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Test Bank Fundamentals Nursing Art Science Nursing Care 7th Edition, Taylor
Chapter 01- Introduction to Nursing
1. Which of the following statements accurately describe an element of nursing? Select all that apply.
A) The skills involved in nursing are primarily technical in nature.
B) The primary focus of nursing is to assist individuals to recover from illness.
C) The science of nursing is the knowledge base for the care that is given.
D) The art of nursing is the collection of knowledge through research.
E) Nursing is considered to be both an art and a science.
F) Nursing is a profession that used specialized knowledge and skills.
2. Which of the following set of terms best describes nursing at the end of the Middle Ages?
A) continuity, caring, critical thinking
B) purpose, direction, leadership
C) assessment, interventions, outcomes
D) advocacy, research, education
3. Which of the following is a characteristic of nursing practiced from early civilization to the 16th century?
A) Most early civilizations believed that illness had supernatural causes.
B) The physician was the priest who treated disease with prayer.
C) The nurse was a nun committed to caring for the needy and homeless.
D) Nursing changed from a spiritual focus to an emphasis on knowledge expansion.
4. In what time period did nursing care as we now know it begin?
B) early civilization to 16th century
C) 16th to 17th century
D) 18th to 19th century
5. Who is considered to be the founder of professional nursing?
A) Dorothea Dix
B) Lillian Wald
C) Florence Nightingale
D) Clara Barton
6. 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
7. What was one barrier to the development of the nursing profession in the United States after the Civil War?
A) lack of educational standards
B) hospital-based schools of nursing
C) lack of influence from nursing leaders
D) independence of nursing orders
8. Which of the following individuals provided community-based care and founded public health nursing?
A) Adelaide Nutting
B) Lillian Wald
C) Sojourner Truth
D) Clara Barton
9. Which of the following nursing groups provides a definition and scope of practice for nursing?
D) The Joint Commission
10. Teaching a woman about breast self-examination is an example of what broad aim of nursing?
A) promoting health
B) preventing illness
C) restoring health
D) facilitating coping with disability and death
Chapter 02- Cultural Diversity
1. How is culture learned by each new generation?
A) ethnic heritage
B) involvement in religious activities
C) formal and informal experiences
D) belonging to a subculture
2. A nurse caring for patients in a culturally diverse neighborhood knows that culture affects the nurses interactions with patients. Which of the following is a characteristic of culture? Select all that apply.
A) Culture guides what is acceptable behavior for people in a specific group.
B) Modeling behavior is the primary means of transmitting culture.
C) Culture is generally not affected by the groups social and physical environment.
D) Cultural practices and beliefs mainly remain constant as long as they satisfy a groups needs.
E) Culture influences the way people of a group view themselves, have expectations, and behave.
F) Because of individual influences, there are differences both within and among cultures.
3. Which of the following statements is true of cultural assimilation?
A) Mutual cultural assimilation occurs when characteristics from two groups are traded.
B) Cultural assimilation is the integration of a majority group with a minority group.
C) Moving to a different culture may result in psychological discomfort.
D) Cultural assimilation is identifying with a collective cultural group, primarily based on common heritage.
4. Mr. Perez is a Mexican immigrant who migrated to the United States and lives in a Spanish-speaking community with other relatives. He is taken to the ER following a fall at work and is admitted to the hospital for observation. Which of the following is the nurse caring for Mr. Perez aware that he is at risk for?
A) cultural assimilation
B) cultural shock
C) cultural imposition
D) cultural blindness
5. What characteristic is used to describe racial categories?
B) skin color
C) music preferences
D) food likes and dislikes
6. A 20-year-old housekeeper, born and educated in Iraq, wears her traditional clothing and head covering. A 50-year-old patient tells the nurse, They are in America and should dress like we do. What is this statement an example of?
A) cultural assimilation
B) cultural blindness
C) cultural conflict
D) cultural imposition
7. A nurse walks by a patients room and observes a Shaman performing a healing ritual for the patient. The nurse then remarks to a coworker that the ritual is a waste of time and disruptive to the other patients on the floor. This nurse is displaying the feelings associated with:
A) culture conflict
B) cultural blindness
D) cultural shock
8. Which of the following statements accurately describe cultural factors that may influence healthcare? Select all that apply.
A) Nurses and patients generally agree upon the health practices that are being instituted.
B) Certain racial and ethnic groups are more prone to developing specific diseases and conditions.
C) Although pain affects people differently, most people react to pain in the same manner.
D) Most mental health norms are based on research and observations made of white, middle-class people.
E) In many cultures, the man is the dominant figure and generally makes decisions for all family members.
F) When people move to the United States, they may speak their own language fluently but have difficulty speaking English.
9. A nurse is doing preoperative teaching for an African American man before he has abdominal surgery. What topic should be included in the teaching?
