Fundamentals of Nursing 9th Edition Test Bank PDF

(Complete info) Test Bank for Fundamentals of Nursing 9th Edition by Craven All chapters latest 2023 guide  1 Table of Contents Table of Contents...

(Complete info) Test Bank for Fundamentals of Nursing 9th Edition by Craven All chapters latest 2023 guide  1 Table of Contents Table of Contents 1 Chapter 01- The Profession of Nursing 3 Chapter 02- The Nurse's Role in Healthcare Quality and Patient Safety 25 Chapter 03- Values, Ethics, and Legal Issues 35 Chapter 04- Nursing Research and Evidence-Based Care 57 Chapter 05- Nursing Process: Foundation for Clinical Judgment 77 Chapter 06- Nursing Assessment 100 Chapter 07- Nursing Diagnosis 122 Chapter 08- Outcome Identification and Planning 134 Chapter 09- Implementation and Evaluation 146 Chapter 10- Healthcare Team Communication: Documenting and Reporting 159 Chapter 11- Health, Wellness, and Integrative Healthcare 179 Chapter 12- Healthcare in the Community and Home 200 Chapter 13- Culture and Diversity 225 Chapter 14- Communication in the Nurse-Patient Relationship 246 Chapter 15- Patient Education and Health Promotion 267 Chapter 16- Caring for the Older Adult 283 Chapter 17- Safety 300 Chapter 18- Health Assessment 320 Chapter 19- Vital Signs 337 Chapter 20- Asepsis and Infection Control 350 Chapter 21- Medication Administration 365 Chapter 22- Intravenous Therapy 382 Chapter 23- Perioperative Nursing 395 Chapter 24- Hygiene and Self-Care 416 Chapter 25- Mobility 438 Chapter 26- Skin Integrity and Wound Healing 458 Chapter 27- Infection Prevention and Management 472 Chapter 28- Pain Management 485 Chapter 29- Sensory Perception 499 Chapter 30- Respiratory Function 521 Chapter 31- Cardiac Function 540 Chapter 32- Fluid, Electrolytes, and Acid-Base 559 Chapter 33- Nutrition 580 Chapter 34- Urinary Elimination 600 Chapter 35- Bowel Elimination 620  ursing (9th Edition by Craven) 2 Chapter 36- Sleep and Rest 640 Chapter 37- Self-Concept 660 Chapter 38- Families and Their Relationships 681 Chapter 39- Cognitive Processes 702 Chapter 40- Sexuality 722 Chapter 41- Stress, Coping, and Adaptation 742 Chapter 42- Loss and Grieving 761 Chapter 43- Spiritual Health 781  ursing (9th Edition by Craven) 3 Chapter 01- The Profession of Nursing 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 Feedback: Nursing students 50 years ago were mostly women and entered nursing school immediately after graduating from high school. Many of todays nursing students have pursued other career paths prior to nursing, are of various ethnic backgrounds, and have jobs and families to consider while attending nursing school. In addition, many more men have entered the field of nursing over the last 50 years. 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  ursing (9th Edition by Craven) 4 C) Neumans systems model D) Watsons theory of caring Ans: A Feedback: The patient has identified a need for change, which will guide the nurses actions. Maslows hierarchy of human needs helps nurses prioritize actions. Neuman and Watson are nursing theorists. 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 Feedback:  ursing (9th Edition by Craven) 5 The QSEN has identified patient-centered care, teamwork and collaboration, evidence-based practice, and quality improvement as a means for nurses to improve the quality and safety of patient care wherever they work. Additional key competencies identified are safety and informatics. 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 Feedback: The nurse is fulfilling the role of caregiver by providing the care and speaking to the patient in a soothing manner. The nurse is also acting as a communicator talking to the patient even if the patient cant respond. The nurse is also acting as an educator by informing the patient of the care that will be performed. The nurse is not assisting in making any decisions or speaking on behalf of the patient. 5. The nurse offers a patient two possible times to ambulate as the physician has ordered. The nurse is acting in which nursing role?  ursing (9th Edition by Craven) 6 A) Communicator B) Patient advocate C) Manager and coordinator D) Caregiver Ans: C Feedback: While the nurse is acting in many roles, the nurse is managing and coordinating the care for the patient by giving choices on when care will be implemented. 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  ursing (9th Edition by Craven) 7 Feedback: The nurse is acting in the role of educator by explaining each step. The act of changing the dressing and providing support is the caregiver role. 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 Feedback: Graduate entry program students possess a baccalaureate degree in a field other than nursing. These students can track directly into a masters or doctorate in nursing program after successfully passing the NCLEX-RN. 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?  ursing (9th Edition by Craven) 8 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 Feedback: A licensed practical or vocational nursing program will allow the student to earn a technical certificate in 1 year and sit for the state board of nursing examination to be licensed as an LPN or LVN. An associate program will take 2 years and a baccalaureate program will take 4 years. There are very few diploma programs remaining in the US, and these programs typically take 3 years to complete. 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) 9 Feedback: Dorthea Dix, while not a nurse, established the Nurse Corps of the United States Army during the Civil War. Linda Richards was the first trained nurse to graduate from a nursing program. Theodor Fliedner opened the first hospital-based school of nursing, and Florence Nightingale was nursings first professional leader. 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 Feedback: Many procedures and treatments are being delivered in outpatient settings since hospital and medical center stays significantly increase healthcare costs to the patient and insurance company. Community healthcare centers typically refer to facilities such as day care centers or ambulatory clinics.  ursing (9th Edition by Craven) 10 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 Ans: A Feedback: The nurse is responsible for making sure the needs of the patient are met based on Maslows hierarchy of needs. Attending a group activity helps meet the needs of love and belonging (need to feel that one belongs and is loved to avoid loneliness and isolation). Self-actualization is the highest need and refers to realizing fully all of ones abilities and qualities. Safety and security refers to physical and psychological protection issues. Self-esteem indicates a feeling of self-worth. 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  ursing (9th Edition by Craven) 11 C) Patient advocacy intervention D) Nurse-prescribed intervention Ans: B Feedback: Nurse initiated interventions, such as turning and repositioning a patient, are described as nurse-prescribed interventions. Physician-directed actions are described as physician-prescribed interventions. The administration of a prn medication requires a physician-prescribed intervention (the medication order) as well as a nurse-prescribed intervention (determining when the order should be carried out and proper administration of the medication); therefore, this action would be considered a collaborative intervention. Patient advocacy refers to communicating the needs and protecting the safety of the patient. 