NURS 274 Fundamental Concepts And Skills For Nursing, 5th Edition-Test Bank

NURS 274 Fundamental Concepts And Skills For Nursing, 5th Edition-Test Bank Chapter 03: Legal and Ethical Aspects of Nursing Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. A student nurse who is not yet licensed: ANS: C Student nurses are held to the same standards as a licensed nurse. This means that although a student nurse may not perform a task as quickly or as smoothly as the licensed nurse would, the student is expected to perform it as effectively. In other words, she must achieve the same outcome without harm to the patient. The student is legally responsible for her own actions or inaction, and many schools require the student to carry malpractice insurance. DIF: Cognitive Level: Knowledge REF: p. 32 OBJ: Theory #1 TOP: Practice Regulations for the Student Nurse KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. During an employment interview, the interviewer asks the nurse applicant about HIV status. The nurse applicant can legally respond: ANS: D In employment practice, it is illegal to discriminate against people with certain diseases or conditions. Asking a question about health status, especially HIV or AIDS infection, is illegal. DIF: Cognitive Level: Application REF: p. 34 OBJ: Clinical Practice #1 TOP: Discrimination KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. An example of a violation of criminal law by a nurse is: ANS: A Theft of a controlled substance is a federal crime and consequently a crime against society. DIF: Cognitive Level: Application REF: p. 32 OBJ: Theory #2 TOP: Criminal Law KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. The LPN (LVN) assigns part of the care for her patients to a nursing assistant. The LPN is legally required to perform which of the following for the residents assigned to the assistant? ANS: C Toileting, feeding, and transporting residents or patients are tasks that can be legally assigned to a nurse’s aide. Administering medications is a nursing act that can be performed only by a licensed nurse or by a student nurse under the supervision of a licensed nurse. DIF: Cognitive Level: Application REF: p. 33 OBJ: Theory #3 TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 5. If a nurse is reported to a state board of nursing for repeatedly making medication errors, it is most likely that: ANS: D The nurse may have his or her license revoked or be required to take a refresher course, but this would be based on the evidence presented at a hearing. The licensing examination is not usually required as a correction of the situation as described. DIF: Cognitive Level: Knowledge REF: p. 33 OBJ: Theory #3 TOP: Professional Discipline KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 6. A nurse co-worker arrives at work 30 minutes late, smelling strongly of alcohol. The fellow nurses’ legal course of action is to: ANS: C Nurses must report the condition. It is a nurse’s legal and ethical duty to protect patients from impaired or incompetent workers. Allowing the impaired nurse to sleep enables the impaired nurse to avoid the consequences of his or her actions and to continue the risky behavior. Threatening to report “the next time” continues to place patients at risk, as does masking the signs of impairment with breath mints. DIF: Cognitive Level: Application REF: p. 33 OBJ: Theory #3 TOP: Professional Discipline KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. When a student nurse performs a nursing skill, it is expected that the student: ANS: B Students are not expected to perform skills as quickly or as smoothly as experienced nurses, but students must achieve the same result in a safe manner. DIF: Cognitive Level: Comprehension REF: p. 33 OBJ: Theory #1 TOP: Practice Regulations for the Student Nurse KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8. If a nurse receives unwelcome sexual advances from a nursing supervisor, the first step the nurse should take is to: ANS: B The first step in dealing with sexual harassment in the workplace is to indicate to the person that the actions or conversations are offensive and ask the person to stop. If the actions continue, then reporting the occurrence to the supervisor or the offender’s supervisor is indicated. DIF: Cognitive Level: Application REF: p. 34 OBJ: Clinical Practice #1 TOP: Sexual Harassment KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 9. A person who has been brought to the emergency room after being struck by a car insists on leaving, although the doctor has advised him to be hospitalized overnight. The nurse caring for this patient should: ANS: A A person has the right to refuse medical care, and agencies use the Leave AMA to document the medical advice given and the patient’s informed choice to leave against that advice. DIF: Cognitive Level: Application REF: p. 39 OBJ: Clinical Practice #3 TOP: Patient Rights KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 10. The information in a patient’s medical record may legally be: ANS: C A release or consent is required to provide information from a patient’s medical record to anyone not directly caring for that patient. The patient must provide consent to provide information to insurers, lawyers, or other health care agencies or providers. The patient has the right to access the information in his or her medical record (copies), but the agency or doctor retains ownership of the document. DIF: Cognitive Level: Application REF: p. 39 OBJ: Theory #5 TOP: Legal Documents KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 11. If a patient indicates that he is unsure if he needs the surgery he is scheduled for later that morning, the nurse would best reply: ANS: D A consent can be withdrawn at any time before the treatment or procedure has been started. The primary care provider should be notified by the supervising nursing staff of the unit. DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #4 TOP: Informed Consent KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. A 16-year-old boy is admitted to the emergency room after fracturing his arm from falling off his bike while visiting with his stepfather who is not the custodial parent. The nurse is preparing him to go to the operating room but must obtain a valid informed consent by: ANS: D The patient is a minor and cannot legally sign his own consent unless he is an emancipated minor; the guardian for this patient is the custodial parent. A step parent is not a legal guardian for a minor unless the child has been adopted by the step parent. The hospital does not have the authority to declare the patient an emancipated minor. DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3 TOP: Consent KEY: Nursing Process Step: Intervention MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 13. A patient has advance directives spelled out in a durable power of attorney, with the appointment of his daughter as his health care agent. The daughter will be responsible for: ANS: C A health care agent makes decisions for the patient only when a patient is unable, according to the wishes made known by the patient in advance directives. A health care agent is not responsible for financial decisions or payments. DIF: Cognitive Level: Application REF: p. 39 OBJ: Clinical Practice #5 TOP: Advance Directives KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 14. A patient has signed a do-not-resuscitate (DNR) order. If a nurse performs cardiopulmonary resuscitation (CPR) when the patient stops breathing and then successfully revives the patient, the: ANS: A A nurse who attempts CPR on a patient who had a doctor’s order for a DNR could be found guilty of battery. DIF: Cognitive Level: Comprehension REF: p. 39 OBJ: Clinical Practice #3 TOP: DNR KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 15. A patient refuses to take his medications or to eat his breakfast. He is alert, mentally competent, and fairly comfortable. The nurse should: ANS: B The competent patient has the right to refuse medicine, food, treatments, and procedures. Giving (or threatening to give) medications by injection over the patient’s objections is considered battery. Threatening the patient or overriding the patient’s wishes is a violation of the patient’s bill of rights and constitutes assault or battery. DIF: Cognitive Level: Application REF: p. 40 OBJ: Clinical Practice #3 TOP: Patient’s Rights KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 16. A nurse remarks to several people that “Dr. X must be getting senile because she makes so many mistakes.” If that remark results in some of Dr. X’s patients changing to another doctor, Dr. X would have grounds to sue the nurse for: ANS: A A person who makes untrue, malicious, or harmful remarks that damage a person’s reputation and cause injury (loss of business) is guilty of defamation and slander. Libel is defamation that is written. DIF: Cognitive Level: Application REF: p. 40 OBJ: Clinical Practice #5 TOP: Defamation/Slander KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 17. A licensed nurse is liable for charges of malpractice when she: ANS: C Malpractice is professional negligence or, in this case, doing (falsifying) something the reasonable and prudent nurse would not do. It is the proximate cause of the patient injury. This is a case of causation. DIF: Cognitive Level: Application REF: p. 40|Box 3-6 OBJ: Theory #5 TOP: Negligence and Malpractice KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 18. A postoperative patient in the intensive care unit (ICU) is so confused and agitated that staff have not been able to safely care for him. He has pulled out his central line once, and he slides to the bottom of the bed, where he attempts to climb out, pulling and disrupting the various tubes and monitors. The nurse’s best course