A) the possibility of developing a keloid over the healed incision
B) the increased risk of developing an infection in the incision
C) his racial characteristics that will slow healing
D) cultural influences on his response to surgery
10. A nurse is caring for a patient from Taiwan who constantly requests pain medication. What should the nurse consider when assessing the patients pain?
A) Most people react to pain in the same way.
B) Pain in adults in less intense than pain in children.
C) The patient is a constant complainer.
D) Pain is what the patient says it is.
Chapter 03- Health and Illness
1. 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
2. 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
3. A patient makes a decision to quit smoking and joins a smoking cessation class. This is an example of which of Dunns processes that help a person know who and what he or she is?
4. 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.
5. A rapid onset of symptoms that last a relatively short time indicates what health problem?
A) a chronic illness
B) an acute illness
C) actual risk factor
D) potential for wellness
6. A nurse caring for patients with diabetes knows that the following is a characteristic of a chronic illness:
A) It is a temporary change.
B) It causes reversible alterations in A&P.
C) It requires special patient education for rehabilitation.
D) It requires a short period of care or support.
7. What manifestation is the most significant symptom indicating an illness?
B) runny nose
8. A nurse calls in to his unit to report he has the flu and will not be at work. What stage of illness behavior is he exhibiting?
A) experiencing symptoms
B) assuming the sick role
C) assuming a dependent role
D) achieving recovery and rehabilitation
9. A patient accepts the fact that he needs bypass surgery for a blocked artery and is admitted into the hospital. Which one of the following stages of illness is this patient experiencing?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
10. Which of the following is an example of a characteristic of the Stage 2 of illness?
A) A person tells his family that he is sick and allows them to take care of him.
B) A person experiences a headache and sore throat and takes an aspirin.
C) A person visits a physician to receive treatment for symptoms of an infection.
D) A person begins rehabilitation following a stroke that left him paralyzed on one side.
Chapter 04- Health of the Individual, Family, and Community
1. According to Maslows basic human needs hierarchy, which needs are the most basic?
B) safety and security
C) love and belonging
2. 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.
3. An 80-year-old woman 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
4. A 2-year-old boy 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
5. A 75-year-old man 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
6. A nurse caring for a patient 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
7. What action by a nurse will help a patient meet self-esteem needs?
A) verbally negate the patients negative self-perceptions
B) freely give compliments to increase positive self-regard
C) independently establish goals to improve self-esteem
D) respect the patients values and belief systems
8. A nurse caring for a female patient with TB who is in isolation is aware that the patients love and belonging needs may not be properly met. Which of the following nursing action would help to meet these needs?
A) respecting the patients values and beliefs
B) focusing on the patients strengths rather than problems
C) using hand hygiene and sterile technique to prevent infection
D) encouraging family to visit and help in the care of the patient
9. Which of the following statements accurately describes how Maslows theory can be applied to nursing practice?
A) Nurses can apply this theory to the nursing process.
B) Nurses can identify met needs as healthcare needs.
C) Nurses cannot use the theory on infants or children.
D) Nurses use the theory for ill, as opposed to healthy patients.
10. Jim and Alice were recently married. Each has previously been married and had two children. What name is given to this type of family?
A) extended family
B) nuclear family
C) blended family
D) cohabiting family
Chapter 05- Theory, Research, and Evidence-Based Practice
1. What phrase best describes the science of nursing?
A) application of clinical skills
B) body of nursing knowledge
C) holistic patient care
D) art of individualized nursing
2. The practice of changing patients bedclothes each day in acute care settings is an example of what type of knowledge?
3. A student nurse learns how to give injections from the nurse manager. This is an example of the acquisition of what type of knowledge?
4. Which of the following sources of knowledge is based on objective data?
5. A patient 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?
6. Which of the following examples represents the type of knowledge known as process? Select all that apply.
A) A nurse dispenses medications to patients.
B) A nurse changes the linens on a patients bed.
C) A nurse studies a nursing journal article on infection control.
D) A nurse consults an ethics committee regarding an ethical dilemma.
E) A nurse believes in providing culturally competent nursing care.
F) A nurse monitors the vital signs of a postoperative patient.
7. Which of the following accurately describes Florence Nightingales influence on nursing knowledge?
A) She defined nursing practice as the continuation of medical practice.
B) She differentiated between health nursing and illness nursing.
C) She established training for nurses under the direction of the medical profession.
D) She established a theoretical base for nursing that originated outside the profession.
8. During the first half of the 20th century, a change in the structure of society resulted in changed roles for women and, in turn, for nursing. What was one of these changes?
A) More women retired from the workforce to raise families.
B) Women became more dependent and sought higher education.
C) The focus of nursing changed to hands-on training.
D) Nursing research was conducted and published.
9. Who was the first nurse to develop a nursing theory?
A) Clara Barton
B) Dorothea Dix
C) Florence Nightingale
D) Virginia Henderson
10. A nurse observes that certain patients have less pain after procedures than do others, and forms a theory of why this happens. What is a theory?