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) 12 Feedback: The clinical nurse specialist has advanced experience and expertise in a specialized area of practice such as gerontology, and would be best suited to provide education on palliative care. The nurse researcher is responsible for the continued development and refinement of nursing knowledge and practice through the investigation of nursing problems. The nurse educator generally has specific clinical specialties and advanced clinical experience in a particular area. The nurse administrator is responsible for managing patient care. 14. During the Christian era, nursing care excluded which area? A) Nutrition B) Personal counseling C) Comfort measures D) Psychiatric services Ans: D Feedback: During the Christian era nursing focused on many of the same areas that nursing focuses on today. Included areas of focus were nutrition, mobility, medication administration, personal counseling, hygiene, and comfort measures. 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:  ursing (9th Edition by Craven) 13 A) Authoritative functioning B) Independent functioning C) Assistive functioning D) Dependent functioning E) Collaborative functioning Ans: E Feedback: Nurses manage collaborative problems using both nurse- and physician-prescribed interventions to reduce risk of complications (Carpenito-Moyet, 2009). 16. Which of the following is an appropriately stated nursing intervention? 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) 14 Feedback: 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 Feedback: To serve as evaluation criteria and meet the standards of the Joint Commission (2010), the plan must be developed by a registered nurse, it must be documented in the patients health record, and it must reflect the standards of care established by the institution and the profession.  ursing (9th Edition by Craven) 15 18. Current trends in nursing practice include the development of A) Acute care centers B) Birthing centers C) Homeless shelters D) Ambulatory surgery centers Ans: B Feedback: Current trends in nursing practice include the development of nursing centers, wellness promotion programs, care of older adults, birthing centers, and home and community healthcare. 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  ursing (9th Edition by Craven) 16 Ans: D Feedback: Standards of practice are essential because they serve as guidelines for providing and evaluating nursing care. 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 D) Researcher Ans: A Feedback: Nurses are communicators when they report findings to the healthcare team. Advocacy involves actions such as protecting the patients safety or rights. Administering care measures directly to the patient and demonstrates the caregiver role. Research involves collecting and analyzing data. 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  ursing (9th Edition by Craven) 17 A) Advocate B) Caregiver C) Counselor D) Educator Ans: B Feedback: As providers of care, nurses assume responsibility for helping patients promote, restore, and maintain health and wellness. Communicating the patients needs and concerns, and protecting the patient and the patients rights are components of the advocacy role of nursing. The nurse is simply assisting in hygiene measures; no education or counseling is being provided. 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) 18 Ans: D Feedback: The baccalaureate degree in nursing offers students a full college or university education with a background in the liberal arts. 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 Feedback: The ANAs 1965 resolution prompted the 1985 ANA statement adopting the titles of associate nurse (a nurse prepared in an associate degree program with an emphasis on technical practice) and professional nurse (a nurse possessing the baccalaureate degree in nursing) for these two levels. Masters and doctoral prepared nurses possess higher degrees and expertise. 24. A nursing student begins to speak using medical terminology. This is considered to be part of which process?  ursing (9th Edition by Craven) 19 A) Learning B) Socialization C) Role development D) Evolutionary Ans: B Feedback: Socialization is a process that involves learning theory and skills and internalizing an identity appropriate to a specific role. 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) 20 Feedback: Professional organizations speak to nurses on various topics and may have some influence on ideas regarding nursing care, but longer lifespans, increased incidence of chronic illness, and new family structures have dramatically affected where and how nurses practice. 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 Feedback: The American Journal of Nursing was first published in 1900 and was owned, operated, and published by nurses. 27. Advocating for financial support for university-based schools of nursing was noted in which government document? A) The Goldmark Report  ursing (9th Edition by Craven) 21 B) Hill Burton Amendment C) Health Care Initiative Reform Act D) Lysaught Report Ans: A Feedback: The Goldmark Report in 1923 advocated for financial support for university-based schools of nursing. 28. The need for university-based nursing education programs was brought to light during which important historical time? A) Spanish American War B) World War I C) World War II D) Korean War Ans: C Feedback:  ursing (9th Edition by Craven) 22 Esther Lucille Brown, in her report on nursing education published at that time, wrote that nursing education belonged in colleges and universities, not in hospitals. 29. The Henry Street Settlement was founded by A) Dorothea Dix B) Lillian Wald C) Florence Nightingale D) Isabel Hampton Robb Ans: B Feedback: Lillian Wald and Mary Brewster established the Henry Street Settlement, which was the first public health service for the sick and poor. 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) 23 D) Isabel Hampton Robb Ans: A Feedback: Dorothea Dix established the Nurse Corps of the United States Army. 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 Feedback: Nightingale viewed sick nursing as helping patients use their own reparative processes to get well. 32. The purpose of nursing was shaped by which of the following eras? A) Egyptian era  ursing (9th Edition by Craven) 24 B) Christian era C) Revolutionary War era D) Victorian era Ans: B Feedback: Christianitys influence improved the status of nursing by attracting intelligent individuals from respected families.  