Test Bank For Basic Nursing Concepts Skills And Reasoning 2Nd Edition Treas Wilkinson

TEST BANK FOR BASIC NURSING CONCEPTS SKILLS AND REASONING 2ND EDITION TREAS WILKINSONTable of Contents Chapter 1. Nursing Past & Present ................................ ............................ 2 Chapter 2. Critical Thinking & the Nursing Process ................................ ............ 22 Chapter 3. Assessment ................................ ................................ .... 37 Chapter 4. Nursing Process: Diagnosis ................................ ....................... 56 Chapter 5. Planning Outcomes ................................ .............................. 75 Chapter 6. Planning Interventions ................................ ........................... 91 Chapter 7. Implementation & Evaluation ................................ .................... 108 Chapter 8. Theory, Research, & Evidence-Based Practice ................................ ....... 123 Chapter 9. Development: Infancy Through Middle Adulthood ................................ ... 138 Chapter 10. Development: Older Adulthood ................................ .................. 155 Chapter 11. Experiencing Health & Illness ................................ ................... 172 Chapter 12. Stress & Adaptation ................................ ........................... 188 Chapter 13. Psychosocial Health & Illness ................................ ................... 204 Chapter 14. Family ................................ ................................ ...... 225 Chapter 15. Culture & Ethnicity ................................ ............................ 241 Chapter 16. Spirituality ................................ ................................ ... 256 Chapter 17. Loss, Grief, & Dying................................ ............................ 272 Chapter 18. Documenting & Reporting ................................ ...................... 292 Chapter 19. Development: Infancy Through Middle Adulthood ................................ .. 311 Chapter 20. Communicating & Therapeutic Relationships ................................ ...... 328 Chapter 21. Physical Assessment ................................ ........................... 347 Chapter 22. Infection Prevention & Control ................................ .................. 373 Chapter 23. Safety ................................ ................................ ....... 392 Chapter 24. Hygiene ................................ ................................ ..... 408 Chapter 25. Administering Medications ................................ ..................... 426 Chapter 26. Teaching & Learning ................................ .......................... 449 Chapter 27: Health Promotion ................................ ............................. 465 Chapter 28. Nutrition ................................ ................................ .... 482 Chapter 29. Bowel Elimination................................ ............................. 504 Chapter 30. Urinary Elimination ................................ ........................... 522 Chapter 31. Sensory Perception ................................ ............................ 541 Chapter 32. Pain................................ ................................ ......... 559 Chapter 33. Activity & Exercise ................................ ............................ 581 Chapter 34. Sexual Health ................................ ................................ . 603 Chapter 35. Sleep & Rest ................................ ................................ .. 619 Chapter 36. Skin Integrity & Wound Healing ................................ ................. 635 Chapter 37. Oxygenation ................................ ................................ .. 657 Chapter 38. Circulation & Perfusion ................................ ........................ 676 1 | P a g eChapter 39. Fluids, Electrolytes, & Acid–Base Balance ................................ ......... 692 Chapter 40. Perioperative Nursing ................................ ......................... 715 Chapter 41. Leading & Managing ................................ ........................... 734 Chapter 42. Community & Home Health Nursing ................................ ............. 749 Chapter 43. Ethics & Values ................................ ............................... 771 Chapter 44. Legal Accountability ................................ ........................... 787 Chapter 45. Nursing Informatics ................................ ........................... 803 Chapter 46. Holistic Healing ................................ ............................... 818 Chapter 1. Nursing Past & Present MULTIPLE CHOICE 2 | P a g e1. Which is the most influential factor that has shaped the nursing profession? 1) Physicians’ need for handmaidens 2) Societal need for healthcare outside the home 3) Military demand for nurses in the field 4) Germ theory influence on sanitation ANS: 3 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Define nursing in your own words. Chapter page reference: p. 7 Heading: Historical Context of Nursing Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Professionalism Difficulty: Easy Feedback 1 The physician's handmaiden was/is a nursing stereotype rather than an influence on nursing. 2 Although there has been a need for healthcare outside the home throughout history, this has more influenceonthedevelopment of hospitals than on nursing; this need provided one more setting for nursing work. 3 Throughout the centuries, stability of the government has been related to the success of the military to protect or extend its domain. As the survival and well-being of soldiers are both critical, nurses provided healthcare to the sick and injured at the battle site. 4 Germ theory and sanitation helped to improve healthcare but did not shape nursing. PTS: 1 CON: Professionalism 2. Which is an example of an illness-prevention activity? 1) Encouraging the use of a food diary 2) Joining a cancer support group 3) Administering immunization for HPV 4) Teaching a diabetic patient about his diet ANS: 3 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Name and recognize the four purposes of nursing care. Chapter page reference: p. 15 Heading: Nursing Practice: Caring for Clients Integrated Processes: Nursing Process – Implementation Client Need: Health Promotion and Maintenance 3 | P a g eCognitive level: Application [Applying] Concept: Health Promotion Difficulty: Moderate Feedback 1 Illness-prevention activities focus on avoiding a specific disease. A food diary is a health-promotion activity. 