A) a concept used to directly prove a fact or a group of facts
B) an understanding borrowed from other disciplines
C) a best guess based on intangible ideas
D) a statement of an occurrence based on observed facts
Chapter 06- Values, Ethics, and Advocacy
1. Which of the following phrases best describes a value?
A) questions about how one should act and live
B) the process by which one decides what is important in life
C) a belief about the worth of something to guide behavior
D) dispositions of character that motivate goodness
2. Mrs. Jones always thanks clerks at the grocery store. Her 6-year-old daughter echoes her thank you. The child is demonstrating what mode of value transmission?
C) reward and punishment
D) responsible choice
3. What is one negative aspect for children of learning values through the moralizing mode of transmission?
A) little likelihood of developing acceptable behaviors
B) can lead to confusion and conflict
C) unacceptable behaviors are punished
D) not much opportunity to weigh values
4. Which of the following modes of value transmission is most likely to lead to confusion and conflict?
D) responsible choice
5. 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
6. Which of the following are examples of a nurse demonstrating the professional value of altruism? Select all that apply.
A) The nurse arranges for an interpreter for a patient whose primary language is Spanish.
B) The nurse calls the physician of a patient whose pain medication is not strong enough.
C) The nurse provides information for a patient so he is capable of participating in planning his care.
D) The nurse reviews a patient chart to determine who may be informed of the patients condition.
E) The nurse documents patient care accurately and honestly and reviews the entry to ensure there are no errors.
F) The nurse encourages legislation for nationalized healthcare insurance for low-income families.
7. Values theorists describe the process of valuing as focusing on three main activities. What is the first activity in the valuing process?
8. Which of the following illustrates the activity of acting in values clarification?
A) respecting the human dignity of all patients
B) seeking public affirmation for actions
C) disregarding several alternatives when choosing
D) considering consequences of actions
9. While at lunch, a nurse heard other nurses at a nearby table talking about a patient 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
10. A middle-aged man is having increasing difficulty breathing. He never exercises, eats fast food regularly, and smokes two packs of cigarettes a day. He tells the nurse practitioner that he wants to change the way he lives. What is one means of helping him change behaviors?
A) ethical change strategy
B) values neutrality choices
C) values transmission
D) values clarification
Chapter 07- Legal Implications of Nursing
1. A nurse is arrested for possession of illegal drugs. What kind of law is involved with this type of activity?
2. A lawyer quotes a precedent for punishment of a crime committed by the defendant in a trial. What is court-made law is known as?
A) public law
B) statutory law
C) common law
D) administrative law
3. A patient is suing a nurse for malpractice. What is the term for the person bringing suit?
4. A nurse is providing patient 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
5. What type of law regulates the practice of nursing?
A) common law
B) public law
C) civil law
D) criminal law
6. 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
7. 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
8. 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.
9. Which of the following statements accurately describe an aspect of the credentialing process used in nursing practice? Select all that apply.
A) Credentialing refers to the way in which professional competence is ensured and maintained.
B) Accreditation is the process by which the state determines a person meets minimum requirements to practice nursing.
C) Certification grants recognition in a specified practice area to people who meet certain criteria.
D) Legal accreditation of a school preparing nursing personnel by the state Board of Nursing is voluntary.
E) Once earned, a license to practice is a property right and may not be revoked without due process.
F) A nurse must be licensed by the state board of nursing in each state in which he or she desires to practice.
10. Which of the following accreditations is a legal requirement for a school of nursing to exist?
A) National League for Nursing Accrediting Commission
B) American Association of Colleges of Nursing accreditation
C) State Board of Nursing accreditation
D) educational institution accreditation
Chapter 08- Healthcare Delivery Systems
1. Which of the following statements accurately describe an aspect of managed care? Select all that apply.
A) Managed care systems control the cost of care with a lower quality of care.
B) The care of the patient is carefully planned and monitored by the primary care provider.
C) The nurse is considered the gatekeeper in the managed care system.
D) The managed care system expands the choice of care providers.
E) The managed care system may required approval for specialty care.
F) Planning and monitoring are conducted to ensure standards are followed.
2. Which of the following is a characteristic of primary healthcare? Select all that apply.
A) It is essential healthcare based on sound methods and technology.
B) It is made universally accessible to individuals and families in the community.
C) It does not require the full participation of the individual and family.
D) It brings healthcare as close as possible to where people live and work.
E) It is the same concept as primary healthcare in that it refers to the delivery of healthcare.
F) The concept was developed based on an increase in illness and death in third-world countries.
3. Which of the following phrases is characteristic of case management as a method of healthcare delivery?
A) brings healthcare to where people live and work
B) essentially the same method as primary care
C) planned and monitored by patients themselves
D) maximize positive outcomes and contain costs
4. 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
5. 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.
