NSG 321 ADVANCED LEADERSHIP
AND MANAGEMENT
FINAL EXAM
Exam Elaborations Questions &
Answers
2026
,A 74-year-old male with a history of COPD, Type 2 diabetes, and stage 3 chronic
kidney disease is admitted to a medical-surgical unit. He has five active prescriptions
from three different specialists, no documented primary care provider, and his
daughter reports he has missed follow-up appointments for six months. The charge
nurse is developing a coordinated care plan. According to Dorothea Orem's Self-
Care Deficit Nursing Theory, which nursing system is most appropriate for this
patient at the time of admission?
A. Wholly compensatory system, because the patient is medically complex and
cannot make independent decisions B. Supportive-educative system, because he
simply needs medication reminders C. Partly compensatory system, because the
patient retains some self-care capacity but requires professional nursing support to
address care deficits created by his multiple comorbidities and fragmented care D.
Wholly compensatory system, because he missed appointments and is therefore non-
compliant
Correct Answer: C
Rationale: Orem's partly compensatory system applies when the patient can perform
some self-care actions but requires nursing assistance for others. This patient has
functional capacity and decision-making ability but has demonstrable self-care
deficits related to knowledge gaps, fragmentation of care, and disease burden.
Labeling him wholly compensatory based on complexity alone or non-compliant
without exploring barriers reflects poor critical thinking and does not align with
Orem's framework.
A nurse coordinator is reviewing a patient's discharge readiness after a left total knee
replacement. The patient scores a 2 on the LACE Index (Length of stay, Acuity of
admission, Comorbidities, Emergency department visits). The patient lives alone and
has no transportation. Using a systems-theory approach to coordinating this
discharge, which action best reflects the nurse's understanding of open systems and
environmental interaction?
A. Discharge the patient immediately because the LACE score is low B. Contact the
hospitalist to extend the admission by 48 hours as a precaution C. Conduct a holistic
assessment that incorporates social determinants of health, activate community-based
resources such as home health and medical transportation, and loop back findings to
the interdisciplinary team before finalizing discharge D. Document the LACE score
and defer coordination to the case manager
2
,Correct Answer: C
Rationale: General Systems Theory, as applied by Betty Neuman, recognizes that the
patient exists as an open system in constant interaction with environmental stressors.
A low LACE score is one data point, not a comprehensive picture. The nurse
coordinator's role demands synthesizing clinical data with psychosocial and
environmental factors. Deferring entirely to the case manager abdicates the
coordinating role of the professional nurse.
A community health nurse is applying Madeleine Leininger's Culture Care Theory
while coordinating care for a recently immigrated Haitian family whose matriarch
was diagnosed with hypertension. The family declines antihypertensive medication,
citing religious practices and preference for herbal treatments. Which critical
thinking approach best reflects culturally congruent care coordination?
A. Insist on medication adherence to reduce stroke risk and document the family's
refusal B. Engage a cultural broker or interpreter, assess the specific herbal practices
for pharmacological interactions, negotiate a mutually acceptable care plan that
honors cultural values while minimizing physiological risk, and coordinate with the
interdisciplinary team C. Refer the family to social work and remove the nurse from
the care plan D. Educate the family on Western medical practices until they accept
pharmacological therapy
Correct Answer: B
Rationale: Leininger's three modes of action include culture care preservation,
accommodation, and restructuring. Forcing Western protocols without cultural
assessment violates the foundational premise of the theory. Competent nurse
coordination here involves bilingual or bicultural engagement, interprofessional
collaboration, and negotiated planning, all of which reflect advanced critical thinking
in a culturally diverse healthcare system.
During morning rounds in a trauma ICU, the bedside nurse identifies that a
mechanically ventilated patient's plateau pressure has increased from 22 cmH2O to
31 cmH2O overnight. The physician has not yet rounded. Using Paul and Elder's
Critical Thinking Framework, which nursing action best demonstrates the intellectual
standard of "completeness" in clinical reasoning before escalating?
