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1. What is the major difference between nursing students today and nursing students 50 years ago? A) Todays students are less caring. B) Todays students are more intelligent. C) Todays students reflect a more diverse population. D) Todays students are less...

1. What is the major difference between nursing students today and nursing students 50 years ago? A) Todays students are less caring. B) Todays students are more intelligent. C) Todays students reflect a more diverse population. D) Todays students are less likely to be competent nurses. Ans: C 2. The nurse is caring for a diabetic patient who expresses the desire to learn more about a diabetic diet in an attempt to gain better control of his blood sugar. The nurses actions will be based on which non-nursing theory? A) Change theory B) Maslows hierarchy of human needs C) Neumans systems model D) Watsons theory of caring Ans: A. 3. The Quality and Safety Education for Nurses Initiative (QSEN) has identified which key competencies for nurses? Select all that apply. A) Patient-centered care B) Teamwork and collaboration C) Evidence-based practice D) Quality improvement E) Correct documentation Ans: A, B, C, D 4. The nurse is caring for a patient who is on a ventilator. The nurse is bathing the patient and talking to them as she is carrying out care, as well as telling the patient what is going to happen next. The nurse speaks to the patient in a soothing manner. The nurse is acting in which role? (Select all that apply) A) Caregiver B) Decision-maker C) Communicator D) Educator E) Patient advocate Ans: A, C, D 5. The nurse offers a patient two possible times to ambulate as the physician has ordered. The nurse is acting in which nursing role? A) Communicator B) Patient advocate C) Manager and coordinator D) Caregiver Ans: C 6. The nurse is performing an extensive dressing change on a burn patient. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step? A) Caregiver B) Patient advocate C) Decision-maker D) Educator Ans: D 7. What type of nursing program would allow a student with a 4-year degree in psychology to enter and complete a baccalaureate degree in  nursing, take the NCLEX examination, and transition into a masters in nursing program? A) Baccalaureate program B) Graduate entry program C) Advanced degree program D) Continuing education program Ans: B 8. A prospective nursing student desires a career that will allow him to provide patient care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student? A) Associate of science registered nursing program B) Baccalaureate of science registered nursing program C) Licensed or vocational nursing program D) Diploma nursing program Ans: C 9. Nurses that enlist their services to the military are able to do so thanks to the work of which organizer of healthcare? A) Linda Richards B) Florence Nightingale C) Theodor Fliedner D) Dorthea Dix Ans: D  ursing (9th Edition by Craven) 6 10. Due to the rising cost of healthcare services, many procedures and treatments are being delivered in what type of setting? A) hospital B) medical centers C) outpatient facility D) community healthcare center Ans: C 11. The nurse in a rehabilitative facility makes certain the patient he is caring for is participating in group activities that are of interest to the patient. The nurse is ensuring which patient need is met? A) Love and belonging B) Self-actualization C) Safety and security D) Self-esteem  ursing (9th Edition by Craven) 7 Ans: A 12. The nurse is caring for a postoperative patient. The nurse administers a pain medication prescribed on a prn basis by the physician. What best describes the type of intervention the nurse is demonstrating? A) Physician-prescribed intervention B) Collaborative intervention C) Patient advocacy intervention D) Nurse-prescribed intervention Ans: B 13. A nurse in the community has been asked to join an organization based on the leadership abilities she has demonstrated both in her facility of employment and community-based activities. What organization best describes this process? A) nurse researcher B) clinical nurse specialist C) nurse educator D) nurse administrator Ans: B  ursing (9th Edition by Craven) 8 14.During the Christian era, nursing care excluded which area? A) Nutrition B) Personal counseling C) Comfort measures D) Psychiatric services Ans: D 15. The nurse is caring for a postoperative patient. The physician has written orders for a pain medication. The order gives a dosage range for the amount the nurse may give depending on the severity of the patients pain. This type of functioning within the healthcare team is called: A) Authoritative functioning B) Independent functioning C) Assistive functioning D) Dependent functioning E) Collaborative functioning Ans: E 16.Which of the following is an appropriately stated nursing intervention?  ursing (9th Edition by Craven) 9 A) Ambulate in the hall B) Stand at bedside with assistance C) Ambulate 30 ft. twice a day with assistance of walker D) Ambulate with assistance of walker Ans: C  ursing (9th Edition by Craven) 10 Correctly stated patient outcomes are specific, measurable, and realistic. The other choices are poorly defined and do not specify when or how or by whom. 17. All members of the healthcare team are encouraged to read and contribute to the individual plans of care for their patients. Which of the following healthcare providers develops the plan of care? A) The RN B) The LPN or RN C) The physician D) The patient E) Any licensed member of the healthcare team Ans: A 18.Current trends in nursing practice include the development of A) Acute care centers B) Birthing centers C) Homeless shelters  ursing (9th Edition by Craven) 11 D) Ambulatory surgery centers Ans: B 19.The Standards of Practice provide nurses with A) Legislation for healthcare reform B) Evaluation of care provided by nurses C) Measurement criteria for payment D) Guidelines for providing care Ans: D 20. A nurse receives an x-ray report on a newly admitted patient suspected of having a fractured tibia. The nurse contacts the physician to report the findings. What role is the nurse engaged in? A) Communicator B) Advocate C) Caregiver  ursing (9th Edition by Craven) 12 D) Researcher Ans: A 21. A nurse is caring for a young victim of a terrorist attack. During the rehabilitative process, the nurse assists the patient in bathing and dressing. The role the nurse is engaged in is A) Advocate B) Caregiver C) Counselor D) Educator Ans: B 22. A student is choosing her educational path and desires a nursing degree that has a track that contains community nursing and leadership, as well as liberal arts. The student would best be suited in which type of program? A) Licensed practical nursing program B) Certification in a nursing specialty C) Diploma nursing program D) Baccalaureate program  ursing (9th Edition by Craven) 13 Ans: D 23. The director of nursing (DON) of a major hospital is searching to hire a nurse with a strong technical background to care for patients on a busy surgical unit. The DON is most likely going to hire a nurse prepared at which level of nursing? A) Doctoral level B) Masters level C) Baccalaureate level D) Associate level Ans: D 24. A nursing student begins to speak using medical terminology. This is considered to be part of which process? A) Learning B) Socialization C) Role development D) Evolutionary Ans: B  ursing (9th Edition by Craven) 14 25. Which of the following factors has most influenced how nurses practice their profession? A) Financial support of nursing education B) Professional organizations such as ANA C) National Commission on Nursing D) Increased incidence of chronic illness Ans: D  ursing (9th Edition by Craven) 15 26.The first nursing journal owned, operated, and published by nurses was A) American Journal of Nursing B) Nurse Educator C) Nursing Research D) Standards of Clinical Nursing Practice Ans: A 27. Advocating for financial support for university-based schools of nursing was noted in which government document? A) The Goldmark Report B) Hill Burton Amendment C) Health Care Initiative Reform Act D) Lysaught Report Ans: A 28. The need for university-based nursing education programs was brought to light during which important historical time?  ursing (9th Edition by Craven) 16 A) Spanish American War B) World War I C) World War II D) Korean War Ans: C 29. The Henry Street Settlement was founded by A) Dorothea Dix B) Lillian Wald C) Florence Nightingale D) Isabel Hampton Robb Ans: B 30.The Nurse Corps of the United States Army was established by A) Dorothea Dix B) Lillian Wald C) Florence Nightingale  ursing (9th Edition by Craven) 17 D) Isabel Hampton Robb Ans: A 31. Florence Nightingale classified sick nursing as A) Care of the dying patient B) Use of patients reparative processes C) Addressing the community problems D) Implementation of restorative processes Ans: B 32.The purpose of nursing was shaped by which of the following eras? A) Egyptian era B) Christian era C) Revolutionary War era D) Victorian era  ursing (9th Edition by Craven) 18 Ans: B 1. A nurse is preparing to administer a medication by using the vastus lateralis site and is unfamiliar with the process. A step-by-step reference that shows how to complete the process is called a: A) Deployment Flowchart B) Top-down Flowchart C) Pareto chart D) Control plot Ans: B 2. A nonprofit organization that distributes to governmental agencies, the public, business, and health care professionals knowledge related to health care for the purpose of improving health is the: A) Institute for Safe Medication Practices. B) Institute of Medicine. C) National Committee for Quality Assurance. D) The Joint Commission.  