of action is to: ANS: C A protective device may not be used (except in an emergency) without a doctor’s order, and it is used only when other less restrictive means do not provide safety for the patient. DIF: Cognitive Level: Application REF: p. 41 OBJ: Clinical Practice #3 TOP: False Imprisonment KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 19. An elderly, slightly confused patient sustains an injury from a heating pad that was wrongly applied by the nurse. The nurse should: ANS: B When an incident occurs that has potential for a future lawsuit, the risk management team should be aware of it as soon as possible. An incident report should be filled out, and the patient medical record should be documented to describe the injury. No mention of the incident report is usually made in the patient medical record. Honesty and a forthright explanation to the patient reduce the risk of lawsuits. DIF: Cognitive Level: Application REF: p. 43 OBJ: Theory #5 TOP: Incident Reports KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. Nursing liability insurance is a policy purchased and put into effect by the nurse for the purpose of: ANS: C Nursing liability insurance pays attorney fees and any award won by the plaintiff. DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: Theory #5 TOP: Nursing Ethics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. Ethics and law are different from each other in that ethics: ANS: B Ethics are voluntary and are based on values. Ethics may change as parameters of health care change. There is no penalty for violation. DIF: TOP: Cognitive Level: Analysis Nursing Ethics REF: p. 43 KEY: OBJ: Theory #6 Nursing Process Step: N/A MSC: NCLEX: N/A 22. To best protect himself or herself from being sued, the nurse should: ANS: C Keeping up with continuing education, maintaining competency, and seeking to improve one’s own practice by self-evaluation will best protect the nurse. DIF: Cognitive Level: Comprehension REF: p. 42|Box 3-7 OBJ: Theory #5 TOP: Avoiding Lawsuits KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. The Health Insurance Portability and Accountability Act’s (HIPAA) main focus is in keeping: ANS: B HIPAA regulates the way patient information is conveyed and stored. DIF: Cognitive Level: Comprehension REF: p. 37|Box 3-4 OBJ: Clinical Practice #1 TOP: HIPAA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 24. Which of the following could place the nurse in a serious legal situation? ANS: B Legal and Ethical Considerations Social Media and HIPAA Health care agencies and institutions have had to become more diligent in protecting personal health information (PHI) as a result. It is imperative that no PHI be disseminated, either intentionally or unintentionally, over social media. Posting of pictures, discussions (even those that do not use patient or hospital names), and images of x-rays all violate HIPAA and place the nurse in a serious legal situation. It is generally best to separate one’s personal and professional life when dealing with social media. The National Council of State Boards of Nursing (2011) provides guidelines and suggestions for nurses in dealing with social media and nursing practice. DIF: Cognitive Level: Analysis REF: p. 37 OBJ: Clinical Practice #6 TOP: Social Media and HIPAA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 25. When a patient asks a nurse to witness the signing of a will, the nurse should refer the request to the: ANS: C Although witnessing a legal document for a patient is not illegal, most agencies have a policy regarding the proper course of action by referring the patient to the notary public. DIF: Cognitive Level: Application REF: p. 39 OBJ: Theory #1 TOP: Witnessing Wills and Other Legal Documents KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 26. Criteria that justify becoming an emancipated minor and able to sign a medical consent include all of the following except: ANS: C Criteria are that the minor be independent by court order, be a member of the military, be pregnant, or be married. DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3 TOP: Emancipated Minor KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 27. A written statement expressing the wishes of a patient regarding future consent for or refusal of treatment in case the patient is incapable of participating in decision making is an example of: ANS: C An advance directive makes the patient’s wishes known regarding medical decisions and consent in the event that he or she is unable to participate in decision making. DIF: Cognitive Level: Knowledge REF: p. 39 OBJ: Clinical Practice #5 TOP: Legal Terms KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 28. A nurse is caring for an unmarried 16-year-old patient who has just given birth to a baby boy. The nurse will get the consent to perform a circumcision on the patient’s son from the: ANS: D Pregnancy qualifies as the