1. Chapter 04-03 (1.0 point) A registered nurse was accused of patient abandonment when she became angry, quit her job, and left the hospital before the end of her shift. This is an example of violating guidelines set by which of the following? a. State Department of Health b. The Joint Commission *c. State Board of Nursing

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1. Chapter 04
03 (1.0 point)

A registered nurse was accused of patient abandonment when she became angry, quit her
job, and left the hospital before the end of her shift. This is an example of violating
guidelines set by which of the following?

a. State Department of Health

b. The Joint Commission

*c. State Board of Nursing

d. National League of Nursing

General Feedback:

Nurse Practice Acts permit the State Board of Nursing to set rules,
regulations, and guidelines that specifically define

the standard of care in nursing
practice. An example is the guidelines that define patient abandonment.

2. Chapter 04
04 (1.0 point)

A RN suffers from chronic back pain that was the result of an injury she suffered when
pulling a patient up in bed. She

is addicted to pain medication and has recently been
accused of stealing narcotics. This is an example of which of the following violations of
the law?

a. Misdemeanor

b. Tort

c. Malpractice

*d. Felony

General Feedback:

A felony

is a serious offen
se that results in significant harm to another person
or to society in general. Felony crimes may carry penalties of monetary restitution,
imprisonment for greater than 1 year, or death. Examples of Nurse Practice Act violations
that may carry criminal pen
alties include practicing nursing without a license and misuse
of controlled substances.

3. Chapter 04
05 (1.0 point)

A registered nurse was pulled from her normal unit to fill in for a pediatric unit. She is
caring for a 16
old patient who refuses

to cooperate for a dressing change. The nurse
tells the patient that she will tie the patient down if she does not hold still. This threat is
an example of which of the following?

*a. Assault

b. Unintentional tort

c. Battery

d. Felony



is an intentional threat toward another person that gives that person a
reasonable fear of harmful contact. No actual contact is required for an assault to occur.
An example of an assault in nursing practice is to threaten to restrain a
patient for an x
ray procedure when the patient has refused consent.

4. Chapter 04
06 (1.0 point)

A wrong
site surgery is considered a sentinel event for a health care organization. In
addition to the hospital being at fault for this situation, the heal
th care provider could also
be considered guilty of committing which of the following?

a. Negligence

*b. Battery

c. Felony

d. Misdemeanor

General Feedback:

An example of a battery in health care is when the patient has consented to a
right knee su
rgery and the surgeon performs surgery on the patient’s left knee. An
example of an assault and battery is to threaten to restrain a competent patient for an x
ray procedure to which the patient has not consented and then to actually restrain the

5. Chapter 04
08 (1.0 point)

Which of the following is the best way for a nurse to avoid being liable for malpractice?

a. Purchasing quality malpractice insurance coverage

*b. Practicing nursing that meets the generally accepted standard of care

Not sharing his or her last name with patients and families

d. Not delegating any tasks to unlicensed assistive personnel

General Feedback:

The best way to avoid being liable for malpractice is to give nursing care that
meets the generally accepted
standard of care. In a malpractice lawsuit the law uses
nursing standards of care to measure nursing conduct and to determine whether the nurse
acted as any reasonably prudent nurse would act under the same or similar circumstances.

6. Chapter 04
(1.0 point)

A registered nurse is caring for a 45
old patient 2 days after a colon resection. The
patient called for assistance to go to the bathroom. Instead of waiting for help, the patient
decided to get up on her own. She fell but did not injure h
erself. After contacting the
patient’s health care provider, which of the following is most important for the nurse to

a. Nothing; the patient wasn’t injured.

b. Call the Risk Management Department.

*c. Submit an incident report.

d. Insist that th
e patient have a radiograph done.

General Feedback:

When there is a deviation from the standard of care, such as a patient or
visitor falls or an error is made, a nurse makes specific documentation of the event or
incident in the form of an occurrence
report/incident report. The nurse should complete
an occurrence report when anything unusual happens that could potentially cause harm to
a patient, visitor, or employee.

7. Chapter 04
12 (1.0 point)

After witnessing a patient fall, a nurse fills out an

occurrence report. Which of the
following is the best way for the nurse to document this occurrence?

*a. “Patient found lying on right side on floor. No noted injuries, patient stated, ‘I
slipped on a wet spot on the floor. I don’t think I am injured.’”

b. “Patient slipped on a wet spot on the floor. No noted injuries, physician

c. “Patient in too much of a hurry and was walking too fast and fell. Was not
injured. Patient instructed to slow down and not be in such a hurry. Health care
er notified.”

d. “Patient fell while going outside to smoke. Patient denied any injuries. Health
care provider notified. Patient counseled.”

General Feedback:

Objectively record the details of the event and any statements the patient
makes. An example

is as follows: “Patient found lying on floor on right side. Abrasion on
right forehead. Patient stated, ‘I fell and hit my head.’” At the time of the event, always
contact the health care provider to examine the patient.

8. Chapter 04
13 (1.0 point)

new registered nurse who recently passed board examinations was on his way home
from the STD clinic where he was working since graduating from nursing school. He
stopped at an automobile accident to see if he could assist. There was one victim who
was not
breathing. The nurse provided CPR at the scene, but the victim died. The
victim’s family sued the nurse. Which of the following provides the best protection to the
nurse in this case?

a. STD clinic’s malpractice insurance policy

*b. Good Samaritan Law

c. The State Board of Nursing

d. Institute of Medicine

General Feedback:

Although Good Samaritan Laws provide immunity to the nurse who does
what is reasonable to save a person’s life, if a nurse performs a procedure for which a
nurse has no training,

the nurse will be liable for any injury resulting from that act.
Therefore, provide only care that is consistent with your level of expertise.

9. Chapter 04
14 (1.0 point)

A registered nurse has recently started working as a surgical nurse. Within his
he was instructed that he would be responsibility for verifying that the Consent for
Surgery form was signed. He understands that the person signing the form must be
competent. Which of the following patients would be considered competent to gi
informed consent?

a. 27
old unconscious patient

*b. 16
old emancipated minor

c. 43
old patient who has been drinking alcohol

d. 33
old patient who has received preanesthesia medication

General Feedback:

Informed consent requ
ires that a nurse gives the patient all relevant
information required to make a decision, that the patient is capable of understanding the
relevant information, and that the patient actually gives consent.

10. Chapter 04
15 (1.0 point)

A nurse works for

a unit caring for patients after open heart surgery. A patient is
confused and is attempting to get out of bed. The nurse is tired after working for more
than 10 hours and is concerned for the patient’s safety. What is the best action that the
nurse shoul
d take to prevent the patient from harm?

a. Restrain the patient with wrist restraints.

b. Restrain the patient with a belt restraint in a chair.

c. Sedate the patient with medication.

*d. Ask a family member to sit with the patient.

General Feedba

The Joint Commission has set guidelines for the use of restraints. These
regulations set the standard that all patients have the right to be free from seclusion and
physical or chemical restraints except to ensure the patient’s safety in emergency
uations. The standards specifically prohibit restraining patients for staff convenience,
punishment, or retaliation.

11. Chapter 04
16 (1.0 point)

A registered nurse is admitting a 65
old patient into the hospital for acute
pancreatitis. As part of

the admission process she asks if the patient has an advance
directive. The patient states that he is not sure. Which of the following is considered an
advance directive?

a. Power of attorney

*b. Living will

c. Legal will

d. Organ donation card

General Feedback:

Many times the decision regarding lifesaving treatment is in writing in the
patient’s living will or advance directive. Living wills are documents instructing the
physician or health care provider to withhold or withdraw life
procedures in a
patient who is terminally ill. If the patient has executed a durable power of attorney for
health care, the document will designate an individual who is able to give consent for
health care treatment when the patient is no longer able.