2 Although cancer is a disease, it is assumed that a person joining a support group would already have the disease; therefore, this is not disease prevention but treatment. 3 Administering immunization for HPV is an example of illness prevention. 4 Teaching a diabetic patient about diet is a treatment for diabetes; the patient already has diabetes, so it cannot prevent diabetes. PTS: 1 CON: Health Promotion 3. Which contribution of Florence Nightingale had an immediate impact on improving patients’ health? 1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) Establishing nursing as a distinct profession ANS: 1 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Name nine expanded roles for nursing. Chapter page reference: p. 9 Heading: Table 1-1 Roles andFunctionsoftheNurseIntegrated Processes: Caring Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Easy Feedback 1 Improved sanitation (a clean environment) greatly and immediately reduced the rate of infection and mortality in hospitals. 2 This is an activity of Florence Nightingale that improved healthcare or nursing, but the impact is long range, not immediate. 3 This is an activity of Florence Nightingale that improved healthcare or nursing, but the impact is long range, not immediate. 4 This is an activity of Florence Nightingale that improved healthcare or nursing, but the impact is long range, not immediate. PTS: 1 CON: Evidence-Based Practice 4. Which aspect of the full-spectrum nursing role is essential for the nurse to do in order to successfully carry out all the others? 1) Thinking and reasoning about the client’s care 2) Providing hands-on client care 3) Carrying out physician orders 4 | P a g e4) Delegating to assistive personnel ANS: 1 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Name and recognize the four purposes of nursing care. Chapter page reference: p. 8 Heading: Nursing Today: Full-Spectrum Nursing Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Analysis [Analyzing] Concept: Patient-Centered Care Difficulty: Difficult Feedback 1 A substantial portion of the nursing role involves using clinical judgment, critical thinking, and problem solving, which directly affect the care the client will actually receive. 2 Providing hands-on care is important; however, clinical judgment, critical thinking, and problem-solving are essential to do it successfully. 3 Carrying out physician orders is a small part of a nurse’s role; it, too, requires nursing assessment, planning, intervention, and evaluation. 4 Many simple nursing tasks are being delegated to nursing assistive personnel; delegation requires careful analysis of patient status and the appropriateness of support personnel to deliver care. PTS: 1 CON: Patient-Centered Care 5. Which statement pertaining toBenner’spracticemodel for clinical competence is true? 1) Progression through the stages is constant, with most nurses reaching the proficient stage. 2) Progression through the stages involves continual development of thinking and technical skills. 3) The nurse must have experience in many areas before being considered an expert. 4) The nurse’s progress through the stages is determined by years of experience and skills. ANS: 2 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Discuss the transitions nursing education has undergone in the last century. Chapter page reference: p. 12 Heading: Benner’s Model Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Easy Feedback 1 Movement through the stages is not constant. 2 Benner’s model is based on integration of knowledge, technical skill, and intuition in the development of clinical wisdom. 5 | P a g e3 The model does not mention experience in many areas. 4 The model does not mention years of experience. PTS: 1 CON: Evidence-Based Care 6. Which best explains why it is difficult for the profession to develop a definition of nursing? 1) There are too many different and conflicting images of nurses. 2) There are constant changes in healthcare and the activities of nurses. 3) There is disagreement among the different nursing organizations. 4) There are different education pathways and levels of practice. ANS: 2 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Discuss the transitions that nursing education has undergone in the last century. Chapter page reference: p. 8 Heading: How Is Nursing Defined? Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Analysis [Analyzing] Concept: Professionalism Difficulty: Difficult Feedback 1 The conflicting images of nursing make it more important to develop a definition; they may also make it more difficult but not to the extent that constant change does. 2 Healthcare is constantlychangingandwith itcome changes in where, how, and what nursing care is delivered. Constant changes make it difficult to develop a definition. 3 Although different nursing organizations have different definitions, they are similar in most ways. 4 The different education pathways affect entry into practice, not the definition of nursing. PTS: 1 CON: Professionalism 7. Nurses have the potential to be very influential in shaping healthcare policy. Which factor contributes most to nurses’ influence? 1) Nurses are the largest health professional group. 2) Nurses have a long history of serving the public. 3) Nurses have achieved some independence from physicians in recent years. 4) Political involvement has helped refute negative images portrayed in the media. ANS: 1 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Discuss issues related to healthcare reform. Chapter page reference: p. 24 Heading: Influence of Nurses on Health Policy Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care 6 | P a g eCognitive level: Comprehension [Understanding] Concept: Health Care System Difficulty: Easy Feedback 1 Nurses are trusted professionals and the largest health professional group. As such, they have political power to effect changes. If nursing were a small group, there would be little potential for power in shaping policies, even if all the other answers were true. 2 Serving the public, although positive, does not necessarily help nurses to be influential in establishing health policy. 