Test Bank for Foundations and Adult Health Nursing, 8th Edition by Kim Cooper and Kelly Gosnell All 58 Chapters Complete

Test Bank for Foundations and Adult Health Nursing, 8th Edition by Kim Cooper and Kelly Gosnell All 58 Chapters Complete Table of Contents Chapter 01: The Evolution of Nursing Chapter 02: Legal and Ethical Aspects of Nursing Chapter 03: Documentation Chapter 04: Communication Chapter 05: Nursing Process and Critical Thinking Chapter 06: Cultural and Ethnic Considerations Chapter 07: Asepsis and Infection Control Chapter 08: Body Mechanics and Patient Mobility Chapter 09: Hygiene and Care of the Patient’s Environment Chapter 10: Safety Chapter 11: Admission, Transfer, and Discharge Chapter 12: Vital Signs Chapter 13: Physical Assessment Chapter 14: Care of the Patient with a Neurologic Disorder Chapter 15: Elimination and Gastric Intubation Chapter 16: Care of Patients Experiencing Urgent Alterations in Health Chapter 17: Dosage Calculation and Medication Administration Chapter 18: Fluids and Electrolytes Chapter 19: Nutritional Concepts and Related Therapies Chapter 20: Complementary and Alternative Therapies Chapter 21: Pain Management, Comfort, Rest, and Sleep Chapter 22: Surgical Wound Care Chapter 23: Specimen Collection and Diagnostic Testing Chapter 24: Lifespan Development Chapter 25: Loss, Grief, Dying, and Death Chapter 26: Health Promotion and Pregnancy Chapter 27: Labor and Delivery Chapter 28: Care of the Mother and Newborn Chapter 29: Care of the High-Risk Mother, Newborn, and Family With Special Needs Chapter 30: Health Promotion for the Infant, Child, and Adolescent Chapter 31: Basic Pediatric Nursing Care Chapter 32: Care of the Child With a Physical and Mental or Cognitive Disorder Chapter 33: Health Promotion and Care of the Older Adult Chapter 34: Concepts of Mental Health Chapter 35: Care of the Patient With a Psychiatric Disorder 1 | P a g e 3 97 Chapter 36: Care of the Patient With an Addictive Personality Chapter 37: Home Health Nursing Chapter 38: Long-Term Care Chapter 39: Rehabilitation Nursing Chapter 40: Hospice Care Chapter 41: Professional Roles and Leadership Chapter 42: Care of the Surgical Patient Chapter 43: Care of the Patient with an Integumentary Disorder Chapter 44: Care of the Patient with a Musculoskeletal Disorder Chapter 45: Care of the Patient with a Gastrointestinal Disorder 424 434 442 452 463 473 481 494 505 518 Chapter 46: Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder 530 Chapter 47: Care of the Patient with a Blood or Lymphatic Disorder 543 Chapter 48: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder Chapter 49: Care of the Patient with a Respiratory Disorder Chapter 50: Care of the Patient with a Urinary Disorder Chapter 51: Care of the Patient with an Endocrine Disorder Chapter 52: Care of the Patient with a Reproductive Disorder Chapter 53: Care of the Patient with a Visual or Auditory Disorder Chapter 54: Care of the Patient with a Neurologic Disorder Chapter 55: Care of the Patient with an Immune Disorder Chapter 56: Care of the Patient with HIV/AIDS Chapter 57: Care of the Patient with Cancer Chapter 58: Professional Roles and Leadership 556 573 584 597 610 623 635 647 658 670 682 2 | P a g eChapter 01: The Evolution of Nursing MULTIPLE CHOICE 1. What is a nursing program considered when certified by a state agency? a. b. c. d. Accredited Approved Provisional Exemplified ANS: B Approved means certified by a state agency for having met minimum standards; accredited means certified by the NLN for having met more complex standards. Provisional and exemplified are not terms used in regard to nursing program certification. DIF: Cognitive Level: Knowledge TOP: Nursing programs Step: N/A MSC: NCLEX: N/A 2. Which of the following must the nurse recognize regarding the health care delivery system? a. b. c. d. It includes all states. It affects the illness of patients. Insurance companies are not in- volved. The major goal is to achieve opti- mal levels of health care. ANS: D The nurse must recognize that in the health care delivery system, the major goal is to achieve optimal levels of health care. The health care system consists of a network of agencies, facilities, and providers in- volved with health care in a specified geographic area. Insurance com- panies do have involvement in the health care system. The illness of patients is not necessarily affected by the health care system. DIF: Cognitive Level: Comprehension TOP: Health care systems Process Step: N/A REF: KEY: 12 OBJ: 7 Nursing 3. What is required by the health care team to identify the needs of a pa- tient and to design care to meet those needs? a. 3 | P a g e The Kardex REF: 10 KEY: OBJ: 5 Nursing Processb. The health care provider’s order sheet c. d. An individualized care plan The nurse’s notes ANS: C An individualized care plan involves all health care workers and out- lines care to meet the needs of the individual patient. The Kardex, health care provider’s order sheet, and nurse’s notes do not identify the needs of the patient nor are they designed to assist all members of the health care team to meet those needs. DIF: Cognitive Level: Comprehension REF: 13 OBJ: 8 | 9 TOP: Care plan KEY: Nursing Process Step: Planning NCLEX: N/A MSC: 4. Patient care emphasis on wellness, rather than illness, begins as a re- sult of: a. b. c. d. increased education concerning causes of illness. improved insurance payments. decentralized care centers. increased number of health care givers. ANS: A The acute awareness of preventive medicine has resulted in today’s emphasis on education about issues such as smoking, heart disease, drug and alcohol abuse, weight control, and mental health and well- ness promotion activities. This preventive education has resulted in an emphasis on wellness, rather than illness. Improved insurance pay- ments, decentralized care centers, and increased numbers of health care givers did not influence an emphasis on wellness. DIF: Cognitive Level: Comprehension REF: 12 OBJ: 4 | 8 TOP: Wellness KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. What is the most effective process to ensure that the care plan is meeting the needs of the patient? 