2. Chapter 04
17 (1.0 point)

Which of the following examples demonstrates a breach of confidentiality and a violation

a. Giving a report to the oncoming nurse in a conference room

b. Discussing a patient’s diagnosis with the patient’s health c
are provider

c. Providing patient information to the nursing assistant caring for the patient

*d. Sharing with other nurses on the unit that a patient is HIV

General Feedback:

Issues of disclosure, privacy, and confidentiality are an importa
nt concern
when working with patients or peers infected with blood
borne illnesses such as human
immunodeficiency virus (HIV) or acquired immunodeficiency virus (AIDS), hepatitis,
and sexually transmitted illnesses. A nurse will care for patients with thes
e illnesses in
every segment of nursing practice. A nurse should always use standard precautions as a
standard of care when caring for all patients. The 1995 American Disabilities Act (ADA)
applies to persons with AIDS. This federal law protects the rights

of disabled people and
infected patients.

13. Chapter 04
18 (1.0 point)

Crystal, a RN, has been caring for a patient of Dr. Hoover. Crystal received an illegible
order for a medication. Dr. Hoover has a reputation for impatience and irritability.
nowing Dr. Hoover’s surly nature, which of the following would be the most
appropriate action by Crystal?

a. Clarify the order with the pharmacy.

b. Clarify the order with the nursing supervisor.

*c. Clarify the order with Dr. Hoover.

d. Ask another nurse to look at the order to try to clarify it.

General Feedback:

A nurse will assess all physician or health care provider orders, and if the
nurse determines they are erroneous or harmful

or illegible

obtain clarification from
that ph
ysician or health care provider.

14. Chapter 04
19 (1.0 point)

During an evening shift, Clara, a senior student nurse, was working as a nursing assistant
in the local hospital where she does her school clinical rotations. One of the nurses she
working with was extremely busy and asked Clara to assist her. The nurse knew that
Clara would be graduating soon and had good clinical skills. Which of the following
tasks would be appropriate for Clara to independently perform?

a. Distributing medicati
ons to patients

b. Administering insulin injections

*c. Collecting intake and output data

d. Assessing patients

General Feedback:

During the time when a student nurse works as an employee of a health care
facility, perform only tasks that appear in
a job description for a nurse’s aide or nursing
assistant. For example, even if a student nurse has learned how to administer
intramuscular medications, a nurse’s aide does not perform this task.

15. Chapter 04
20 (1.0 point)

Only one nurse was schedule
d to care for 12 postsurgical patients with a nursing
assistant. He is concerned for the safety of the patients and his nursing license. What is
the most appropriate first step in this situation?

*a. Contacting the nursing supervisor and documenting the

b. Refusing to care for the patients without appropriate help and leaving

c. Contacting the State Board of Nursing and documenting the action

d. Contacting the hospital administrator on call to complain and documenting the

General Feedb

If a nurse is assigned to care for more patients than is reasonable for safe care,
he or she should notify the nursing supervisor. If the nurse is required to accept the
assignment, he or she must document this information in writing and provide the
document to nursing administrators. Although documentation does not relieve a nurse of
responsibility if patients suffer harm because of inattention, it shows that the nurse
attempted to act appropriately.

16. Chapter 04
21 (1.0 point)

A nurse administe
red the wrong medication to a patient. As a result, the patient received
a large cash settlement. What did the nurse commit?

*a. Tort

b. Misdemeanor

c. Negligence

d. Violation of criminal law

General Feedback:

A misdemeanor is a less serious crime

that has a penalty of a fine or
imprisonment for less than 1 year. An example is misuse of a controlled substance by a
nurse. Negligence is conduct that falls below a standard of care. Violation of a criminal
law is either a felony or misdemeanor.

Chapter 04
22 (1.0 point)

If a patient falls out of bed because the side rails were not raised, this action would

a. a felony.

b. assault.

c. battery.

*d. negligence.

General Feedback:

A felony is a serious offense that has a penalty o
f imprisonment for greater
than a year or possibly even death. Assault is any intentional threat to bring about
harmful or offensive contact with another individual. Battery is any intentional touching
without consent.

18. Chapter 04
23 (1.0 point)

es may place a patient in restraint devices to:

a. ensure staff convenience.

b. retaliate against poor behavior.

c. punish a patient.

*d. ensure the patient’s safety.

General Feedback:

Medicaid statute (1988), Department of Health and Human
Services (1992),
and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2005)
regulate the use of physical or chemical restraints. The regulations set the standards that
patients have the right to be free from seclusion and physical

or chemical restraints
except to ensure a patient’s safety in emergency situations. A nurse can be liable for
improper or unlawful restraint.

19. Chapter 04
25 (1.0 point)

A state with abuse legislation requires a nurse who suspects child abuse or negl
ect to:

*a. report it to the proper legal authority.

b. inform the parents that their actions are illegal.

c. call the security department to handle the problem.

d. prevent the parents from seeing the child during hospitalization.

General Feedback:

Health care providers are required to report incidents such as child, spousal,
or elder abuse; rape; gunshot wounds; attempted suicide; and certain communicable

Health care providers are provided legal immunity if the report is made in good fa

Not reporting suspected child abuse or neglect can cause a nurse to be liable in civil or
criminal legal actions.

20. Chapter 04
26 (1.0 point)

A student nurse employed as a personal care assistant may perform patient care:

a. learned in school.

b. expected of a nurse at that level.

*c. identified in the position’s job description.

d. requiring technical rather than professional skills.

General Feedback:

During the time a student nurse works as an employee of a health care
facility, he or
she must only perform tasks that appear in a job description for a nurse’s
aide or nursing assistant. Even if a student nurse has previously learned a task or
procedure in nursing school, he or she must not perform this task as a nursing assistant
it is outside the scope of the nursing assistant job description.

21. Chapter 05
05 (1.0 point)

A registered nurse is working on a pediatric oncology unit and caring for four children
undergoing chemotherapy. Today she has a new nursing assistive person
nel (NAP)
assigned to assist her. Although she has never worked with this person, she understands
that the NAP had to pass a basic competency examination before he was allowed to work
on the unit with patients. She will delegate a portion of the fundamenta
l nursing tasks to
the NAP during the shift. This is an example of demonstrating which of the following?

a. Ethical dilemma

*b. Code of ethics

c. Bioethics

d. Feminist ethics

General Feedback:

The code of ethics reflects underlying principles that

include responsibility,
accountability, respect for confidentiality, competency, judgment, and advocacy.

22. Chapter 05
06 (1.0 point)

The mother of a 45
old patient is a retired physician and requests to discuss her
daughter’s plan of care with t
he nurse caring for the patient. What is the nurse’s best
response to this request?

a. “I will need to ask permission from my supervisor before I can share that

b. “I cannot share that information with you. I would suggest you ask your

c. “I would suggest that you discuss that with your daughter’s physician.”

*d. “I will have to get your daughter’s permission before I can share that

eneral Feedback:

The concept of confidentiality

in health care has widespread acceptance in the
United States. Federal legislation known as HIPAA (Health Insurance Portability and
Accountability Act of 1996) requires that those with access to personal hea
information not disclose the information to a third party without patient consent.

23. Chapter 05
10 (1.0 point)

Although a registered nurse has been working for several years as a staff nurse on an
adult oncology unit, he recently transferred to a
pediatric unit in the hospital. He will be
in orientation for several days to learn about the different systems, and he will need to
demonstrate proficiency in various pediatric areas such as medication administration.
This is because he will need to demon
strate which of the following?

