Foundations and Adult Health Nursing 9th Edition Test Bank PDF

FOUNDATIONS AND ADULT HEALTH NURSING 9TH EDITION COOPER GOSNELL TEST BANK QUESTIONS & ANSWERS WITH RATIONALES 2023 Chapter 01: The Evolution of Nursing Cooper: Foundation of Nursing, 9th Edition MULTIPLE CHOICE 1. What is a nursing program considered when certified by a state agency? a. Accredited b. Approved c. Provisional d. Exemplified ANS: B Approved means certified by a state agency for having met minimum standards; accredited means certified by the NLN for having met more complex standards. Provisional and exemplified are not terms used in regard to nursing program certification. DIF: Cognitive Level: Knowledge REF: p. 10 OBJ: 5 TOP: Nursing programs KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. Which of the following must the nurse recognize regarding the health care delivery system? a. It includes all states. b. It affects the illness of patients. c. Insurance companies are not involved. d. The major goal is to achieve optimal levels of health care. ANS: D The nurse must recognize that in the health care delivery system, the major goal is to achieve optimal levels of health care. The health care system consists of a network of agencies, facilities, and providers involved with health care in a specified geographic area. Insurance companies do have involvement in the health care system. The illness of patients is not necessarily affected by the health care system. DIF: Cognitive Level: Comprehension REF: p. 12 OBJ: 7 TOP: Health care systems KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. What is required by the health care team to identify the needs of a patient and to design care to meet those needs? a.The Kardex b.The health care provider's order sheet c.An individualized care plan d.The nurse's notes ANS: C An individualized care plan involves all health care workers and outlines care to meet the needs of the individual patient. The Kardex, health care provider's order sheet, and nurse's notes do not identify the needs of the patient nor are they designed to assist all members of the health care team to meet those needs. DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 8 | 9 TOP: Care plan KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 4. Patient care emphasis on wellness, rather than illness, begins as a result of: a. increased education concerning causes of illness. b. improved insurance payments. c. decentralized care centers. d. increased number of health care givers. ANS: A The acute awareness of preventive medicine has resulted in today's emphasis on education about issues such as smoking, heart disease, drug and alcohol abuse, weight control, and mental health and wellness promotion activities. This preventive education has resulted in an emphasis on wellness, rather than illness. Improved insurance payments, decentralized care centers, and increased numbers of health care givers did not influence an emphasis on wellness. DIF: Cognitive Level: Comprehension REF: p. 12 OBJ: 4 | 8 TOP: Wellness KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. What is the most effective process to ensure that the care plan is meeting the needs of the patient? a. Documentation b. Communication c. Evaluation d. Planning ANS: B Communication is the primary essential component among the health care team to evaluate and modify the care plan. Documentation, evaluation, and planning are not primary essential components to ensure the care plan is meeting the needs of the patient. DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 8 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 6. How does an interdisciplinary approach to patient treatment enhance care? a. By improving efficiency of care b. By reducing the number of caregivers c. By preventing the fragmentation of patient care d. By shortening hospital stay ANS: C An interdisciplinary approach prevents fragmentation of care. An interdisciplinary approach does not improve the efficiency of care, reduce the number of caregivers, or shorten hospital stay. DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8 | 9 TOP: Interdisciplinary approach KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. How may a newly licensed LPN/LVN practice? a. Independently in a hospital setting b. With an experienced LPN/LVN c. Under the supervision of a health care provider or RN d. As a sole health care provider in a clinic setting ANS: C An LPN/LVN practices under the supervision of a health care provider, dentist, OD, or RN. DIF: Cognitive Level: Knowledge REF: p. 11 OBJ: 11 TOP: Vocational nursing KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8. Whose influence on nursing practice in the 19th century was related to improvement of patient environment as a method of health promotion? a. Clara Barton b. Linda Richards c. Dorothea Dix d. Florence Nightingale ANS: D The influence of Florence Nightingale was highly significant in the 19th century as she fought for sanitary conditions, fresh air, and general improvement in the patient environment. Clara Barton developed the American Red Cross in 1881. Linda Richards is known as the first trained nurse in America, was responsible for the development of the first nursing and hospital records, and is credited with the development of our present-day documentation system. Dorothea Dix was the pioneer crusader for elevation of standards of care for the mentally ill and superintendent of female nurses of the Union Army. DIF: Cognitive Level: Knowledge REF: p. 17 OBJ: 2 | 4 TOP: Nursing leaders KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 9. What document identifies the roles and responsibilities of the LPN/LVN? a. NLN Accreditation Standards b. Nurse Practice Act c. NAPNE Code d. American Nurses' Association Code ANS: B The LPN/LVN functions under the Nurse Practice Act. NLN Accreditation Standards, the NAPNE Code, and the American Nurses' Association Code do not identify the roles and responsibilities of the LPN/LVN. DIF: Cognitive Level: Knowledge REF: p. 12 | p. 14 OBJ: 11 TOP: Roles and responsibilities KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 10. What is a cost-effective delivery of care used by many hospitals that allows the LPN/LVN to work with the RN to meet the needs of patients? a. Focused nursing b. Team nursing c. Case management d. Primary nursing ANS: C Case management is a cost-effective method of care. Focused nursing, team nursing, and primary nursing are not cost-effective methods of delivering care that allow the LPN/LVN to work with the RN to meet patient needs. DIF: Cognitive Level: Comprehension REF: p. 15 OBJ: 7 | 9 TOP: Patient care delivery systems KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 11. What is the title of the American Hospital Association's 1972 document that outlines the patient's expectations to be treated with dignity and compassion? a. Code of Ethics b. Patient's Bill of Rights c. OBRA d. Advance directives ANS: B Patient expectations are outlined by the Patient's Bill of Rights. Patient expectations are not outlined in the Code of Ethics, OBRA, or advance directives. DIF: Cognitive Level: Knowledge REF: p. 16 OBJ: 4 | 8 TOP: Patient's rights KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 12. The relationships among nursing, patients, health, and the environment are the basis for: a. care plans. b. nursing models. c. health care provider's orders. d. evaluation of patient care. ANS: B Nursing models are theories based on the relationship between nursing, patients, health, and environment. Care plans, health care provider's orders, and evaluation of patient care are not based on the relationships among nursing, patients, health, and environment. DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 1 TOP: Nursing models KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 13. What system reduces the number of employees but still provides quality care for patients? a. Team nursing b. Cross-training c. Use of critical pathways d. Case management ANS: B Cross-training reduces the number of employees but does not alter the quality of patient care. Team nursing, use of critical pathways, and case management do not reduce the number of employees while continuing to provide quality care for patients. DIF: Cognitive Level: Comprehension REF: p. 15 OBJ: 8 TOP: Patient care KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 14. What is the purpose of licensing laws for LPN/LVNs? a. To limit the number of LPN/LVNs b. Prevention of malpractice c. Protection of the public from unqualified people d. To increase revenue for the state board of nursing ANS: C The purpose of licensing laws for LPN/LVNs is to protect the public from unqualified health care providers. Licensing laws' purpose is not to limit the number of LPNs/LVNs, prevent malpractice, or increase revenue for the state board of nursing. DIF: Cognitive Level: Comprehension REF: p. 11 OBJ: 4 | 9 | 10 TOP: Licensure KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 15. What premise is Maslow's hierarchy of needs based on? a. All needs are equally important. b. Basic needs must be met before the next level of needs can be met. c. Self-actualization is a primary need. d. Individuals prioritize needs the same way. ANS: B Maslow's hierarchy of needs is based on the premise that basic needs must be met first. It is not based on all needs being equally important or that individuals prioritize needs the same way. Self-actualization is not a primary need according to Maslow. DIF: Cognitive Level: Comprehension REF: p. 12 | p. 13 OBJ: 8 TOP: Maslow's Hierarchy of Needs KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 16. What must the nurse realize when assessing physical and social environmental factors affecting health and illness? a. They affect one another. b. They cause illness. c. They cause patients to react similarly. d. They can be separated. ANS: A Physical and social factors