basis for the 16-year-old to be treated as an emancipated minor. DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3 TOP: Patient Rights KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 29. A 48-year-old man refuses to take a medication ordered for the control of his blood pressure. The nurse’s most effective response would be: ANS: B Patients have the right to refuse medication, but it is the nurse’s responsibility to explain the reason for the particular drug. DIF: Cognitive Level: Application REF: p. 38 OBJ: Theory #1 TOP: Legal Standards KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 30. The Occupational Safety and Health Act includes all of the following, except: ANS: C The Occupational Safety and Health Act was passed in 1970 to improve the work environment in areas that affect workers’ health or safety. It includes regulations for handling infectious or toxic materials, radiation safeguards, and the use of electrical equipment. DIF: Cognitive Level: Comprehension REF: p. 34 OBJ: N/A TOP: OSHA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 31. The most frequently cited cause of a sentinel event by the Joint Commission is a problem in: ANS: D The most frequently cited cause of a sentinel event by the Joint Commission is communication. During “handoff” communication, there is a risk that critical patient care information might be lost due to lack of communication. DIF: Cognitive Level: Knowledge REF: p. 35 OBJ: Clinical Practice #2 TOP: Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 32. The acronym SBAR is a method to communicate with a primary care provider that clarifies a situation that may result in litigation. The acronym stands for: ANS: C SBAR is an acronym that stands for situation, background, assessment, and recommendation. This undetailed analysis clarifies the situation in a manner that is concise yet complete. DIF: Cognitive Level: Knowledge REF: p. 35 OBJ: Theory #5 TOP: SBAR Reporting KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 33. The patient who cannot legally sign his or her own surgical consent is: ANS: D The person giving the consent must be able to take part in the decision making. A sedated person does not have this ability. DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3 TOP: Patient Rights KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 34. The nurse who may be liable for invasion of privacy would be the nurse who is: ANS: C Discussing a patient with anyone, even another health professional, who is not involved in the patient’s care can put a nurse at risk for invasion of privacy. DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3 TOP: Patient Rights KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 35. A characteristic of an advance directive is that: ANS: A An advance directive is a written statement expressing the wishes of the patient regarding future consent for or refusal of treatment if the patient is incapable of participating in decision making, and they do not expire. All states recognize advance directives, but each state regulates advance directives differently, and an advance directive from one state may not be recognized in another. DIF: Cognitive Level: Comprehension REF: p. 38 OBJ: Clinical Practice #5 TOP: Advance Directives KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 36. A patient who is refusing to take his medication is threatened that he will be held down and forced to take the dose. This is an example of: ANS: C Assault is the threat to harm another or even to touch another without that person’s permission. The person being threatened must believe that the nurse has the ability to carry out the threat. DIF: Cognitive Level: Comprehension REF: p. 40 OBJ: Theory #3 TOP: Legal Terms KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 37. The nurse explains that a sentinel event is a situation in which a patient: ANS: D A sentinel event is an unexpected situation in which the patient comes to harm. DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: Theory #5 TOP: Legal Terms KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. Professional accountability includes: (Select all that apply.) ANS: A, C, D, E Professional accountability is a nurse’s responsibility to meet the health care needs of the patient in a safe and caring application of nursing skills and understanding of human needs. DIF: Cognitive Level: Analysis REF: p. 33 OBJ: Theory #3 TOP: Professional Accountability KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. A nurse arrives at the scene of a motor vehicle accident. A person in the vehicle mumbles incoherently when asked his name. Which actions are not covered by the Good Samaritan Law? (Select all that apply.) ANS: D The Good Samaritan Law covers care given in an emergency, but only within the scope of one’s practice, and care that does not cause harm resulting from negligence. DIF: Cognitive Level: Comprehension REF: p. 35 OBJ: Theory #5 TOP: Legal Scope of Practice KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment 3. The Ethics Committee of a facility has the responsibility to: (Select all that apply.) ANS: A, B, E An Ethics Committee of an institution has representatives from various fields to formulate, address, and help clarify ethical problems that present themselves in their facility. DIF: Cognitive Level: Comprehension REF: p. 45 OBJ: Theory #6 TOP: Ethics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. The commonalities of The Codes of Ethics of the National Association for Practical Education and Service (NAPNES) and The National Federation of Licensed Practical Nurses (NFLPN) include: (Select all that apply.) ANS: A, B, C, E Both Codes of Ethics support maintenance of competency, preservation of confidentiality of the nurse patient relationship, commitment to continuing education, and respect for human dignity. DIF: Cognitive Level: Application REF: p. 43 OBJ: Theory #6 TOP: Ethics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. In 2003, the Patients’ Bill of Rights was revised to become the _ _: Understanding Expectations, Rights, and Responsibilities. ANS: Patient Care Partnership The Patient Care Partnership addresses patient rights and the responsibility of health care facilities. DIF: Cognitive Level: Knowledge REF: p. 33 OBJ: Clinical Practice #3 TOP: Patient Rights KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. CAPTA, passed in 1973, is a law regarding the safety of minors. It is the _ and _. ANS: Child Abuse Prevention; Treatment Act This is a law that requires mandated reporting and defines who is a mandated reporter. DIF: Cognitive Level: Knowledge REF: p. 34 OBJ: Theory #1 TOP: Professional Accountability KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 05: Assessment, Nursing Diagnosis, and Planning Williams: deWit’s Fundamental Concepts and Skills for Nursing, 5th Edition MULTIPLE CHOICE 1. When the patient complains of nausea and dizziness, the nurse recognizes these complaints as data. ANS: C Subjective data are symptoms that only the patient can identify. DIF: Cognitive Level: Application REF: p. 58 OBJ: Theory #3 TOP: Assessment Data KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The major goal of the admission interview (usually performed by the RN) is to: ANS: C The interview is used as part of the assessment process to elicit information about the patient’s physical, emotional, and spiritual health. DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1 TOP: Interview KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 3. An example of a structured format for gathering data that aids in forming a database is: ANS: D Mary Gordon’s assessment guide is a guided path to cover 11 health points. Although Maslow may be used, it is not structured. DIF: Cognitive Level: Knowledge REF: p. 58|Box 5-1 OBJ: Theory # 2 TOP: Gordon’s 11 Health Patterns KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. During the assessment phase of the nursing process, the nurse: ANS: D Gathering and organizing data is the first step in the assessment phase of the nursing process. DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1 TOP: Data Collection KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 5. After the admission assessment is completed, on subsequent shifts or days, the nurse: ANS: D The patient should be briefly assessed at the beginning of each shift and more thoroughly if his or her condition changes or as per the plan of care. DIF: Cognitive Level: Comprehension REF: p. 70 OBJ: Theory #1 TOP: Physical Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. The nurse performing an admission interview on an older adult person should: ANS: C When interviewing an older adult person, allow more time because the person will probably have a more extensive history and may take a little longer to recall the needed information. DIF: Cognitive Level: Application REF: p. 59 OBJ: Theory #5 TOP: Admission Interview KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. A nursing diagnosis consists of: ANS: B NANDA-I has formulated an official list of nursing diagnoses to identify patient problems and problems that patients are at risk of developing. A nursing diagnosis is independent of a medical diagnosis. DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: Theory #5 TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 8. An older adult patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she “can’t breathe.” Based on this information, an appropriately worded nursing diagnosis for this patient is: ANS: A The nursing diagnosis from the NANDA list is complete with a cause and signs and symptoms. DIF: Cognitive Level: Analysis REF: p. 66|Box 5-4 OBJ: Theory #5 TOP: Nursing Diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 9. If a patient has several nursing diagnoses, the