*a. Competency

b. Judgment

c. Advocacy

d. Utilitarianism

General Feedback:


refers to specific knowledge and skills necessary to perform a
task. In the practice of nursing, competence ensures the provision
of safe nursing care.
Regulations that guide the documentation of competence vary from state to state, but the
agreement to practice with competence is a common denominator for all states and is in
the nursing code of ethics.

24. Chapter 07
01 (1.0 poin

A registered nurse is caring for a 68
old patient in the trauma unit who had been
involved in a motor vehicle accident. Although the patient denied pain, during the nurse’s
assessment, she observed that he groaned when moving and was protective of
his right
arm. She believed the patient had pain and reported it to the health care provider who
ordered a radiograph of his right arm. The radiograph revealed a fractured humerus. This
is best described as which of the following?

a. Intuition

*b. Criti
cal thinking

c. Nursing process

d. Reflection

General Feedback:

Critical thinking is the active, organized, cognitive process used to carefully
examine one’s thinking and the thinking of others. It involves recognizing that an issue
(e.g., patient
problem) exists, analyzing information related to the issue (e.g., clinical data
about a patient), evaluating information (including assumptions and evidence), and
drawing conclusions.

25. Chapter 07
02 (1.0 point)

A registered nurse is caring for a pos
toperative patient whose systolic blood pressure has
dropped 10 points during his shift. He remembers that this was similar to a situation that
happened in the past when the patient developed an internal bleed. The nurse’s thoughts
are best described as wh
ich of the following?

a. Intuition

b. Critical thinking

c. Nursing process

*d. Reflection

General Feedback:


is a part of critical thinking that involves the process of
purposefully thinking about or recalling a situation to discover its

purpose or meaning.

26. Chapter 07
03 (1.0 point)

Blair, a student nurse, is assisting a nurse with admitting a 73
old woman with a
fractured ulna and radius to the trauma unit of the hospital. The patient’s daughter and
law are with her. B
lair notices that the patient does not make eye contact when
answering questions and she feels that something is not right about the situation. This can
best be explained by which of the following?

*a. Intuition

b. Critical thinking

c. Nursing process

d. Reflection

General Feedback:


is the inner sensing or “gut feeling” that something is so. For
example, a nurse walks into a patient’s room and, by looking at the patient’s appearance
without the benefit of a thorough assessment, senses
that he or she has worsened
physically. Intuition is a common experience that many people have when interacting
with their environments.

27. Chapter 07
04 (1.0 point)

A student nurse is with a medical unit during this clinical rotation. She is administe
an enema with her instructor in the room. The patient states that they can no longer hold
the enema solution. The student nurse acknowledges the patient’s request and begins to
tell the patient that he can go to the bathroom to expel the enema. The in
structor suggests
that the patient wait a few minutes to give the enema solution time to be absorbed into the
bowel. In this situation the student nurse follows the suggestion of the instructor, which
demonstrates what level of critical thinking according
to Kataoka
Yahiro and Saylor’s

*a. Level 1: Basic

b. Level 2: Complex

c. Level 3: Commitment

d. The student nurse is not demonstrating critical thinking.

General Feedback:

At the basic level of critical thinking a learner trusts that expert
s have the
right answers for every problem. Thinking is concrete and based on a set of rules or

28. Chapter 07
05 (1.0 point)

A novice nursing student will most likely practice nursing at level _____ of critical
thinking according to Kataoka
Yahiro and Saylor's model.

*a. 1

b. 2

c. 3

d. 4

General Feedback:

At the basic level of critical thinking a learner trusts that exp
erts have the
right answers for every problem. Thinking is concrete and based on a set of rules or

29. Chapter 07
06 (1.0 point)

A nursing student learning about the critical thinking process begins with which of the

. Collecting data

*b. Identifying a problem

c. Formulating a question

d. Evaluating the results

General Feedback:

The steps of the scientific method are as follows: Problem identification;
Collection of data; Formulation of a question or hypothesis;

Testing the question or
hypothesis; Evaluating results of the study.

30. Chapter 07
08 (1.0 point)

A 56
old patient receiving blood after an abdominal surgery notified the nurse that
her IV pump was alarming. The nurse checked the pump and determi
ned that the tubing
was kinked. The tubing was straightened out and the nurse left the room. Five minutes
later the IV pump again alarmed. The nurse returned to find the tubing was again kinked.
On further investigation, the nurse discovered that the IV tu
bing had become twisted.
This is an example of which of the following on the part of the nurse?

*a. Effective problem solving

b. Diagnostic reasoning

c. Scientific method

d. Commitment level of critical thinking

General Feedback:

Effective problem

solving involves evaluating the solution over time to be
sure that it is still effective.

31. Chapter 07
09 (1.0 point)

A 16
old patient on a pediatric unit who underwent an appendectomy for a ruptured
appendix 3 days ago complains of acute pain a
nd has a high fever. The nurse is
concerned that she may have an infection and notifies the health care provider of the
change in her condition. This concern is based on the nurse’s experience as a pediatric
nurse. Her ability to make a tentative conclusio
n regarding this patient’s situation based
on observed data is known as what?

a. Scientific method

*b. Clinical inference

c. Effective problem solving

d. Data collection

General Feedback:

Clinical inference

is a critical thinking skill in which a
nurse makes tentative
conclusions based on observed data or cues existing in patient situations.

32. Chapter 07
10 (1.0 point)

Roger, a 34
old patient with cancer, is undergoing outpatient chemotherapy. Nancy,
the nurse caring for him at the clinic

where he goes for his treatments notes that Roger’s
white blood cell count is very low. Roger’s plan of care is based upon the nursing
Risk for infection
. Nancy provides patient teaching in order to reduce Roger’s
risk for infection. Nancy is us
ing which skill in this situation?

a. Medical diagnosis

b. Scientific method

*c. Diagnostic reasoning

d. Data collection

General Feedback:

Diagnostic reasoning involves the use of cognitive thinking, metacognition
(thinking about thinking), and as
sessment skills to structure situations so a nurse can
apply knowledge. Expert nurses make diagnostic conclusions in the form of nursing

33. Chapter 07
11 (1.0 point)

Stacie, a nursing student, is caring for Mrs. Thames, an elderly lady who r
experienced a stroke. Stacie notices that Mrs. Thames coughs after she eats or drinks.
Stacie knew that Mrs. Thames was at risk for aspiration because of the stroke that she had
experienced and was concerned that Mrs. Thames may have impaired swall
owing. Stacie
develops a care plan for Mrs. Thames based on the nursing diagnosis
. Which of the following is Stacie using to make this nursing diagnosis?

a. Medical diagnosis

b. Scientific method

*c. Diagnostic reasoning

d. Data co

General Feedback:

In nursing, diagnostic reasoning is a process of using gathered data, forming
inferences, and then logically explaining a clinical judgment.

34. Chapter 07
12 (1.0 point)

A nurse who is demonstrating clinical decision
ng is:

a. collecting information about a patient and coming to a conclusion about his or
her health problems.

b. clarifying the problem and analyze possible causes.

c. developing a new idea based on experience and knowledge over time.

*d. selecting ap
propriate treatment after forming a nursing diagnosis.

General Feedback:

Clinical decision
making is a problem
solving activity that focuses on
selecting appropriate treatment after forming diagnostic conclusions. Clinical decision

requires care
ful reasoning so that a nurse chooses the option for the best patient
outcome on the basis of the patient’s condition and priority of the problem.