affect each other, cannot be separated, and cause each patient to react in a unique manner. They do not necessarily cause illness or cause patients to react similarly, and they cannot be separated. DIF: Cognitive Level: Comprehension REF: p. 14 OBJ: 4 | 8 TOP: Environmental factors KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 17. What organization, established during World War II, provided nursing education and training? a. Nightingale school b. Cadet Nurse Corps c. Public health department d. Frontier Nursing Service ANS: B The Cadet Nurse Corps was established during World War II to provide nursing education and training. The Nightingale school, public health department, and Frontier Nursing Service are not organizations established during World War II to provide nursing education and training. DIF: Cognitive Level: Knowledge REF: p. 5 OBJ: 1 | 4 TOP: Nursing education KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 18. What is a modern educational advancement program for the LPN/LVN to enter RN education? a. Repetition b. Exclusion c. Articulation d. Coexistence ANS: C Most states have some type of articulation program in which the LPN/LVN can achieve advanced standing in an RN program without having to enroll in the entire curriculum. Repetition, exclusion, and coexistence do not refer to educational advancement. DIF: Cognitive Level: Knowledge REF: p. 10 OBJ: 1 | 9 TOP: Nursing education KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 19. Where did Florence Nightingale's original nursing education take place? a. Saint Thomas b. Kings College Hospital c. Crimean Hospital d. Kaiserswerth School ANS: D Florence Nightingale trained at Kaiserswerth School. Florence Nightingale's original training was not at Saint Thomas, Kings College Hospital, or Crimean Hospital. DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 2 TOP: Nursing programs KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. What system of comprehensive patient care considers the physical, emotional, and social environment and spiritual needs of a person? a. Interdependent care b. Holistic health care c. Illness prevention care d. Health promotion care ANS: B Holistic health care encompasses the physical, emotional, social, and spiritual aspects of the patient. DIF: Cognitive Level: Comprehension REF: p. 12 OBJ: 8 TOP: Health care KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. What official agency exists exclusively for LPN/LVN membership and promotes standards for the LPN/LVN? a. NFLPN b. ANA c. NLN d. NAPNES ANS: A The NFLPN exists solely for the LPN/LVN. The other options have membership that includes RNs and the lay public. DIF: Cognitive Level: Knowledge REF: p. 10 OBJ: 5 | 6 | 9 TOP: Nursing organizations KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 22. What score does the graduate practical nurse require to be issued a license upon completion of the computerized examination? a. 70% or better b. This is defined and set by each state c. Designated as ―pass‖ d. Within the 75th percentile ANS: C Currently graduates of an approved vocational school are eligible to take the licensing examination and be awarded a license with a score of ―pass‖ that is recognized by all states. DIF: Cognitive Level: Knowledge REF: p. 12 OBJ: 3 TOP: Licensure examination KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. What document, published in 1965 by the ANA, clearly defined two levels of nursing practice? a. Licensing standards b. Position paper c. Smith-Hughes Act d. Nurse practice act ANS: B The ANA's position paper of 1965 defined two levels of nursing: registered nurse and technical nurse. Licensing standards, the Smith-Hughes Act, and the nurse practice act were not documents defining two levels of nursing practice published in 1965. DIF: Cognitive Level: Knowledge REF: p. 11 OBJ: 3 | 4 | 9 TOP: Position paper KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 24. What is the wellness/illness continuum defined as? a. A concept that never changes b. The range of a person's total health c. A continuum influenced only by one's physical condition d. An idea that focuses strictly on an individual's social well-being ANS: B The wellness/illness continuum is defined as the range of a person's total health. This continuum is ever changing, and it is influenced by the individual's physical condition, mental condition, and social well-being. DIF: Cognitive Level: Comprehension REF: p. 12 OBJ: 8 TOP: Wellness/illness continuum KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 25. According to Maslow's hierarchy of needs, what is an individual's most basic need? a. Safety and security b. Love/belongingness c. Physiologic d. Self-actualization e. Esteem ANS: C Abraham Maslow believed that an individual's behavior is formed by the individual's attempts to meet essential human needs, which he identified as physiologic, safety and security, love and belongingness, and esteem and self-actualization. DIF: Cognitive Level: Comprehension REF: p. 12 | p. 13 OBJ: 8 TOP: Maslow's Hierarchy of Needs KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. Florence Nightingale established a nursing school at Saint Thomas Hospital in London. What was it characterized by? (Select all that apply.) a. Allowing all applicants who applied to be enrolled b. Offering formal and practical educational experiences c. Keeping records of students' progress d. Focusing on sanitation and hygiene e. Retaining a registry of all graduates ANS: B, C, D, E The nursing school established by Florence Nightingale rigorously screened its applicants. The curriculum, which included both formal education and practical experiences, was focused on hygiene and sanitation. The school kept records of the students' progress during their school years, and also kept a registry of the graduates. DIF: Cognitive Level: Comprehension REF: p. 3 OBJ: 1 | 2 TOP: School established by Florence Nightingale KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. Primitive medical interventions were based on the belief that illness was caused by the presence of spirits. ANS: evil Illness was thought to be caused by the inhabitation of the body by evil spirits. Medical interventions were designed to drive out the evil spirits by introducing good spirits. DIF: Cognitive Level: Comprehension REF: p. 1 OBJ: 1 TOP: Primitive health care KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. During early civilization men performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person. ANS: medicine Medicine men performed witchcraft and rituals to induce the bad spirits to leave the body of the ailing person during early civilization. DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 1 TOP: Primitive health care KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. The National Council of State Boards of Nursing (NCSBN) performs a job analysis every years to determine the scope of practice of LPN/LVNs. ANS: 3 three The National Council of State Boards of Nursing performs a job analysis every 3 years to measure the scope of practice for LPN/LVNs. DIF: Cognitive Level: Knowledge REF: p. 18 OBJ: 6 | 9 TOP: National Council analysis KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. Graduates of the first school for training the practical nurse were referred to as nurses. ANS: attendant The first school for training the practical nurse started in Brooklyn, New York, in 1892 and was conducted under the auspices of the Young Women's Christian Association (YWCA). The Ballard School, as it was known, was approximately 3 months in duration and trained its students to care for the chronically ill, invalids, children, and the elderly. The main emphasis was on home care and included cooking, nutrition, basic science, and basic procedures. Graduates of this program were referred to as attendant nurses. DIF: Cognitive Level: Knowledge REF: p. 9 OBJ: 1 TOP: Attendant nurses KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by Lillian. ANS: Kuster In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by Lillian Kuster. This association is the official membership organization for licensed practical nurses/licensed vocational nurses (LPN/LVNs), and membership is limited to LPNs and LVNs. DIF: Cognitive Level: Knowledge REF: p. 10 OBJ: 2 TOP: National Federation of Licensed Practical Nurses KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 02: Legal and Ethical Aspects of Nursing Cooper: Foundation of Nursing, 9th Edition MULTIPLE CHOICE 1. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an appropriate court. What is this document called? a. Deposition b. Appeal c. Complaint d. Summons ANS: C A document called a complaint is filed in an appropriate court as the first step in litigation. A deposition is when witnesses are required to undergo questioning by the attorneys. An appeal is a request for a review of a decision by a higher court. A summons is a court order that notifies the defendant of the legal action. DIF: Cognitive Level: Knowledge REF: p. 24 OBJ: 1 TOP: Legal KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. The nurse caring for a patient in the acute care setting assumes responsibility for a patient's care. What is this legally binding situation? a. Nurse-patient relationship b. Accountability c. Advocacy d. Standard of care ANS: A When the nurse assumes responsibility for a patient's care, the nurse-patient relationship is formed. This is a legally binding ―contract‖ for which the nurse must take responsibility. Accountability is being responsible for one's own actions. An advocate is one who defends or pleads a cause or issue on behalf of another. Standards of care define acts whose performance is required, permitted, or prohibited. DIF: Cognitive Level: Comprehension REF: p. 24 OBJ: 3 TOP: Legal KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. What are the universal guidelines that define appropriate measures for all nursing interventions? a. Scope of practice b. Advocacy c. Standard of care d. Prudent practice ANS: C Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on behalf of another. Prudent is a term that refers to careful and/or wise practice. DIF: Cognitive Level: Knowledge REF: p. 22 OBJ: 4 TOP: Legal KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention? a. Standards of care b. Regulation of practice c. American Nurses' Association Code d. Nurse practice act ANS: D It is the nurse's responsibility to know the nurse practice act in his or her state. Standards of care, regulation of practice, and the American Nurses' code are not laws that the nurse should refer to before initiating this treatment. DIF: Cognitive Level: Application REF: p. 26 OBJ: 5 TOP: Legal KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of: a. malpractice. b. harm to the patient. c. negligence. d. failure to follow the nurse practice act. ANS: A The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The nurse practice act has general guidelines that can support the charge of malpractice. DIF: Cognitive Level: Application REF: p. 24 OBJ: 2 TOP: Legal KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 6. Patients have expectations regarding the health care services they receive. To protect these expectations, which of the following has become law? a. American Hospital Association's Patient's Bill of Rights b. Self-Determination Act c. American Hospital Association's Standards of Care d. The Joint Commission's rights and responsibilities of patients ANS: A Patients have expectations regarding the health care services they receive. In 1972, the American Hospital Association (AHA) developed the Patient's Bill of Rights. The Self- Determination Act, American Hospital Association's Standards of Care, and The Joint Commission's rights and responsibilities do not address patients' expectations regarding health care. DIF: Cognitive Level: Comprehension REF: p. 27 OBJ: 3 | 4 TOP: Legal KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? a. Physical assessment b. Interview c. Informed consent d. Surgical checklist ANS: C The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure. DIF: Cognitive Level: Application REF: p. 27 OBJ: 8 TOP: Legal KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8. When a nurse protects the information in a patient's record, what ethical responsibility is the nurse fulfilling? a. Privacy b. Disclosure c. Confidentiality d. Absolute secrecy ANS: C The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret. DIF: Cognitive Level: Comprehension REF: pp. 29-30 OBJ: 9 TOP: Confidentiality KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 9. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action? a. Cover the bruises with bandages. b. Take photographs of the bruises. c. Ask the patient if anyone has hit her. d. Report the bruises to the charge nurse. ANS: D The law stipulates that the health care professional is required to report certain information to the appropriate authorities. The report should be given to a supervisor or directly to the police, according to agency policy. When acting in good faith to report mandated information (e.g., certain communicable diseases or gunshot wounds), the health care professional is protected from liability. DIF: Cognitive Level: Application REF: p. 31 OBJ: 9 TOP: Elder abuse KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 10. What is the best way for a nurse to avoid a lawsuit? a. Carry malpractice insurance. b. Spend time with the patient. c. Provide compassionate, competent care. d. Answer all call lights quickly. ANS: C The best defense against a lawsuit is to provide compassionate and competent nursing care. Carrying malpractice insurance is prudent, but it will not avoid a lawsuit. Spending time with patients and answering call lights quickly will not necessarily help avoid a lawsuit. DIF: Cognitive Level: Comprehension REF: p. 29 OBJ: 8 TOP: Avoiding a lawsuit KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 11. The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her legal obligation? a.To question the health care provider b.To seek advice from the family c.To discuss it with the patient d.To follow the order ANS: D When a DNR order is written in the chart, the nurse has a duty to follow the order. Questioning the health care provider, seeking advice from the family, and discussing it with the patient are not legal obligations of the nurse. DIF: Cognitive Level: Application REF: p. 37 OBJ: 10 | 14 TOP: Legal KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 12. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take? a. Ask for another assignment. b. Leave work. c. Transfer to another floor. d. Protest to the supervisor. ANS: A The nurse should not abandon the patient, but ask for another assignment. DIF: Cognitive Level: Application REF: p. 37 OBJ: 9 | 16 TOP: Ethics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 13. The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information? a. Nurse practice act b. Standards of care c. Scope of nursing practice d. Professional organizations ANS: B Standards of care define what should or should not be done for patients. The nurse practice act, scope of nursing practice, and professional organizations do not provide the best information as to what should or should not be done for patients. DIF: Cognitive Level: Comprehension REF: p. 24 OBJ: 5 TOP: Standards of care KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 14. What role is the nurse who diligently works for the protection of patients' interests playing? a. Caregiver b. Health care administrator c. Advocate d. Health care evaluator ANS: C A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patient's interests. Caregiver, health care administrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patients. DIF: Cognitive Level: Comprehension REF: p. 25 OBJ: 9 | 12 TOP: Advocate KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 15. When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself? a. Go ahead and do it. b. Refuse to perform it, citing lack of knowledge. c. Discuss it with the charge nurse, asking for direction. d. Ask another nurse who has performed the procedure. ANS: C The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently. DIF: Cognitive Level: Application REF: p. 26 OBJ: 8 TOP: Legal KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 16. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse? a. Compare values with those of the patient. b. Make a judgment. c. Withhold an opinion. d. Give advice. ANS: C The nurse can assist the patient in values clarification without giving an opinion. DIF: Cognitive Level: Application REF: p. 35 OBJ: 3 | 8 TOP: Values clarification KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 17. What fundamental principle must the nurse first observe when confronted with an ethical decision? a. Autonomy b. Beneficence c. Respect for people d. Nonmaleficence ANS: C The first fundamental principle is respect for people. Autonomy, beneficence, and nonmaleficence are not the first fundamental principles to observe when confronted with an ethical decision. DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 13 | 15 TOP: Ethics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 18. A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the patient's health, safety, and well-being. Given this knowledge, which of the following is most necessary for the nurse to report? a. Unethical behavior of other staff members b. A worker who arrives late c. Favoritism shown by nursing administration d. Arguments among the staff ANS: A A member of the nursing profession must report behavior that does not meet established standards. Unethical behavior involves failing to perform the duties of a competent caring nurse. DIF: Cognitive Level: Application REF: p. 36 OBJ: 13 TOP: Unethical behavior KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 19. A nurse is considering purchasing malpractice insurance. What should the nurse be aware of regarding malpractice insurance provided by the hospital? a. Only offers protection while on duty. b. Is limited in the amount of coverage. c. Is difficult to renew. d. Can be terminated at any time. ANS: A Most institutional insurance only provides liability coverage if the nurse is on duty at that facility. DIF: Cognitive Level: Comprehension REF: p. 32 OBJ: 2 TOP: Malpractice insuranceKEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)? a. Administering a stronger dose of drug than was ordered b. Refusing to give a patient's daughter information over the phone c. Informing the patient's medical power of attorney of a medication change d. Leaving a copy of the patient's history and physical in the photocopier ANS: D Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. Refusing to give a patient's daughter information over the phone is appropriate practice. DIF: Cognitive Level: Comprehension REF: p. 27 OBJ: 7 TOP: Health Insurance Portability and Accountability Act (HIPAA) KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. Which of the following could cause a nurse to be cited for malpractice? a. Refusing to give 60 mg of morphine as ordered b. Giving prochlorperazine (Compazine) to a patient allergic to phenothiazines c. Dragging an injured motorist off the highway and causing further injury d. Informing a visitor about a patient's condition ANS: B Standards of care dictate that a nurse must be aware of all the properties of drugs administered. Prochlorperazine (Compazine) is a phenothiazine. Providing confidential information or refusing to give an excessively large narcotic dose is not considered malpractice. Good Samaritan laws generally protect a person giving aid to an injured motorist. DIF: Cognitive Level: Application REF: p. 26 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 22. A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for: a. punitive damages. b. civil battery. c. assault. d. nothing; no violation has occurred. ANS: B Civil battery charges can be brought against someone performing an invasive procedure without the patient's informed consent legally documented. This patient could not sue for punitive damages or an assault. DIF: Cognitive Level: Comprehension REF: p. 27 OBJ: 6 | 8 TOP: Informed consent KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurse's actions exemplify? a. Malpractice b. Battery c. Assault d. Neglect of duty ANS: A A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient. DIF: Cognitive Level: Application REF: p. 25 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 24. What is true about nurse practice acts? a. They informally define the scope of nursing practice. b. They provide for unlimited scope of nursing practice. c. Only some states have adopted a nurse practice act. d. The nurse must know the nurse practice act within his or her state. ANS: D The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurse's responsibility to know the nurse practice act that is in effect for her geographic region. DIF: Cognitive Level: Comprehension REF: p. 26 OBJ: 5 TOP: Nurse practice acts KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. How can the medical record be used in litigation? (Select all that apply.) a. Public record b. Proof of adherence to standards c. Evidence of omission of care d. Documentation of time lapses e. Evidence by only the plaintiff ANS: A, B, C, D The information when used in court becomes a public record. The information can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document. DIF: Cognitive Level: Comprehension REF: p. 24 OBJ: 1 | 4 TOP: Legal properties of medical record KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.) a. HIPAA violation b. Slander c. Libel d. Invasion of privacy e. Defamation ANS: A, D The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel. DIF: Cognitive Level: Application REF: p. 30 OBJ: 7 TOP: Disclosure of information KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. A nurse failed to monitor a patient's respiratory status after medicating the patient with a narcotic analgesic. The patient's respiratory status worsened, requiring intubation. The patient's family claimed the nurse committed malpractice. What must be present for the nurse to be held liable? (Select all that apply.) a. A nurse-patient relationship exists. b. The nurse failed to perform in a reasonable manner. c. There was harm to the patient. d. The nurse was prudent in her performance. e. The nurse did not cause the patient harm. f. Duty does not exist. ANS: A, B, C For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred. DIF: Cognitive Level: Application REF: p. 24 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. Personal beliefs about the worth of an object, idea, custom, or attitude that influence a person's behavior in a given situation are referred to as. ANS: values Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influence our behavior in a given situation. DIF: Cognitive Level: Knowledge REF: p. 34 OBJ: 11 | 12 TOP: Values KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. Acts whose performance is required, permitted, or prohibited are defined by of care. ANS: standards Standards of care define acts whose performance is required, permitted, or prohibited. DIF: Cognitive Level: Knowledge REF: p. 26 OBJ: 4 TOP: Standards of care KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 03: Documentation Cooper: Foundation of Nursing, 9th Edition MULTIPLE CHOICE 1. What does documentation of type of care, time of care, and signature of the person prove? a. The person who signed the documentation did all the work noted. b. No litigation can be brought against the person who signed. c. Interventions were implemented to meet the patient's needs. d. The patient's response to the intervention was positive. ANS: C Documenting type of care, time of care, and signature of the person results in recording the interventions that are implemented to meet the patient's needs. Many charting entries include health care provider's visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive. DIF: Cognitive Level: Comprehension REF: p. 40 OBJ: 1 TOP: Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 2. Why is documentation especially significant in managed care? a. The hospital needs to show that employees care for patients. b. Institutions are reimbursed only for patient care that is documented. c. Patients might bring lawsuits if care was not given. d. Documents may become part of a lawsuit. ANS: B Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs): a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation? a. SOAP b. Block c. CBE d. Focus ANS: C Charting additional treatments done, changes in a patient's condition, and new concerns during the shift is charting by exception (CBE). DIF: Cognitive Level: Comprehension REF: pp. 47-48 OBJ: 1 | 5 | 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. What form explains the lapse when events are not consistent with facility or national standards of expected care? a. Subjective data b. Focus chart c. Incident report d. Nursing assessment ANS: C An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified. DIF: Cognitive Level: Knowledge REF: p. 49 OBJ: 1 | 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a: a. nursing order. b. Kardex. c. nursing care plan. d. critical pathway. ANS: D Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type. DIF: Cognitive Level: Knowledge REF: p. 41 OBJ: 8 TOP: Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 6. What makes home health care documentation unique? a. Some charting is retained at the hospital. b. The health care provider's office needs separate charting. c. Different health care providers need access. d. The health care provider is the pivotal person in the charting. ANS: C Home health care documentation has unique problems because of the need for different health care workers to access the medical record. DIF: Cognitive Level: Comprehension REF: p. 55 OBJ: 9 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. What regulates standards for long-term care documentation? a. OBRA b. Title XXII c. Patient problems d. The care plan ANS: A OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation. DIF: Cognitive Level: Knowledge REF: p. 55 OBJ: 10 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8. What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record? a. Provide information only to another nurse. b. Provide information only to an attorney. c. Share information only with the family. d. Have a clinical reason for reading the record. ANS: D The nurse should not read the patient's medical record unless there is a clinical reason for doing so. DIF: Cognitive Level: Comprehension REF: p. 56 OBJ: 4 TOP: Confidentiality KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 9. Documentation is necessary for the evaluation of patient care. Which of the following phases of the nursing process is necessary for the evaluation of patient care? a. Assessment b. Planning c. Implementation d. Evaluation ANS: C Documentation is part of the implementation phase of the nursing process. DIF: Cognitive Level: Comprehension REF: p. 40 OBJ: 1 | 4 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 10. What does the nurse use as a basis for documentation in focus charting? a. Problem list b. Nursing orders c. Patient problems d. Evaluation ANS: C In focus charting, instead of using the problem list, modified patient problems are used as an index for nursing documentation. DIF: Cognitive Level: Knowledge REF: p. 47 OBJ: 7 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 11. What is the purpose of QA (quality assurance)? a. To screen employment applications b. To evaluate care results against accepted standards c. To conduct in-services for ―quality documentation‖ d. To report deviation from standards to the state health department ANS: B QA is an in-house department that evaluates care services and results against accepted standards. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 1 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 12. What is the process used to appraise the practice of an individual nurse known as? a. Quality assurance b. Incident reporting c. OBRA d. Peer review ANS: D Peer review is an in-house department study that may appraise the nursing practice of individual nurses. DIF: Cognitive Level: Knowledge REF: p. 41 OBJ: 4 TOP: Peer review KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 13. What is the documentation format that uses the acronym SOAPE? a. Problem-oriented b. Focused c. Traditional d. Crisis ANS: A The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems. DIF: Cognitive Level: Comprehension REF: p. 46 OBJ: 7 TOP: Problem-oriented medical record (POMR) KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 14. Who is the legal owner of the patient's medical record? a. Patient b. Health care provider c. Institution d. State ANS: C Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the health care provider in the case of private office visits. DIF: Cognitive Level: Knowledge REF: p. 56 OBJ: 4 TOP: Legal ownership KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered? a. Charting in code b. Logging off c. Charting in privacy d. Signing on with a password ANS: B Logging off closes the computer file that was opened with the nurse's password. Any other data entry will require that person to sign on with their password. DIF: Cognitive Level: Comprehension REF: p. 57 OBJ: 2 TOP: Computer documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 16. What is the system that classifies patients by age, diagnosis, and surgical procedure, and produces 300 different categories used for predicting the use of hospital resources? a. Quality assurance b. Resource assessment c. Quality