ursing (9th Edition by Craven) 19 Ans: B 3. A nurse is assisting with the delivery of twins. The first infant is placed on the scale to be weighed. The physician requests an instrument stat. The nurse turns to hand the instrument to the physician, and the infant falls off the scale. When evaluating the incident, the nurse and her manager list contributory factors such as the need for two nurses when multiple births are known, and the location of the scale so far from the delivery field. These nurses are performing a(n): A) standardization of care. B) root cause analysis. C) process variation. D) analysis of a deployment flowchart. Ans: B 4. Each month data on admission assessments that are based on the following standard are entered: “All patients will be assessed by an RN within 2 hours of admission.” The target goal for this standard is 97% compliance. Data are displayed on a graph that shows number and time of admission assessments and compliance variation limits. This pictorial representation is a: A) Pareto chart. B) control chart. C) deployment chart.  ursing (9th Edition by Craven) 20 D) top-down flowchart. Ans: B 5. Regardless of the term used to describe high-quality health care, the focus of quality is: A) what the consumer needs and wants. B) economical care. C) having the greatest technologic advancement. D) services equally distributed among populations. Ans: A 6. In differentiating between early efforts of quality assurance and present-day quality improvement efforts, which statement is correct? Quality assurance: A) had a broad focus. B) promoted problem-solving by all members of the health care team. C) was preventive in nature. D) tended to occur as a reaction to a specific problem. Ans: D  ursing (9th Edition by Craven) 21 7. An organization’s emergency preparedness task force meets to discuss how it should react in case of a terrorist attack and develops a disaster evacuation plan that details how each department will assist individuals in reaching safety. This type of diagram is referred to as a: A) Pareto chart. B) control chart. C) top-down flowchart. D) deployment chart. Ans: D 8. Patients with heart failure have extended lengths of stay and are often readmitted shortly after they have been discharged. To improve quality of care, a type of “road map” that included all elements of care for this disease and that standardized treatment by guiding daily care was implemented. This road map is referred to as a(n): A) benchmark. B) critical pathway. C) algorithm. D) case management. Ans: B  ursing (9th Edition by Craven) 22 9. The staff on a nursing unit notes that patient satisfaction varies from month to month. They plot the degree of patient satisfaction each month for 1 year to determine when the periods of greatest dissatisfaction are occurring. The staff uses which type of graph? A) Time plot. B) Pareto chart. C) Flowchart. D) Cause-and-effect diagram. Ans: A 10. The number of IV site infections has more than doubled on a nursing unit. The staff determine common causes include the site is cleaned using inconsistent methods, dressing frequently becomes wet when patient showers, IV tubing is not changed every 48 hours per protocol, and inadequate hand washing of RN prior to insertion. A bar graph demonstrates the frequency in descending order, with 80% of infections being attributed to inadequate hand washing. The quality tool used is a: A) cause-and-effect diagram. B) run chart. C) Pareto chart.  ursing (9th Edition by Craven) 23 D) flowchart. Ans: C 1. The nurse is preparing to administer a medication ordered by the surgeon in a dose much higher than is recommended. What action should the nurse take? A) Call the surgeon to clarify the order. B) Administer the medication as ordered and chart the high dose. C) Administer the medication and stay with the patient to observe for adverse reactions. D) Administer the medication in the usual dosage. Ans: A 2. When the nurse inserts an ordered urinary catheter into the patients urethra after the patient has refused the procedure and the patient suffers an injury, the patient may sue the nurse for which type of tort? A) Battery B) Assault C) Invasion of privacy  ursing (9th Edition by Craven) 24 D) Dereliction of duty Ans: A 3. A baccalaureate-prepared nurse is applying for a nurse practitioner position. The nurse is A) Well educated and can perform these duties B) Able to practice as a nurse practitioner C) Educated to practice only with pediatric patients D) Practicing beyond his scope according to licensure Ans: D 4. A nurse fails to administer a medication that prevents seizures, and the patient has a seizure. The nurse is in violation of the Nurse Practice Act. What type of law is the nurse in violation of? A) Criminal B) Federal C) Civil D) Supreme  ursing (9th Edition by Craven) 25 Ans: C 5. A post-anesthesia nurse is reporting about the patient to the intensive care unit nurse in the elevator. There are staff members and visitors in the elevator. The nurse is A) Implementing therapeutic communication B) Interacting to maintain coordination of care C) Breaching the patients confidentiality  Maintaining the continuity of care C 6. When the nurse informs a patients employer of his autoimmune deficiency disease, the nurse is committing the tort of A) Breach of contract B) Assault C) Invasion of privacy D) Battery Ans: C 7. A nurse states to the patient that she will keep her free of pain. However, her family wishes to try a treatment to prolong her life that may necessitate withholding pain medication. This factor will cause an ethical dilemma for the nurse in relation to which ethical principle? A) Fidelity B) Veracity C) Justice D) Autonomy  ursing (9th Edition by Craven) 27 Ans: A 8. An oncology patient in an outpatient chemotherapy clinic asks several questions regarding his care and treatment. The nurse explains the clinics routine, typical side effects of the chemotherapy, and ways to decrease the number of side effects experienced. What characteristic is the nurse demonstrating? A) Veracity B) Fidelity C) Justice Autonomy A 9. The foundation for decisions about resource allocation throughout a society or group is based on the ethical principle of A) Veracity B) Autonomy C) Justice D) Confidentiality Ans: C 10. The patient being admitted to the oncology unit conveys his wishes regarding resuscitation in the event of cardiopulmonary arrest. The nurse advises the patient that it would be in his best interest to obtain which document? A) A will B) A living will C) Proof of healthcare power of attorney D) A proxy directive Ans: B 11. A legal document that states a patients health-related wishessuch as a preference for pain management if the patient becomes terminally illand also allows the patients daughter to direct his or her care, is a(an) A) Will B) Standard of care C) License Advance directive D  ursing (9th Edition by Craven) 29 12. A patient is in a persistent vegetative state. The patient has no immediate family and is a ward of the state. Under these circumstances, who will speak on her behalf? A) Surrogate decision maker B) Church-appointed guardian C) A significant other D) Her best friend Ans: A 13. An 83-year-old woman who has suffered a cerebrovascular accident and is unable to swallow refuses the insertion of a feeding tube. This is an example of what ethical principle? A) Nonmaleficence B) Veracity C) Autonomy D) Justice Ans: C 14. An emergency department nurse and healthcare team, caring for a 2- year-old, semiconscious child with numerous fractures and evidence of cigarette burns, suspect child abuse. The nurse reports the family to the child abuse hotline. The nurse is following which ethical principle? A) Beneficence B) Nonmaleficence C) Justice Fidelity B 15. A home care nurse visits a patient who is confined to bed and is cared for by her daughter. The daughter is known to suffer from chemical dependence. The home is cluttered and unclean. During the assessment the nurse notes that the patient is wet with urine and has dried feces on her buttocks, and demonstrates signs of dehydration. After caring for the patient, the nurse contacts the physician and reports the incident to Adult Protective Services. This is an example of which ethical framework? A) Justice B) Beneficence C) Nonmaleficence D) Fidelity Ans: C  ursing (9th Edition by Craven) 31 16. A nurse is caring for a 28-year-old woman who has delivered a baby by cesarean section. She describes her pain as a 9. The nurse medicates her for pain. This is an example of which of the following ethical frameworks? A) Justice B) Fidelity C) Beneficence D) Nonmaleficence Ans: C 17.The American Nurses Associations Code of Ethics for Nurses A) Serves to establish personal ethics for nurses B) Delineates nurses conduct and responsibilities  ursing (9th Edition by Craven) 32 C) Serves as a guideline for all healthcare D) Plays an important role in legal proceedings Ans: B 18. A nurse is caring for a patient who is a practicing Jehovahs Witness. The physician orders 2 units of packed cells based on his low hemoglobin and hematocrit levels. The nurse states to the surgeon that it is unethical to go against the patients beliefs even though his blood counts are very low. What is the best description of the nurses intentions? A) Acting in the patients best interest B) Siding with the patient over the surgeon C) Observing institutional policies D) Being legally responsible Ans: A 19. To practice ethically, the nurse should A) Allow a committee to guide her practice B) Review past cases before guiding practice  ursing (9th Edition by Craven) 33 C) Avoid allowing her judgment to guide practice D) Ask the family their views on caring Ans: C 20. A hospital owned by a Catholic order of nuns will not allow tubal ligations to be performed. This is considered to be A) Personal morality B) Personal values C) Institutional policy D) Legal obligation Ans: C 21.A nurse is of the Catholic faith and votes pro-life. He is considered to have A) Personal morality B) Personal values C) Ethics D) Legal obligations  ursing (9th Edition by Craven) 34 Ans: B 22. A nurse believes that abortion is an acceptable option if a pregnancy results from a situation of rape. What is the best description of this belief? A) Personal morality B) Professional values C) Ethics D) Legal obligations Ans: A 23. Ethics is best defined as A) Basis for