6. What is one responsibility of nurses who work in physicians offices?
A) prescribing medications
B) conducting health assessments
C) performing minor surgery
D) making independent home visits
7. A nurse in a walk-in healthcare setting provides technical services, such as, administering medications, determines the priority of care needs, and provides patient teaching on all aspects of care. Which of the following terms best describes this type of healthcare setting?
B) physicians office
C) ambulatory center
D) long-term care
8. 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 patients on financial matters
D) collaborate with other care providers
9. 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 care for people only with dementia.
10. A grade school is preparing a series of classes on the dangers of smoking. Who would be most likely to teach the classes?
A) the principal
B) an outside consultant
C) a teacher
D) the school nurse
Chapter 09- Continuity of Care
1. 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
2. Which of the following roles of the nurse are most important in providing continuity of care to patients? Select all that apply.
E) role model
3. A focus of healthcare today is community-based care. What is community-based care?
A) care provided to patients within a defined geographic area
B) a focus on providing appropriate care for mental health
C) a focus on the health of the community
D) an emphasis on population-based care
4. Which of the following is a result of the effect of increasing healthcare costs on hospital admissions?
A) decreased length of hospital stay
B) decreased number of surgeries
C) increased hospital admissions
D) fewer surgeries in ambulatory centers
5. Which of the following nursing diagnoses would be appropriate for almost all patients entering a healthcare 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. How can a nurse best provide care to patients whose cultural and religious backgrounds are different from the nurses?
A) ignore differences and treat everyone the same
B) respect values and beliefs even if they differ from the nurses beliefs
C) convince patients to change to the nurses beliefs
D) refuse to care for patients with different beliefs
8. A nurse is admitting a patient to the hospital for surgery. Which of the following pieces of information must be obtained from the patient? Select all that apply.
B) date of birth
C) admitting physician
D) symptoms experienced
F) religious preference
G) admitting diagnosis
9. 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 patients 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
10. A nurse is preparing a room for a new patient. Which of the following is an accepted guideline for this activity? Select all that apply.
A) Position the bed in the highest position for ambulatory patients.
B) Open the bed by folding back the top linens.
C) Assemble routine equipment and supplies.
D) Provide a hospital gown to be worn by the patient at all times.
E) If lab work has not been done, provide a container for a clean urine specimen.
F) Adjust the temperature to 65F and turn off overhead lights.
Chapter 10- Home Healthcare
1. Which of the following statements about the history of home healthcare nursing is most accurate?
A) Home healthcare nursing is a new area of nursing care.
B) There is little evidence of home healthcare nursing before 1995.
C) The predicted trend is that the demand for home healthcare will decrease.
D) Nursing is coming full circle and moving back to the home
2. Which of the following statements accurately describes an aspect of home healthcare?
A) Home healthcare is illness care provided at home.
B) Home healthcare is setting up a hospital in the home.
C) Home healthcare is designed for people with chronic, not acute illness.
D) Home healthcare is provided for people of all ages in various settings.
3. A home healthcare agency providing care in a local community is supported by the United Way and local donations. What type of agency is this?
4. Why would a home healthcare agency choose to be certified by Medicare?
A) to remain open and offer services
B) to ensure that all available services can be provided
C) to receive reimbursement for Medicare-covered services
D) to be able to admit patients without a physicians order
5. Which of the following interventions would be performed by the occupational therapist as a member of the home healthcare team? Select all that apply.
A) Evaluate the patients functional level.
B) Provide muscle-strengthening exercises.
C) Teach patient and family to promote self-care in ADLs.
D) Provide assistance with securing needed equipment.
E) Implement the plan of care designed by the nurse.
F) Conduct research to ensure cost-effectiveness of care plan.
6. Which of the following home healthcare skills are considered skilled professional/paraprofessional services? Select all that apply.
A) nursing care
B) ventilator management
C) physical therapy
E) live-in services
F) pain management
7. A home healthcare nurse is caring for Louis, an 82-year-old patient with end-stage lung cancer who is on a ventilator. The primary caregiver is the 75-year-old wife of the patient. Which of the following questions would best assess the familys decision about end-of-life care for this patient?
A) Where do you see yourself and your family in 5 years?
B) What are your goals for spending your remaining time?
C) How does being on a ventilator support your goals for healthcare?
D) What services do you need that are not currently being provided?
8. In addition to a physicians order, what is one of the eligibility requirements for Medicare-covered home healthcare?
A) The patient must have transportation to the physicians office.
B) The family must be willing to meet healthcare needs.
C) The patient must be essentially homebound.
D) The patient must be able to leave the home unassisted.
9. Which of the following home healthcare services is reimbursed by Medicare?
A) 150 home visits following a hospital stay
B) a visit to teach a patient how to change a sterile dressing
C) assessment of a chronic pre-existing illness
D) a visit from a social worker to discuss socioeconomic needs
10. Following the death of a hospice patient, the nurse continues to care for the family. What is this type of care called?