improvement d. Diagnosis-related groups ANS: D Cost reimbursement rates under government plans are based on diagnosis-related groups (DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay. DIF: Cognitive Level: Knowledge REF: pp. 41-42 OBJ: 5 TOP: Diagnostic-related groups KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 17. A nurse is using the data, action, response, education (DARE) system of charting, and is completing the data portion. What data are the nurse's focus? a.Planning b.Assessment c.Implementation d.Patient teaching ANS: B DARE is the acronym for four different aspects of charting using the focus format. Data (D) is both subjective and objective and is equivalent to the assessment step of the nursing process. Action (A) is a combination of planning and implementation. Response (R) of the patient is the same as evaluation of effectiveness. Some facilities include education/patient teaching (E). DIF: Cognitive Level: Comprehension REF: p. 47 OBJ: 7 TOP: Charting KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 18. A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified? a. Health care provider b. Registered nurse c. Unlicensed assistive personnel d. Licensed practical nurse/licensed vocational nurse ANS: B The registered nurse (RN) has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 4 | 10 TOP: Scope of practice KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 19. Which of the following will the nurse implement when an error is made when documenting in a patient's chart? a. Scratch out the error. b. Apply correction fluid. c. Erase the error completely. d. Draw a single line through the error. ANS: D A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patient's chart. Instead, the nurse should draw a single line through the error, write the word ―error‖ above it, and sign her name or initials. DIF: Cognitive Level: Application REF: p. 45 OBJ: 6 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. What should the nurse be sure to do when documenting in a patient's chart? a. Include speculation. b. Chart consecutively. c. Leave blank spaces. d. Include retaliatory comments. ANS: B A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurse's notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line. DIF: Cognitive Level: Application REF: p. 45 OBJ: 6 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. A nurse is receiving a telephone order from a health care provider. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the second step of this method? a. Read back b. Background c. Recommendation d. Situation e. Assessment ANS: B SBAR (Situation, Background, Assessment, and Recommendation) is a method of communication among health care workers and a part of documentation (Kaiser Permanente, 2007). SBAR is considered a safety measure in preventing errors from poor communication during ―hand-off‖ or ―handover‖ interactions, the communication that occurs from one shift to the next or when a nurse phones a health care provider with information about a patient. An additional ―R‖ is added. The additional ―R‖ (SBARR) represents ―read back‖ when the nurse reads back the order for clarification. DIF: Cognitive Level: Application REF: p. 43 OBJ: 3 TOP: SBARR KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.) a. Incorrectly recording the time of an event b. Failing to record verbal orders c. Charting events in advance d. Documenting an incorrect date e. Marking out and initialing charting errors ANS: A, B, C, D Marking out with a single line and initialing is an acceptable method to indicate a charting error. DIF: Cognitive Level: Application REF: p. 45 OBJ: 4 TOP: Inadequate documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. What are some problems associated with electronic (or computerized) charting? (Select all that apply.) a. Security b. Expense of training staff c. Legibility d. Easy retrieval e. New terminology ANS: A, B, E Security, expensive staff training, and learning new terminology are all problems of electronic charting. Legibility and easy retrieval are advantages. DIF: Cognitive Level: Comprehension REF: pp. 42-43 OBJ: 1 TOP: Computer charting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. What are the basic purposes of written patient records? (Select all that apply.) a. Teaching b. Legal record of care c. Written communication d. Research and data collection e. Permanent record for accountability f. Temporary record of hospitalization ANS: A, B, C, D, E There are five basic purposes for written patient records: (1) written communication, (2) permanent record for accountability, (3) legal record of care, (4) teaching, and (5) research and data collection. DIF: Cognitive Level: Comprehension REF: p. 41 OBJ: 1 TOP: Medical record KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. What should a medical record provide for all health care providers? (Select all that apply.) a. Care given to the patient b. Care planned for the patient c. A patient's nursing problems d. A patient's medical problems e. Details about any incident reports f. The patient's response to treatment ANS: A, B, C, D, F A medical record should furnish all health care providers with a concise, accurate, written picture of a patient's medical and nursing problems, care planned and given, and the patient's response to treatments. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 1 TOP: Medical record KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. The best defense against malpractice claims associated with nursing care is accurate. ANS: documentation Accurate documentation can guard against malpractice claims because it should describe when, what, and how events occurred. DIF: Cognitive Level: Comprehension REF: p. 41 | p. 42 OBJ: 4 TOP: Documentation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. Twenty-four-hour charting is designed to establish levels to help determine staffing needs. ANS: acuity Patient acuity, which is reflected in 24-hour charting compilation, can dictate staffing needs. DIF: Cognitive Level: Comprehension REF: p. 49 OBJ: 7 TOP: 24-hour charting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. Documentation using the DARE format (Data, Action, Response, Education) includes elements of the charting system. ANS: focused Focused charting uses the acronym DARE to direct and formalize charting. DIF: Cognitive Level: Comprehension REF: p. 47 OBJ: 7 TOP: Focused charting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. A health care audit that evaluates services provided and the results achieved compared with accepted standards is known as. ANS: quality assurance quality assessment quality improvement Quality assurance/assessment/improvement is an audit in health care that evaluates services provided and the results achieved compared with accepted standards. DIF: Cognitive Level: Knowledge REF: p. 41 OBJ: 1 TOP: Quality assurance, Assessment, Improvement KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 04: Communication Cooper: Foundation of Nursing, 9th Edition MULTIPLE CHOICE 1. Although the patient denies pain, the nurse observes the patient breathing rapidly with clenched fists and facial grimacing. What is the nurse's best response to these observations? a. ―I am glad you are feeling better and have no discomfort.‖ b. ―Where do you hurt?‖ c. ―What you are saying and what I am observing don't seem to match.‖ d. ―It makes me uncomfortable when you are not honest with me.‖ ANS: C The nonverbal communication should be clarified to prevent miscommunication. DIF: Cognitive Level: Application REF: p. 69 OBJ: 2 | 3 TOP: Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse considers the feelings and needs of a patient by stating, ―I know you are concerned about your surgery tomorrow. How can I help you?‖ What type of communication is this? a. Intrusive b. Aggressive c. Closed d. Assertive ANS: D Assertive communication takes a patient's feelings and needs into account, yet honors the patient's rights as an individual. DIF: Cognitive Level: Comprehension REF: p. 63 OBJ: 4 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. What does therapeutic communication accomplish? a. Facilitates the formation of a positive nurse-patient relationship. b. Manipulates the patient. c. Assigns the patient a passive role. d. Requires the patient to accept what the nurse says. ANS: A A positive nurse-patient relationship is facilitated by therapeutic communication. DIF: Cognitive Level: Comprehension REF: p. 64 OBJ: 10 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. The nurse is sitting in a chair near the patient's bed, leaning forward to hear what the patient is saying, and does not interrupt. What is the nurse demonstrating? a. Support b. Caring c. Active listening d. Interest ANS: C When demonstrating active listening, the nurse must give his or her full attention and make an effort to understand both the verbal and nonverbal message. DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: 5 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 5. What therapeutic communication technique requires a great deal of skill and is not used as frequently as other communication techniques? a. Touch b. Silence c. Listening d. Summarizing ANS: B Silence is an extremely effective therapeutic communication skill that is frequently underused because the nurse feels uncomfortable applying it. DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: 5 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 6. A patient does not speak English; therefore, the nurse cannot use words to provide comfort during a painful procedure. What is another intervention that may provide comfort to this patient? a. Silence b. Listening c. Touch d. Restating ANS: C Holding the hand of a non–English-speaking patient is effective and comforting. DIF: Cognitive Level: Application REF: p. 76 OBJ: 9 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. A patient states, ―I do cocaine when I feel things are out of my control.