moral reasoning B) Standards of conduct C) Dealing with conflict D) Decision making Ans: B 24. A child on a pediatric unit hits one of the other children and subsequently has video game privileges revoked for the rest of the day. The next day the same child plays with the other children without any problems in order to  ursing (9th Edition by Craven) 35 avoid losing video game privileges again. According to Kohlberg, the child is demonstrating what stage of development? A) Trust versus mistrust B) Moralizing C) First-level preconventional stage D) Self-actualization Ans: C 25. During adolescence, values are primarily formed from A) Schools B) Work C) Parents D) Peers Ans: D 26. How are values converted from knowledge into messages which can then be processed as information? A) Religion  ursing (9th Edition by Craven) 36 B) Nature C) Time D) Activity Ans: A 27.The purpose of a values inquiry discussion with a group of nursing students is to A) Examine past decisions B) Examine social issues C) Alter the groups views D) Improve the groups image Ans: B 28. The differences between the pro-life and abortion rights movement is an example of A) Values inquiry B) Social activism C) Ethical inconsistency  ursing (9th Edition by Craven) 37 D) Values clarification Ans: A 29. A dying patient tells the nurse that he doesnt want to see his family because he doesnt want to cause them more sadness. Which action by the nurse is most appropriate? A) Arrange a meeting between the family and the patient B) Help the patient clarify his values C) Educate the patient on death and dying concepts D) Allow the patient time for quiet reflection Ans: B 30. A hospice nurse is caring for a patient with terminal cancer. The family would like the patient to continue aggressive therapy to treat the cancer, but the patient has voiced to the nurse that, after much thought, he does not want to pursue any further treatment. The nurse speaks to the family about the patients wishes, condition, and terminal state. This action is most likely derived from which nursing obligation? A) Legal responsibilities B) Nursing education principles  ursing (9th Edition by Craven) 38 C) Advanced practice licensure guidelines D) Moral values Ans: D 31. A nursing students attitude is defined as: A) Belief in ones self B) Desire to do good C) Disposition toward situations D) Choosing between alternatives Ans: C 32. Socialization into the nursing profession may have the most significant effect on A) Roles B) Values C) Documentation D) Planning  ursing (9th Edition by Craven) 39 Ans: B 33. What are standards for decision making that endure for a significant time in ones life? A) Beliefs B) Ethics C) Roles D) Values Ans: D 1. A modern approach to the development of clinical decisions and clinical judgments is the use of human patient simulators in simulation laboratories on campus. Human patient simulators are best described as A) Life-sized mannequins with a sophisticated computer interface B) Small doll-like devices used for measuring vital signs C) Healthcare equipment that has practice modes D) Life-saving equipment that resuscitates patients in cardiac arrest Ans: A  ursing (9th Edition by Craven) 40 2. What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations? A) Memorization B) Reflection C) Reminiscing D) Evangelization Ans: B 3. The nurse is caring for a newly admitted patient. How can a nurse arrive at a more complete database for this patient? A) Through clustering of data B) Analysis of lab values C) Review of the chart D) Consult with several sources Ans: D 4. A patient complains of weakness following his administration of insulin. The nurse decides to assess the patients blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?  ursing (9th Edition by Craven) 41 A) Clinical reasoning B) Caring C) Reflection D) Assessment Ans: A 5. A nursing student is caring for a patient who has diabetes mellitus. The patient takes insulin two times per day. Based on the students knowledge of insulins onset of action, he makes sure the patients meals arrive in coordination with the insulins effect. The knowledge used by the student is A) Evaluative B) Lacking C) Integrated D) Creative Ans: C 6. For the nursing student to implement the most effective care for her patients, she must A) Have rudimentary critical-thinking skills  ursing (9th Edition by Craven) 42 B) Apply preexisting knowledge C) Apply clinical knowledge to theoretic knowledge D) Establish a clinical log for evaluation Ans: B 7. What type of learning best takes place in the nursing laboratory? A) Kinesthetic learning B) Auditory learning C) Concrete learning D) Collaborative learning Ans: A 8. Which of the following learners enjoy learning that takes place in the clinical setting? A) Sequential thinkers B) Grade-oriented students C) Learning-oriented students  ursing (9th Edition by Craven) 43 D) Active experimenters Ans: D 9. A nurse is educating a pregnant woman in preterm labor on the use of her home monitoring equipment and her medications. What factor could impede the patients ability to learn? A) Preparation B) Intelligence C) Previous knowledge D) Anxiety Ans: D 10. A patient who has limited finances and limited capacity for education requires home healthcare for a chronic illness. For the nurse to provide a high level of care to this patient, she must first A) Implement critical-thinking skills B) Develop a relationship with the patient C) Engage the services of a social worker D) Determine what care has been provided  ursing (9th Edition by Craven) 44 Ans: A 11. The nurse assesses a patients blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. This nursing action is A) Evaluation B) Assessment C) Planning D) Implementation Ans: B 12. When the nurse assesses the patients blood sugar, the type of skill that the nurse is using is termed? A) Technical B) Therapeutic C) Interactional D) Adaptive Ans: A  ursing (9th Edition by Craven) 45 13. When the nurse administers pain medication to a postoperative patient, the phase of the nursing process that is occurring is which of the following phases? A) Assessment B) Nursing diagnosis C) Planning D) Implementation Ans: D 14. When the nurse is administering Lasix 20 mg to a patient in congestive heart failure, what phase of the nursing process does this represent? A) Assessment B) Planning C) Implementation D) Evaluation Ans: C 15. The functional health patterns provide the nurse with a(an)  ursing (9th Edition by Craven) 46 A) Framework for collecting assessment data B) Method for evaluation of diagnostic testing C) Preparation of diagnostic statements D) System for documenting patient care Ans: A 16. Clustering of data to ascertain a nursing diagnosis is accomplished through the use of: A) general systems theory process. B) problem-solving process. C) decision-making process. D) information-processing theory. Ans: D 17. A nurse ascertains that the patient is showing signs and symptoms of dehydration due to nausea and vomiting. The nurse makes the patient NPO and calls the physician. The nursing action of making the patient NPO is  ursing (9th Edition by Craven) 47 A) General systems theory process B) Problem-solving process C) Decision-making process D) Information-processing theory Ans: C 18. The information that enters the system or data collected during the assessment is considered to be the: A) input. B) immediate outcome. C) throughput. D) output. Ans: A  ursing (9th Edition by Craven) 48 19. Three weeks after surgery the nurse notes the patient has partial healing of the surgical wound. This assessment would occur in which phase of the nursing process? A) Outcome B) Nursing diagnosis C) Planning D) Evaluation Ans: D 20. Nursing actions should be A) Associated with the family B) Goal-directed C) Individually attained D) Evaluated by team members Ans: B  ursing (9th Edition by Craven) 49 21. The nurse changes a patients surgical dressing daily. This is considered to be part of which phase of the nursing process? A) Nursing diagnosis B) Patient goal C) Outcome identification D) Implementation Ans: D 22.A written plan of care for each patient is required by what organization? A) The Joint Commission B) The National Institutes of Health C) The American Association on the Accreditation of Colleges of Nursing D) The American Nurses Association Ans: A  ursing (9th Edition by Craven) 50 23. When the nurse formulates three nursing diagnoses for an adult patient hospitalized for abdominal surgery, the nurse has focused on the patients A) Medical record. B) Actual health problems C) Medical diagnosis D) Past medical history Ans: B 24. After the nurse has formulated expected outcomes, the next step of the nursing process is to: A) outline evaluation strategies. B) prepare an oral report. C) document the rationale. D) write the plan of care. Ans: D 25.What is the primary goal of the planning phase of the nursing process?  