4 | P a g ea. b. c. d. Documentation Communication Evaluation Planning ANS: B Communication is the primary essential component among the health care team to evaluate and modify the care plan. Documentation, eval- uation, and planning are not primary essential components to ensure the care plan is meeting the needs of the patient. DIF: Cognitive Level: Comprehension REF: TOP: Communication 17 OBJ: 8 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 6. How does an interdisciplinary approach to patient treatment enhance care? a. b. c. d. By improving efficiency of care By reducing the number of care- givers By preventing the fragmentation of patient care By shortening hospital stay ANS: C An interdisciplinary approach prevents fragmentation of care. An inter- disciplinary approach does not improve the efficiency of care, reduce the number of caregivers, or shorten hospital stay. DIF: Cognitive Level: Comprehension TOP: Interdisciplinary approach REF: 16 OBJ: 8 | 9 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. How may a newly licensed LPN/LVN practice? a. b. c. d. Independently in a hospital set- ting With an experienced LPN/LVN Under the supervision of a health care provider or RN As a sole health care provider in 5 | P a g ea clinic setting ANS: C An LPN/LVN practices under the supervision of a health care provider, dentist, OD, or RN. DIF: Cognitive Level: Knowledge TOP: Vocational nursing Step: N/A MSC: NCLEX: N/A 8. Whose influence on nursing practice in the 19th century was related to improvement of patient environment as a method of health promotion? a. b. c. d. Clara Barton Linda Richards Dorothea Dix Florence Nightingale ANS: D The influence of Florence Nightingale was highly significant in the 19th century as she fought for sanitary conditions, fresh air, and general im- provement in the patient environment. Clara Barton developed the American Red Cross in 1881. Linda Richards is known as the first trained nurse in America, was responsible for the development of the first nursing and hospital records, and is credited with the development of our present-day documentation system. Dorothea Dix was the pio- neer crusader for elevation of standards of care for the mentally ill and superintendent of female nurses of the Union Army. DIF: Cognitive Level: Knowledge TOP: Nursing leaders MSC: NCLEX: N/A 9. a. What document identifies the roles and responsibilities of the LPN/LVN? NLN Accreditation Standards b. c. d. Nurse Practice Act NAPNE Code American Nurses’ Association Code ANS: B The LPN/LVN functions under the Nurse Practice Act. NLN Accreditation Standards, the NAPNE Code, and the American Nurses’ Association Code do not identify the roles and responsibilities of the LPN/LVN. DIF: Cognitive Level: Knowledge TOP: Roles and responsibilities MSC: NCLEX: N/A 10. What is a cost-effective delivery of care used by many hospitals that al- lows the LPN/LVN to work with the RN to meet the needs of patients? 6 | P a g e REF: 12 | 14 OBJ: 11 KEY: Nursing Process Step: N/A REF: 17 OBJ: 2 | 4 KEY: Nursing Process Step: N/A REF: 11 KEY: OBJ: 11 Nursing Processa. b. c. d. Focused nursing Team nursing Case management Primary nursing ANS: C Case management is a cost-effective method of care. Focused nursing, team nursing, and primary nursing are not cost-effective methods of delivering care that allow the LPN/LVN to work with the RN to meet pa- tient needs. DIF: Cognitive Level: Comprehension TOP: Patient care delivery systemsKEY: MSC: NCLEX: N/A 11. What is the title of the American Hospital Association’s 1972 document that outlines the patient’s expectations to be treated with dignity and compassion? a. b. c. d. Code of Ethics Patient’s Bill of Rights OBRA Advance directives ANS: B Patient expectations are outlined by the Patient’s Bill of Rights. Patient expectations are not outlined in the Code of Ethics, OBRA, or advance directives. DIF: Cognitive Level: Knowledge TOP: Patient’s rights MSC: NCLEX: N/A 12. The relationships among nursing, patients, health, and the environ- ment are the basis for: a. care plans. REF: 16 OBJ: 4 | 8 KEY: Nursing Process Step: N/A REF: 15 OBJ: 7 | 9 Nursing Process Step: N/A 7 | P a g eb. c. d. nursing models. health care provider’s orders. evaluation of patient care. ANS: B Nursing models are theories based on the relationship between nurs- ing, patients, health, and environment. Care plans, health care provider’s orders, and evaluation of patient care are not based on the relationships among nursing, patients, health, and environment. DIF: Cognitive Level: Comprehension REF: TOP: Nursing models 17 OBJ: 1 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 13. What system reduces the number