35. Chapter 07
13 (1.0 point)

A new registered nurse working for a busy unit of an acute care teaching hos
pital begins
her shift with four patients. She needs to prioritize care. Which of the following patients
should she attend to first?

a. Patient who needs assistance in ambulating the hall

*b. Patient whose blood pressure suddenly drops and who passes ou

c. Recovering surgical patient whose family has just arrived

d. Patient who was just diagnosed with cancer and is alone

General Feedback:

When a nurse provides care for several patients at one time, he or she will
need to use decision
making criter
ia. These criteria include the clinical conditions of the
patients, Maslow’s hierarchy of needs, risks involved in treatment delays, and the
patients’ expectations of care to determine what patients have the greatest priorities for

36. Chapter 07
15 (1.0 point)

A new nurse is working for a surgical unit. One of the postoperative patients has been
experiencing a great deal of pain. She notified the surgeon who wrote an order for pain
medication. Upon checking the order, she noticed that the dosage w
as more than three
times the normal range for this medication. She called the surgeon to question the order.
This is primarily an example of which of the following critical thinking attitudes?

a. Confidence

b. Risk

c. Fairness

*d. Thinking inde

General Feedback:

A critical thinker does not accept another person’s ideas without question.
When thinking independently, a person challenges the ways in which others think and
looks for rational and logical answers to problems.

37. Chapt
er 07
16 (1.0 point)

A nurse for 6 years has always worked for the oncology unit of a hospital. Recently,
however, there were cutbacks because more patients are being treated on an outpatient
basis, so the nurse transferred to an orthopedic unit where he i
s caring for a patient who
underwent an above
knee amputation, something for which he has never provided
care. He is to do a dressing change for the amputated leg, so he asks another nurse to help
him. He is demonstrating which of the following critica
l thinking attitudes?

*a. Humility

b. Confidence

c. Risk

d. Fairness

General Feedback:

Critical thinkers admit what they do not know and try to find the knowledge
they need to make a proper decision. Humility is recognizing when one needs m
information to make a decision. When a nurse is new to a clinical division and unfamiliar
with the patients, he or she should ask for an orientation to the area and ask nurses
regularly assigned to the area for assistance. Nurses should also read profe
journals regularly to keep updated on new approaches to care.

38. Chapter 07
17 (1.0 point)

A student nurse in her last semester of nursing school found that keeping a journal of her
experiences helped her to understand why she took a certain ac
tion and to evaluate
whether there was a better way of approaching the task. She has found that this has
helped her to grow into the role of a nurse. Which of the following critical thinking
attitudes is she demonstrating?

a. Humility

b. Confidence


*d. Reflection

General Feedback:

Reflection is an important aspect of critical thinking. Purposeful reflection
leads to a deeper understanding of issues and to the development of judgment and skill.
One activity that will help a nurse deve
lop into a critical thinker is reflective journaling.

39. Chapter 07
19 (1.0 point)

A nurse walks into a room and finds a patient to be incoherent. As the nurse examines
and observes the patient closely, searches for ideas, and considers scientific prin
ciples to
plan the patient’s care, the nurse is using:

*a. inferences.

b. reflection.

c. intuition.

d. accountability.

General Feedback:

When reflecting, one thinks about or recalls a situation to discover purpose or
meaning. Intuition is an inner

sensing or “gut feeling” about something. Accountability
refers to being answerable for one’s actions.

40. Chapter 07
20 (1.0 point)

Last night a nurse spent time instructing a patient on how to monitor his pulse while
taking digoxin. The next day the
nurse asks the patient to recount the details of this skill.
The nurse is using:

*a. reflection.

b. evaluation.

c. perseverance.

d. assessment.

General Feedback:

When a nurse evaluates, he or she is determining if a patient goal has been
met. When

a nurse perseveres, he or she seeks resources until a successful approach has
been found. Assessment involves the act of collecting pertinent patient data.

41. Chapter 07
21 (1.0 point)

A patient is admitted with dependent edema. As a nurse assesses th
e patient for the
presence of jugular vein distention, the nurse is using the process of:

a. evaluation.

*b. data collection.

c. problem identification.

d. testing the hypothesis.

General Feedback:

When a nurse evaluates, he or she is determining
if a patient goal has been
met. Problem identification and testing the hypothesis are two steps used in the scientific

42. Chapter 09
02 (1.0 point)

Sadie, a registered nurse was caring for Mr. Harris, an older adult patient with lung
cancer. H
is daughter, a nurse, asked Sadie to let her look at Mr. Harris’ chart. Sadie’s
best reply should be:

a. “I’m sorry; you will have to wait until I am done with my documentation to
look at the chart.”

*b. “I’m sorry; this information is confidential.”

. “Let me ask my supervisor if it is okay.”

d. “You should know better than to ask me that.”

General Feedback:

Do not disclose information about patients’ status to other patients, family
members (unless granted by the patient), or to health care staf
f not involved in their care.
Legal and ethical obligations require nurses to keep information about patients strictly

43. Chapter 09
03 (1.0 point)

A nursing student is working on his clinical assignment. He knows that he must maintain
tient confidentiality. Which of the following is acceptable for him to write on the
clinical care plan that he will give to his instructor?

a. Patient room number

b. Patient date of birth

c. Patient medical record number

*d. Patient nursing diagnosis

General Feedback:

To further maintain confidentiality and protect patient privacy, make sure
written materials used in student clinical practice do not have patient identifiers, such as
room number, date of birth, medical record number, or other identi
fiable demographic

44. Chapter 09
05 (1.0 point)

Practitioners from many disciplines use the medical record to document data. The most
important purpose of the medical record is to:

a. invoice the patient or insurance company for reimburs

b. protect the clinician in case of a malpractice suit.

*c. ensure everyone is working toward a common goal of providing safe care.

d. contribute to a databank for medical and nursing research.

General Feedback:

The overall purpose of the med
ical record is to ensure all health team
members are working toward a common goal of providing safe, effective, continuity of

45. Chapter 09
06 (1.0 point)

A nurse is frustrated about what she feels is a lack of staff on her shift. When one of the

patients fell and broke his hip, she documented the incident in the patient’s chart. Which
of the following is the best way that she should document what happened?

*a. “Fell while going to the bathroom. Physician notified.”

b. “Nobody available to answ
er call bell; patient got up on own and fell.”

c. “Patient fell due to unsafe staffing levels on unit.”

d. “Patient waited as long as he could; nobody there to help him and he fell.”

General Feedback:

Never use the record for complaining, finger
ting, or commenting on
other nonpatient care issues. Only information relevant to patient care belongs in the

46. Chapter 09
07 (1.0 point)

A registered nurse is documenting her patient assessment. Which of the following
examples of documentatio
n is most clear?

a. “Seems comfortable at this time.”

b. “Is asleep, appears not to be experiencing pain.”

c. “Apparently is not in pain because he didn’t rate it high on the scale.”

*d. “States pain is a 2 on a 0 to 10 scale.”

General Feedback:

o be factual, avoid words such as


they are vague and lead to conclusions that cannot be supported by objective information.

47. Chapter 09
08 (1.0 point)

A patient states that she is experiencing pain in her lower b
ack. What is the best way for
the nurse to document this subjective information?

a. “States her back is hurting.”

*b. “States ‘My lower back hurts.‘”

c. “Grimaces when moving; I believe she has lower back pain.”

d. “Appears to be uncomfortable with lo
wer back pain.”

General Feedback:

The only subjective data included in a record are what the patient says. Write
subjective information with quotation marks, using the patient’s own words. For
example, a patient’s statement of “
My lower back hurts

subjective and acceptable

48. Chapter 09
11 (1.0 point)

Which of the following documentation samples is most appropriate?

a. “The patient states he would except moving to a semi
private room.”

b. “Patient stated he developed aspiration

pneumonia due to dysphasia.”

c. “Bruise noted on right side over fractured ileum.”

*d. “Right jugular vein distended.”