ursing (9th Edition by Craven) 51 A) To identify goals for the patient B) To prepare a plan of care C) To establish priorities for care D) To acknowledge patient needs Ans: B 26. The nurse writes the following on the patients chart: The patient will have complete healing of the surgical incision on the right lower quadrant of the abdomen in 3 weeks. This is a(n) A) Nursing diagnosis B) Assessment C) Evaluation D) Outcome identification Ans: D 27. Which organization defines the nursing diagnosis? A) American Nurses Association B) North American Nursing Diagnosis AssociationInternational  ursing (9th Edition by Craven) 52 C) American Association of Colleges of Nursing D) Sigma Theta Tau International Ans: B 28. Which of the following healthcare professionals are licensed to make a nursing diagnosis? A) Licensed practical nurses B) Registered nurses C) Social workers D) Physicians assistants Ans: B 29. A patient has had an appendectomy. He has an incision at the right lower quadrant of the abdomen. Nurse has written: Alteration in skin integrity related to incision at right lower quadrant of the abdomen. This is A) A planned outcome B) Subjective data C) A nursing intervention  ursing (9th Edition by Craven) 53 D) An actual nursing diagnosis Ans: D 30. An in-depth history and physical builds the A) Plan of care B) Future interventions C) Database D) Secondary source Ans: C 31. The nurse caring for a newly admitted patient recognizes that the patients past chart at an acute care facility is considered to be the A) Primary source B) Secondary source C) Subjective data D) Nursing diagnosis Ans: B  ursing (9th Edition by Craven) 54 32. A patient states, I am having a severe headache with pain over my right eye. This statement is classified as A) Primary source B) Objective data C) Symptom identification D) Planning care Ans: A 33.Which of the following is a distinct nursing function in the nursing process? A) Assessment B) Planning C) Nursing diagnosis D) Evaluation Ans: C 34. The term nursing process is synonymous with the A) Identification of health problems  ursing (9th Edition by Craven) 55 B) Verification of wellness issues C) Application of nursing diagnosis D) Problem-solving approach Ans: D 35. In 1955, Lydia Hall introduced the nursing process. Nursing care delivery changed based on A) Guidelines from the medical model B) Information from the scientific process C) The patients and nurses interaction D) The process of pathophysiology Ans: C 1. During data collection the nurse may validate data by which method? (Select all that apply) A) Comparing cues to normal function B) Referring to textbooks, journals, and research reports  ursing (9th Edition by Craven) 56 C) Checking consistency of cues D) Clarifying the patients statements E) Seeking consensus with colleagues about inferences Ans: A, B, C, D, E 2. When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind? A) Validate inferences with the patient B) Do not share inferences with the patient C) Document all inferences D) Avoid making any inferences Ans: A 3. While performing the nursing history the nurse notes that the patient states he is having very little pain, but is grimacing and holding his arm throughout the history taking. This observation takes place during which phase of the nursing history? A) Preparatory  ursing (9th Edition by Craven) 57 B) Introductory C) Maintenance D) Concluding Ans: C 4. The home care nurse is preparing to perform a nursing history on a newly assigned adult patient with a venous stasis ulcer. Which statement by the nurse is most accurate? A) When I perform the nursing history I will need to ask your family to leave the room. B) I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes. C) I will perform a physical assessment while I am obtaining the nursing history. D) I will leave a form with you to complete the nursing history information I need. Ans: B 5. The RN is admitting a patient to a medical unit. The nurse delegates the measurement of the vital signs to unlicensed assistive personnel (UAP) while she collects data. After completing the admission process, the patient complains of a severe headache so the nurse reassesses the vital signs to find the patients blood pressure extremely elevated. Whose responsibility is the accuracy of the blood pressure measurement?  ursing (9th Edition by Craven) 58 A) The company that made the blood pressure equipment B) The nurse C) The UAP D) The charge nurse Ans: B 6. A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method? A) Size of the liver B) Presence of peristalsis C) Pupil reaction D) Skin temperature Ans: B 7. Which of the following are examples of objective data?  ursing (9th Edition by Craven) 59 A) Patient describing his pain B) Laboratory results C) Breath sounds D) Mother describing her childs asthma attack E) a patients temperature Ans: B, C, E 8. Which of the following would be considered examples of subjective data? Select all that apply. A) Comments made by the patients family. B) Description of a symptom by a patient. C) A mother telling a nurse what the baby looked like when he was very ill. D) A nursing assessment of the patients vital signs. E) The physical exam notes made by the physician. Ans: A, B, C  ursing (9th Edition by Craven) 60 9. The nurse has identified a priority problem on her unit. Which of the following statements is true regarding addressing a priority problem? A) Setting priorities involves skipping interventions. B) Priorities are set at predetermined intervals throughout the shift. C) A priority problem requires a nursing intervention before another problem is addressed. D) Priority of problems is established and continued according to the nursing plan of care. E) The physician is responsible for determining priority of patient needs. Ans: C 10. During the interview component of the health assessment, the nurse conveys to the patient that the information is important by A) Nodding frequently during the interview B) Sitting at eye level with the patient C) Standing next to the patient while interviewing  ursing (9th Edition by Craven) 61 D) Limiting questions to those with yes or no answers Ans: B 11.Before conducting a health assessment on a patient, the nurse should first A) Ask a family member to be present for the assessment B) Tell the patient the amount of time for the assessment C) Inform the patient of the procedure done in the assessment D) Introduce herself or himself to the patient Ans: D 12. A patient is receiving home care due to an unstable blood pressure. Which of the following nursing interventions is a priority? A) Assess the patients diet B) Assess the patients activity level C) Assess the patients blood pressure D) Assess the patients medication regimen  ursing (9th Edition by Craven) 62 Ans: C 13. After assessment of a patient in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data? A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach Ans: A 14. When assessing the patients pulse, the nurse is using the following assessment technique: A) Inspection B) Palpation C) Percussion  ursing (9th Edition by Craven) 63 D) Auscultation Ans: B 15. During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should A) Review literature pertinent to the patients attributes B) Assess his or her own feelings regarding similar clinical situations C) Inform the patient of the maintenance of confidentiality D) Implement supportive nursing interventions Ans: C 16. During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should A) Clarify the patients health status B) Review as much information as possible C) Identify actual and potential nursing diagnoses  ursing (9th Edition by Craven) 64 D) Develop the nursing plan of care Ans: B. 17. The purpose of obtaining a nursing history is to A) Assist the physician to establish a medical diagnosis B) Minimize the time required to establish a nursing diagnosis C) Focus on objective physical data specific to the patient D) Identify actual and potential nursing diagnoses Ans: D 18. Which of the following cultural groups may interpret touch by another as an invasion of privacy? A) Chinese American B) Spanish American  ursing (9th Edition by Craven) 65 C) European American D) African American Ans: A 19. A patient is a poor historian of his past medical history. Whom should the nurse consult about the patients past history? A) Physician B) Old chart C) Social worker D) Family Ans: D 20. The nurse observes the patient as he walks into the room. What information will this provide the nurse? A) Information regarding the patients gait B) Information regarding the patients personality C) Information regarding the patients psychosocial status  ursing (9th Edition by Craven) 66 D) Information on the rate of recovery from surgery Ans: A 21. What would be a nursing priority when assessing a patient who weighs 250 pounds and stands 5 3 tall? A) Assess the HDL/LDL levels B) Obtain an electrocardiogram daily C) Assess blood pressure with a large cuff D) Begin patient teaching regarding a low fat diet Ans: C 22.When assessing an infant, it is important to involve the A) Parents B) Siblings C) Physician D) Infant Ans: A  ursing (9th Edition by Craven) 67 23. A patient describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a patients description of pain in the right leg? A) Explanatory B) Subjective C) Objective D) Severe Ans: B 24. When collecting subjective and objective data for a database in a patients home, it is important to A) Ask the patient to turn off the television B) Ask the social worker to verify the collected data C) Collect a 24-hour diet recall D) Evaluate the care provided by the physician Ans: A  ursing (9th Edition by Craven) 68 25. A nurse is asking questions about a patients sexual history. It is important for the nurse to A) Evaluate the patients past history of sexual dysfunction B) Provide a time that enhances openness C) Collect data in a quiet, private environment D) Pull the curtains in a semiprivate room Ans: C 26. An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The patients airway should be assessed. B) The nurse should determine the reason for admission. C) The nurse should review the patients medications. D) The patients past medical history is assessed. Ans: A  ursing (9th Edition by Craven) 69 27. A nurse practitioner has a private practice in conjunction with a physician. She is providing psychiatric care to a woman who has a past history of being abused by her husband. During the last visit, she stated that she was planning to leave her husband. On the next visit in 2 weeks, the nurse practitioner will assess her patients commitment to changing her life situation and her ability to feel empowered. What type of assessment is the nurse practitioner implementing? A) Complete B) Focus C) Time-lapsed D) Emergency Ans: C 28. When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focus C) General D) Time-lapse Ans: B  ursing (9th Edition by Craven) 70 29. In order for a hospital to meet criteria regarding nursing care established by the Joint Commission on Accreditation of Healthcare Organizations, the nurse must conduct which of the following types of assessment? A) Focus B) Psychosocial C) Physical