of employees but still provides qual- ity care for patients? a. b. c. d. Team nursing Cross-training Use of critical pathways Case management ANS: B Cross-training reduces the number of employees but does not alter the quality of patient care. Team nursing, use of critical pathways, and case management do not reduce the number of employees while con- tinuing to provide quality care for patients. DIF: Cognitive Level: Comprehension TOP: Patient care REF: 15 OBJ: 8 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 14. What is the purpose of licensing laws for LPN/LVNs? a. b. c. d. To limit the number of LPN/LVNs Prevention of malpractice Protection of the public from un- qualified people To increase revenue for the state board of nursing ANS: C The purpose of licensing laws for LPN/LVNs is to protect the public from unqualified health care providers. Licensing laws’ purpose is not to limit the number of LPNs/LVNs, prevent malpractice, or increase rev- enue for the state board of nursing. DIF: Cognitive Level: Comprehension REF: 11 OBJ: 4 | 9 | 10 TOP: Licensure KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8 | P a g ea. b. 15. What premise is Maslow’s hierarchy of needs based on? All needs are equally important. Basic needs must be met before the next level of needs can be met. c. d. Self-actualization is a primary need. Individuals prioritize needs the same way. ANS: B Maslow’s hierarchy of needs is based on the premise that basic needs must be met first. It is not based on all needs being equally important or that individuals prioritize needs the same way. Self-actualization is not a primary need according to Maslow. DIF: Cognitive Level: Comprehension 8 REF: 12 | 13 OBJ: TOP: Maslow’s Hierarchy of Needs KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 16. What must the nurse realize when assessing physical and social envi- ronmental factors affecting health and illness? a. b. c. d. They affect one another. They cause illness. They cause patients to react sim- ilarly. They can be separated. ANS: A Physical and social factors affect each other, cannot be separated, and cause each patient to react in a unique manner. They do not necessar- ily cause illness or cause patients to react similarly, and they cannot be separated. DIF: Cognitive Level: Comprehension REF: TOP: Environmental factors KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 17. What organization, established during World War II, provided nursing education and training? a. b. c. d. Nightingale school Cadet Nurse Corps Public health department Frontier Nursing Service ANS: B The Cadet Nurse Corps was established during World War II to provide 9 | P a g e 14 OBJ: 4 | 8nursing education and training. The Nightingale school, public health department, and Frontier Nursing Service are not organizations estab- lished during World War II to provide nursing education and training. DIF: Cognitive Level: Knowledge TOP: Nursing education Step: N/A MSC: NCLEX: N/A 18. What is a modern educational advancement program for the LPN/LVN to enter RN education? a. b. c. d. Repetition Exclusion Articulation Coexistence ANS: C Most states have some type of articulation program in which the LPN/LVN can achieve advanced standing in an RN program without having to enroll in the entire curriculum. Repetition, exclusion, and co- existence do not refer to educational advancement. DIF: Cognitive Level: Knowledge TOP: Nursing education Step: N/A MSC: NCLEX: N/A 19. Where did Florence Nightingale’s original nursing education take place? a. Saint Thomas REF: 10 KEY: OBJ: 1 | 9 Nursing Process REF: 5 KEY: OBJ: 1 | 4 Nursing Process 10 | P a g eb. c. d. Kings College Hospital Crimean Hospital Kaiserswerth School ANS: D Florence Nightingale trained at Kaiserswerth School. Florence Nightin- gale’s original training was not at Saint Thomas, Kings College Hospi- tal, or Crimean Hospital. DIF: Cognitive Level: Knowledge TOP: Nursing programs Step: N/A MSC: NCLEX: N/A 20. What system of comprehensive patient care considers the physical, emotional, and social environment and spiritual needs of a person? a. b. c. d. Interdependent care Holistic health care Illness prevention care Health promotion care ANS: B Holistic health care encompasses the physical, emotional, social, and spiritual aspects of the patient. DIF: Cognitive Level: Comprehension REF: 12 OBJ: 8 TOP: Health care KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. What official agency exists exclusively for LPN/LVN membership and promotes standards for the LPN/LVN? a. b. c. d. NFLPN ANA NLN NAPNES ANS: A The NFLPN exists solely for the LPN/LVN. The other options have mem- bership that includes RNs and the lay public. DIF: Cognitive Level: Knowledge TOP: Nursing organizations Step: N/A MSC: NCLEX: N/A 22. What score does the graduate practical nurse require to be issued a li- cense upon completion of the computerized examination? a. 11 | P a g e 70% or better REF: 10 KEY: OBJ: 5 | 6 | 9 Nursing Process REF: 2 KEY: OBJ: 2 Nursing Processb. This is defined and set by each state c. d. Designated as “pass” Within the 75th percentile ANS: C Currently graduates of an approved vocational school are eligible to take the licensing examination and be awarded a license with a score of “pass” that is recognized by all states. DIF: Cognitive Level: Knowledge TOP: Licensure examination MSC: NCLEX: N/A 23. What document, published in 1965 by the ANA, clearly defined