‖ The nurse responds by asking, ―What else does cocaine do for you?‖ What communication skill does this exemplify? a. Summarization b. Restating c. Showing acceptance d. Stating observations ANS: C Acceptance is the willingness to listen and respond to what the patient is saying without passing judgment. DIF: Cognitive Level: Application REF: p. 66 OBJ: 5 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8. A patient states, ―I'm really strung out about this pregnancy.‖ The nurse responds by asking, ―What about this pregnancy worries you?‖ What communication technique is this? a.Closed inquiry b.Restating c.Open-ended question d.Minimal encouraging ANS: C Open-ended questions convey interest and do not require a specific response. DIF: Cognitive Level: Application REF: p. 68 OBJ: 5 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 9. A grieving young widow cries out, ―Why was my husband killed? Why wasn't it me?‖ What is the nurse's best response? a. Stating ―You need to be strong for your children.‖ b. Silently placing her hand on the widow's arm. c. Asking if there is anyone the widow needs to have notified. d. Stating ―You are feeling overwhelmed about your husband's death.‖ ANS: B The ability to listen and assist those who are newly grieving through the use of silence and a quiet presence is very effective. Stating ―You need to be strong for your children‖ is a cliché. Asking if there is anyone the widow needs to have notified and stating ―You are feeling overwhelmed about your husband's death‖ are not therapeutic in this immediate grieving time. DIF: Cognitive Level: Application REF: p. 73 OBJ: 5 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 10. A nurse is assessing a patient with a patient problem of impaired verbal communication. What is the lowest number of defining characteristics for this diagnosis? a. One b. Two c. Three d. Four ANS: A If one or more of the defining characteristics is present, a patient problem of impaired verbal communication can be determined. DIF: Cognitive Level: Comprehension REF: p. 74 OBJ: 9 TOP: Communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 11. What communication technique should the nurse use when communicating with an unresponsive patient? a. Avoid speaking directly to the patient. b. Assume verbal stimuli are heard. c. Speak in a loud voice. d. Use simple words. ANS: B A person interacting with an unresponsive patient should assume all sounds and verbal stimuli have the potential of being heard by the patient. DIF: Cognitive Level: Application REF: p. 76 OBJ: 10 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 12. The patient states, ―I am upset about all this lab work.‖ The nurse responds ―You're upset?‖ This response is an example of: a. An open-ended question b. Reflecting c. Restating d. Paraphrasing ANS: C Restating is one of the most effective methods of therapeutic communication to encourage the patient to offer more information. DIF: Cognitive Level: Application REF: p. 69 OBJ: 5 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. What is one of the main characteristics of therapeutic communication? a. It allows the patient a passive role. b. It uses only verbal communication. c. It involves the patient as a person. d. It is directive. ANS: C Therapeutic communication actively involves the patient in all areas of the nursing process. DIF: Cognitive Level: Comprehension REF: p. 64 OBJ: 1 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 14. A nurse actively avoids the use of one-way communication. What is the major problem with one-way communication? a. The receiver is in control. b. Feedback is provided to the sender. c. Participation is not equal. d. The communication is unstructured. ANS: C One-way communication is seldom effective because the sender is in control and gets very little feedback from the receiver. DIF: Cognitive Level: Comprehension REF: p. 61 OBJ: 7 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. A nurse must violate the personal space of a patient to perform an invasive procedure. How can the nurse reduce the discomfort of the patient? a. By approaching the interaction in a professional manner b. By distracting the patient with jokes and humor c. By asking another nurse to be present at the bedside d. By assuring the patient that all people dislike invasion of personal space ANS: A The intimate zone can cause uneasiness for both patient and nurse; therefore, approach the interaction in a professional manner. DIF: Cognitive Level: Application REF: p. 70 OBJ: 6 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 16. What would be the best method for a literate, English-speaking patient on a ventilator to communicate his or her needs? a. Eye blinking for ―yes‖ and ―no‖ b. Magic slate or paper and pencil c. Computer d. Message board or cards ANS: B Writing devices are preferred as they do not limit the patient's messages compared to a message board or cards. Eye blinks are tiring and time-consuming. Computers require space and the ability to type. DIF: Cognitive Level: Application REF: p. 76 OBJ: 10 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17. A patient roughly asks the nurse to bring him some ice cream. What would be considered an assertive response by the nurse? a. ―You are hungry and want a snack.‖ b. ―I can do that in 10 minutes when I finish my rounds.‖ c. ―Maybe I can get one of the aides to bring you something in a while.‖ d. ―Call the nurses' station and ask them to have the kitchen bring whatever you want.‖ ANS: B Assertiveness is the most effective style of communication to be responsive to the patient and set limits. DIF: Cognitive Level: Application REF: p. 63 OBJ: 4 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 18. A nurse tells a patient, ―This PM you are going for an abdominal A&P, an H&H, as well as an IV pyelogram. Please sign these consent forms.‖ What may this use of medical jargon cause? a. Understanding b. Speed in communication c. Misinterpretation d. Clarity in the message ANS: C Jargon is terminology unique to people in a special type of work and is not understood by everyone. Although jargon does speed communication and is clear to those who know it, it may be misinterpreted and not understood by all people. DIF: Cognitive Level: Comprehension REF: p. 61 OBJ: 7 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 19. During a complete assessment, which type of questioning is not usually conducive to fostering communication? a. Open-ended b. Focused c. Closed d. Clarifying ANS: C Closed questions are types of questions that the nurse may choose to use that are not usually conducive to fostering communication. DIF: Cognitive Level: Comprehension REF: p. 67 OBJ: 7 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 20. A patient states, ―My husband has told me how he feels about my having a mastectomy.‖ The nurse nods and says, ―Go on.‖ This is an example of: a. clarifying. b. restating. c. focusing. d. minimal encouraging. ANS: D The nurse uses minimal encouragement to lead the patient to provide more information. DIF: Cognitive Level: Application REF: p. 66 OBJ: 5 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 21. A nurse is communicating with an older adult. How might the nurse enhance communication? a. Speak in a rapid manner to accommodate the patient's short attention span. b. Speak in a lower voice tone to accommodate hearing loss. c. Speak in a simple manner as if speaking to a child. d. Speak in a loud voice directly at ear level. ANS: B Older adults lose their ability to hear higher frequency sound. Speaking in a lower tone enhances communication. Speaking overly loud and as if to a child may be irritating and demeaning. Rapid speech may be difficult for older adults to understand. DIF: Cognitive Level: Application REF: p. 73 OBJ: 6 TOP: Physiologic factors affecting communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 22. What does maintaining eye contact for 2 to 6 seconds during communication with a patient do? a. Keeps the nurse's attention on the conversation b. Counteracts shyness in the patient c. Indicates continuous focused attention d. Assesses if the patient is involved in the conversation ANS: C Maintaining eye contact for 2 to 6 seconds involves the person in what is being said, is indicative of continued interest, and conveys to the patient an accepting attitude. DIF: Cognitive Level: Comprehension REF: p. 62 OBJ: 2 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 23. The nurse recognizes that a patient experiencing stress feels vulnerable. What would be the most appropriate way for the nurse to intervene? a.Use technical language. b.Direct the conversation. c.Modify communication methods. d.Offer all the information. ANS: C When the patient is experiencing stress, the nurse should modify communication methods. DIF: Cognitive Level: Application REF: p. 73 OBJ: 6 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 24. A nurse communicates with a patient by maintaining eye contact and through the use of touch. What type of communication technique is the nurse demonstrating? a.Verbal b.Persuasive c.Directive d.Nonverbal ANS: D Messages transmitted without the use of words (either oral or written) constitute nonverbal communication. Nonverbal cues include tone and rate of voice, volume of speech, eye contact, physical appearance, and use of touch. DIF: Cognitive Level: Comprehension REF: p. 61 OBJ: 5 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 25. A nurse frequently looks at her watch when giving a patient a bed bath. What message is most likely conveyed to the patient from the nurse? a. She desires to spend more time with the patient. b. She is anxious to listen to the patient's concerns. c. She is feeling hurried. d. She likes her watch. ANS: C Frequently looking at one's watch while interacting with a patient conveys to the patient that