D) Initial Ans: D 30. A patient has been discharged from an acute care facility. The first task a home health nurse must accomplish is A) Care of the patients physical pain B) Establish the patients database C) Evaluate the care provided previously D) Receive a report from the nursing staff Ans: B  ursing (9th Edition by Craven) 71 31. The phase of the nursing process when the nurse gathers data about the patient to establish a plan of care is the A) Assessment B) Goals C) Interventions D) Evaluation Ans: A 32.What must the nurse do to identify actual or potential health problems? A) Evaluate care implemented B) Meet with significant others C) Call the physician D) Gather data from sources Ans: D  ursing (9th Edition by Craven) 72 1. Which of the following assessment findings would support the nursing diagnosis of acute pain? Select all that apply. A) Patient had an abdominal hysterectomy 1 day ago. B) Patient is crying in pain about 20 minutes before her pain medicine is due. C) Patient has a history of osteoarthritis. D) Patient had back surgery 2 years ago and expresses the need for ibuprofen on most days. E) Patient is a heavy cigarette smoker. Ans: A, B 2. What is the process of gathering and clustering data to draw inferences and propose a diagnosis? A) Critical thinking B) Analytical reasoning C) Diagnostic reasoning  ursing (9th Edition by Craven) 73 D) Recollection Ans: C 3. The purpose of establishing a nursing diagnosis is to A) Describe a functional health problem B) Collaborate with the physician C) Identify medical problems D) Meet accreditation criteria Ans: A 4. Why is coding important when writing a nursing diagnosis? A) Enhances the professionalism of the nursing process B) Allows for direct reimbursement for nurses C) Evaluates the diagnostic statement for accuracy D) Provides legal characteristics for licensure  ursing (9th Edition by Craven) 74 Ans: B 5. Which of the following statements appropriately identifies an at-risk nursing diagnosis for a 78-year-old woman who is confined to bed? A) Ineffective airway clearance related to bed rest B) Immobility related confinement to bed C) P o t e n t i a l for pneumonia related to inactivity D) Risk for impaired skin integrity related to bed rest Ans: D 6. A nurse sees the patient grimace and documents that the patient is in pain, without interviewing the patient to obtain further cues. The nurse has A) Impaired cluster interpretation B) A lack of cues or premature closure C) Ineffective database  ursing (9th Edition by Craven) 75 D) Inaccurate evaluation Ans: B 7. The act of analyzing and synthesizing cues requires A) critical thinking B) certification C) advanced practice D) attendance at NANDA Ans: A 8. A patient is experiencing shortness of breath, lethargy, and cyanosis. These three cues provides organization or A) Categorizing B) Diagnosing C) Grouping D) Clustering Ans: D  ursing (9th Edition by Craven) 76 9. One major requirement of a nursing diagnosis is that it focuses on a problem that is A) Established by the physician B) Based on the patients pathophysiology C) Legally treatable by registered nurses D) Included within the diagnosis-related group Ans: C 10. What information provides the nurse with accuracy when developing a nursing diagnosis? A) A set of lab values B) Abnormal diagnostic tests C) A set of clinical cues D) Specific nursing interventions Ans: C  ursing (9th Edition by Craven) 77 11. What is meant by impaired state of equilibrium? A) It describes the patients condition B) It is common terminology C) It is a nursing diagnosis D) It assists in planning care Ans: A 12.What gives additional meaning to a nursing diagnosis? A) Composition B) Descriptors C) Dysfunction D) Qualifications Ans: B  ursing (9th Edition by Craven) 78 13. What does the nursing diagnosis represent? A) Symptoms B) Signs C) Cues D) Maladaptation Ans: C 14. In the development of a nursing diagnosis for a patient who has cachexia and decreased weight, what would be an appropriate nursing diagnosis? A) Anorexia nervosa and bulimia B) Lack of adequate nutrition related to decreased calories C) Weight loss related to abdominal discomfort D) Imbalanced nutrition: less than body requirements Ans: D  ursing (9th Edition by Craven) 79 15. Nursing diagnoses that require physician-prescribed and nurse-prescribed actions would be A) Independent health problems B) Collaborative health problems C) Physician-developed problems D) Interdisciplinary health problems Ans: B 16.Which of the following is classified as a nursing diagnosis? A) Esophageal cancer B) Cholecystitis C) Grieving D) Pneumonia Ans: C 17.The nursing diagnosis taxonomy provides nursing with A) Legal information  ursing (9th Edition by Craven) 80 B) Common language C) Discharge planning D) Evaluative care Ans: B 18.What is the nurse accountable for according to the state nurse practice act? A) Continuing education B) Nursing diagnoses C) Prescribing medications D) Mentoring other nurses Ans: B 19. The purpose of establishing a nursing diagnosis is to A) Describe a functional health problem B) Collaborate with physicians C) Identify medical problems D) Meet accreditation criteria  ursing (9th Edition by Craven) 81 Ans: A 1. One of the primary factors that the nurse considers when setting priorities for the patient in the acute care setting after cardiac surgery is the patients A) Support system B) Medical orders C) Past medical history D) Condition Ans: D 2. The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students in that the clinical nursing care plan usually A) does not contain documented scientific rationales B) Does not contain abbreviated nursing diagnoses C) Separates goal statements from the plan of care D) Separates outcome criteria from the plan of care Ans: A  ursing (9th Edition by Craven) 82 3. When a nurse assists a postoperative patient to the chair, which type of nursing intervention does this represent? A) Maintenance B) Surveillance C) Psychomotor D) Psychosocial Ans: C 4. A nurse is demonstrating foley catheter care to a patient. Which type of nursing intervention does this best represent? A) Surveillance B) Maintenance C) Supervisory D) Educational Ans: D  ursing (9th Edition by Craven) 83 5. A treatment based on a nurses clinical judgment and knowledge to enhance patient outcomes is a nursing: A) Diagnosis B) Evaluation C) Intervention D) Goal Ans: C 6. The most basic level of nursing interventions is A) Physiologic B) Behavioral C) Safety D) Family Ans: A 7. What are specific measurable and realistic statements of goal attainment? A) Nursing diagnoses  ursing (9th Edition by Craven) 84 B) Nursing interventions C) Evaluation D) Outcome criteria Ans: D 8. When establishing patient outcomes with the patient, what is the qualifier in the outcome? A) The short-term goal B) The long-term goal C) The problem statement D) The outcome parameter Ans: D 9. What is the purpose of the patient outcome? A) To address the problem in the nursing diagnosis B) To evaluate the plan of care developed C) To provide a basis for the scientific rationale  ursing (9th Edition by Craven) 85 D) To coordinate the nursing intervention Ans: A 10. For the postoperative patient, which of the following nursing diagnoses will require outcome identification that could contribute to a maladaptive postoperative recovery? A) Pain B) Ineffective breathing patterns C) Alteration in bowel elimination D) Anxiety Ans: B 11. Which of the following nursing diagnosis is high priority? A) Spiritual distress B) Stress incontinence C) Anxiety D) Ineffective breathing patterns Ans: D  ursing (9th Edition by Craven) 86 12. A patient is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the patient states, I am very nervous and scared to have surgery. What patient outcome is the priority? A) Evaluate the need for antibiotics B) Resolve the patients anxiety C) Provide preoperative education D) Prepare the patient for surgery Ans: B 13.The Nursing-Sensitive Outcomes Classification system organizes outcomes by A) Nursing diagnosis B) Medical diagnosis C) Critical pathway D) Measurement activities Ans: D  ursing (9th Edition by Craven) 87 14. A computerized information system developed to classify patient outcomes is the A) North American Nursing Diagnoses List B) Nursing-Sensitive Outcomes Classification C) McCaffery Pain Management Scale D) Outcome Criteria Listing Source Ans: B 15. A nurse identifies outcomes of care for the hospitalized, postoperative patient primarily to A) Document nursing practice B) Evaluate nursing interventions C) Focus on health promotion D) Provide individualized care Ans: D 16. A patient is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes?  ursing (9th Edition by Craven) 88 A) Family B) Physical therapists C) Occupational therapists D) Pharmacists Ans: A 17. When a nurse notices the patient is in pain and needs to learn to walk on crutches, which outcome identification is the priority? A) Crutch walking B) Safe walking C) Capillary refill D) Pain management Ans: D 18. A patient is rehabilitating from a fractured right leg. She is learning to walk on crutches. Together, the patient and the nurse have established a plan for the patient to walk with a three-point gait for 20 feet by the next day. In outcome identification, what is this termed? A) Establishing a patient goal  ursing (9th Edition by Craven) 89 B) Evaluation of crutch training C) Collaboration with physical therapy D) Implementation of crutch walking Ans: A 19. Planning care in the outcome identification phase allows A) Implementation of nursing interventions B) Promotion of patient participation in care C) The diagnostic process to progress D) The identification of proper diagnoses Ans: B 1. A new mother is having difficulty breastfeeding her newborn infant. A goal was established stating the baby would be nursing every two to three hours by age 1 week. The mother presents to the follow-up center at 1 week and reports the she discontinued breastfeeding. The nurse evaluates the original goal as: A) Met  ursing (9th Edition by Craven) 90 