General Feedback:

Correct spelling demonstrates competency and attention to detail. Misspelled
words lead to confusion. For exampl
e, often words sound the same but have different

49. Chapter 09
15 (1.0 point)

A student nurse as been scheduled to do her clinical rotation this semester for a busy
medical unit in an acute care hospital. This is the first time she has been a
t this hospital,
and she is told during orientation that the organization is very patient focused and that it
uses a documentation system with the acronym PIE. What does PIE stands for?

*a. Problem, Intervention, Evaluation

b. Patient, Intervention, Eva

c. Population, Intervention, Evaluation

d. Plan, Intervention, Evaluation

General Feedback:

PIE is an acronym for


as follows (see
Table 9


Problem or nursing diagnosis applicable to patient


ventions or actions taken


Evaluation of the outcomes of nursing

The PIE format simplifies documentation by unifying the care plan and progress notes
into a complete record.

50. Chapter 09
16 (1.0 point)

A new registered nurse is w
orking on a pediatric unit in a large teaching hospital that uses
focus charting with the acronym DAR. What does this stand for?

a. Data, Assessment, Reaction

b. Data, Assessment, Response

*c. Data, Actions, Response

d. Data, Actions, Reaction

ral Feedback:

Focus charting is a unique narrative format in that it places less emphasis on
patient problems and instead focuses on patient concerns such as a sign or symptom, a
condition, a behavior, or a significant event. Each entry includes data, act
ions, and patient
response (DAR) for the particular patient situation.

51. Chapter 09
17 (1.0 point)

A registered nurse recently changed jobs and is now working in home health. She
understood that the reason for accurate documentation in the acute care
setting where she
had previously worked was to provide an accurate record for safe patient care. Working
in home health, she now has learned that in addition to providing an accurate record for
safe patient care, this documentation is also used by Medicare
, Medicaid, and private
insurance companies for which of the following?

a. Justification for prescribed medications

b. Data for nursing research

*c. Justification for home care reimbursement

d. Data to support social security benefits for the disabled

General Feedback:

Medicare has specific guidelines for establishing eligibility for home care
reimbursement. When nurses provide home care, documentation must specifically
address the category of care and the patients’ responses to care. Documentation

in the
home care system has different implications than in other areas of nursing. The
documentation is both the quality control and the justification for reimbursement from
Medicare, Medicaid, or private insurance companies.

52. Chapter 09
19 (1.0 poi

When a student nurse began working at a local hospital this past summer, she learned that
the hospital had just instituted a “hand
off” protocol. Which of the following is the best
example of a hand
off report?

*a. Transfer report

b. IV fluid flow s

c. Documentation in the nurse’s notes of the patient chart

d. Laboratory report

General Feedback:

A hand
off report

happens any time one health care provider transfers care of
a patient to another health care provider. The purpose of hand
off re
ports is to provide
better continuity and individualized care for patients.

53. Chapter 09
21 (1.0 point)

A nurse records that a patient states his abdominal pain is worse now than last night. Of
what is this an example?

a. PIE documentation


*c. Narrative charting

d. Charting by exception

General Feedback:

PIE charting focuses on problem, intervention, and evaluation. SOAP
documentation addresses subjective data, objective data, assessment, and the plan period.
Charting by
exception reduces the time required to compete documentation, using a flow
sheet to indicate normal findings or routine interventions.

54. Chapter 09
22 (1.0 point)

A nurse completes an incident report on a patient who fell while walking in the hallway.

The purpose of this documentation is to:

a. exchange information among health care members.

b. provide information about patients on one unit to another.

c. ensure proper care for the patient.

*d. aid in the hospital’s quality improvement program.

General Feedback:

A report is an exchange of information between health care members.
Transfer reports involve communication of information about patients from one nurse on
the sending unit to the nurse on the receiving unit.

55. Chapter 09
23 (1.0 po

After a nurse receives a medication telephone order for a patient, what is the proper

a. Withholding the medication until the physician or health care provider is able to
write the prescription in person

b. Verifying the physician’s or heal
th care provider’s order with the pharmacy

*c. Documenting the new medication order in the patient’s chart

d. Clarifying the new medication order with another registered nurse

General Feedback:

The purpose of a telephone order (TO) is to begin a ther
apy before the
physician or health care provider can arrive at the hospital. The nurse reads back to the
physician or health care provider the order. The read
back is a Joint Commission
requirement. The nurse reads back the order to the physician or health

care provider, and
then the physician or health care provider has 24 hours to sign the order.

56. Chapter 09
24 (1.0 point)

During a change
shift report the nurse who is going off duty is expected to:

a. exchange judgments made about the patient’s


b. include a description of how to perform procedures.

*c. provide a concise and organized description of the patient’s status and needs.

d. make walking rounds with the nurse coming on duty to review the patient’s
plan of care.

General F

Describing interactions in subjective terms will contribute to prejudiced
opinions about patients. A change
shift report provides information to ensure
continuity and individualized care for patients. Walking rounds allow the nurse to obtain
mmediate feedback when questions arise about a patient’s plan of care. Walking rounds
are one type of shift report used by health care facilities.

57. Chapter 09
25 (1.0 point)

Multidisciplinary team members use a critical pathway to monitor the patient
’s progress.
This is an example of using a critical pathway as a:

*a. documentation tool.

b. method to track changes.

c. way to format the nursing process.

d. substitute for a Kardex form.

General Feedback:

Variances track patient outcomes when th
e patient deviates from the critical
path plan.

Critical pathways summarize the standardized plan of care. A critical path includes plans
to address patient problems, key interventions, and expected outcomes for the patient
with a specific disease or condi

58. Chapter 09
26 (1.0 point)

The discharge summary deals with important elements pertaining to the patient’s
problems and health care after discharge. When preparing the summary, the nurse needs
to include:

*a. the specific teaching plan.

b. d
eviations from the plan of care.

c. the standardized nursing care plan.

d. a detailed description of nursing procedures.

General Feedback:

Deviations from the plan of care are tracked as variances. Standardized
nursing care plans are based on the ins
titution’s standards of nursing practice. Detailed
descriptions of nursing procedures are shared in change
shift reports.

59. Chapter 09
27 (1.0 point)

Information about a patient’s status may not be disclosed to non

health care team
members because:

*a. legal and ethical obligations require health care team members to keep
information strictly confidential.

b. regulations require health care institutions to document evidence of physical
and emotional well

c. reimbursement issues relating t
o patient care and procedures may be of

d. a fragmentation of nursing and medical care procedures may be identified.

General Feedback:

The Joint Commission requirements require documentation of physical and
emotional well
being; however, HIPA
A regulations must be strictly enforced.
Reimbursement is linked to documentation; however, only authorized hospital personnel
can view a patient care record. An audit may discover fragmentation between nursing and
medical care.

60. Chapter 09
28 (1.0 p

A nursing unit is conducting a trial on a computerized documentation system. The nurse
is anxious to implement this type of system because it:

a. maximizes the need to duplicate records.

*b. can be used to document all aspects of care.

c. alters
the need to document on a regular basis.

d. has a much narrower scope than current charting systems.

General Feedback:

Computerized documentation is designed to minimize repetitive clerical and
monitoring tasks. When used properly, computerized docume
ntation improves
documentation accuracy, timeliness, completeness, and communication. Computerized
documentation is virtually unlimited.

61. Chapter 09
29 (1.0 point)

A nurse has just admitted a patient with a medical diagnosis of
Rule out myocardial
. When completing the paperwork the nurse needs to record:

a. an interpretation of patient behavior.

*b. objective data that are observed.

c. lengthy entries using lay terminology.

d. abbreviations familiar to the nurse.

General Feedback:

Nurses should only include descriptive, objective information about what
they see, hear, feel, and smell. Entries should be precise and accurate. Nurses must only
use acceptable abbreviations identified by their institution. The Joint Commission has

regulations regarding the use of abbreviations.