A) family-centered care
B) palliative care
C) bereavement care
D) after-death care
Chapter 11- Blended Skills and Critical Thinking
1. Which of the following is an essential feature of professional nursing? Select all that apply.
A) provision of a caring relationship to facilitate health and healing
B) attention to a range of human experiences and responses to health and illness
C) use of objective data to negate the patients subjective experience
D) use of judgment and critical thinking to form a medical diagnosis
E) advancement of professional nursing knowledge through scholarly inquiry
F) influence on social and public policy to promote social justice
2. 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
3. Which of the following group of terms best describes the nursing process?
A) nursing goals, medical terminology, linear
B) nurse-centered, single focus, blended skills
C) patient-centered, systematic, outcomes-oriented
D) family-centered, single point in time, intuitive
4. A patient comes to the emergency department complaining of severe chest pain. The nurse asks the patient questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?
5. A nurse is examining a 2-year-old. 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?
6. A home health nurse reviews the nursing care with the patient 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?
7. Based on an established plan of care, a nurse turns a patient every 2 hours. What part of the nursing process is the nurse using?
8. Which of the following statements indicates that a plan to assist a patient in developing and following an exercise program has been effective?
A) I have just been too busy to do my daily exercises.
B) I guess I will begin the activity we discussed next week.
C) I know I should exercise, but my health is not very good.
D) I have lost 10 pounds because I walk 2 miles every day.
9. What name is given to standardized plans of care?
A) critical pathways
B) computer databases
C) nursing problems
D) care plan templates
10. Which of the following groups developed standard language to increase the visibility of nursings contribution to patient care by continuing to develop, refine, and classify phenomena of concern to nurses?
Chapter 12- Assessing
1. Which of the following group of terms best defines assessing in the nursing process?
A) problem focused, time lapsed, emergency based
B) design a plan of care, implement nursing interventions
C) collection, validation, communication of patient data
D) nurse focused, establishing nursing goals
2. A nurse performing triage in an emergency room makes assessments of patients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply.
A) carrying out a physicians order to intubate a patient
B) teaching a novice nurse the principles of triage
C) using the nursing process to diagnose a blocked airway
D) interviewing a patient suspected of being a victim of abuse privately
E) checking the data supplied by a patient with dementia with the family
F) teaching a diabetic patient about the importance of proper foot care
3. On admission, a physician diagnoses a patient with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nurse diagnosing?
A) the pathology of the illness
B) the response of the patient to the illness
C) information from a nursing textbook
D) knowledge from more experienced nurses
4. The nurse completes a health history and physical assessment on a patient 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
5. Mrs. James comes to her healthcare 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
6. 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
7. A nurse performs an assessment of a patient in a long-term care facility and records baseline data. The nurse reassesses the patient a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
8. Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis?
A) The nursing diagnosis confirms the medical diagnosis.
B) The nursing diagnosis duplicates the medical diagnosis.
C) There is no relationship between nursing and medical diagnoses.
D) The nursing diagnosis is based on patient response to the medical diagnosis.
9. 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
10. A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?
A) My leg hurts so bad. I cant stand it.
B) Appears anxious and frightened.
C) I am so sick; I am about to throw up.
D) Unable to palpate femoral pulse in left leg.
Chapter 13- Diagnosing
1. 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
2. Which of the following patient care concerns is clearly a nursing responsibility?
A) prescribing medications
B) monitoring health status changes
C) ordering diagnostic examinations
D) performing surgical procedures
3. After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a patient. What are the nursing diagnoses used for?
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
4. Which of the following are examples of nursing responsibilities? Select all that apply.
A) recognizing the signs and symptoms of pancreatitis when it presents in a patient
B) making a diagnosis of uterine cancer following diagnostic testing
C) referring a patient diagnosed with lung cancer to a smoke-cessation group
D) researching and prescribing medication for an adolescent with uncontrolled asthma
E) performing range-of-motion exercises on an elderly patient who is in a wheelchair
F) teaching a group of high school students about the dangers of having unprotected sex
5. Which of the following statements accurately describe the legal responsibility of the nurse making a diagnosis for a patient?
A) The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the patient.
B) The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the patient.
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 healthcare facility directs the nursing diagnosis in order to receive payment for services performed.
6. A student is reviewing a patients chart before giving care. She notes the following diagnoses in the contents of the chart: appendicitis and acute pain. Which of the diagnoses is a medical diagnosis?
A) neither appendicitis nor acute pain
B) both appendicitis and acute pain
D) acute pain
7. A nurse develops a plan of care to meet the needs of a patient who has had a large loss of blood after a snowmobile crash. The interventions include administering and monitoring the patients physiologic response to intravenous fluids and blood. What has the nurse focused care on?
A) a medical diagnosis
B) a nursing diagnosis
C) a collaborative problem
D) a goal for care
8. A nurse is reviewing the health history and physical assessment findings for a patient who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?