two lev- els of nursing practice? a. b. c. d. Licensing standards Position paper Smith-Hughes Act Nurse practice act ANS: B The ANA’s position paper of 1965 defined two levels of nursing: regis- tered nurse and technical nurse. Licensing standards, the Smith- Hughes Act, and the nurse practice act were not documents defining two levels of nursing practice published in 1965. DIF: Cognitive Level: Knowledge TOP: Position paper Step: N/A MSC: NCLEX: N/A a. b. c. 24. What is the wellness/illness continuum defined as? A concept that never changes The range of a person’s total health A continuum influenced only by REF: 11 KEY: OBJ: 3 | 4 | 9 Nursing Process REF: 12 OBJ: 3 KEY: Nursing Process Step: N/A 12 | P a g eone’s physical condition d. An idea that focuses strictly on an individual’s social well-being ANS: B The wellness/illness continuum is defined as the range of a person’ s to- tal health. This continuum is ever changing, and it is influenced by the individual’s physical condition, mental condition, and social well-being. DIF: Cognitive Level: Comprehension REF: 12 OBJ: 8TOP : Wellness/illness continuum KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 25. According to Maslow’s hierarchy of needs, what is an individual’s most basic need? a. b. c. d. e. Safety and security Love/belongingness Physiologic Self-actualization Esteem ANS: C Abraham Maslow believed that an individual’s behavior is formed by the individual’s attempts to meet essential human needs, which he identified as physiologic, safety and security, love and belongingness, and esteem and self- actualization. DIF: Cognitive Level: Comprehension 8 REF: 12 | 13 OBJ: TOP: Maslow’s Hierarchy of Needs KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. Florence Nightingale established a nursing school at Saint Thomas Hos- pital in London. What was it characterized by? (Select all that apply.) a. b. c. Allowing all applicants who ap- plied to be enrolled Offering formal and practical ed- ucational experiences Keeping records of students’ progress 13 | P a g ed. Focusing on sanitation and hy- giene e. Retaining a registry of all gradu- ates ANS: B, C, D, E The nursing school established by Florence Nightingale rigorously screened its applicants. The curriculum, which included both formal ed- ucation and practical experiences, was focused on hygiene and sanita- tion. The school kept records of the students’ progress during their school years, and also kept a registry of the graduates. DIF: Cognitive Level: Comprehension REF: 3 TOP: School established by Florence Nightingale KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. Primitive medical interventions were based on the belief that illness was caused by the presence of spirits. ANS: evil Illness was thought to be caused by the inhabitation of the body by evil spirits. Medical interventions were designed to drive out the evil spirits by introducing good spirits. DIF: Cognitive Level: Comprehension TOP: Primitive health care Process Step: N/A MSC: NCLEX: N/A 2. During early civilization men performed witchcraft and rit- uals to induce the bad spirits to leave the body of the ailing person. ANS: medicine Medicine men performed witchcraft and rituals to induce the bad spir- its to leave the body of the ailing person during early civilization. DIF: Cognitive Level: Knowledge REF: 2 TOP: Primitive health care Step: N/A 3. The National Council of State Boards of Nursing (NCSBN) performs a job analysis every years to determine the scope of practice of LPN/LVNs. 14 | P a g e KEY: OBJ: 1 Nursing Process REF: KEY: 1 OBJ: 1 Nursing OBJ: 1 | 2ANS: 3 three The National Council of State Boards of Nursing performs a job analysise very 3 years to measure the scope of practice for LPN/LVNs. DIF: Cognitive Level: Knowledge TOP: National Council analysis MSC: NCLEX: N/A 4. Graduates of the first school for training the practical nurse were re- ferred to as ANS: attendant nurses. The first school for training the practical nurse started in Brooklyn, New York, in 1892 and was conducted under the auspices of the Young Women’s Christian Association (YWCA). The Ballard School, as it was known, was approximately 3 months in duration and trained its stu- dents to care for the chronically ill, invalids, children, and the elderly. The main emphasis was on home care and included cooking, nutrition, basic science, and basic procedures. Graduates of this program were referred to as attendant nurses. DIF: Cognitive Level: Knowledge TOP: Attendant nurses MSC: NCLEX: N/A 5. In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by Lillian . ANS: Kuster In 1949, the National Federation of Licensed Practical Nurses (NFLPN) was founded by Lillian Kuster. This association is the official member- ship organization for licensed practical nurses/licensed vocational DIF: Cognitive Level: Knowledge REF: 10 OBJ: 2 TOP: National Federation of Licensed Practical Nurses KEY: Nursing Process Step: N/A MSC: NCLEX: N/A Chapter 02: Legal and Ethical Aspects of Nursing MULTIPLE CHOICE 1. When a nurse becomes involved in a legal action, the first step to oc- 15 | P a g e REF: 9 OBJ: 1 KEY: Nursing Process Step: N/A REF: 18 OBJ: 6 | 9 KEY: Nursing Process Step: N/Acur is that a document is filed in an appropriate court. What is this doc- ument called? a. b. c. d. Deposition Appeal Complaint Summons ANS: C A document called a complaint is filed in an appropriate court as the first step in litigation. A