62. Chapter 19
01 (1.0 point)

Martha is a student nurse who is caring for Ileana, a 25
old Mexican American
woman who has learned that she has cervical cancer. Martha has learned that in the
American culture, decisions about healthcare are often made by the family
group. Martha would like to help Ileana as she makes a decision about her treatment
options. The most appropriate way for her to assist in this situation is to do which of the

a. Suggest the health care provider meet with Ileana privately.

*b. Let Ileana know what time the health care provider will make rounds so that
she can invite her family to be present.

c. Explain to Ileana what the treatment options are.

d. Have
an interpreter present to answer any questions.

General Feedback:

A worldview is the way a particular cultural group thinks. Professional
worldviews about health and illness are often different from those of patients.

63. Chapter 19
09 (1.0 point)


nurse working in an ambulatory care center is caring for a patient who requires
dressing changes every other day. The family caregiver indicates that the patient does not
value adhering to a time schedule. What is the most appropriate action?

a. Continu
e to schedule the appointments.

b. Ask the patient to call the ambulatory care center to cancel appointments.

c. Call every other day to remind the patient of the scheduled appoint.

*d. Explain to the patient and family members the importance of wound d
changes and explore anticipated barriers to time adherence.

General Feedback:

Present time orientation is in conflict with the dominant organizational norm
in health care emphasizing punctuality and adherence to appointments. Nurses should
ct conflicts and make adjustments when dealing with other ethnic groups. Improving
the accessibility of health services so time schedules accommodate cultural patterns may
assist patients with making appointments and referrals.

64. Chapter 21
01 (1.0 po

A student nurse who works in a pediatric clinic is assisting with an assessment on a
young child who is not yet walking. She knows that it is considered a delayed gross
motor ability if the child does not walk by _____ months.

a. 16

b. 18

*c. 20

d. 22

General Feedback:

A critical period of development refers to a specific phase or period when the
presence of a function or reasoning has its greatest effect on a specific aspect of
development. For example, if a child does not walk by the age of
20 months, there is
delayed gross motor ability, which slows exploration and manipulation of the
environment. The success or failure experienced within a phase affects the child’s ability
to complete the next phases.

65. Chapter 21
06 (1.0 point)

et has just found out she is pregnant. The nurse at the clinic told her that she
should stop smoking, avoid alcohol, and avoid eating king mackerel because of the high
mercury content in the fish. Although this advice should be followed during the entire
regnancy, the fetus is most vulnerable to adverse affects in the _____ trimester.

*a. first

b. second

c. third

d. final

General Feedback:

Exposure to potential teratogens can affect fetal development during any of
the trimesters; however, vulnerab
ility is increased during the first trimester when fetal
cells are differentiating and organs are forming.

66. Chapter 21
07 (1.0 point)

A student nurse is in her community health clinical rotation. She is visiting a family with
a new baby. Which of the

following statements made by the mother of a 1
infant indicates the need for client education?

a. “My baby should double his birth weight by the time he is 6 months old.”

b. “I shouldn’t give my baby any cow’s milk until he is at least a year


*c. “My baby has been fussy lately; I believe he is probably cutting his teeth.”

d. “I shouldn’t put my baby on a fluffy pillow to sleep.”

General Feedback:

The first tooth to erupt is usually one of the lower central incisors at the
average a
ge of 7 months. Most babies have six teeth by their first birthday.

67. Chapter 21
08 (1.0 point)

The mother of a toddler is concerned that her son is not eating enough, although he has
not lost any weight. She tells the nurse that her son used to have
a very good appetite, but
now does not eat as much as he did a couple of months ago. What is the best response for
the nurse to provide?

a. “You should try to get him to eat, even if it is only cereal.”

b. “He needs a lot of protein for growth during hi
s toddler years.”

*c. “Toddlers have periods when they aren’t growing as fast and they don’t need
to eat as much.”

d. “Why don’t you let him eat off of your plate instead of making him his own

General Feedback:

Slower growth rates often occur

with a decrease in caloric needs and a
smaller food intake. Confirming the child’s pattern of growth with standard growth charts
is reassuring to parents concerned about their toddler’s decreased appetite (physiological
anorexia). Encourage parents to off
er a variety of nutritious foods, in reasonable servings,
for mealtime and snacks.

68. Chapter 21
09 (1.0 point)

Kevin is the father of 11
old Harry, who is being seen at the clinic for his annual
up. As part of anticipatory guidance, you ins
truct Kevin that accidents and injuries
are major health problems affecting school age children. Kevin asks what the number one
cause of death is in this age group and your response is:

a. drowning.

*b. motor vehicle accidents.

c. fire.

d. firearms.

General Feedback:

Accidents and injuries are major health problems affecting school
children and are the causative factor in a large number of deaths in this age group. Motor
vehicle accidents, followed by drowning, fires, burns, and firearms are th
e most frequent
fatal accidents.

69. Chapter 21
10 (1.0 point)

Margery is the mother of 8
old Bonnie. Margery has brought Bonnie in to the health
clinic for her annual check
up. She is concerned about the high blood pressure in her
family and asks
the nurse if there is some way to know if Bonnie is at risk for
hypertension. What is the nurse’s best response?

*a. “Blood pressure elevation in childhood is the single best predictor of adult

b. “There is no way of knowing because there

are so many variables involved.”

c. “If you are concerned about hypertension, you need to keep Bonnie on a low
sodium diet.”

d. “Childhood obesity is the single best predictor of adult hypertension.”

General Feedback:

Blood pressure elevation in chi
ldhood is the single best predictor of adult
hypertension. This recognition has reinforced the significance of making blood pressure
measurement a part of every annual assessment of the child.

70. Chapter 21
12 (1.0 point)

A nurse is caring for a 5
old child who is hospitalized for stabilization of asthma. To
provide age
specific care, which of the following is the most appropriate action by the

*a. Allowing the child to handle medical equipment

b. Responding immediately to the child’s eve
ry need

c. Telling the child he has to be good while in the hospital

d. Rationalizing the child’s complaints as part of the developmental process

General Feedback:

These strategies can be used to reduce preschooler’s fears when they are

allowing children to sit up when performing assessments and procedures;
allowing the child to see and handle equipment; allowing the child to assist with the
procedure if appropriate; giving simple and factual information to these children because
they ha
ve a great sense of imagination.

71. Chapter 21
14 (1.0 point)

A patient is experiencing incisional pain after an operation. When using Maslow’s
hierarchy of needs, the nurse realizes that for the patient to return to a prehospitalized
status, the patie
nt needs to progress beyond:

a. belonging.

b. self

c. self actualization.

*d. safety and security.

General Feedback:

Individuals need to satisfy each level before moving on to the next.
Belonging occupies the third stage, where threats to
relationships create anticipatory
loneliness and alienation. Self
esteem occupies the fourth stage, and threats create
alienation. Self actualization is the highest level that one can achieve

the realization that
one has reached their highest potential. Sa
fety and security occupies the second stage,
and threats to security (such as pain) produce feelings of insecurity.

72. Chapter 21
15 (1.0 point)

A pregnant teenager asks the clinic nurse why she cannot smoke during the first
trimester. Remembering grow
th and development, what is the nurse’s best response?

a. “The distribution of body hair can be altered.”

*b. “The organ systems are beginning to develop.”

c. “Development of fingers and toes can be affected.”

d. “The sex of the baby is determined in
the first 3 months.”

General Feedback:

During the first trimester, fetal cells differentiate and develop into essential
organ systems. During the second trimester most organs are complete and able to
function. During the third trimester, skin thickens,

lanugo disappears, and central nervous
system is established.

73. Chapter 21
16 (1.0 point)

A nurse is conducting a community
based education class. A strategy for positive health
habits is:

a. daily monitoring of blood pressure.