ursing (9th Edition by Craven) 25 Chapter 02- The Nurse's Role in Healthcare Quality and Patient Safety 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 Feedback: Correct: A top-down flowchart shows the sequence of steps in a job or process such as medication administration. Incorrect: a. A deployment flowchart shows the detailed steps involved in a process and the people or departments that are involved at each step in the process; this is not involved in this scenario. c. The Pareto chartis used in quality improvement to indicate that 80% of problems usually stem from 20% of causes; it displays data so that a few problems are easily depicted and facilitates improvement that focuses on those few. d. A control plotis a run chart that has a center-line and added statistical control limits; it helps reveal specific types of change within a process, rather than providing a sequencing of steps.  ursing (9th Edition by Craven) 26 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. Ans: B Feedback: Correct: The Institute of Medicine is a nonprofit organization whose mission is to advance and disseminate to the government, the corporate sector, the professions, and the public scientific information that will improve human health. Incorrect: a. The Institute for Safe Medication Practices is a nonprofit organization that is an educational resource only for the prevention of medication errors. c. The National Committee for Quality Assurance is the accrediting body for health maintenance organizations. d. The Joint Commission is a national agency that conducts surveys and certifies compliance with established standards for inpatient and ambulatory facilities. 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):  ursing (9th Edition by Craven) 27 A) standardization of care. B) root cause analysis. C) process variation. D) analysis of a deployment flowchart. Ans: B Feedback: Correct: A root cause analysis is a process by which factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event, are identified. The purpose of root cause analysis is to identify improvements that can be implemented to prevent future occurrences. Incorrect: a. Standardization of care is the process of developing and adhering to best known methods and repeating key tasks in the same way, thereby creating exceptional service with maximum efficiency. c. Process variation looks at the steps in a process to determine how variation affects each step but does not identify causal events. d. A deployment flowchart analysis looks at the steps of a process and determines which department is responsible for each step, but it does not identify causal events. 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.  ursing (9th Edition by Craven) 28 B) control chart. C) deployment chart. D) top-down flowchart. Ans: B Feedback: Correct: The control chart is a run chart that has a center-line and added statistical control limits that help to detect specific types of change needed to improve a process. Incorrect: a. The Pareto chart is used in quality improvement to identify that 80% of problems usually stem from 20% of causes; it displays data so that a few problems are easily depicted and facilitates improvement that focuses on those few. c. A deployment flowchart shows the detailed steps involved in a process and the people or departments that are involved at each step. d. A top-down flowchart shows the sequence of steps in a job or process such as medication administration at a particular site, but it does not show variation limits. 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.  ursing (9th Edition by Craven) 29 Ans: A Feedback: Correct: The customer determines quality on the basis of his or her unique perception of high-quality care. Incorrect: b. High-quality health care can be inexpensive, but if it does not meet the criteria established by the consumer, then it is not high-quality health care. c. Although technologic advancements may indeed facilitate superior diagnostics, unless the patient perceives that the technology was an indicator of quality or that it improved quality, then it is not the focus. d. The perception of quality is unique among individuals. 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 Feedback:  ursing (9th Edition by Craven) 30 Correct: Early efforts focused on identified problems and were reactive rather than proactive. Incorrect: a. Quality assurance focused on specific incidents rather than on broad system improvements. b. With quality assurance, only a few people such as auditors focused on problems, and administration only later recognized the importance of proactive initiatives involving all members of the health care team. c. Early efforts of quality assurance focused on identified problems rather than on avoiding future problems. 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 Feedback:  ursing (9th Edition by Craven) 31 Correct: A deployment flowchart would show the detailed steps involved in the process and the people or departments that are to be involved at each step to assist individuals in reaching safety. Incorrect: a. The Pareto chart displays data so that a few problems that cause the greatest variance are easily depicted and facilitates improvement that focuses on those few. b. A control chart distinguishes between common and special cause variations and is basically a run chart with added statistical control limits. c. The top-down flowchart simply lists the main steps and substeps of a process in a linear fashion and does not detail the departments or people needed. 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 Feedback:  ursing (9th Edition by Craven) 32 Correct: A critical pathway determines the best order and timing of interventions provided by health care team members for a particular diagnosis. Incorrect: a. A benchmark is a process used in quality improvement to evaluate different aspects of a process in relation to best practices, with the goal of improving performance. c. An algorithm represents a decision path that a practitioner might take for a particular condition. d. Case management is a type of health care delivery that matches the most appropriate services to the patient’s care needs in the most efficient, effective manner, often with the use of a critical pathway or a clinical guideline. 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 Feedback:  ursing (9th Edition by Craven) 33 Correct: A run plot, or time plot, graphs data in time order to identify any changes that occur over time. Incorrect: b. A Pareto chart is used in quality improvement to display data so that a few problems that cause the greatest variance are easily depicted and facilitates improvement that focuses on those few. c. A flowchart provides pictures of the sequence of steps in a process. d. A cause-and-effect diagram lists potential causes, arranged by categories, to show their potential impact on a problem. It is not arranged by time. 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. D) flowchart. Ans: C Feedback:  ursing (9th Edition by Craven) 34 Correct: Pareto charts are bar graphs that show causes contributing to a problem in descending order so the leading cause is easily recognized. Incorrect: a. With the cause-and-effect diagram, all causes are listed but not in frequency of occurrence. b. Run charts show data over time. d. Flowcharts show steps in a process.  