nurse will first: ANS: C Nursing diagnoses (and thus their interventions) must be prioritized to identify the order of importance based on Maslow’s hierarchy. DIF: Cognitive Level: Analysis REF: p. 65 OBJ: Clinical Practice #4 TOP: Prioritizing KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 10. A patient has a nursing diagnosis of imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months. An appropriate short-term goal for this patient is to: ANS: A Short-term goals should be realistic and attainable and should have a timeline of 7 to 10 days before discharge. DIF: Cognitive Level: Application REF: p. 66 OBJ: Clinical Practice #6 TOP: Expected Outcomes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. The nursing diagnoses that has the highest priority is: ANS: D Choking and aspiration are life-threatening events and take priority over problems such as weakness, inability to speak, or weight loss. DIF: Cognitive Level: Analysis REF: p. 65 OBJ: Clinical Practice #4 TOP: Prioritizing KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. A patient with visual impairment is identified as at-risk for falls related to blindness. An appropriate intervention would be: ANS: B Providing clear pathways directly reduces the risk of patient falls. DIF: Cognitive Level: Analysis REF: p. 62 OBJ: Clinical Practice #6 TOP: Clinical Planning KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 13. The North American Nursing Diagnosis Association–I (NANDA-I) list is revised and updated every: ANS: B NANDA-I meets every 2 years to revise and update the list. DIF: Cognitive Level: Knowledge REF: p. 65 OBJ: Theory #5 TOP: NANDA I KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 14. A nursing care plan consists of: ANS: A The nursing care plan consists of the nursing orders for interventions to address problems and establish outcomes by which the plan can be evaluated. DIF: Cognitive Level: Comprehension REF: p. 69 OBJ: Clinical Practice #5 TOP: Nursing Care Plan KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 15. In an acute care facility, a nursing care plan is usually reviewed and updated: ANS: B Ongoing assessment, intervention, and evaluation lead to attainment or modification of the original plan for the patient who is acutely ill. The nursing care plan must be updated every day to reflect these changes. DIF: Cognitive Level: Knowledge REF: p. 69 OBJ: Clinical Practice #6 TOP: Nursing Care Plan KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 16. The nurse takes into consideration that the difference between a sign and a symptom is that a sign is: ANS: C Signs are objective data that can be confirmed by examination, assessment, or observation. Signs are reliable research-based data. DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #2 TOP: Assessment (Data Collection) KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. The nurse clarifies that nursing orders are also called: ANS: C Nursing orders are also called nursing interventions and follow the same requirements when placed in a nursing care plan. DIF: Cognitive Level: Knowledge REF: p. 64 OBJ: Theory #2 TOP: Nursing Orders KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 18. The nurse designs the goals for patients in long-term facilities to be: ANS: D Long-term goals are more appropriate for patients in long-term facilities because they will be there for an extended period and many of their health problems are chronic. DIF: Cognitive Level: Comprehension REF: p. 69 OBJ: Theory #7 TOP: Long Term Goals KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 19. Standardized Nursing Care Plans can: ANS: B Standardized Nursing Care Plans are generic and need to be altered to become individualized. They must be documented. DIF: Cognitive Level: Comprehension REF: p. 69 OBJ: Theory #7 TOP: Assessment (Data Collection) KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 20. A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is: ANS: A The nursing diagnosis is from the NANDA-I list and is complete with a cause and signs and symptoms. The other answers contain a medical diagnosis of pneumonia, which is inappropriate. DIF: Cognitive Level: Analysis REF: p. 65 OBJ: Theory #7 TOP: Nursing Diagnosis KEY: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. Reginald is a nurse caring for a 56-year-old man who is admitted with an acute MI. As he completes the initial assessment, he knows that concerning the practice of nursing, the purpose of the assessment on admission is to: ANS: A The practice of nursing is concerned with how a patient responds, physiologically and psychologically, to their disease or disorder, to their treatment(s), their life situation and environment, etc. In order to determine this, a database containing information about the patient must be established. It is in this capacity that LPN/LVNs contribute, via data collection, to the assessment stage