the nurse is in a hurry and really has no desire to spend time with him or her. DIF: Cognitive Level: Application REF: p. 62 | p. 66 OBJ: 8 TOP: Gestures KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 26. When listening to a patient, what action by the nurse demonstrates disinterest and coldness? a. Tightly crossing her arms b. Uncrossing her arms c. Uncrossing her legs d. Facing the patient ANS: A The way that an individual sits, stands, and moves is called posture. Posture has the potential to convey warmth and acceptance, or distance and disinterest. An open posture is demonstrated with a relaxed stance with uncrossed arms and legs while facing the other individual. A slight shift in body position toward an individual, a smile, and direct eye contact are all consistent with open posturing and convey warmth and caring. Closed posture is a more formal, distant stance, generally with the arms, and possibly the legs, tightly crossed. A person will often interpret closed posture as disinterest, coldness, and even nonacceptance. DIF: Cognitive Level: Comprehension REF: p. 62 OBJ: 1 | 7 | 8 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 27. How can the nurse demonstrate warmth and acceptance when listening to a patient? a. Tightly crossing her arms b. Uncrossing her arms c. Tightly crossing her legs d. Facing away from the patient ANS: B The way that an individual sits, stands, and moves is called posture. Posture has the potential to convey warmth and acceptance, or distance and disinterest. An open posture is demonstrated with a relaxed stance with uncrossed arms and legs while facing the other individual. A slight shift in body position toward an individual, a smile, and direct eye contact are all consistent with open posturing and convey warmth and caring. Closed posture is a more formal, distant stance, generally with the arms, and possibly the legs, tightly crossed. A person will often interpret closed posture as disinterest, coldness, and even nonacceptance. DIF: Cognitive Level: Application REF: p. 62 OBJ: 1 | 5 | 8 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 28. How may a nurse caring for a pediatric patient best be perceived as nonthreatening? a. Tightly crossing her arms b. Maintaining an open posture c. Maintaining a tense posture d. Standing at the bedside ANS: B Standing at the bedside looking down at the patient in the bed places the nurse in a position of authority and control. The patient is likely to experience this as intimidating and condescending. Whenever possible, the nurse should be level with the patient; this is especially important with pediatric patients. Sitting at the bedside in a relaxed and open posture is one example. DIF: Cognitive Level: Application REF: pp. 62-63 OBJ: 1 | 5 TOP: Posture KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 29. A nurse is caring for a patient who is experiencing excruciating pain and requires frequent administration of analgesics. What statement would be an example of the nurse demonstrating aggressive communication? a. ―Please let me know when you start to have pain.‖ b. ―Let's practice some guided imagery.‖ c. ―Let's try repositioning you.‖ d. ―I will only medicate you every 4 hours.‖ ANS: D Aggressive communication is when a person interacts with another in an overpowering and forceful manner to meet his or her own personal needs at the expense of the other. By only medicating a patient every 4 hours for excruciating pain, the nurse meets his or her own needs at the expense of the patient. DIF: Cognitive Level: Application REF: p. 63 OBJ: 7 TOP: Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 30. A nurse is caring for a newly admitted diabetic patient and is performing the initial assessment. What statement made by the nurse demonstrates the use of a closed question? a. ―What time do you take your insulin?‖ b. ―How do you feel about taking insulin?‖ c. ―Tell me about your support system.‖ d. ―How do you feel about having diabetes?‖ ANS: A Much of the information gathered from a patient comes from questioning them directly. A closed question is focused and seeks a particular answer. For example, when interviewing a newly admitted patient with diabetes, the nurse asks, ―What time do you take your insulin?‖ A specific question with a specific answer is a typical closed question, which generally requires only one or two words in response. DIF: Cognitive Level: Application REF: p. 67 OBJ: 7 TOP: Closed questioning KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 31. A nurse is caring for a patient experiencing respiratory distress. The health care provider places an endotracheal tube. What is the most appropriate patient problem for this patient? a. Ineffective coping b. Risk for infection c. Altered nutrition: less than body requirements d. Impaired verbal communication ANS: D Because of the placement of an endotracheal tube, the patient is unable to speak. The patient problem of impaired verbal communication is most appropriate. DIF: Cognitive Level: Application REF: p. 74 OBJ: 9 TOP: Patient problem KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Psychosocial Integrity 32. A nurse examines whether patient interventions have been appropriate and expected outcomes have been met. The nurse is demonstrating which step in the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation ANS: D A nurse evaluates the effectiveness of interventions based on the patient's ability to meet established goals and outcomes. DIF: Cognitive Level: Application REF: p. 74 OBJ: 9 TOP: Nursing process KEY: Nursing Process Step: Evaluation MSC: NCLEX: Evaluation 33. Which question below is open-ended? a. ―Are you going to Europe this fall?‖ b. ―Are you sailing to Europe?‖ c. ―What are you most looking forward to in Europe?‖ d. ―Have you been to Europe before?‖ e. ―Where in Europe are you going?‖ ANS: C Only the question ―What are you most looking forward to in Europe?‖ allows an unlimited answer. DIF: Cognitive Level: Comprehension REF: p. 67 OBJ: 5 TOP: Open-ended communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. Which are true regarding communicating while using eye contact? (Select all that apply.) a. Eye contact is responsible for much communication. b. Eye contact is responsible for much miscommunication. c. Making eye contact generally indicates an intention to interact. d. Eye contact always results in a positive outcome. e. Extended eye contact can imply aggression. f. Extended eye contact can lead to heightened anxiety. ANS: A, B, C, E, F Eye contact is responsible for much communication and much miscommunication. Generally, making eye contact communicates an intention to interact. However, the nature of the interaction and the results of eye contact are not necessarily always positive. Extended eye contact sometimes implies aggression and arouses anxiety. DIF: Cognitive Level: Comprehension REF: p. 61 OBJ: 3 TOP: Eye contact KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. Which are examples of passive listening? (Select all that apply.) a. The nurse nods frequently while the patient speaks. b. The nurse maintains eye contact while listening to the patient. c. The nurse occasionally interjects, ―I see,‖ when listening to the patient. d. The nurse gives verbal feedback to the patient. e. The nurse verbally interprets the meaning of what the patient has said. ANS: A, B, C, D Listening is sometimes active and sometimes passive. Active listening requires full attention to what the patient is saying. The message is heard, its meaning is interpreted, and the patient is given feedback, indicating understanding of the message. Verbally interpreting the meaning of what the patient has said is an example of active listening. In passive listening, the nurse indicates that they are listening to what the patient is saying either nonverbally, through eye contact and nodding, or verbally through encouraging phrases such as ―Uh-huh‖ and ―I see.‖ All of the other options are examples of passive listening. DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: 5 TOP: Listening KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 3. What is true about the use of touch in therapeutic communication? (Select all that apply.) a. Touch is a form of nonverbal communication. b. Touch is a form of verbal communication. c. Touch should be used with indiscretion. d. Touch can convey warmth and caring. e. Touch can convey support and understanding. f. Touch should be used sincerely and genuinely. ANS: A, D, E, F Touch is a form of nonverbal communication that is inherent in the practice of nursing. Nearly every nursing intervention for the purpose of providing physical care calls for touch. Touch is frequently highly personal or of an intimate nature (e.g., giving a bed bath, assisting a patient on or off a bedpan, inserting a urinary catheter). Because of the intimate nature of touch in the nursing context, it is necessary to use it with great discretion to fit into sociocultural norms and guidelines. Some nurses are uncomfortable with touch because of a fear of it seeming inappropriate or being misinterpreted. When a nurse feels comfortable with physical contact with a patient, touch has great potential for conveying warmth, caring, support, and understanding. For the nurse to convey warmth, it is absolutely necessary for the nature of their touch to be sincere and genuine. DIF: Cognitive Level: Comprehension REF: pp. 65-66 OBJ: 5 TOP: Touch KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 4. When speaking to a person of a different culture, how should the nurse consider modifying his or her communication style? (Select all that apply.) a. Speak slowly and with increased volume b. Use of touch c. Use of eye contact d. Reference of address e. Meaning of gestures ANS: B, C, D, E Use of touch, eye contact, reference of address, and meaning of gestures all may have cultural significance and connotation. Slow, loud