ursing (9th Edition by Craven) 35 Chapter 03- Values, Ethics, and Legal Issues 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 Feedback: Under current nurse practice laws, nurses are responsible for their own actions regardless of the providers written order. If an order is ambiguous or inappropriate, the nurse must clarify the medication order with the prescribing healthcare provider. If the nurse is dissatisfied with the providers response and still believes that the order is incorrect or unsafe, he or she must notify a supervisor. 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  ursing (9th Edition by Craven) 36 B) Assault C) Invasion of privacy D) Dereliction of duty Ans: A Feedback: Battery is the actual carrying out of such threat (unlawful touching of a persons body). A nurse may be sued for battery if he or she fails to obtain consent for a procedure. 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 Feedback:  ursing (9th Edition by Craven) 37 A nurse without an advanced practice license is not able to practice beyond his or her scope in accordance with the Nurse Practice Act. 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 Ans: C Feedback: Malpractice cases are generally the kind of civil cases that involve nurses. 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  ursing (9th Edition by Craven) 38 D) Maintaining the continuity of care Ans: C Feedback: The principle of confidentiality requires that information about a patient be kept private. Discussing patients outside the clinical setting, telling friends or family about patients, or even discussing patients in the elevator with other workers violates patient confidentiality and must be avoided. 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 Feedback: Nurses have access to information recorded in the medical record, information shared or observed through care or interactions with friends and family, and through access to the patients body. A loss of privacy occurs if others inappropriately use their access to a person.  ursing (9th Edition by Craven) 39 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 Ans: A Feedback: Fidelity means being faithful to ones commitments and promises. 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  ursing (9th Edition by Craven) 40 D) Autonomy Ans: A Feedback: Veracity means telling the truth, which is essential to the integrity of the patientprovider relationship. 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 Feedback: Justice is the foundation for decisions about resource allocation throughout a society or group.  ursing (9th Edition by Craven) 41 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 Feedback: A living will is an advance directive that specifies the type of medical treatment patients do or do not want to receive should they be unable to speak for themselves in a terminal or permanently unconscious condition. 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  ursing (9th Edition by Craven) 42 D) Advance directive Ans: D Feedback: Patients communicate their wishes to healthcare providers by verbally participating in healthcare decision making and by employing written documents called advance directives. 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 Feedback: Infants, young children, people who are severely mentally handicapped or incapacitated, and people in a persistent vegetative state or coma do not have the capacity to participate in decision making about their healthcare. For such people, a surrogate decision maker must be identified to act on their behalf.  ursing (9th Edition by Craven) 43 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 Feedback: Autonomy essentially means independence and the ability to be self-directed. 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  ursing (9th Edition by Craven) 44 D) Fidelity Ans: B Feedback: The principle of nonmaleficence means to avoid doing harm, to remove harm, and to prevent harm. 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 Feedback:  ursing (9th Edition by Craven) 45 The principle of nonmaleficence means to avoid doing harm, to remove harm, and to prevent harm. Beneficence means doing or promoting good. Nurses work to accomplish good for patients by promoting their best interests and striving to achieve optimal outcomes. The patients circumstances indicate harm. 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 Feedback: Beneficence means doing or promoting good. The treatment of the patients pain is the nurses act of doing good. 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) 46 C) Serves as a guideline for all healthcare D) Plays an important role in legal proceedings Ans: B Feedback: The ANA recently revised the Code of Ethics for Nurses that delineates the conduct and responsibilities expected of all nurses in their nursing practices. 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 Feedback:  ursing (9th Edition by Craven) 47 Nurses ethical obligations include acting in the best interest of their patients not only as individual practitioners but also as members of the nursing profession, the healthcare team, and the community at large. 19. To practice ethically, the nurse should A) Allow a committee to guide her practice B) Review past cases before guiding practice C) Avoid allowing her judgment to guide practice D) Ask the family their views on caring Ans: C Feedback: Personal convictions apply only to situations and decisions pertaining to the individual. In ethical practice, nurses avoid allowing personal judgments to bias their treatment of patients. 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  ursing (9th Edition by Craven) 48 D) Legal obligation Ans: C Feedback: Institutional policies are guidelines developed by healthcare institutions to direct professional practice. 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 Ans: B Feedback: Personal values are ideas or beliefs a person considers important and feels strongly about. 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?  ursing (9th Edition by Craven) 49 A) Personal morality B) Professional values C) Ethics D) Legal obligations Ans: A Feedback: Personal morality is the set of beliefs about the standards of right and wrong that helps a person determine the correct or permissible action in a given situation. 23. Ethics is best defined as A) Basis for moral reasoning B) Standards of conduct C) Dealing with conflict D) Decision making Ans: B  ursing (9th Edition by Craven) 50 Feedback: Ethics is the branch of philosophy dealing with standards of conduct and moral judgment. 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 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 Feedback: As children progress to toddlerhood, morals and values development begins as they identify behaviors that elicit reward or punishment. Kohlberg refers to this process as the first-level preconventional stage when children learn to distinguish right from wrong and understand the choice between obedience and punishment. 25. During adolescence, values are primarily formed from  ursing (9th Edition by Craven) 51 A) Schools B) Work C) Parents D) Peers Ans: D Feedback: In adolescence, peer groups are the primary source of value formation. The attitudes, beliefs, and behaviors that grow out of peer group relationships are powerful. 