of the nursing process. DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #1 TOP: Assigning Admission Tasks KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A 22. Theresa is a nurse caring for a 14-year-old girl who is admitted with an asthma attack. When she writes the nursing diagnosis statement she includes? ANS: C Most care facilities use a problem statement in care planning that may (or may not) conform to the NANDA-I terminology. Whatever the terminology used, the nursing diagnosis reflects the nurse’s clinical judgment regarding the patient’s response to an actual or potential health problem, and is the basis for the nurse’s plan of care for the patient. DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: Theory #5 TOP: Nursing Diagnosis KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: N/A MULTIPLE RESPONSE 1. The nurse understands that an expected outcome should be: (Select all that apply.) ANS: A, C, D, E An expected outcome should be realistic and attainable and should have a defined time line after collaboration with the patient. DIF: Cognitive Level: Knowledge REF: p. 67 OBJ: Theory #6 TOP: Nursing Process KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurological impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.) ANS: A, B, D, E The nurse selects appropriate nursing interventions to alleviate the problems and assist the patient in achieving the expected outcomes. Consider all possible interventions for relief of the problems and then select those most likely to be effective. DIF: Cognitive Level: Application REF: p. 68 OBJ: Clinical Practice #5 TOP: Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. Appropriate nursing roles in the initial assessment would include: (Select all that apply.) ANS: A, B, D, E The LPN/LVN, under the NFLPN standard, contributes assessments; the RN performs the physical assessment and medical records review and organizes the database. DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #2 TOP: Planning KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 4. Aside from the information obtained from the patient (primary source) in the admission interview, the nurse will also access: (Select all that apply.) ANS: A, C, D, E The nurse conducting the interview uses information from the patient’s family, from the health care provider’s s admission note and history and physical, and from personal observation of the patient. DIF: Cognitive Level: Comprehension REF: p. 58 OBJ: Theory #2 TOP: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. A nursing diagnosis identifies: (Select all that apply.) ANS: A, B, D, E Defining characteristics of nursing diagnosis includes the patient’s response to illness and the causative factors. Signs and symptoms must also be identified for a nurse to select an appropriate nursing diagnosis. Medical diagnoses label an illness; nursing diagnoses are independent of medical diagnoses. DIF: Cognitive Level: Comprehension REF: p. 65 OBJ: Theory #5 TOP: Defining Characteristics KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 6. The statements that are correctly stated as expected outcomes are: (Select all that apply.) ANS: B, D Expected outcomes need to have a time frame and be measurable. Ambulating with a walker within 3 days and performing ROM independently for 4 hours are both measurable outcomes with clear time frames. The outcome of voiding independently does not have a time frame. Assisting the patient to the bathroom is a nursing intervention. DIF: Cognitive Level: Comprehension REF: p. 66|p. 67 OBJ: Theory #6 TOP: Expected Outcomes KEY: Nursing Process Step: Planning MSC: NCLEX: N/A 7. The nurse should make a point when closing the initial interview to: (Select all that apply.) ANS: B, C The nurse should summarize the problems discussed, thank the patient for his or her time, and explain what happens next and when the nurse will return. DIF: Cognitive Level: Comprehension REF: p. 59 OBJ: Theory #1 TOP: Nursing Process KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.) ANS: A, B, D, E The seven domains of the NIC taxonomy are physiological: basic; physiological: complex; behavioral; safety; family; health system; and community. DIF: Cognitive Level: Knowledge REF: p. 68 OBJ: Theory #5 TOP: NIC KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 9. The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.) ANS: A, B, C, E The purpose of NOC is to provide language labels to help identify and classify patient outcomes and validate classifications by field testing. DIF: Cognitive Level: Knowledge REF: p. 68 OBJ: Theory #6 TOP: NOC KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. Conclusions that have been made based on observed data are . ANS: inferences Inferences are conclusions made based on observed data. DIF: Cognitive Level: Knowledge REF: p. 65 OBJ: Theory #6 TOP: Inferences KEY: Nursing Process Step: N/A MSC: NCLEX: N/A