B) Partially met C) Completely unmet D) Inappropriately chosen for this patient Ans: C 2. A patient with a recently fractured left femur has been reluctant to comply with his physical therapy for fear of the pain associated with movement. A goal for this patient is to attend therapy treatments three times each day. The nurse is evaluating the goal for this patient. The patient states, I dont like therapy, it hurts, but I have been going twice a day. The patient chart has an entry from the last shift nurse stating the patient went to therapy two times with encouragement. The nurse evaluates the goal as: A) Goal met B) Goal partially met C) Goal completely unmet D) New diagnoses have developed E) Goal revision needed Ans: B 3. The nurse is assessing the patients behavioral response to a nursing intervention. This type of evaluation is known as:  ursing (9th Edition by Craven) 91 A) Structural evaluation B) Behavior modification C) Outcome evaluation D) Process evaluation E) Goal evaluation Ans: C 4. The nursing supervisor is presenting the staff nurse with her yearly performance evaluation. This type of evaluation would be called: A) outcome evaluation B) technical evaluation C) structural evaluation D) process evaluation E) goal evaluation Ans: D  ursing (9th Edition by Craven) 92 5. The nursing supervisor is evaluating how many patients each of the department nurses has been assigned for the shift. This type of evaluation would be considered: A) process B) outcome C) goal D) subjective E) structure Ans: E 6. Which of the following describe the purpose of evaluation? Select all that apply. A) To examine the patients behavioral responses to nursing interventions B) To appraise the extent to which patient goals were attained or problems resolved C) To appraise involvement and collaboration of the patient, family members, nurses, and healthcare team members in healthcare decisions D) To ensure the plan of care was followed as it was originally prepared  ursing (9th Edition by Craven) 93 E) To collect subjective and objective data to make judgments about nursing care delivered Ans: A, B, C, E 7. After the nursing plan of care has been developed, the nurse knows: A) each encounter with the patient is an opportunity to reassess and revise the plan of care if necessary. B) the plan will be followed by other healthcare providers and filed with the patients chart upon discharge. C) the responsibility for the assessment of the patient has ended. D) care plans are rigid and do not change. E) the plan of care can only be changed by the nurse who developed it. Ans: A 8. Which of the following are the two priority nursing diagnoses? A) Risk for infection B) Anxiety C) Acute Pain  ursing (9th Edition by Craven) 94 D) Ineffective Airway Clearance E) Feeding Self-Care Deficit Ans: C, D 9. The primary purpose for evaluating data about a patients care according to a functional health approach is to A) Meet accreditation standards B) Determine implementation of medical orders C) Evaluate the need for healthcare consultations D) Revise or modify the nursing care plan Ans: D 10. When a nursing supervisor evaluates the staff nurses performance with a group of patients to whom the staff nurse has provided nursing care, the supervisor is performing which type of evaluation? A) Outcome evaluation B) Summary evaluation C) Structure evaluation D) Process evaluation  ursing (9th Edition by Craven) 95 Ans: D 11. When a charge nurse evaluates the need for additional staff nurses and additional monitoring equipment to meet the patients needs, the charge nurse is performing an evaluation termed A) Process evaluation B) Structure evaluation C) Outcome evaluation D) Summary evaluation Ans: B 12. What guides professional practice? A) ANA Standards of Nursing Practice B) National Institutes of Health publications C) Nursing Intervention Classification D) Risk Appraisal Index Ans: A  ursing (9th Edition by Craven) 96 13. When the nurse prepares to discharge a patient, to evaluate the effectiveness of the nursing care, the nurse should determine whether the A) Physician orders have been completed B) Patients goals have been achieved C) Critical pathways are completed D) Documentation is thorough Ans: B 14. When a nurse assesses a patient and notifies the physician that the patient is demonstrating abnormal breath sounds, the nurse is performing a nursing intervention termed A) Supportive B) Surveillance C) Collaborative D) Maintenance Ans: B  ursing (9th Edition by Craven) 97 15. A nurse encourages a mother who has lost a child to attend the support group of parents with deceased children. This intervention is termed A) Surveillance B) Psychosocial C) Coordinating D) Technical Ans: B 16. A patient has terminal cancer. The medical intern has ordered an upper GI x-ray. The patient states he does not want the x-ray. The nurse speaks to the intern about the patients refusal to have the x-ray. This is what type of intervention? A) Surveillance B) Supportive C) Coordinating D) Technical Ans: C  ursing (9th Edition by Craven) 98 17. Educating patients on their diabetic regimen of administering their insulin is the implementation of which skill? A) Intrinsic B) Technical C) Interpersonal D) Visual Ans: B 18. The primary purpose of nursing implementation is to A) Improve the patients postoperative status B) Identify a need for collaborative consults C) Help the patient achieve optimal levels of health D) Implement the critical pathway for the patient Ans: C  ursing (9th Edition by Craven) 99 1. Which of the following statements by the student nurse demonstrates understanding of the appropriate way to document an error in her charting? A) If I make an error, I can draw a red circle around it. B) If I make an error, I have to rewrite the entire entry. C) If I make an error, I draw a single line through it and put my initials by it. D) If I make an error, I place an X through it. E) If I make an error, I use white-out on it. Ans: C 2. The nurse is caring for an elderly resident in a long-term care facility. The patient is crying and states, I dont want to live anymore. I am a burden on everyone. I dont feel like doing anything at all. I dont even want to get up today. Which of the following should the nurse record in his charting? Select all that apply. A) Patient is crying. B) Patient states, I dont want to live anymore. I am a burden of everyone. I dont feel like doing anything at all. I dont even want to get up today. C) Patient seems depressed.  ursing (9th Edition by Craven) 100 D) Patient is suicidal. E) Patient is in a bad mood. Ans: A, B 3. The patient states, I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today. His arms are folded across his chest. His brow is furrowed and he refuses to allow his morning vital sign measurements. Which of the following should be included in the nurses charting? Select all that apply. A) Seems angry today B) Unhappy with his care C) Arms are folded across his chest and brow is furrowed D) States, I hate this place. I want to go home. No one listens to me and my doctor has not been in to see me today. E) Refuses to allow morning vital sign measurements Ans: C, D, E 4. Which of the following describe best practices for charting? Select all that apply. A) Use long narratives to be sure your documentation is understood  ursing (9th Edition by Craven) 101 B) Always use complete sentences C) Use only approved abbreviations D) Always use the patients name and words referring to the patient in each entry E) Use partial sentences and phrases Ans: C, E 5. Which of the following should the nurse include in his/her charting? Select all that apply. A) The nursing assistant reports the patients breath smelled of alcohol. B) I feel something is going on she is not telling me. C) The patient was overheard telling his family about more bleeding than he has reported to his physician. D) The incision is oozing a small amount of red blood. E) The patients pupils are dilated. Ans: A, C, D, E 6. The federally initiated goal of computer-based personal records would likely produce which of the following benefits? Select all that apply.  ursing (9th Edition by Craven) 102 A) Access to records outside of the patients home facility B) Increased accuracy of treatment for the patient outside their home facility C) Easier access to data for research D) Increased incidence of identity theft E) Greater accuracy and improved patient care Ans: A, B, C, E 7. The patient record is utilized for many purposes. Which of following might be uses for the patient record? A) Education of student nurses B) Reimbursement for services C) Research D) Giving information over the phone when unidentified callers call the hospital unit E) Education for medical students Ans: A, B, C, E  ursing (9th Edition by Craven) 103 8. The nurse is caring for a patient with uncontrolled hypertension. His blood pressure has remained controlled for the nurses shift. At two-hour intervals the blood pressure was checked by the nurse and found to be essentially the same. The nurse, although taking the blood pressure as directed, forgets to write down the number. During the next shift, the patient has a stroke. Years later, the patient files a lawsuit blaming the hospital for his stroke. The nurse who was caring for the patient when his blood pressure was stable cannot recall the exact blood pressure she obtained, but remembers it was normal. Will this recollection suffice in court and why? A) Yes, the nurse remembers the pressure as normal during her shift and can swear to it during the deposition. B) No, but it will relieve the nurse of any wrongdoing. C) No, if the blood pressure measurement was not documented, it did not happen. D) Yes, the nurse was not on duty when the stroke occurred. Ans: C 9. Which of the following flow sheets provides the reader with information on an ongoing record of fluid loss? A) Vital sign sheet B) Intake and output sheet C) Critical care flow sheet D) Health assessment flow sheet  ursing (9th Edition by Craven) 104 Ans: B 10. Charting in which the nurse writes