A) I often have diarrhea after I eat spicy foods.
B) My skin is so dry I just cant keep from scratching.
C) I get out of breath when I walk a few steps.
D) I just feel so bad about myself these days.
9. What is the focus of a diagnostic statement for a collaborative problem?
A) the patient problem
B) the potential complication
C) the nursing diagnosis
D) the medical diagnosis
10. Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process?
A) Trust clinical judgment and experience over asking for help.
B) Respect clinical intuition, but never allow it to determine a diagnosis.
C) Recognize personal biases as a strength in formulating diagnoses.
D) Keep an open mind and trust your intuition when formulating diagnoses.
Chapter 14- Outcome Identification and Planning
1. 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 to identify health problems
C) to write appropriate patient-centered nursing diagnoses
D) to design a plan of care for and with the patient
2. 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?
3. Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply.
A) professional physicians organizations
B) state Nurse Practice Acts
C) The Joint Commission
D) the Agency for Health Care Research and Quality
E) the Patient Health Partnership
F) the Patient Bill of Rights
4. A nurse admits a patient to the hospitals short-stay unit and completes a health history and physical assessment. Using these data, the nurse develops a(n) ___________plan of care, based on _____________ planning?
A) intermittent, focused
B) comprehensive, initial
C) single-use, ongoing
D) standard, emergency
5. Although each care plan is individualized, there are certain risks and health problems that, for example, patients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?
6. A nurse is discharging a patient from the hospital. When should discharge planning be initiated?
A) at the time of discharge from an acute healthcare setting
B) at the time of admission to an acute healthcare setting
C) before admission to an acute healthcare setting
D) when the patient is at home after acute care
7. A nurse assesses the vital signs of a patient who is one day postsurgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of care. What are these actions considered?
A) initial planning
B) comprehensive planning
C) on-going planning
D) discharge planning
8. A father runs into the emergency room with his 18-month-old son in his arms. The father screams, Help, he is not breathing! The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?
A) no priority
B) low priority
C) medium priority
D) high priority
9. 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
10. A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what patient need should have priority?
A) the need to have nutrition
B) the need to feel good about oneself
C) the need to live in a safe environment
D) the need for love from others
Chapter 15- Implementing
1. What is the unique focus of nursing implementation?
A) patient response to health and illness
B) patient response to nursing diagnosis
C) patient compliance with treatment regimen
D) patient interview and physical assessment
2. What is one advantage of having a standard classification of nursing interventions?
A) to standardize nomenclature (names or terms)
B) to legitimize the use of the nursing process
C) to classify indicators of patient outcomes
D) to facilitate documentation of expected goals
3. The researchers developing classifications for interventions are also committed to developing a classification of which of the following?
D) data clusters
4. 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 patient outcomes are determined.
C) Planned nursing actions (interventions) are carried out.
D) Desired outcomes are evaluated and, if necessary, the plan is modified.
5. What role of the nurse is crucial to the prevention of fragmentation of care?
6. What phrase best describes nurse-initiated interventions?
A) nurse-prescribed interventions
B) physician-prescribed interventions
C) healthcare team interventions
D) interventions based on medical orders
7. Which of the following examples of nursing actions involve direct care of the patient? Select all that apply.
A) A nurse counsels a young family who is interested in natural family planning.
B) A nurse massages the back of a patient while performing a skin assessment.
C) A nurse arranges for a consultation for a patient who has no health insurance.
D) A nurse helps a patient in hospice fill out a living will form.
E) A nurse arranges for physical therapy for a patient who had a stroke.
F) A nurse comforts a distraught patient whose baby was stillborn.
8. A nurse documents the following diagnosis for a hospitalized patient: Risk for Imbalanced Nutrition: More Than Body Requirements. What is the major goal of interventions for a risk diagnosis?
A) reduce or eliminate contributing factors
B) prevent the problem
C) collect additional data
D) promote higher-level wellness
9. A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean?
A) The nurse is using critical thinking to implement the dressing change.
B) The patient has specified how the dressing should be changed.
C) Written plans are developed that specify nursing activities for this skill.
D) The physician verbally requested specific steps of the dressing change.
10. What must occur before physician-initiated interventions can be carried out?
A) They must be written on the nursing plan of care.
B) The nurse relinquishes all responsibility for them.
C) Any healthcare provider may order them.
D) The physician gives a verbal or written order.
Chapter 16- Evaluating
1. Which of the following best summarizes the evaluating step of the nursing process?
A) The nurse completes a health assessment to establish a database.
B) The patient and family have met healthcare goals and no longer need care.
C) The nurse and patient identify nursing diagnoses and appropriate interventions.
D) The nurse and patient measure achievement of planned outcomes of care.
2. What is the purpose of evaluation in the nursing process?
A) to direct future nursing interventions
B) to formulate a database of nursing diagnoses
C) to complete an initial plan of care
D) to transfer medical orders to the plan of care
3. Which of the following would not be part of the nurses decision about care after evaluating the patients responses to the plan of care?
