established and desired client outcomes are determined.
C) Planned nursing actions (interventions) are carried out.
D) Desired outcomes are evaluated and, if necessary, the plan is modified.
Chapter 15: Evaluating
1. Upon evaluation of the clients plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will do what?
A) Terminate the plan of care.
B) Modify the plan of care.
C) Continue the plan of care.
D) Re-evaluate the plan of care.
2. Nursing care and client outcomes may be evaluated by use of a retrospective evaluation process. Which of the following is an example of a retrospective evaluation process?
A) Postdischarge questionnaire.
B) Direct observation of nursing care.
C) Client interview during hospitalization.
D) Review of clients chart during hospitalization.
3. An older adult client has lost significant muscle mass during her recovery from a systemic infection. As a result, she has not yet met the outcomes for mobility and activities of daily living that are specified in her nursing plan of care. How should her nurses best respond to this situation?
A) Continue the plan of care with the aim of helping the client achieve the outcomes.
B) Terminate the plan of care since it does not accurately reflect the clients abilities.
C) Modify the plan of care to better reflect the clients current functional ability.
D) Replace the clients individualized plan of care with a clinical pathway.
4. The nurse has responded to a clients request to view her medical chart by arranging a meeting between the client, the clinical nurse leader, and her primary care physician. The nurse is exemplifying which of the following characteristics of quality health care?
5. Nurses have identified the following outcome in the care of a client who is recovering from a stroke: Client will ambulate 100 feet without the use of mobility aids by 12/12/2011. Several nurses have evaluated the clients progression towards this outcome at various points during her care. Which of the following evaluative statements is most appropriate?
A) 12/12/2011 Outcome partially met. Patient ambulated 75 feet without the use of mobility aids
B) 12/12/2011 Outcome unmet. Patients ambulation remains inadequate.
C) 12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation.
D) 12/14/2011 Outcome met.
6. The nurse witnessed a more senior nurse make six unsuccessful attempts at starting an intravenous (IV) line on a client. The senior nurse persisted, stating, I refuse to admit defeat. This resulted in unnecessary pain for the client. How should the first nurse best respond to this colleagues incompetent practice?
A) Report the nurses practice and have the nurse manager address the matter.
B) Encourage the nurse to attend an in-service on IV starts.
C) Reassure the nurse that this is a difficult skill and give her feedback on her performance.
D) Document an unmet outcome in the clients plan of care.
7. The manager of a medical unit regularly reviews the incident reports that result from errors and near misses that occur on the unit. How should the manager best respond to these incident reports?
A) Use them to inform improvements and education on the unit.
B) Use them to identify deficient workers for removal or demotion.
C) Cross-reference them with client satisfaction reports from the unit.
D) Use them to identify individuals who would benefit from probationary measures.
8. What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation?
A) Intuitive thinking
B) Critical thinking
C) Traditional knowing
D) Rote memory
9. A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this?
10. A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would this outcome be evaluated?
A) Asking the client to verbally repeat the steps of the injection
B) Asking the client to demonstrate self-injection of insulin
C) Asking family members how much trouble the client is having with injections
D) Asking the client how comfortable he or she is with injections
Chapter 16: Documenting, Reporting, Conferring, and Using Informatics
1. A clients diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the clients chart should be written as
A) Avelox (moxifloxacin) 400 mg daily
B) Avelox (moxifloxacin) 400 mg Q.D.
C) Avelox (moxifloxacin) 400 mg qd
D) Avelox (moxifloxacin) 400 mg OD
2. The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks?
A) Vulnerability to legal liability since nurses safe, routine care is not recorded
B) Increased workload for nurses in order to complete necessary documentation
C) Failure to identify and record client problems and associated interventions
D) Significant differences in the charting between nurses due to lack of standardization
3. The nurse managers of a home health care office wish to maximize nurses freedom to characterize and record client conditions and situations in the nurses own terms. Which of the following documentation formats is most likely to promote this goal?
A) Narrative notes
B) SOAP notes
C) Focus charting
D) Charting by exception
4. A hospital utilizes the SOAP method of charting. Within this model, which of the nurses following statements would appear at the beginning of a charting entry?
A) Client complaining of abdominal pain rated at 8/10.
B) Client is guarding her abdomen and occasionally moaning.
C) Client has a history of recent abdominal pain.
D) 2 mg Dilaudid PO administered with good effect
5. What is the nurses best defense if a client alleges nursing negligence?
A) Testimony of other nurses
B) Testimony of expert witnesses
C) Clients record
D) Clients family
6. A nurse is documenting the intensity of a clients pain. What would be the most accurate entry?
A) Client complaining of severe pain.
B) Client appears to be in a lot of pain and is crying.
C) Client states has pain; walking in hall with ease.
D) Client states pain is a 9 on a scale of 1 to 10.
7. Which of the following data entries follows the recommended guidelines for documenting data?
A) Client is overwhelmed by the diagnosis of pancreatic cancer.
B) Clients kidneys are producing sufficient amount of measured urine.
C) Following oxygen administration, vital signs returned to baseline.
D) Client complained about the quality of the nursing care provided on previous shift.
8. Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry?
A) Alice J, RN
B) A. Jones, RN
C) Alice Jones
9. A student has reviewed a clients chart before beginning assigned care. Which of the following actions violates client confidentiality?
A) Writing the clients name on the student care plan
B) Providing the instructor with plans for care
C) Discussing the medications with a unit nurse
D) Providing information to the physician about laboratory data
10. A physicians order reads up ad lib. What does this mean in terms of client activity?
A) May walk twice a day
B) May be up as desired
C) May only go to the bathroom
D) Must remain on bed rest
Chapter 17: Developmental Concepts
1. A child demonstrates increasing language skills and an understanding of symbols. Creative play and the use of imagination is an important activity in the childs life. Based upon these characteristics and according to Jean Piagets theory, what stage of cognitive development is the child demonstrating?
A) Preoperational stage
B) Sensorimotor stage
C) Concrete operational stage
D) Formal operational stage
2. A female client age 35 years explains to the community health nurse that her primary focus daily is the care of her family, her job, and her volunteer activities at her church. The client verbalizes contentment with her various roles and the balancing of these roles. According to the theory on individual life structure developed by Daniel Levinson and associates, this client is demonstrating characteristics associated with what phase of adulthood?
A) Settling down
B) Early adult transition
C) Entering the adult world
D) Midlife transition
3. A child who attends church with his parents imitates religious gesture but does not have an understanding of these religious behaviors. The child also asks his parents, How do you know God exists? Have you ever seen him? This child is described as having characteristics associated with which stage of faith development as defined by Fowler?
A) IntuitiveProjective Faith
B) MysticalLiteral Faith
C) SyntheticConventional Faith
D) IndividuativeReflective Faith
4. After a child plays in the yard, his mother asks him to pick up his toys and put them in the toy bin in the garage. Knowing that he does not want to spend time in his room as a punishment, the child follows his mothers directions. What stage of moral development, according to Kohlberg, is this child demonstrating?
A) Preconventional level: stage 1
B) Preconventional level: stage 2
C) Conventional level: stage 1
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