deposition is when witnesses are required to undergo questioning by the attorneys. An appeal is a request for a re- view of a decision by a higher court. A summons is a court order that notifies the defendant of the legal action. DIF: Cognitive Level: Knowledge TOP: Legal REF: 24 OBJ: 1 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. The nurse caring for a patient in the acute care setting assumes re- sponsibility for a patient’s care. What is this legally binding situation? a. b. c. d. Nurse-patient relationship Accountability Advocacy Standard of care ANS: A When the nurse assumes responsibility for a patient’s care, the nurse- patient relationship is formed. This is a legally binding “contract” for which the nurse must take responsibility. Accountability is being re- sponsible for one’s own actions. An advocate is one who defends or pleads a cause or issue on behalf of another. Standards of care define acts whose performance is required, permitted, or prohibited. DIF: Cognitive Level: Comprehension TOP: Legal REF: 24 OBJ: 3 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. What are the universal guidelines that define appropriate measures for all nursing interventions? a. b. c. d. Scope of practice Advocacy Standard of care Prudent practice ANS: C Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on be- half of another. Prudent is a term that refers to careful and/or wise practice. 16 | P a g eDIF: Cognitive Level: Knowledge TOP: Legal REF: 22 OBJ: 4 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention? a. b. c. d. Standards of care Regulation of practice American Nurses’ Association Code Nurse practice act ANS: D It is the nurse’s responsibility to know the nurse practice act in his or her state. Standards of care, regulation of practice, and the American Nurses’ code are not laws that the nurse should refer to before initiat- ing this treatment. DIF: Cognitive Level: Application TOP: Legal REF: 26 OBJ: 5 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of: a. b. c. d. malpractice. harm to the patient. negligence. failure to follow the nurse prac- tice act. ANS: A The nurse can be held liable for malpractice for acts of omission. Fail- ure to meet a legal duty, thus causing harm to another, is malpractice. The nurse practice act has general guidelines that can support the charge of malpractice. DIF: Cognitive Level: Application TOP: Legal REF: 24 OBJ: 2 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 6. Patients have expectations regarding the health care services they re- ceive. To protect these expectations, which of the following has be- come law? a. b. c. d. ANS: A 17 | P a g e American Hospital Association’s Patient’s Bill of Rights Self-Determination Act American Hospital Association’s Standards of Care The Joint Commission’s rights and responsibilities of patientsPatients have expectations regarding the health care services they re- ceive. In 1972, the American Hospital Association (AHA) developed the Patient’s Bill of Rights. The Self-Determination Act, American Hospital Association’s Standards of Care, and The Joint Commission’s rights and responsibilities do not address patients’ expectations regarding health care. DIF: Cognitive Level: Comprehension TOP: Legal REF: 27 OBJ: 3 | 4 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? a. Physical assessment 18 | P a g eb. c. d. Interview Informed consent Surgical checklist ANS: C The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure. DIF: Cognitive Level: Application TOP: Legal REF: 27 OBJ: 8 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8. When a nurse protects the information in a patient’s record, what ethi- cal responsibility is the nurse fulfilling? a. b. c. d. Privacy Disclosure Confidentiality Absolute secrecy ANS: C The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and an- ticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret. DIF: Cognitive Level: Comprehension REF: TOP: Confidentiality 29-30 OBJ: 9 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 9. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action? a. b. c. d. Cover the bruises with bandages. Take photographs of the bruises. Ask the patient if anyone has hit her. Report the bruises to the charge nurse. ANS: D The law stipulates that the health care professional is required to re- port certain information to the appropriate authorities. The report should be given to a supervisor or directly to the police, according to agency policy. When acting in good faith to report mandated informa- tion (e.g., certain communicable diseases or gunshot wounds), the health care professional is protected from liability. DIF: Cognitive Level: Application TOP: Elder abuse KEY: NCLEX: N/A REF: 31 OBJ: 9 Nursing Process Step: N/A MSC:a. b. c. 10. What is the best way for a nurse to avoid a lawsuit? Carry malpractice insurance. Spend time with the patient. Provide compassionate, compe- tent care. d. Answer all call lights quickly. ANS: C The best defense against a lawsuit is to provide compassionate and competent nursing care. Carrying malpractice insurance is prudent, but it will not avoid a lawsuit. Spending time with patients and answering call lights quickly will not necessarily help avoid a lawsuit. DIF: Cognitive Level: Comprehension TOP: Avoiding a lawsuit Process Step: N/A MSC: NCLEX: N/A 11. The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her le- gal obligation? a. b. c. d. To question the health care provider To seek advice from the family To discuss it with the patient To follow the order ANS: D When a DNR order is written in the chart, the nurse has a duty to follow the order. Questioning the health care provider, seeking advice from the family, and discussing it with the patient are not legal obligations of the nurse. TOP: Legal REF: KEY: 29 OBJ: 8 Nursing KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 12. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take? a. b. c. d. Ask for another assignment. Leave work. Transfer to another floor. Protest to the supervisor. ANS: A The nurse should not abandon the patient, but ask for another assign- ment. DIF: Cognitive Level: Application TOP: Ethics REF: 37 OBJ: 9 | 16 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A13. The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information? a. b. c. d. Nurse practice act Standards of care Scope of nursing practice Professional organizations ANS: B Standards of care define what should or should not be done for pa- tients. The nurse practice act, scope of nursing practice, and profes- sional organizations do not provide the best information as to what should or should not be done for patients. DIF: Cognitive Level: Comprehension REF: TOP: Standards of care 24 OBJ: 5 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 14. What role is the nurse who diligently works for the protection of pa- tients’ interests playing? a. b. c. d. Caregiver Health care administrator Advocate Health care evaluator A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patient’s interests. Caregiver, health care ad- ministrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patients. DIF: Cognitive Level: Comprehension REF: 25 OBJ: 9 | 12 TOP: Advocate KEY: Nursing Process Step: N/A MSC: NCLEX: N/A a. b. c. d. 15. When asked to perform a procedure that the nurse has never done be- fore, what should the nurse do to legally protect himself or herself? Go ahead and do it. Refuse to perform it, citing lack of knowledge. Discuss it with the charge nurse, asking for direction. Ask another nurse who has per- formed the procedure. ANS: C The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently. DIF: Cognitive Level: Application TOP: Legal REF: 26 OBJ: 8 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A16. The nurse is assisting a patient to clarify values by encouraging the ex- pression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse? a. b. c. d. Compare values with those of the patient. Make a judgment. Withhold an opinion. Give advice. ANS: C The nurse can assist the patient in values clarification without giving an opinion. DIF: Cognitive Level: Application TOP: Values clarification Step: N/A MSC: NCLEX: N/A 17. What fundamental principle must the nurse first observe when con- fronted with an ethical decision? a. b. c. d. Autonomy Beneficence Respect for people Nonmaleficence ANS: C The first fundamental principle is respect for people. Autonomy, benefi- cence, and nonmaleficence are not the first fundamental principles to observe when confronted with an ethical decision. DIF: Cognitive Level: Comprehension 15 TOP: Ethics REF: 36 OBJ: 13 | KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 18. A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the patient’s health, safety, and well-being. Given this knowledge, which of the following is most necessary for the nurse to report? a. b. c. d. Unethical behavior of other staff members A worker who arrives late Favoritism shown by nursing ad- ministration Arguments among the staff ANS: A A member of the nursing profession must report behavior that does not meet established standards. Unethical behavior involves failing to per- form the REF: 35 KEY: OBJ: 3 | 8 Nursing Processduties of a competent caring nurse. DIF: Cognitive Level: Application TOP: Unethical behavior Step: N/A MSC: NCLEX: N/A 19. A nurse is considering purchasing malpractice insurance. What should the nurse be aware of regarding malpractice insurance provided by the hospital? a. Only offers protection while on duty. REF: 36 KEY: OBJ: 13 Nursing Processb. Is limited in the amount of cover- age. c. d. Is difficult to renew. Can be terminated at any time. ANS: A Most institutional insurance only provides liability coverage if the nurse is on duty at that facility. DIF: Cognitive Level: Comprehension TOP: Malpractice insurance Process Step: N/A MSC: NCLEX: N/A 20. Which is a nursing care error that violates the Health Insurance Porta- bility and Accountability Act (HIPAA)? a. b. c. d. Administering a stronger dose of drug than was ordered Refusing to give a patient’s daughter information over the phone Informing the patient’s medical power of attorney of a medica- tion change Leaving a copy of the patient’s history and physical in the photo- copier ANS: D Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing in- formation with the power of attorney is legal. Refusing to give a pa- tient’s daughter information over the phone is appropriate practice. DIF: Cognitive Level: Comprehension REF: 27 OBJ: 7 TOP: Health Insurance Portability and Accountability Act (HIPAA) KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. Which of the following could cause a nurse to be cited for malpractice? a. Refusing to give 60 mg of mor- phine as ordered b. Giving prochlorperazine (Com- pazine) to a patient allergic to REF: KEY: 32 OBJ: 