26. How are values converted from knowledge into messages which can then be processed as information? A) Religion B) Nature C) Time D) Activity Ans: A  ursing (9th Edition by Craven) 52 Feedback: Values are codified in social institutions such as family, school, and religion. Values can then be adopted, adapted, or dismissed based on the persons life experiences and social system. 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 Feedback: Values inquiry is a method of examining social issues and the values that motivate human choices. 28. The differences between the pro-life and abortion rights movement is an example of A) Values inquiry B) Social activism  ursing (9th Edition by Craven) 53 C) Ethical inconsistency D) Values clarification Ans: A Feedback: Values inquiry is a method of examining social issues and the values that motivate human choices. 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 Feedback:  ursing (9th Edition by Craven) 54 Values clarification is a method of self-discovery by which people identify their personal values and value rankings. The patients value of family may be obscured because of his overwhelming need to protect his family. 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 C) Advanced practice licensure guidelines D) Moral values Ans: D Feedback: Moral values involve correct behavior, such as having some sense of right and wrong. Moral values help direct nurses to deal with human interactions that involve the integrity of life or health. 31. A nursing students attitude is defined as: A) Belief in ones self B) Desire to do good  ursing (9th Edition by Craven) 55 C) Disposition toward situations D) Choosing between alternatives Ans: C Feedback: An attitude is ones disposition toward an object or a situation; it can be a mental or emotional mindset, and it can be positive or negative. 32. Socialization into the nursing profession may have the most significant effect on A) Roles B) Values C) Documentation D) Planning Ans: B Feedback:  ursing (9th Edition by Craven) 56 Values that the nurse will need to balance include truth, harmony, duty, and responsibility. 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 Feedback: Values are standards for decision making that endure for a significant time in ones life.  ursing (9th Edition by Craven) 57 Chapter 04- Nursing Research and Evidence-Based Care 1. In the development of a literature review, the most effective source of information for nursing research is which of the following? New England Journal of Medicine A) Cumulative Index of Nursing and Allied Health Literature B) Journal of Nursing Research C) American Journal of Nursing D) Ans: B Feedback: Indexes such as the Cumulative Index to Nursing and Allied Health Literature, International Nursing Index, Index Medicus, Nursing Studies Index, MedLine, and Nursing Research Index are valuable in locating nursing-based literature and research studies. 2. When did evidenced-based practice become an important component of the delivery of nursing care? A) The early 1800s B) The early 1900s  ursing (9th Edition by Craven) 58 C) The late 1900s D) The early 2000s Ans: D Feedback: In the early years of the 21st century, a heightened focus on evidence-based practice has developed, which relies on research findings to support nursing practice. 3. Why is it important for the findings of a research study to be disseminated? Select all that apply. A) So that clinical application can occur B) To allow the nurse researcher to receive notoriety for the findings C) In order for research replication by other nurses to take place D) Because graduate-level nurses must conduct a specific number of research studies to maintain nursing licensure E) To strengthen and validate conclusions by similar findings in more than one research study Ans: A, C, E Feedback:  ursing (9th Edition by Craven) 59 The study and its findings must be dispersed in order to validate the findings through clinical practice and through replication of the study; hopefully, with similar findings. There is not a specified number of studies required for graduate-level nurses to conduct, and the nurse researcher should never conduct a study for the purpose of being recognized. 4. The nurse researcher is aware that the type of variable that can be manipulated in a study is which type of variable? A) Dependent B) Independent C) Quantitative D) Qualitative Ans: B Feedback: The independent variable is presumed to have an effect on the dependent variable. It may be manipulated if the researcher is doing an experimental study; in a non- experimental study, it is assumed to have occurred naturally before or during the study. 5. The director of nurses (DON) in a long-term care facility has noticed an increased number of urinary tract infections (UTIs) on the east wing of the facility, and would like the infection control nurse to investigate this problem. What is the best problem statement for this study?  ursing (9th Edition by Craven) 60 A) Is there a relationship between the personnel caring for specific patients and whether or not these patients developed UTIs? B) Is there an increase in the number of UTIs on the east wing of the facility? C) Does the east wing have a greater number of UTIs than the west wing of the facility? D) What is the patient census on the east wing as opposed to the other wings of the facility? Ans: A Feedback: The problem statement in a research study identifies the direction that a research project will take. The statement should be clear and unambiguous, express a relationship between two or more variables, identify the population to be studied, and encourage empiric testing. 6. A nursing researcher presents the findings of his current study at a School of Nursings research conference. While there, he speaks with another nurse researcher interested in similar topics and the two decide to discuss forming a partnership for further research projects. What is this type of interaction an example of? A) Hypothesizing B) Identifying variables C) Investigating foreground questions  ursing (9th Edition by Craven) 61 D) Networking Ans: D Feedback: Networking is a way to meet other nurses with similar interests and is a good way to disseminate and to expand ones knowledge, as well as to meet with other professional nurses. 7. What type of research study would a hospital conduct to determine additional services the community would like to see offered by the facility? A) Quantitative B) Qualitative C) Ordinal D) Interval Ans: B Feedback: Quantitative researchers tend to use deductive reasoning, logic, and measurable attributes of human experience, whereas qualitative researchers tend to use dynamic, individual aspects of the human experience in a holistic approach. Ordinal and interval refers to types of variables.  