A. Call the physician immediately with only the plateau pressure change B. Review
the patient's entire ventilator flow sheet, recent chest X-ray, fluid balance, and
3
, sputum characteristics, then formulate a differential and present a structured SBAR
communication to the physician C. Reposition the patient and reassess in one hour D.
Document the finding and wait for the physician to round
Correct Answer: B
Rationale: Paul and Elder's Universal Intellectual Standards include clarity, accuracy,
precision, relevance, depth, breadth, logic, significance, and completeness.
Completeness demands that the nurse gather all relevant data before drawing
conclusions or escalating. Option B demonstrates this standard by synthesizing
multiple data streams into a coherent clinical picture before SBAR-based
communication, which itself is a coordination tool within the healthcare delivery
system.
A nurse manager is asked to implement a new sepsis bundle on a 30-bed medical
unit. She uses Lewin's Change Theory to guide the process. Three weeks into the
implementation, nursing staff have reverted to previous practice patterns. According
to Lewin, which phase has failed and what is the appropriate coordinating
intervention?
A. Unfreezing has failed; reissue the policy memo B. Moving has failed; discipline
the staff for non-compliance C. Refreezing has failed; the nurse manager must
institutionalize the change through embedding the new behavior into policies,
workflows, performance evaluations, and ongoing education to create lasting
equilibrium D. Unfreezing has failed; the nurse manager must conduct additional
needs assessments
Correct Answer: C
Rationale: In Lewin's three-step model, refreezing is the stabilization phase where
new behaviors become the standard. Reversion indicates the change was not
anchored. The coordinating role of the nurse in change implementation requires that
new practices be structurally embedded, not just introduced. This is a systems-level
coordination responsibility, not a compliance issue addressed through discipline
alone.
A 58-year-old woman with metastatic ovarian cancer is admitted for pain
management. She has an advance directive requesting no resuscitation but her adult
son insists on "full code" status. The oncology nurse is coordinating an ethics
consultation. Applying Beauchamp and Childress's Four Principles of Biomedical
4
AND MANAGEMENT
FINAL EXAM
Exam Elaborations Questions &
Answers
2026
,A 74-year-old male with a history of COPD, Type 2 diabetes, and stage 3 chronic
kidney disease is admitted to a medical-surgical unit. He has five active prescriptions
from three different specialists, no documented primary care provider, and his
daughter reports he has missed follow-up appointments for six months. The charge
nurse is developing a coordinated care plan. According to Dorothea Orem's Self-
Care Deficit Nursing Theory, which nursing system is most appropriate for this
patient at the time of admission?
A. Wholly compensatory system, because the patient is medically complex and
cannot make independent decisions B. Supportive-educative system, because he
simply needs medication reminders C. Partly compensatory system, because the
patient retains some self-care capacity but requires professional nursing support to
address care deficits created by his multiple comorbidities and fragmented care D.
Wholly compensatory system, because he missed appointments and is therefore non-
compliant
Correct Answer: C
Rationale: Orem's partly compensatory system applies when the patient can perform
some self-care actions but requires nursing assistance for others. This patient has
functional capacity and decision-making ability but has demonstrable self-care
deficits related to knowledge gaps, fragmentation of care, and disease burden.
Labeling him wholly compensatory based on complexity alone or non-compliant
without exploring barriers reflects poor critical thinking and does not align with
Orem's framework.
A nurse coordinator is reviewing a patient's discharge readiness after a left total knee
replacement. The patient scores a 2 on the LACE Index (Length of stay, Acuity of
admission, Comorbidities, Emergency department visits). The patient lives alone and
has no transportation. Using a systems-theory approach to coordinating this
discharge, which action best reflects the nurse's understanding of open systems and
environmental interaction?