2 Nursingphenothiazines c. d. Dragging an injured motorist off the highway and causing further injury Informing a visitor about a pa- tient’s condition ANS: B Standards of care dictate that a nurse must be aware of all the proper- ties of drugs administered. Prochlorperazine (Compazine) is a phenoth- iazine. Providing confidential information or refusing to give an exces- sively large narcotic dose is not considered malpractice. Good Samari- tan laws generally protect a person giving aid to an injured motorist. DIF: Cognitive Level: Application REF: 26 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 22. A lumbar puncture was performed on a patient without a signed in- formed consent form. This patient might sue for: a. b. c. d. punitive damages. civil battery. assault. nothing; no violation has oc- curred. ANS: B Civil battery charges can be brought against someone performing an invasive procedure without the patient’s informed consent legally doc- umented. This patient could not sue for punitive damages or an as- sault. DIF: Cognitive Level: Comprehension TOP: Informed consent REF: 27 OBJ: 6 | 8 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient’s indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurse’s actions exemplify? a. b. c. Malpractice Battery Assaultd. Neglect of duty ANS: A A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient. DIF: Cognitive Level: Application REF: 25 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 24. What is true about nurse practice acts? a. b. c. d. They informally define the scope of nursing practice. They provide for unlimited scope of nursing practice. Only some states have adopted a nurse practice act. The nurse must know the nurse practice act within his or her state. ANS: D The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legis- latures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurse’s re- sponsibility to know the nurse practice act that is in effect for her geo- graphic region. DIF: Cognitive Level: Comprehension TOP: Nurse practice acts Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. How can the medical record be used in litigation? (Select all that ap- ply.) a. Public record b. c. Proof of adherence to standards Evidence of omission of care REF: KEY: 26 Nursing Processd. e. Documentation of time lapses Evidence by only the plaintiff ANS: A, B, C, D The information when used in court becomes a public record. The infor- mation can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document. DIF: Cognitive Level: Comprehension REF: TOP: Legal properties of medical record KEY: Step: N/A MSC: NCLEX: N/A 2. During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.) a. b. c. d. e. HIPAA violation Slander Libel Invasion of privacy Defamation ANS: A, D The disclosure is an invasion of privacy and a violation of HIPAA. Be- cause the information is true and verbal, it cannot be considered slan- der or libel. DIF: Cognitive Level: Application TOP: Disclosure of information MSC: NCLEX: N/A 3. A nurse failed to monitor a patient’s respiratory status after medicating the patient with a narcotic analgesic. The patient’s respiratory status worsened, requiring intubation. The patient’s family claimed the nurse committed malpractice. What must be present for the nurse to be held liable? (Select all that apply.) a. A nurse-patient relationship ex- ists. b. c. The nurse failed to perform in a reasonable manner. There was harm to the patient. REF: 30 OBJ: 7 KEY: Nursing Process Step: N/A 24 OBJ: 1 | 4 Nursing Processd. The nurse was prudent in her performance. e. f. The nurse did not cause the pa- tient harm. Duty does not exist. ANS: A, B, C For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred. DIF: Cognitive Level: Application REF: 24 OBJ: 2 TOP: Malpractice KEY: Nursing Process Step: N/A MSC: NCLEX: N/A COMPLETION 1. Personal beliefs about the worth of an object, idea, custom, or attitude that influence a person’s behavior in a given situation are referred to as . ANS: values Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing cir- cumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influ- ence our behavior in a given situation. DIF: Cognitive Level: Knowledge TOP: Values REF: 34 OBJ: 11 | 12 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. Acts whose performance is required, permitted, or prohibited are de- fined by of care. ANS: standards Standards of care define acts whose performance is required, permit- ted, or prohibited. DIF: Cognitive Level: Knowledge TOP: Standards of care MSC: NCLEX: N/A Chapter 03: Documentation MULTIPLE CHOICE 1. What does documentation of type of care, time of care, and signature of the person prove? a. The person who signed the docu- mentation did all the work noted. REF: 26 OBJ: 4 KEY: Nursing Process Step: N/Ab. No litigation can be brought against the person who signed. c. d. Interventions were implemented to meet the patient’s needs. The patient’s response to the in- tervention was positive. ANS: C Documenting type of care, time of care, and signature of the person re- sults in recording the interventions that are implemented to meet the patient’s needs. Many charting entries include health care provider’s visits, presence of family, or interventions by other departments. Pa- tient response to some interventions is not always positive. DIF: Cognitive Level: Comprehension TOP: Documentation REF: 40 OBJ: 1 KEY: Nursing Process Step: Imple- mentation MSC: NCLEX: N/A 2. Why is documentation especially significant in managed care? a. b. c. d. The hospital needs to show that employees care for patients. Institutions are reimbursed only for patient care that is docu- mented. Patients might bring lawsuits if care was not given. Documents may become part of a lawsuit. ANS: B Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups (DRGs): a system that classifies patients by age, diagnosis, sur- gical procedure, and other information with hundreds of different cate- gories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount. DIF: Cognitive Level: Comprehension REF: TOP: Documentation 41 OBJ: 1 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation? a. b. c. d. ANS: C SOAP Block CBE FocusCharting additional treatments done, changes in a patient’s condition, and new concerns during the shift is charting by exception (CBE). DIF: Cognitive Level: Comprehension TOP: Documentation MSC: NCLEX: N/A 4. What form explains the lapse when events are not consistent with facil- ity or national standards of expected care? a. b. c. d. Subjective data Focus chart Incident report Nursing assessment ANS: C An incident report is completed when patient care was not consistent with facility or national standards. The form explains the event, time, extent of injury, and who was notified. DIF: Cognitive Level: Knowledge TOP: Documentation MSC: NCLEX: N/A 5. The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a: a. b. c. d. nursing order. Kardex. nursing care plan. critical pathway. ANS: D Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay for patients of a specific case type. DIF: Cognitive Level: Knowledge TOP: Documentation mentation MSC: NCLEX: N/A 6. What makes home health care documentation unique? a. b. c. d. Some charting is retained at the hospital. The health care provider’s office needs separate charting. Different health care providers need access. The health care provider is the pivotal person in the charting. REF: 41 OBJ: 8 KEY: Nursing Process Step: Imple- REF: 49 OBJ: 1 | 7 KEY: Nursing Process Step: N/A REF: 47-48 OBJ: 1 | 5 | 7 KEY: Nursing Process Step: N/AANS: C Home health care documentation has unique problems because of the need for different health care workers to access the medical record. DIF: Cognitive Level: Comprehension REF: TOP: Documentation 55 OBJ: 9 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. What regulates standards for long-term care documentation? a. b. c. d. OBRA Title XXII Patient problems The care plan ANS: A OBRA (Omnibus Budget Reconciliation Act) was a significant Medicare and Medicaid legislation for long-term health care documentation. DIF: Cognitive Level: Knowledge TOP: Documentation MSC: NCLEX: N/A 8. What is the nurse required to do to adhere to the concept of confiden- tiality for the patient’s medical record? a. b. c. d. Provide information only to an- other nurse. Provide information only to an at- torney. Share information only with the family. Have a clinical reason for reading the record. ANS: D The nurse should not read the patient’s medical record unless there is a clinical reason for doing so. DIF: Cognitive Level: Comprehension REF: TOP: Confidentiality 56 OBJ: 4 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 9. Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part? a. b. c. d. ANS: C Assessment Planning Implementation Evaluation REF: 55 OBJ: 10 KEY: Nursing Process Step: N/ADocumentation is part of the implementation phase of the nursing process. DIF: Cognitive Level: Comprehension TOP: Documentation REF: 40 OBJ: 1 | 4 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 10. What does the nurse use as a basis for documentation in focus chart- ing?a. b. c. d. Problem list Nursing orders Patient problems Evaluation ANS: C In focus charting, instead of using the problem list, modified patient problems are used as an index for nursing documentation. DIF: Cognitive Level: Knowledge TOP: Documentation MSC: NCLEX: N/A 11. What is the purpose of QA (quality assurance)? a. b. c. d. To screen employment applica- tions To evaluate care results against accepted standards To conduct in-services for “qual- ity documentation” To report deviation from stan- dards to the state health depart- ment ANS: B QA is an in-house department that evaluates care services and results against accepted standards. DIF: Cognitive Level: Comprehension REF: TOP: Documentation 41 OBJ: 1 KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 12. What is the process used to appraise the practice of an individual nurse known as? a. b. c. d. Quality assurance Incident reporting OBRA Peer review ANS: D Peer review is an in-house department study that may appraise the nursing practice of individual nurses. DIF: Cognitive Level: Knowledge REF: 41 OBJ: 4 TOP: Peer reviewKEY: Nursing Process Step: N/A MSC: NCLEX: N/A 13. What is the documentation format that uses the acronym SOAPE? a. Problem-oriented REF: 47 OBJ: 7 KEY: Nursing Process Step: N/Ab. c. d. Focused Traditional Crisis ANS: A The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems. DIF: Cognitive Level: Comprehension REF: 46 OBJ: 7 TOP: Problem-oriented medical record (POMR) KEY: Nursing Process Step: N/A MSC: NCLEX: N/A a. b. c. d. 14. Who is the legal owner of the patient’s medical record? Patient Health care provider Institution State ANS: C Ownership of a medical record belongs to the institution in the