A) terminate the plan of care
B) modify the plan of care
C) continue the plan of care
D) begin the plan of care
4. Nurses evaluate many aspects of the healthcare delivery system. Which of the following is always the primary concern when performing the evaluating step of the nursing process?
A) the nurse
B) the patient
C) the healthcare system
D) outcome achievement
5. What cognitive processes must the nurse use to measure patient achievement of outcomes during evaluation?
A) intuitive thinking
B) critical thinking
C) traditional knowing
D) rote memory
6. A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected patient outcomes), what must the nurse do next?
A) Interpret and summarize findings.
B) Document his or her judgment.
C) Collect data about patient responses.
D) Formulate a new plan of care.
7. Which of the following is a descriptor that helps to define the term criteria?
A) immeasurable qualities
B) established by authority
C) acceptable level of performance
D) evidence-based practice
8. A nurse is evaluating the outcomes of a plan of care to teach an obese patient about the calorie content of foods. What type of outcome is this?
9. A nurse is teaching a patient how to administer insulin, with the expected outcome that the patient will be able to self-administer the insulin injection. How would this outcome be evaluated?
A) asking the patient to verbally repeat the steps of the injection
B) asking the patient to demonstrate self-injection of insulin
C) asking family members how much trouble the patient is having with injections
D) asking the patient how comfortable he or she is with injections
10. A nurse is counseling a novice nurse who gives 150% effort at all times and is becoming frustrated with a healthcare system that provides substandard care to patients. Which of the following advice would be appropriate in this situation? Select all that apply.
A) Tell the new nurse to help other nurses perform their jobs to ensure quality patient care is being delivered.
B) Encourage the new nurse to leave her problems at work behind, instead of rehashing them at home.
C) After establishing a reputation for delivering quality nursing care, have her seek creative solutions for nursing problems.
D) Tell her to view nursing care concerns as challenges rather than overwhelming obstacles and seek help for solutions.
E) State that if resources do not permit quality care, it is not the role of the new nurse to explore change strategies within the institution.
F) Tell the nurse that if administration is not supportive, moving to another practice setting might be more appropriate.
Chapter 17- Documenting, Reporting, Conferring
1. What is the nurses best defense if a patient alleges nursing negligence?
A) testimony of other nurses
B) testimony of expert witnesses
C) patients record
D) patients family
2. A nurse is documenting the intensity of a patients pain. What would be the most accurate entry?
A) Patient complaining of severe pain.
B) Patient appears to be in a lot of pain and is crying.
C) Patient states has pain; walking in hall with ease.
D) Patient states pain is a 9 on a scale of 1 to 10.
3. Which of the following data entries follows the recommended guidelines for documenting data?
A) Patient is overwhelmed by the diagnosis of pancreatic cancer.
B) Patient kidneys are producing sufficient amount of measured urine.
C) Following oxygen administration, vital signs returned to baseline.
D) Patient complained about the quality of the nursing care provided on previous shift.
4. 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
5. In which of the following cases should a progress note be written? Select all that apply.
A) for any nursepatient interaction
B) when admitting a patient
C) when receiving a patient postoperatively
D) when assisting a patient with ADLs
E) when a procedure is performed
F) when a patient sends back an untouched dinner tray
6. A student has reviewed a patients chart before beginning assigned care. Which of the following actions violates patient confidentiality?
A) writing the patients 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
7. Which of the following are examples of breaches of patient confidentiality? Select all that apply.
A) A nurse discusses a patient with a coworker in the elevator.
B) A nurse shares her computer password with a relative of a patient.
C) A nurse checks the medical record of a patient to see who should be called in an emergency.
D) A nurse updates the employer of a patient regarding the patients return to work.
E) A nurse uses a computer to document a patients response to pain medication.
F) A head nurse accesses the medical records of a nurse on her shift to check her condition.
8. Which of the following are examples of incidental disclosures of patient health information that are permitted? Select all that apply.
A) A nurse working in a physicians office puts out a sign-in sheet for incoming patients.
B) Two nurses are overheard talking about a patient through the door of an empty patient room.
C) A nurse places a patient chart in a holder on the examining room door with the name facing out.
D) A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms.
E) A nurse calls out the name of a patient who is seated in the waiting room.
F) A nurse leaves a reminder for an appointment on a patients answering machine along with the results of lab work.
9. A patient asks to see his medical record (chart). How would the nurse respond?
A) I cant let you do that without a doctors order.
B) Our hospital policy is that you cant do that.
C) I will get your chart and provide you with privacy to read it.
D) Why would you want to do that? It will only make you worry.
10. A physicians order reads up ad lib. What does this mean in terms of patient 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 18- Developmental Concepts
1. A child gains weight and becomes taller each year. What is this process called?
B) orderly change
2. All humans learn from both formal and informal experiences. What orderly pattern of changes results in part from learning?