ursing (9th Edition by Craven) 62 8. What are the four properties identified by Diers that comprise the holistic perspective of nursing research? A) The focus of nursing research must be on a variance that makes a difference in improving patient care. B) Nursing research has the potential for contributing to the development of theory and the body of scientific nursing knowledge. C) A research problem is a nursing research problem when nurses have access to and control over the phenomena being studied. D) A nurse interested in research must have an inquisitive, curious, and questioning mind. E) A nurse interested in research must be a graduate-level nurse to be able to adequately perform nursing research. Ans: A, B, C, D Feedback: Nursing is concerned with the whole person, which describes holistic nursing. When nurses conduct research, they tend to focus on the physiologic, psychological, sociologic, cultural, and economic factors that affect a person. They view the situation from a nursing perspective and ask questions about what they see. 9. When the nurse researcher informs the participant that his or her identity will not be linked with the information that is collected, the researcher is ensuring the participants  ursing (9th Edition by Craven) 63 A) Anonymity B) Protection from harm C) Ability to withdraw D) Confidentiality Ans: D Feedback: Confidentiality ensures that the subjects identities will not be linked with the information they provide and will not be publicly divulged. 10. The role of the institutional review boards for research studies is to A) Determine the worthiness of a research study B) Document the costs of the study C) Publish the research study D) Protect the rights of human subjects Ans: D Feedback:  ursing (9th Edition by Craven) 64 Research involving human subjects also needs approval by institutional review boards before implementation. 11. A well-constructed problem statement formulated at the beginning of a nursing research study should A) Incorporate nursing theory B) Include significant references C) Identify benefits of the study D) Indicate the population Ans: D Feedback: The problem statement should be clear and unambiguous, express a relationship between two or more variables, identify) the population to be studied, and encourage empiric testing. 12. A nursing instructor would like to study the effect peer tutoring has on student success. What is the independent variable? A) Nursing student  ursing (9th Edition by Craven) 65 B) Nursing education C) Peer tutoring D) Student success Ans: C Feedback: The independent variable is the presumed cause or influence on the dependent variable. 13. Following the identification of a researchable problem, the nurse must A) Obtain a list of possible outcomes B) Evaluate the number of ways to collect data C) Select literature relevant to the problem D) Determine a source appropriate to collect data Ans: C Feedback:  ursing (9th Edition by Craven) 66 Literature review is the process of selecting published materials that have relevance to the potential research. 14. A nurse researcher is collecting nominal data. What type of research is being conducted? A) Quantitative research B) Qualitative research C) Interval research D) Experimental research Ans: A Feedback: Quantitative research involves the systematic collection of numeric information. Nominal data is of a numeric nature. 15. The nurse researcher would like to gather data on the attitudes of young adults on spirituality and healthcare. The most effective form of research on this topic is A) Quantitative research B) Methodologic survey C) A Delphi study  ursing (9th Edition by Craven) 67 D) Qualitative research Ans: D Feedback: Attitudes on spirituality and healthcare require the nurse to interview patients or informants to obtain qualitative research. Qualitative research involves the systematic collection and analysis of more subjective narrative materials using procedures in which there tends to be a minimum of researcher-imposed control. 16. The National Institute of Nursing Research (NINR) was established following a study in 1983. The centers purpose is to A) Advance the level of nursing research funding B) Investigate and expand nursing theory C) Promote research for health promotion D) Evaluate the effect of current research Ans: C Feedback:  ursing (9th Edition by Craven) 68 The National Institute of Nursing Research was established under the National Institutes of Health to place nursing securely in the sphere of scientific investigation and to support research and training into patient care, health promotion, disease prevention, and the mitigation of the effects of acute and chronic disabilities. 17. From 1900 to 1940, research in nursing focused on: A) Cost-effectiveness of nursing care B) Improving patient care outcomes C) Nursing education and teaching D) Increasing workforce in the nursing profession Ans: C Feedback: Between 1900 and 1940, research in nursing centered on education, methods of teaching, and methods of evaluating how nurses learned. 18. Who is considered to be the first nursing researcher? A) Florence Nightingale B) Dorothea Dix  ursing (9th Edition by Craven) 69 C) Clara Barton D) Lillian Wald Ans: A Feedback: Nursing research has been an integral part of the profession since Florence Nightingale documented the care of soldiers in the Crimean War. 19. How are the first stages of the nursing process and nursing research linked? A) They will answer a posed question. B) Each begins with goal development. C) The nurse assesses problems initially. D) There is a period of evaluation. Ans: C Feedback: The first step for the practicing nurse is to assess a problem; for the researcher, the step is to recognize the general problem area.  ursing (9th Edition by Craven) 70 20. What is a systematic inquiry into the problems encountered in nursing practice and into the modalities of patient care? A) Nursing research B) Evidence-based practice C) Outcome criteria D) Scientific inquiry Ans: A Feedback: Nursing research is defined as a systematic inquiry into the problems encountered in nursing practice and into the modalities of patient care, such as support and comfort, prevention of trauma, promotion of recovery, health education, health appraisal, and coordination of healthcare. Evidence-based practice supports nursing care given to patients by emphasizing decision making based on the best available evidence and the use of outcome studies to guide decisions. 21. Evidence-based care emphasizes decision making based on the best available evidence and A) Use of outcome studies to guide decisions B) Evaluation by experts to direct specialty areas C) Care based on pathophysiologic factors  ursing (9th Edition by Craven) 71 D) Cost efficiency of treatment models Ans: A Feedback: Evidence-based care emphasizes decision making based on the best available evidence and the use of outcome studies to guide decisions. 22. Nursing research is linked most closely to A) Propositions B) Outcome measures C) Treatments D) Nursing process Ans: D Feedback: Many similarities are found between the formalized research process and the nursing process format that is an integral part of nursing education. 23. The question, Does handwashing significantly lower the rate of infection in hospitalized patients?, is an example of what research component?  ursing (9th Edition by Craven) 72 A) Hypothesis B) Problem statement C) Conclusion D) Implication for the future Ans: A Feedback: Research is defined as a formalized process of systematic investigation designed to test a research question or hypothesis and draw conclusions from collected data. 24. In what way can a nurse discriminate strong research from poor research? A) By conducting the research B) Through author dialogue C) By critiquing the study D) Through the nurses own informal investigation Ans: C  ursing (9th Edition by Craven) 73 Feedback: Nurses must have a working knowledge of research methods and a beginning ability to read for application and to critique research. 