a progress note that relates to one health problem is a A) PIE note B) Flow sheet C) Narrative note D) SOAP note Ans: D 11. A nurse in a nursing home is writing a note on a resident that addresses the care the resident has received during the day and the residents response to care. What type of note does this represent? A) PIE note B) Flow sheet C) Narrative note D) SOAP note Ans: C  ursing (9th Edition by Craven) 105 12. A concise document that provides most of the patients nursing and medical information is a(n) A) Nursing care plan B) Kardex C) Past chart D) Office record Ans: B 13. During a patients hospitalization, he has developed shortness of breath, with edema. What action should the nurse take? A) Review the nursing care plan B) Implement changes in the current interventions C) Involve the family in changes D) Revise the plan of care Ans: D 14. A patients record can be more accurate if the nurse A) Charts at least every 2 hours  ursing (9th Edition by Craven) 106 B) Uses point-of-care documentation C) Summarizes patient care at the end of the shift D) Delegates charting to the nurse assistant Ans: B 15. A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic patient chart is that A) No other charting method is necessary. B) Access is open to anyone. C) Retrieval of information is more efficient. D) It is less costly to maintain. Ans: C 16.What activity in charting will assist most in the avoidance of errors? A) Objectivity B) Organization C) Legibility  ursing (9th Edition by Craven) 107 D) Timeliness Ans: D 17. The nurse is interviewing a newly admitted patient. Quoting statements made by the patient will help in maintaining A) Subjectivity B) Objectivity C) Organization D) Reimbursement Ans: A 18. A new graduate is working at her first job. Which of the following statements is most important for the new nurse to follow? A) Use abbreviations approved by the facility. B) Document lengthy entries using complete sentences. C) Use PIE charting even if it is not the institutions charting method. D) Only document changes in the patients status. Ans: A  ursing (9th Edition by Craven) 108 19. When the nurse recognizes that he has documented one patients assessment data on the wrong patients medical record, the nurse should A) Draw a single line through the error, and initial it B) Use a felt tip pen to cover the error C) Use white out to cover the error D) Replace the record, rewriting the error Ans: A 20. Which of the following principles should guide the nurses documentation of entries on the patients medical record? A) Nurses may not document for another health professional. B) Documentation does not include photographs. C) Precise measurements are preferred over approximations. D) Nurses should not refer to the names of physicians. Ans: C. 21.How can the nurse researcher obtain information from a patient record?  ursing (9th Edition by Craven) 109 A) Audit discharge records B) Interview nursing staff C) Examine institutional procedures D) Study patient records Ans: D 22. Besides being an instrument of continuous patient care, the patients medical record also serves as a(an) A) Assessment tool B) Legal document C) Kardex D) Incident report Ans: B 23. What organization audits charts regularly? A) Joint Commission on Accreditation of Healthcare Organizations  ursing (9th Edition by Craven) 110 B) National League for Nursing C) C) American Nurses Association D) Sigma Theta Tau International Ans: A 24. A nurse is working as a case manager, and in this role she audits charts. Audits of patient records are performed primarily for quality assurance and A) Reimbursement B) Staff development C) Research D) Change of mechanisms Ans: A 25. What dual purpose does an audit serve? A) Communication and evaluation  ursing (9th Edition by Craven) 111 B) Knowledge and quality C) Education and confidentiality D) Quality assurance and reimbursement Ans: D 26. How can a nurse obtain additional information about a patient? A) Read the patients history and assessment. B) Call the patients family. C) Ask the patients sister about the family history. D) Review nursing literature. Ans: A 27.The highest standard for maintaining a patients condition is A) Reporting B) Documentation C) Confidentiality  ursing (9th Edition by Craven) 112 D) Management Ans: C 28. The sharing of information about a patient is A) Communication B) Documentation C) Reporting D) Verification Ans: C 29. What ensures continuity of care? A) Reassessment B) Critical thinking C) Communication D) Integration Ans: C  ursing (9th Edition by Craven) 113 1. A woman over the age of 40 years has an annual mammogram. What level of prevention does this represent? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Medical prevention Ans: B 2. A patient inquires about the use of herbal therapy. Which statement by the nurse is most accurate? A) All herbs are equal in purity, so purchase the cheapest brand. B) Herbs can have side effects and can interact with prescription medications. C) Be sure to pay attention to the packagings therapeutic and prevention information. D) It is best if you select a licensed herbalist as a practitioner. Ans: B  ursing (9th Edition by Craven) 114 3. The nurse is caring for a terminally ill patient and asks the patients permission to incorporate therapeutic touch into the care provided. The nurses goal for this patient is to: A) Prolong life B) Control the dying process C) Bring strength D) Produce relaxation Ans: D 4. The practitioner of therapeutic touch is listening with his/her A) Ears B) Mind C) Soul D) Hands Ans: D  ursing (9th Edition by Craven) 115 5. When practicing therapeutic touch, the practitioner begins by performing which intervention? A) Calling to rebalance the soul B) Bringing the practitioners attention to an inward peaceful consciousness C) Embracing the patient for energy D) Moving her hands 2 to 6 inches away from the patients skin surface Ans: B 6. What nurse theorist developed therapeutic touch? A) Dorothea Orem B) Martha Rogers C) Jean Watson D) Dolores Krieger Ans: D 7. A patient is asking for the nurse to explain acupuncture. What would you tell the patient? A) Acupuncture is only done in Eastern countries  ursing (9th Edition by Craven) 116 B) Acupuncture is a dangerous option for the treatment of disease C) Acupuncture is beneficial to creating a mood of distraction D) Acupuncture is used to correct disharmony Ans: D 8. A patient is in the last stage of labor. During each contraction, she is focusing on her husbands voice and a picture brought from home. She is demonstrating which type of meditation? A) Concentrative B) Receptive C) Reflective D) Expressive Ans: A 9. A patient is very anxious before an invasive procedure. What CAM therapy would be most helpful to assist in decreasing anxiety? A) Meditation B) Chinese medicine  ursing (9th Edition by Craven) 117 C) Acupuncture D) Herbs Ans: A 10. Which of the following questions or statements to a patient convey acceptance? A) You know supplements can be harmful. Do you take any supplements? B) Have you ever discussed taking vitamins and supplements with your doctor? C) Will you please share with me the prescription medicines and vitamins you take? D) What helpful herbal supplements are you taking? Ans: C 11. When obtaining information for a database, which of the following represents a nurse commitment and interest in reflected integrative medicine (CAM)? A) What types of foods do you consume in 24 hours? B) Do you take any vitamins or minerals, and if so, what?  ursing (9th Edition by Craven) 118 C) What prescription medications do you take daily? D) What diseases do you suffer from and what are your allergies? Ans: B 12. Which of the following forms of medicine combines health promotion, establishment of a partnership with the patient and practitioner, and captures an evolving model of healthcare? A) Integrative healthcare and medicine B) Homeopathic healthcare and medicine C) Holistic healthcare and medicine D) Palliative healthcare and medicine Ans: A 13. A patient suffers from chronic pain. The nurse suggests the patient have monthly massages. This is an example of A) Adjuvant medicine B) Palliative medicine  ursing (9th Edition by Craven) 119 C) Alternative medicine D) Allopathic medicine Ans: C 14. What term is defined as those practices that do not form part of the dominant system for managing health and disease? A) Alternative medicine B) Complementary health C) Homeopathic medicine D) Holistic healthcare Ans: A 15. The mind and body are connected in the provision of care. This statement describes A) Homeopathic care B) Holistic care  ursing (9th Edition by Craven) 120 C) Altruistic care D) Allopathic care Ans: B 16. What type of practice was challenged by patients who want to be treated as whole persons, not just as a disease? A) Homeopathic care B) Holistic care C) Altruistic medicine D) Allopathic medicine Ans: D 17.To be an effective change agent for wellness, the nurse must A) Skip breakfast to reduce calories B) Drink caffeinated beverages  ursing (9th Edition by Craven) 121 C) Lead a sedentary lifestyle D) Consume a diet low in fat Ans: D 18. An 80-year-old woman has had a cerebrovascular accident. She has flaccidity of her right side with aphasia. For this patient, which of the following activities constitutes tertiary prevention? A) Assessment of her blood pressure B) Daily bleeding and clotting times C) Gait training and speech therapy D) Education on the symptoms of a CVA Ans: C 19. What level of prevention is noted when the nurse educates a group of women who have school-age children on self breast examinations? A) Educational prevention  ursing (9th Edition by Craven) 122 B) Primary prevention C) Secondary prevention D) Tertiary prevention Ans: B 20. A nurse assists the patient in the development of a healthy lifestyle. The adoption of these lifestyle changes in the patients life is considered A) Adaptation B) Self-care C) Self-esteem D) Health management Ans: B 21. The bodys attempt to restore balance through self-regulatory mechanisms is