3. As the fetus develops, certain growth and development trends are regular and predictable. The first trend is cephalocaudal growth. What does this mean?
A) Legs and feet develop first.
B) Both sides of the body develop equally.
C) Head and brain develop first.
D) Gross motor skills are learned last.
4. A second trend occurring with growth and development of the infant states that development is proximodistal. This means:
A) Growth progresses from gross motor movements to fine motor movements.
B) Both sides of the body grow equally.
C) All humans experience the same growth patterns.
D) As nerve pathways develop, they become more specialized.
5. Many different factors affect growth and development. For example, why does Mary have blonde hair and blue eyes while John has brown hair and green eyes?
A) childhood illnesses
B) genetic inheritance
C) prenatal influences
D) maternal nutrition
6. Which of the following statements accurately describe factors that may affect an individuals growth and development? Select all that apply.
A) Physical characteristics such as height, bone size, and eye and hair color are inherited from the family of origin.
B) Fetal development can be altered by maternal age or inadequate maternal nutrition or substance abuse.
C) Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships, low self-esteem, and poor social skills.
D) Infants who are malnourished in utero develop fewer brain cells than infants who have had adequate prenatal nutrition.
E) Environmental factors such as poverty and violence do not have a direct effect on growth and development.
F) Inadequate caregiving skills may affect growth of the individual, but it has no effect on predetermined development.
7. According to Freud, what is the name given to the part of the mind that represents ones conscience?
A) unconscious mind
8. The mother of a 6-month-old infant asks the nurse at a community health center what she should do about her baby, who always wants to put everything in his mouth. What would be an appropriate response by the nurse, based on Freuds theory?
A) There must be something wrongyour baby should not be doing that.
B) I dont know if that is normal or not, but I will check on it.
C) Babies at this age explore and enjoy their world with their mouths.
D) This usually does not happen until babies are 2 years old.
9. A 10-year-old boy tells his mother that he is going to be just like his father when he grows up. According to Freud, what stage of development is this child experiencing?
10. Based on Piagets theory of cognitive development, what type of activities would a nurse recommend to parents of children in the preoperational stage?
A) play activities
B) toilet training
C) church lessons
D) organized sports
Chapter 19- Conception Through Young Adult
1. A nurse is teaching a 2-week pregnant woman what is occurring in the development of her baby. Which of the following occur in this preembryonic stage? Select all that apply.
A) The zygote implants in the uterine wall.
B) Rapid growth and differentiation of the cell layers occurs.
C) All basic organs are established.
D) Some human features are recognizable.
E) Three distinct layers of cells exist.
F) The heartbeat can be heard by doppler.
2. A pregnant woman is at the end of her first trimester. The nurse tells her that normally the following developments have occurred in her fetus. Select all that apply.
A) some reflexes are present
B) kidney secretion begins
C) the sex of the infant is distinguishable
D) sleepwake patterns are established
E) lung surfactant is produced
F) eyelids open
3. A nurse is teaching a young woman about healthy behaviors during the embryonic stage of pregnancy. Which of the following should the nurse emphasize to prevent congenital anomalies?
A) adequate intake of food and fluids
B) importance of rest and sleep
C) avoidance of alcohol and nicotine
D) progression of stages during delivery
4. A nurse is teaching a pregnant woman about nutritional needs. Which of the following nutritional deficiencies during pregnancy might result in neural tube defects in the developing fetus?
A) vitamin D
D) folic acid
5. At birth, the neonate must adapt to extrauterine life through several significant physiologic adjustments. Which of the following is the most important adjustment that occurs?
A) body temperature responds to the environment
B) reflexes develop
C) stool and urine are eliminated
D) breathing begins
6. A nurse documents the following data upon assessment of a neonate: heart rate 89 BPM, slow respiratory effort, flaccid muscle tone, weak cry, and pale skin tone. What would be the Apgar score for this neonate?
7. A mother watches as a neonate cries, spreads his arms, and draws them in again in response to being pulled up and laid back down. She asks the nurse what is going on with her baby. What is the best explanation for this response?
A) Your baby is experiencing gas, and this movement helps to expel it.
B) Your baby is demonstrating a normal CNS response called the Moro reflex.
C) Your baby is experiencing the signs and symptoms of an abnormal neural response to being startled.
D) Your babys actions are normal automatic movements to help maintain core body temperature.
8. Of the following components of psychosocial development in the neonate and infant, which one facilitates emotional linkage between a baby and caregiver?
9. A nurse is teaching a group of parents about the dangers of Sudden Infant Death Syndrome (SIDS). The nurse recommends that parents place their children on a firm surface laying on their:
A) left side
B) right side
10. A nurse is observing a group of toddlers at play. What behavior illustrates normal physiologic development in children of this age?
A) attempting to feed self
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