*b. adhering to a r
egular exercise regimen.

c. adhering to a daily exercise regimen and abstaining from alcohol consumption.

d. following the most popular diet to control the effects of weight gain.

General Feedback:

Community health programs are designed to prevent il
lness, promote health,
and detect diseases. Actively plan screening sessions that lend themselves to health
teaching and counseling. Regular exercise, a healthy diet, and periodic blood pressure
monitoring contribute to a healthy lifestyle.

74. Chapter
17 (1.0 point)

A patient asks about strategies that can be used to aid in weight reduction. The nurse can
inform the patient to follow a well
balanced diet, including selections of low
fat foods
such as:

*a. grilled chicken.

b. hot dog with relish.

c. hamburger and French fries.

d. baked potato with bacon and cheese.

General Feedback:

Refer to the food guide pyramid for healthy choices. Young, middle age, and
older adults are interested and want to be informed about health practices.

75. Chap
ter 22
01 (1.0 point)

Kate is caring for Nancy, a 34
old abused woman, who was admitted to the hospital
with multiple rib fractures that she received from her partner. Nancy states, “I don’t
blame Mike for what he did to me; I can be so stupid sometim
es.” Kate recognizes this
statement as a manifestation of which of the following?

a. Body image disturbance

*b. Low self

c. Cultural differences

d. Sexual orientation

General Feedback:

concept is your view of who you are. It is a combi
nation of unconscious
and conscious thoughts, attitudes, and perceptions. Self
concept, or how you think about
yourself, directly affects your self
esteem, or how you feel about yourself.

76. Chapter 22
02 (1.0 point)

Lilly is a 66
old patient who
has been admitted to the hospital for a stroke. Her
health care provider has told her that she should consider retiring from her high
position as a hospital administrator. Lilly is distraught over this suggestion. The nurse
caring for her recognizes

the most likely cause of distress is due to:

a. body image.

*b. role performance.

c. self

d. self evaluation.

General Feedback:

Role performance

is the way in which a person views his or her ability to
carry out significant roles. Common
roles include mother or father, wife or husband,
daughter or son, sister or brother, employee or employer, and nurse or patient.

77. Chapter 22
03 (1.0 point)

Frank is a nurse who works at a pediatric clinic. Elliott is a 16
old patient who is in
he clinic for his annual check
up. During the assessment, Frank asks Elliott about his use
of tobacco. Although he denies smoking, he tells Frank that he dips snuff. He tells him
that he started last year because all his friends do it. Frank recognized thi
s as a stressor of:

a. body image.

*b. identity.

c. role performance.

d. sexuality.

General Feedback:

An adolescent who wants to be identified as part of the popular crowd at
school develops a poor self
concept if not included in that group. Famil
y and cultural
factors sometimes influence negative health practices, such as cigarette smoking.

78. Chapter 22
04 (1.0 point)

Robert is a 47
old patient who has recently undergone surgery to remove a tumor
from his colon. As a result of his surger
y he has a colostomy. Robert’s nurse is planning
his care and would like to incorporate measures to support the adaptation to stress. Which
of the following is

likely to support Robert’s adaptation to stress?

a. Adequate sleep

b. Regular exercise

c. Appropriate nutrition

*d. Beginning smoking cessation classes

General Feedback:

Measures that support adaptation to stress, such as proper nutrition, regular
exercise within the patient’s capabilities, adequate sleep and rest, and stress reducing
practices contribute to a healthy self

79. Chapter 22
05 (1.0 point)

A 35
old new mother returned to the clinic for her 6 week postpartum check. As the
nurse, you plan to discuss any questions that she might have regarding her sexual healt
When is the best time to initiate this discussion?

a. As soon as the health care provider completes her pelvic exam

b. As the patient is preparing for the examination

*c. After the examination is over and the patient is dressed

d. In the waiting ar

General Feedback:

Exploring a person’s sexuality and providing useful sex education require
good communication skills. Make sure the environment and timing provide privacy,
uninterrupted time, and patient comfort.

80. Chapter 22
06 (1.0 point)

thy is assessing a 27
old woman who confides to her in the clinic that she has
three sex partners and none of them are aware of the others. Which of the following
would be the most appropriate statement that Kathy should make?

a. “Don’t you think th
at is risky behavior?”

*b. “Are you practicing safe sex and using condoms?”

c. “Do you think that you are being responsible in your behavior?”

d. “What do you think they would say if they found out about each other?”

General Feedback:

Individuals ne
ed to learn more about safe sex practices when they have more
than one sex partner or when their partner had other sexual experiences. Provide
information on sexually transmitted infections, including their symptoms, use of
condoms, and high
risk sexual ac

81. Chapter 22
07 (1.0 point)

Bill is a 17
old patient who was admitted to the hospital after a motorcycle accident.
He has become a paraplegic as a result of his injuries. The nurse recognizes that Bill is
ready to have another paraplegi
c visit him when he says:

a. “I am going to spend the remainder of the school year at home.”

b. “I don’t want to go back to school.”

*c. “I’m not sure how I will manage going back to school in a wheelchair.”

d. “I don’t want the kids at school to feel

sorry for me.”

General Feedback:

You will care for patients who are faced with the need to adapt to an altered
body image as a result of surgery or other physical change. Often a visit by someone who
has experienced similar changes and adapted to them

is helpful. Signs that a person is
receptive to such a visit include the patient’s asking questions related to how to manage a
particular aspect of what has happened or looking at the changed area.

82. Chapter 22
08 (1.0 point)

Leigh is a 45
old m
other of three who recently underwent bladder surgery. She has a
Hemovac drain in her abdomen and a urinary catheter in place. The nurse needs to
ambulate her, but Leigh doesn’t want to walk down the hall of her hospital unit. She tells
the nurse, “I don’t

want anyone to see the tubes and the gross drainage bags.” This
indicates to the nurse that Leigh is at risk for:

a. infection.

*b. low self

c. deep vein thrombosis.

d. decreased self

General Feedback:

In the acute care settin
g you are likely to encounter patients who are
experiencing potential threats to their self
concept because of the nature of the treatment
and diagnostic procedures. Threats to a patient’s self
concept result in anxiety and/or

83. Chapter 22
09 (1
.0 point)

Faith, a student nurse, is discussing a 4
old patient, Mike, with her nursing
instructor. The instructor asks Faith about how Erikson’s Developmental Tasks have an
impact on a 4
old child’s self
concept and sexuality. What is the best r

*a. “Mike says he wants to be a mechanic like his dad when he grows up.”

b. “Mike likes to go to the park to play.”

c. “Mike’s favorite food is hot dogs.”

d. “Mike likes to play video games with his older sister.”

General Feedback:

tive Versus Guilt (3 to 6 Years):

Takes initiative; identifies with a
gender; enhances self
awareness; increases language skills, including identification of

84. Chapter 22
10 (1.0 point)

The mother of a 7
old boy asked the nurse what fact
ors tended to increase self
esteem in boys. According to research, which of the following is the nurse’s best

*a. Positive family communication

b. Parents who have at least 4 years of college

c. Boys with older siblings

d. Boys from two
nt households

General Feedback:

One group of researchers found that family income above the federal poverty
level, positive family communication, and involvement in a religious community are
associated with high self
esteem in boys.

85. Chapter 22
1 (1.0 point)

As a nurse caring for a patient with a colostomy that resulted from the treatment of a
benign tumor of the bowel, you most appropriately classify this self
concept component

a. role performance stressor.

b. sexuality stressor.

c. iden
tity stressor.

*d. body image stressor.