speech would not assist with speaking to a person of a different culture. DIF: Cognitive Level: Application REF: p. 66 OBJ: 7 TOP: Culture KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 5. Which defining characteristics support the patient problem of impaired verbal communication? (Select all that apply.) a.Aphasia b.Geriatric patients c.Profoundly deaf d.Legally blind e.Severe COPD ANS: A, C, D, E Difficulty speaking, attending, disorientation, dyspnea, and sensory deficits are all defining characteristics that warrant a diagnosis of impaired verbal communication. Being a geriatric patient does not necessarily support the patient problem of impaired verbal communication. DIF: Cognitive Level: Application REF: p. 73 OBJ: 9 TOP: Impaired communication KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity 6. What is true about the use of silence in therapeutic communication? (Select all that apply.) a. Maintaining silence is an effective therapeutic communication technique. b. Maintaining silence is generally overused in therapeutic communication. c. The sender often becomes uncomfortable when using silence. d. The ability to use silence effectively requires skill and timing. e. Prolonged periods of misunderstood silence can cause tension. f. Purposeful use of silence often conveys lack of respect. ANS: A, C, D, E Maintaining silence is an extremely effective therapeutic communication technique, and yet tends to be quite underused. Because silence often feels awkward in American society, people tend to feel the need to ―fill‖ it. This impulse does not always allow the people involved in an interaction time to organize their thoughts sufficiently to communicate what they would like. It is common for a person to need several seconds after hearing a verbal message to interpret what has been stated and to formulate the most appropriate response. Unfortunately, the receiver often does not get this amount of time before a response is necessary. In many cases, the sender becomes uncomfortable with the silence and begins speaking again before the receiver has had an opportunity to formulate a response and is really ready to deliver it. The ability to use silence effectively requires skill and timing. It is easy for prolonged periods of misunderstood silence to cause uneasiness and tension. However, in many cases, purposeful use of silence conveys respect, understanding, caring, and support, and it is often used in conjunction with therapeutic touch. DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: 5 TOP: Silence KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity COMPLETION 1. The nurse explains to a patient that based on the description of ―personal space,‖ the area within 18 in of the patient is designated as the zone. ANS: intimate Personal space zones: 0 to 18 in = intimate, 18 in to 4 ft = personal zone, 4 to 12 ft = social zone, more than 12 ft = public zone. DIF: Cognitive Level: Knowledge REF: p. 70 OBJ: 8 TOP: Space and territoriality KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 2. A patient with aphasia who cannot understand a spoken or written message is said to have aphasia. ANS: receptive Aphasic patients who do not understand verbal exchanges are classified as receptive aphasics. DIF: Cognitive Level: Comprehension REF: p. 76 OBJ: 7 TOP: Aphasia KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. The term that describes an individual's perception or understanding of a particular word or phrase is. ANS: connotation Connotation is the meaning an individual applies to a word or phrase. DIF: Cognitive Level: Knowledge REF: p. 61 OBJ: 2 TOP: Connotation KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. When a nurse lectures to a large group, the method of communication is usually in the form of communication. ANS: one-way One-way communication allows the sender to be in control with little expectation of or desire for feedback. DIF: Cognitive Level: Comprehension REF: p. 61 OBJ: 5 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. As the nurse listens to a supervisor, the nurse has a smile on her face but has crossed her arms in front of her chest and has crossed her legs. This is an example of a posture. ANS: closed A posture with crossed limbs frequently is indicative of nonacceptance. DIF: Cognitive Level: Comprehension REF: p. 62 OBJ: 6 | 7 TOP: Posture KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 6. is described as the exchange of information. ANS: Communication Communication is described as the exchange of information. DIF: Cognitive Level: Knowledge REF: p. 60 OBJ: 1 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. The is the person conveying the message, whereas the receiver is the individual or individuals to whom the message is conveyed. ANS: sender For communication to occur, a sender and a receiver of a message are both necessary. The sender is the person conveying the message, whereas the receiver is the individual or individuals to whom the message is conveyed. DIF: Cognitive Level: Knowledge REF: p. 60 OBJ: 1 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 05: Nursing Process and Critical Thinking Cooper: Foundation of Nursing, 9th Edition MULTIPLE CHOICE 1. What best defines the nursing process? a. A method to ensure that the health care provider's orders are implemented correctly. b. A series of assessments that isolate a patient's health problem. c. A framework for the organization of individualized nursing care. d. A preset formula for the design of nursing care. ANS: C The nursing process is a framework by which to organize individualized nursing care. DIF: Cognitive Level: Comprehension REF: p. 80 OBJ: 1 TOP: Nursing process KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment? a.53-year-old admitted with a perforated ulcer b.5-year-old admitted for the implant of grommets in the middle ear c.76-year-old admitted for a knee replacement d.40-year-old admitted for possible bowel obstruction ANS: A A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses. DIF: Cognitive Level: Application REF: p. 81 | p. 82 OBJ: 2 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. What subjective data does the nurse record following a head-to-toe examination? a. Rash on back b. Prolonged nausea c. Blood pressure of 190/100 d. White blood cell count of 19,000 ANS: B Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient. DIF: Cognitive Level: Application REF: p. 82 OBJ: 3 TOP: Subjective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. What objective data should the nurse include after a patient assessment? a. Headache of 3 days' duration b. Severe stomach cramps c. Flatulence d. Anxiety ANS: C Objective data are observable and measurable by people other than the patient. DIF: Cognitive Level: Application REF: p. 82 OBJ: 3 TOP: Objective data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. When the nurse is prioritizing care during the planning phase of the nursing process, what is the guiding framework? a. Primary b. Secondary c. Unreliable d. Biased ANS: B Secondary sources include family members. DIF: Cognitive Level: Comprehension REF: p. 82 OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 6. What are the two primary methods used to collect data? a. Written report by patient and family b. Review of the chart and the nurse's notes c. Interview and physical examination d. Review of the health care provider's orders and the Kardex ANS: C The two primary methods of collecting data are interviewing and physical examination. DIF: Cognitive Level: Comprehension REF: p. 82 OBJ: 3 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 7. The nurse writes two patient problems: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses? a. The second diagnosis needs no defined nursing interventions. b. The second diagnosis needs medical intervention. c. The second diagnosis will not need to be evaluated. d. The second diagnosis reflects a problem that does not yet exist. ANS: D The actual patient problem represents a condition that is currently present. ―Risk for‖ diagnoses are those that the patient is susceptible to, but not yet troubled by. DIF: Cognitive Level: Comprehension REF: p. 84 OBJ: 4 TOP: Patient problem KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. What framework does the establishment of priorities of care during the planning phase of the nursing process often use? a. Erikson's developmental tasks b. Piaget's cognitive table c. Maslow's hierarchy of needs d. Freud's classifications ANS: C A useful framework to guide prioritization is Maslow's hierarchy of needs. DIF: Cognitive Level: Comprehension REF: p. 86 OBJ: 9 TOP: Priorities of care KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. What is an appropriate outcome statement for a patient with a patient problem of ineffective airway clearance related to thick secretions? a. The patient will increase intake to 1000 mL daily to liquefy secretions. b. The patient will cough more frequently within 3 days. c. The patient will breathe better within 3 days. d. The patient will perform deep-breathing exercises four times daily. ANS: A The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague. DIF: Cognitive Level: Comprehension REF: p. 90 OBJ: 6 TOP: Patient problem KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10. What is the primary purpose of nursing interventions? a. To support health care provider's orders b. To provide direction for all caregivers c. To provide broad, general statements d. To clarify nursing principles ANS: B Nursing orders are necessary to provide instructions for all caregivers. DIF: Cognitive Level: Comprehension REF: p. 87 | p. 88 OBJ: 7 TOP: Nursing interventions KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 11. What documentation reflects implementation? a. ―Patient selected low-sugar snacks independently.‖ b. ―Patient was medicated with Tylen

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