25. One of the primary focuses of nursing research is to A) Quantify outcomes related to patients B) Determine outcomes for patients C) Generate knowledge to guide practice D) Prevent further disease and death Ans: C Feedback: One of the major reasons for conducting research is to expand a professions knowledge base. 26. What nursing activity forms the bridge between theory and practice? A) Theoretic writing B) Evidence-based research  ursing (9th Edition by Craven) 74 C) Patient-focused care D) Case management Ans: B Feedback: Evidence-based research is translational research that forms the bridge between theory and practice. 27. Which of the following terms describes or explains the nursing model? A) Conceptual framework B) Theory C) Construct D) Proposition Ans: B Feedback: The nursing model or theory acts as a guide to identify and study systematically the logical relationships between variables, thus supporting nursing care.  ursing (9th Edition by Craven) 75 28. A conceptual framework is defined as A) An explanation of nursing and nursing practice B) A set of phenomena and related abstractions C) A foundation for nursing skills and care D) A set of concepts and propositions Ans: D Feedback: A conceptual framework or model is defined as a set of concepts and the propositions that integrate them into a meaningful configuration. 29. Of the following, which best explains the importance of theoretic frameworks? A) Theoretic frameworks guide physiologic nursing care B) Theoretic frameworks guide psychosocial nursing care C) Theoretic frameworks advance nursing knowledge and practice D) Theoretic frameworks advance the ethical aspects of practice  ursing (9th Edition by Craven) 76 Ans: C Feedback: Theoretic frameworks are important to the advancement of nursing knowledge and professional practice.  ursing (9th Edition by Craven) 77 Chapter 05- Nursing Process: Foundation for Clinical Judgment 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 Feedback: The human patient stimulator, a life-sized mannequin with a sophisticated computer interface, presents students with clinical scenarios that evolve based on decisions that students make. 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  ursing (9th Edition by Craven) 78 C) Reminiscing D) Evangelization Ans: B Feedback: Reflection is defined as those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations. 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 Feedback:  ursing (9th Edition by Craven) 79 By having a more complete database from several sources, including the patient, the nurse can arrive at a more accurate conclusion. The nurse can obtain data from secondary sources, such as family members, significant others, other healthcare professionals, health records, and literature review. 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? A) Clinical reasoning B) Caring C) Reflection D) Assessment Ans: A Feedback: Clinical reasoning is the process of making a nursing judgement that will provide safe and quality care. 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  ursing (9th Edition by Craven) 80 B) Lacking C) Integrated D) Creative Ans: C Feedback: This scenario indicates the integration of a students knowledge in the provision of safe patient care. 6. For the nursing student to implement the most effective care for her patients, she must A) Have rudimentary critical-thinking skills B) Apply preexisting knowledge C) Apply clinical knowledge to theoretic knowledge D) Establish a clinical log for evaluation Ans: B Feedback:  ursing (9th Edition by Craven) 81 To deal with the patients problems appropriately, the student nurse will need to use his or her knowledge base from previous classes. 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 Feedback: Learning in the clinical setting or nursing laboratory may be more active, kinesthetic, and random. 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) 82 D) Active experimenters Ans: D Feedback: Active experimenters enjoy clinical rotations and skills laboratories. 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 Feedback: Too much anxiety can paralyze high-order thinking skills.  ursing (9th Edition by Craven) 83 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 Ans: A Feedback: Critical thinking requires nurses to choose solutions or identify options for patient care situations. 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  ursing (9th Edition by Craven) 84 D) Implementation Ans: B Feedback: The nurse is collecting data when measuring the patients blood pressure. Collection of patient data is considered assessment regardless of when it occurs. 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 Feedback: Technical skills are used to carry out treatments and procedures. 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?  ursing (9th Edition by Craven) 85 A) Assessment B) Nursing diagnosis C) Planning D) Implementation Ans: D Feedback: Implementation refers to the action phase of the nursing process in which nursing care is provided. 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  ursing (9th Edition by Craven) 86 Feedback: Implementation refers to the action phase of the nursing process in which nursing care is provided. 15. The functional health patterns provide the nurse with a(an) 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 Feedback: The functional health patterns provide a framework for the collection of assessment data. 16. Clustering of data to ascertain a nursing diagnosis is accomplished through the use of: A) general systems theory process. B) problem-solving process.  ursing (9th Edition by Craven) 87 C) decision-making process. D) information-processing theory. Ans: D Feedback: Nurses use information-processing theory to help cluster data to arrive at a diagnosis. 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 A) General systems theory process B) Problem-solving process C) Decision-making process D) Information-processing theory Ans: C Feedback:  ursing (9th Edition by Craven) 88 Making decisions about patient care is the essence of nursing practice. Decision making is integral to every step of the nursing process. 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 Feedback: Input, the information that enters a system, is the data collected during the assessment step. 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  ursing (9th Edition by Craven) 89 D) Evaluation Ans: D Feedback: In the evaluation phase, nurses collect data to determine if patient goals have been met. 20. Nursing actions should be A) Associated with the family B) Goal-directed C) Individually attained D) Evaluated by team members Ans: B Feedback: Nursing actions are goal-directed, assisting the patient to reach maximum functional health. 21. The nurse changes a patients surgical dressing daily. This is considered to be part of which phase of the nursing process?  ursing (9th Edition by Craven) 90 A) Nursing diagnosis B) Patient goal C) Outcome identification D) Implementation Ans: D Feedback: Implementation is the action phase of the nursing process. 