termed A) Homeostasis  ursing (9th Edition by Craven) 123 B) Equilibration C) Self conception D) Biofeedback Ans: A 22. A patient enjoys high-calorie carbohydrates but understands that they raise her blood sugar sharply and ultimately cause the feeling of butterflies in her stomach as her blood sugar decreases. This is considered A) Health promotion B) Illness prevention C) Holism D) Self-awareness Ans: D 23. The concept of holism is based on the belief that  ursing (9th Edition by Craven) 124 A) Individuals can be seen in an atomistic fashion B) Health is achieved through medical care C) Health is achieved by treatment from physicians D) Individuals cannot be seen apart from the environment Ans: D 24. Traditional medicines view of health is typically explained by the health model termed A) High-level wellness B) Health belief model C) Wellness-illness continuum D) Holistic health model Ans: C  ursing (9th Edition by Craven) 125 25. What is defined as the recognition of health as an ongoing process toward a persons highest potential of functioning? A) Illness B) Agent-host-environment C) Health belief model D) High-level wellness Ans: D 26. A patient states, I must be in poor health because I am a senior citizen. Thats what my neighbor says and she is older than I am. This statement is based on which of the following factors? A) Age B) Gender C) Peer influence D) Illness factors Ans: C  ursing (9th Edition by Craven) 126 27. When admitting an adolescent to the hospital, the nurse anticipates that the patient will respond to questions about his health beliefs based on his A) Age and developmental state B) Gender and medical history C) Peer influence and education D) Health promotion activities Ans: A 28. What is a dynamic balance among the physical, psychological, social, and spiritual aspects of a persons life? A) Health B) Wellness C) Holism D) Promotion Ans: B  ursing (9th Edition by Craven) 127 29. What is a dynamic state in which a person constantly adapts to changes in the internal and external environment? A) Health B) Wellness C) Holism D) Infirmity Ans: A 30. What is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity? A) Health B) Wellness C) Holism D) Host Ans: A  ursing (9th Edition by Craven) 128 31. A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Residual prevention Ans: A 32. A patient has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this patient? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Residual prevention Ans: C  ursing (9th Edition by Craven) 129 1. In the provision of nursing care, it is most important to perform which of the following actions? A) Administration of prescribed medications B) Implementation of physicians orders C) Evaluation of patients responses D) Coordination of care with the healthcare team Ans: D 2. A nurse is caring for a 17-year-old pregnant woman. The woman needs to buy a baby bed and obtain baby items. The nurse should encourage the patient to go to A) The visiting nurse association B) A resale shop C) A rental equipment store D) The welfare office Ans: B  ursing (9th Edition by Craven) 130 3. A home care nurse has completed a home assessment. Of the following findings, which should be reported to service providers immediately? A) Infestation with roaches B) The smell of natural gas C) Unclean environment D) Diminished food sources Ans: B 4. A patient is diagnosed with mild dementia while in the hospital. In preparing for discharge, the nurse should discuss with the family the: A) Possible need for home care B) Legal responsibility for the future C) Need for transfer to a long-term care facility D) Lack of free resources of care Ans: A  ursing (9th Edition by Craven) 131 5. The home care nurse asks the patient and family about their socioeconomic status, culture, and beliefs. This occurs during which phase of care? A) Assessment B) Nursing diagnosis C) Outcome criteria D) Implementation Ans: A 6. When the nurse is involved in the in-home phase, the nurse should A) Use therapeutic communication B) Record findings C) Plan the next visit D) Summarize accomplishments Ans: A 7. A home care nurse has just completed a dressing change on her patient. Which statement best describes the termination phase? A) You need to eat more protein to assist you with wound healing.  ursing (9th Edition by Craven) 132 B) On a scale of 0 to 10 with 0 being no pain and 10 being the worst, where would you rate your pain? C) Your wound is healing nicely. It is draining less and it is smaller by a half centimeter. D) Have you had any problems since our last visit? Is your wife doing well with your dressing changes? Ans: C 8. What is the purpose of the Standards of Care and Standards of Professional Performance? A) To list treatments in the home care setting B) To assist with virtual scenarios in the home C) To understand the role of the medical nurse in the home D) To guide the home care nurse in a collaborative role Ans: D 9. When initiating home healthcare services, during which phase is it appropriate for the nurse to implement the initial patient assessment?  ursing (9th Edition by Craven) 133 A) Initiation phase B) Previsit phase C) In-home phase D) Termination phase Ans: C 10. An 82-year-old woman is being discharged from the hospital following a bowel resection. The woman lives alone and her family is out of town. Which factor will have the greatest effect on her home care management? A) Support systems B) Medication management C) Transportation D) Psychosocial needs Ans: A  ursing (9th Edition by Craven) 134 11. A patient has severe pain related to degenerative joint disease. On which aspect of care will the nurse need to focus first? A) Patient education on pathophysiology Ability to perform daily activities Patients financial resources D) The effects of social isolation Ans: B 12. A single parent, aged 17 years with one child and pregnant with her second child, has the mental age of a 12-year-old. As the home care nurse, what is your greatest concern in caring for this woman? A) Her ability to bond with her children B) Her ability to receive financial aid C) Her cognitive ability to understand D) Her physical care abilities Ans: C  ursing (9th Edition by Craven) 135 13. A 16-year-old girl has been injured in an accident and is receiving home care due to fractures and multiple trauma related injuries. She states, I dont know why I survived and not my best friend. It is most important to A) Communicate her feelings to family and friends B) Allow the religious force in her life to visit C) Be certain that her educational needs are being met D) Increase her activity to assist in her coping ability Ans: A 14. An 18-month-old child is ventilator dependent due to infantile scoliosis. This is the first time the child has been home since birth. His parents are very concerned about providing care. It is most important to assist the parents with A) Financial needs of care Prevention of infection Emotional bonding D) Genetic counseling Ans: C  ursing (9th Edition by Craven) 136 15. Home care nurses are required to complete the Outcome and Assessment Information Set according to A) Medicare B) Medicaid C) Third-party payer D) Insurance Ans: A 16. It is important for home healthcare nurses to remember which point? A) The nurse is the primary caregiver. B) The nurse is the guest in the patients home. C) Rehabilitation is the major patient goal. D) The nurse should act as a counselor and advisor. Ans: B  ursing (9th Edition by Craven) 137 17. A patient is having an increasing amount of difficulty caring for herself in her home alone. She states to the nurse, I need more help. What am I going to do? It would be important for the nurse to have the A) Social worker visit to discuss care options B) Physical therapist help with rehabilitation C) Home health aide increase visits for bathing D) Occupational therapist assess for adaptive devices Ans: A 18. A woman living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for her to bathe herself, and her blood pressure is unstable. What type of care would this patient benefit from most? A) Acute care B) Ambulatory care C) Home care D) Respite care Ans: C  ursing (9th Edition by Craven) 138 19.One of the primary advantages to the managed care model is A) Increased patient satisfaction B) Economic quality care C) All RN staff D) Distinct area of care Ans: B 20. Prior to the patients discharge from an acute care facility, the nursing case manager has the nursing staff, patient, patients family, physical therapist, and home health nurse meet. The purpose of this is to A) Provide patient teaching B) Evaluate the effectiveness of the hospitalization Determine hospital-based services Prepare the patient for home care Ans: D 21. A nurse is covering all aspects of admission procedures for a patient who is receiving home health services. The nurse explains what procedures will be  ursing (9th Edition by Craven) 139 covered during his visits. Which of the following aspects of the admission process does this represent? A) Establishing rapport and showing willingness to listen B) Clearly defining the purpose and expectations of the admission C) Documenting the procedure D) Assisting in participation of the care-related decisions Ans: B 22.Continuity of care for a particular patient is important to prevent A) Multiple providers B) Infection C) Fragmentation of services D) Rising healthcare costs Ans: C 23. The home care nurse is providing care and education to a woman who is pregnant with her first child. The patient states, I have no money or food. I dont know what I should do. I want to provide for my unborn child. The nurse refers the woman to the WIC program and a local food bank. This is an example of what aspect of community-based nursing?  ursing (9th Edition by Craven) 140 A) Assessment B) Planning C) Restoration D) Evaluation Ans: B 24. A community health nursing student is assessing the birth rates and death rates of his local municipality and comparing these rates to the nation and the world. This is an example of what type of nursing? A) C