A. Discharge the patient immediately because the LACE score is low B. Contact the
hospitalist to extend the admission by 48 hours as a precaution C. Conduct a holistic
assessment that incorporates social determinants of health, activate community-based
resources such as home health and medical transportation, and loop back findings to
the interdisciplinary team before finalizing discharge D. Document the LACE score
and defer coordination to the case manager
2
,Correct Answer: C
Rationale: General Systems Theory, as applied by Betty Neuman, recognizes that the
patient exists as an open system in constant interaction with environmental stressors.
A low LACE score is one data point, not a comprehensive picture. The nurse
coordinator's role demands synthesizing clinical data with psychosocial and
environmental factors. Deferring entirely to the case manager abdicates the
coordinating role of the professional nurse.
A community health nurse is applying Madeleine Leininger's Culture Care Theory
while coordinating care for a recently immigrated Haitian family whose matriarch
was diagnosed with hypertension. The family declines antihypertensive medication,
citing religious practices and preference for herbal treatments. Which critical
thinking approach best reflects culturally congruent care coordination?
A. Insist on medication adherence to reduce stroke risk and document the family's
refusal B. Engage a cultural broker or interpreter, assess the specific herbal practices
for pharmacological interactions, negotiate a mutually acceptable care plan that
honors cultural values while minimizing physiological risk, and coordinate with the
interdisciplinary team C. Refer the family to social work and remove the nurse from
the care plan D. Educate the family on Western medical practices until they accept
pharmacological therapy
Correct Answer: B
Rationale: Leininger's three modes of action include culture care preservation,
accommodation, and restructuring. Forcing Western protocols without cultural
assessment violates the foundational premise of the theory. Competent nurse
coordination here involves bilingual or bicultural engagement, interprofessional
collaboration, and negotiated planning, all of which reflect advanced critical thinking
in a culturally diverse healthcare system.
During morning rounds in a trauma ICU, the bedside nurse identifies that a
mechanically ventilated patient's plateau pressure has increased from 22 cmH2O to
31 cmH2O overnight. The physician has not yet rounded. Using Paul and Elder's
Critical Thinking Framework, which nursing action best demonstrates the intellectual
standard of "completeness" in clinical reasoning before escalating?
A. Call the physician immediately with only the plateau pressure change B. Review
the patient's entire ventilator flow sheet, recent chest X-ray, fluid balance, and
3
, sputum characteristics, then formulate a differential and present a structured SBAR
communication to the physician C. Reposition the patient and reassess in one hour D.
Document the finding and wait for the physician to round
Correct Answer: B
Rationale: Paul and Elder's Universal Intellectual Standards include clarity, accuracy,
precision, relevance, depth, breadth, logic, significance, and completeness.
Completeness demands that the nurse gather all relevant data before drawing
conclusions or escalating. Option B demonstrates this standard by synthesizing
multiple data streams into a coherent clinical picture before SBAR-based
communication, which itself is a coordination tool within the healthcare delivery
system.
A nurse manager is asked to implement a new sepsis bundle on a 30-bed medical
unit. She uses Lewin's Change Theory to guide the process. Three weeks into the
implementation, nursing staff have reverted to previous practice patterns. According
to Lewin, which phase has failed and what is the appropriate coordinating
intervention?
A. Unfreezing has failed; reissue the policy memo B. Moving has failed; discipline
the staff for non-compliance C. Refreezing has failed; the nurse manager must
institutionalize the change through embedding the new behavior into policies,
workflows, performance evaluations, and ongoing education to create lasting
equilibrium D. Unfreezing has failed; the nurse manager must conduct additional
needs assessments
Correct Answer: C
Rationale: In Lewin's three-step model, refreezing is the stabilization phase where
new behaviors become the standard. Reversion indicates the change was not
anchored. The coordinating role of the nurse in change implementation requires that
new practices be structurally embedded, not just introduced. This is a systems-level
coordination responsibility, not a compliance issue addressed through discipline
alone.
A 58-year-old woman with metastatic ovarian cancer is admitted for pain
management. She has an advance directive requesting no resuscitation but her adult
son insists on "full code" status. The oncology nurse is coordinating an ethics
consultation. Applying Beauchamp and Childress's Four Principles of Biomedical
4