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 Feedback:  ursing (9th Edition by Craven) 91 The patient plan of care is a written summary of care that a patient is to receive. The Joint Commission requires a written plan of care for each patient. 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 Feedback: Formulating the diagnostic statement requires knowledge of the differences among actual, risk, possible, and wellness nursing diagnoses. 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.  ursing (9th Edition by Craven) 92 D) write the plan of care. Ans: D Feedback: Nurses work together with patients to identify goals and intervention strategies that will address identified problems. 25. What is the primary goal of the planning phase of the nursing process? 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 Feedback: The planning phase involves preparing a patient plan of care, which directs the activities of the nursing staff in the provision of patient care. 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)  ursing (9th Edition by Craven) 93 A) Nursing diagnosis B) Assessment C) Evaluation D) Outcome identification Ans: D Feedback: According to the ANAs Nursing: Scope and Standards of Practice, outcome identification refers to formulating and documenting measurable, realistic, patient- focused goals. 27. Which organization defines the nursing diagnosis? A) American Nurses Association B) North American Nursing Diagnosis AssociationInternational C) American Association of Colleges of Nursing D) Sigma Theta Tau International Ans: B  ursing (9th Edition by Craven) 94 Feedback: The North American Nursing Diagnosis AssociationInternational defines the nursing diagnosis as a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. 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 Feedback: Registered nurses are educated and licensed to make nursing diagnoses. 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  ursing (9th Edition by Craven) 95 B) Subjective data C) A nursing intervention D) An actual nursing diagnosis Ans: D Feedback: Diagnosing human responses to actual or potential health problems is the second phase of the nursing process. 30. An in-depth history and physical builds the A) Plan of care B) Future interventions C) Database D) Secondary source Ans: C Feedback:  ursing (9th Edition by Craven) 96 An in-depth history and physical assessment are usually required at admission to a hospital or long-term care facility, or during the first visit by community or home health nurse. 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 Feedback: Secondary sources include family members, significant others, other healthcare professionals, health records, and literature review. 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  ursing (9th Edition by Craven) 97 C) Symptom identification D) Planning care Ans: A Feedback: This patient is the primary source of information for assessment. 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 Feedback: In the 1980s, further support was gained for making diagnosis a distinct nursing function and a separate step of the nursing process. In the landmark Nursing: A Social Policy Statement, the ANA again identified diagnosis of actual and potential health problems as an integral part of nursing practice.  ursing (9th Edition by Craven) 98 34. The term nursing process is synonymous with the A) Identification of health problems B) Verification of wellness issues C) Application of nursing diagnosis D) Problem-solving approach Ans: D Feedback: The term nursing process is synonymous with the problem-solving approach for discovering the healthcare and nursing care needs of patients. 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  ursing (9th Edition by Craven) 99 Ans: C Feedback: The nursing process is that which goes on between a patient and a nurse in a given setting; it records the behaviors of patient and nurse and the resulting interaction.  ursing (9th Edition by Craven) 100 Chapter 06- Nursing Assessment 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 C) Checking consistency of cues D) Clarifying the patients statements E) Seeking consensus with colleagues about inferences Ans: A, B, C, D, E Feedback: These methods of validating data and inferences are necessary before cues are clustered and analyzed for identification of nursing diagnoses. 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  ursing (9th Edition by Craven) 101 C) Document all inferences D) Avoid making any inferences Ans: A Feedback: The nurse should validate inferences made from assessment data in order to ensure accuracy. Incorrect cues and inferences lead to the development of inappropriate nursing diagnoses and patient plans of care. 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 B) Introductory C) Maintenance D) Concluding Ans: C Feedback:  ursing (9th Edition by Craven) 102 Watching the patient to determine if nonverbal cues match their verbal communication typically occurs during the maintenance, or working, phase of the interview. 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 Feedback: Nurses are responsible for completing nursing histories, and it usually takes approximately 30 to 60 minutes to obtain data such as history of present illness, past medical history, support network, and other pertinent data. The physical is performed separately. Family members can offer valuable information as long as the patient gives permission for them to remain present during the history taking.  ursing (9th Edition by Craven) 103 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? A) The company that made the blood pressure equipment B) The nurse C) The UAP D) The charge nurse Ans: B Feedback: While the nurse may delegate duties to UAP, the professional RN is ultimately responsible for the completeness and accuracy of the information. Since this was part of the admission assessment it would be advisable for the nurse to have measured the vital signs herself. 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  ursing (9th Edition by Craven) 104 C) Pupil reaction D) Skin temperature Ans: B Feedback: Peristalsis (bowel sounds) are assessed by auscultation with a stethoscope. The size of the liver is determined with percussion, inspection yields pupil size, and skin temperature is assessed through palpation. 7. Which of the following are examples of objective data? 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 Feedback:  ursing (9th Edition by Craven) 105 Objective data from observation (e.g., posture, skin color, behavior), health records (e.g., laboratory results, reports from other healthcare team members), physical assessment (e.g., breath sounds, strength of extremities), and measurement devices (e.g., blood pressure, temperature) are collected to judge the patients behavioral responses to nursing interventions. 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 Feedback: Subjective data are collected from many sources: the patient, family members or significant others, nursing staff, and other healthcare team members. 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.