General Feedback:

A role performance stressor occurs when acute and chronic illness alters a
person’s ability to carry out his or her roles. Alterations in sexual health occur from a
variety of situations such a
s illness, infertility, trauma, or abuse. Identity stressors affect
an individual’s identity, but identity is particularly vulnerable during adolescence.

86. Chapter 22
12 (1.0 point)

A nurse is caring for an adult patient who retired last year. While r
endering care, the
nurse identifies that the patient is struggling emotionally with this change. This situation
is most likely associated with what self
concept component?

*a. Role

b. Identity

c. Self

d. Body image disturbance

General Feedba

Identity stressors affect an individual’s identity, but identity is particularly
vulnerable during adolescence. Self
esteem stressors vary with developmental stages.
Potential self
esteem stressors in older adults include health problems, declining
cioeconomic status, spousal loss or bereavement, loss of social support. Body image
stressors involve attitudes related to the body, including appearance, femininity and
masculinity, youthfulness, health, and strength.

87. Chapter 22
13 (1.0 point)

r a large weight loss a patient tells the nurse, “There still is a fat person inside of
me.” This type of statement illustrates a flaw in what self
concept component?

a. Role

b. Identity

c. Self

*d. Body image

General Feedback:

Role is the
way in which a person views his or her ability to carry out
significant roles. Identity stressors affect an individual’s identity, but identity is
particularly vulnerable during adolescence. Self
esteem stressors vary with
developmental stages. Potential s
esteem stressors in older adults include health
problems, declining socioeconomic status, spousal loss or bereavement, and loss of social

88. Chapter 22
14 (1.0 point)

An older adult patient who recently lost her husband is admitted for sur
gery. The nurse
notices that the patient is experiencing an alteration in psychosocial development when
the patient:

a. accepts her own limits.

b. voices concerns about the upcoming surgery.

c. expresses her opinions about the quality of care.

*d. dem
ands unnecessary assistance from her daughter.

General Feedback:

Knowledge regarding developmental stage will help the nurse to determine
responses that are important to the patient. A change in behavior suggests an alteration in

89. C
hapter 22
15 (1.0 point)

To devise a plan of care, when taking a patient’s health history the nurse should always:

a. focus only on physical factors that affect sexual functioning.

b. discuss sexual concerns only if the patient raises questions or conce

c. use emotionally laden terms when discussing sexual concepts.

*d. routinely include a few questions related to sexual functioning.

General Feedback:

Every nursing history needs to include a few questions related to sexual
functioning. In gathe
ring the sexual history, consider physical, functional, relationship,
lifestyle, and self
esteem factors that influence sexual functioning.

90. Chapter 23
03 (1.0 point)

Gene and Jackie are parents of twins. As their daughters have entered high school t
have gradually become more independent and the family boundaries have become more
flexible. This family is in what developmental stage?

a. Unattached young adults

b. Family with young children

*c. Family with adolescents

d. Family with young adult

General Feedback:

Family with adolescents experience changes in family status that are needed
to proceed developmentally; these include shifting of parent
child relationships to permit
adolescents to move into and out of system; refocusing on midlife

marital and career
issues; beginning to shift toward concerns for older generations.

91. Chapter 23
07 (1.0 point)

Mark is the nurse admitting Mr. Kern to the neurology unit of the hospital. Mr. Kern is an
old man who lives at home with his wif
e of 60 years. His daughter and her
family live next door to the Kerns and help care for them. Mrs. Kern has diabetes and
hypertension, which are both controlled with medication and diet. As Mark develops a
plan of care for Mr. Kern, he should consider whi
ch of the following nursing diagnoses?

Risk for caregiver role strain

Disabled family coping

Impaired parenting

Ineffective role performance

General Feedback:

During times of acute illness a family becomes distressed and focuses solel
on the ill member, neglecting the needs of the other family members. For example, you
will always consider the diagnosis of
Risk for caregiver role strain
a possibility when
extended care of a family member is necessary.

92. Chapter 23
08 (1.0 point)

Sarah is a nurse who works in home care. She is caring for Mr. Jenkins, a 78
patient with liver cancer. Mr. Jenkins lives at home with his wife of 53 years. In addition
to caring for Mr. Jenkins, Sarah also assesses caregiver stress in Mrs. Jenkin
s. Which of
the following indicates caregiver stress in Mrs. Jenkins?

a. Increased visits from church members

b. Mrs. Jenkins asking her daughter for help with shopping

c. Mrs. Jenkins arranging for Meals
Wheels three days a week

*d. Mrs. Jenkins c
ontracting pneumonia

General Feedback:

Assess for caregiver stress, such as tension in relationships with family and
care recipient, changes in level of health, changes in mood, and anxiety and depression.

93. Chapter 23
09 (1.0 point)

When evaluati
ng patient expectations of family
centered nursing, it is most important to
obtain which of the following?

a. Patient outcome information

*b. Family’s perspective of nursing care

c. Physician’s perspective of nursing care

d. Health care goals of the p

General Feedback:

It is important to obtain the family’s perspective of nursing care: how you
planned and delivered the care with them, whether it was satisfactory, whether it met the
family’s goals, and if not, what they think was needed instea
d. This evaluation needs to
be ongoing so that care delivery techniques can be modified or adjusted as needed.

94. Chapter 23
15 (1.0 point)

A husband and wife are having a loud discussion regarding acceptable health care
practices. The nurse uses thera
peutic communication to deal with this situation. The nurse
understands that effective communication within the family promotes:

a. increased financial opportunities for the family.

b. socialization among individual family members.

c. role development
of each individual family member.

*d. problem solving and emotional support of the family members.

General Feedback:

Economic factors are always a concern for families, especially for those at the
lower end of the economic scale and single
income fami
lies. The family is the primary
social context in which health promotion and disease prevention take place. Families, just
like individuals, change and grow over time. Each developmental stage has challenges,
needs, and resources.

95. Chapter 23
18 (1.0


An older adult patient is returning home after a total knee replacement. The patient lives
within an alternative pattern relationship. The patient is unable to perform the
postoperative exercises. What is the most appropriate action the nurse shoul
d take?

a. Referring the patient to an outpatient exercise group

b. Arranging for a private duty nurse to help perform exercises three times a week

c. Informing the patient that if he cannot do the exercises, he will have to go to an
extended care faci

*d. Investigating whether or not someone else in the home will be able to assist
with the knee exercises

General Feedback:

When assessing a patient, it is important to include family form, structure,
and function, including developmental stage. I
dentifying the family form and system will
assist you in determining if support is available within the family form.

96. Chapter 23
19 (1.0 point)

The family of a patient attends a patient care conference. When planning family goals the
nurse should:

a. view the family as a system.

b. make the goals as broad as possible.

*c. assess the availability of family members.

d. not recognize developmental stages of family members.

General Feedback:

Family is viewed as context, family, and system. When g
oals are made broad,
they are less measurable and less practical. Each individual, as well as the family,
changes and grows over time. Each stage has challenges and needs.

97. Chapter 25
01 (1.0 point)

Harold is a 45
old man who recently lost his j
ob as a result of downsizing at his
company. Harold was employed at this company since graduating from college and
identifies himself by the work that he did. He is currently grieving as a result of which
type of loss in his life?

a. Maturational

b. Sit

*c. Actual

d. Perceived

General Feedback:

People experience an actual loss

when they can no longer touch, hear, see, or
have near them valued people or objects. Examples include the loss of a body part, pet,
friend, life partner, or role at

98. Chapter 25
02 (1.0 point)

Kelly is a nursing student who has maintained a 4.0 GPA since she has been in nursing
school. The past semester she has started working, is planning a wedding, and has moved
into a new home. Kelly has not been able to

maintain the 4.0 GPA this semester and as a
result, Kelly is feeling like a failure. How is this loss best described?

a. Maturational