3 Independence from physicians, although positive, does not necessarily make nurses influential in establishing healthcare policy. 4 Refuting negative media, although positive, does not necessarily make nurses influential in establishing healthcare policy. PTS: 1 CON: Health Care System 8. Nursing was described as a distinct occupation in the sacred books of which faith? 1) Buddhism 2) Christianity 3) Hinduism 4) Judaism ANS: 3 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Discuss the transitions that nursing education has undergone in the last century. Chapter page reference: p. 6 Heading: Historical Context of Nursing Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Knowledge [Remembering] Concept: Professionalism Difficulty: Easy Feedback 1 Nursing was not described as a distinct occupation in the sacred books of Buddhism. 2 Nursing was not described as a distinct occupation in the sacred books of Christianity. 3 The Vedas, the sacred books of the Hindu faith, described Indian healthcare practices and were the earliest writings of a distinct nursing occupation. 4 Nursing was not described as a distinct occupation in the sacred books of Judaism. PTS: 1 CON: Professionalism 9. Which individual established the American Red Cross? 1) Louisa May Alcott 2) Clara Barton 7 | P a g e3) Dorothea Dix 4) Harriet Tubman ANS: 2 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Give four examples of influential nursing organizations. Chapter page reference: p. 19 Heading: Charitable Organizations Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Knowledge [Remembering] Concept: Evidence-Based Practice Difficulty: Easy Feedback 1 Louisa May Alcott was an American novelist who wrote Little Women in 1868. 2 Clara Barton was an American teacher, nurse, and humanitarian who organized the American Red Cross after the Civil War. 3 Dorothea Dix was an American activist who acted on behalf of the indigent population with mental illness. She was credited for establishing the first psychiatric institution. 4 Harriet Tubman was an African American abolitionist and Union spy during the Civil War. After escaping captivity, she set up a network of antislavery activists known as the Underground Railroad. PTS: 1 CON: Evidence-Based Practice 10. Which is the most important reason todevelopadefinition of nursing? 1) Recruit more informed people into the nursing profession 2) Evaluate the degree of role satisfaction 3) Dispel the stereotypical images of nurses and nursing 4) Differentiate nursing activities from those of other health professionals ANS: 4 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Define nursing in your own words. Chapter page reference: p. 8 Heading: How Is Nursing Defined? Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Professionalism Difficulty: Easy Feedback 1 A definition of nursing would not be likely to increase the number of informed people recruited into nursing. 2 A definition of nursing would do little to improve the nurse’s role satisfaction. 3 Although a definition of nursing might contribute to fighting stereotypes of nursing, other, more powerful influences (e.g., media portrayals) exist to counteract it. 4 Nursing organization leaders think it is important to develop a definition of 8 | P a g enursing to bring value and understanding to the profession, differentiate nursing activities from those of other health professionals, and help student nurses understand what is expected of them. PTS: 1 CON: Professionalism 11. Which provides evidence-based support for the contribution that advanced practice nurses (APNs. make within healthcare? 1) Reduced usage of diagnostics using advanced technology 2) Decreased number of unnecessary visits to the emergency department 3) Improved patient compliance with prescribed treatments 4) Increased usage of complementary alternative therapies ANS: 3 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Name nine expanded roles for nursing. Chapter page reference: p. 22 Heading: Expanded Career Roles for Nurses Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Easy Feedback 1 No well-known scientific studies support APNs’ effect on the use of advanced technology. 2 No well-known scientific studiessupport APNs’effect on the frequency of emergency department visits. 3 Studies demonstrate that APNs have improved patient outcomes over those of physicians, including increased patient understanding and cooperation with treatments and decreased need for hospitalizations. 4 No well-known scientific studies support APNs’ effect on the use of alternative therapies. PTS: 1 CON: Evidence-Based Practice 12. Which is an example of what traditional medicine and complementary and alternative medicine therapies have in common? 1) Both can produce adverse effects in some patients. 2) Both use prescription medications. 3) Both are usually reimbursed by insurance programs. 4) Both are regulated by the FDA. ANS: 1 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Delineate the forces and trends affecting contemporary nursing practice. Chapter page reference: p. 22 Heading: What Are Some Trends in Nursing and Healthcare? Integrated Processes: Caring 9 | P a g eClient Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Evidence-Based Practice Difficulty: Easy Feedback 1 Both traditional and complementary therapies can produce adverse effects in some patients. 2 Many medications are derived from herbs, but the alternative treatments usually use the herbs, not prescription medication. 3 Insurance programs do not necessarily reimburse alternative treatments, because many are not supported by sound scientific research methodology. 4 Alternative medications are not regulated by the FDA. PTS: 1 CON: Evidence-Based Practice 13. Which is the biggest disadvantage of having nursing assistive personnel (NAP) assist nurses in practice? 1) Nurses must know what aspects of care can legally and safely be delegated to the NAP. 2) Nurses may rely too heavily on information gathered by the NAP when making patient care decisions. 3) Nurses are removed from many components of direct patient care that have been delegated to the NAP. 4) Nurses still maintain responsibility for the patient care given by the NAP. ANS: 2 Chapter number and title: 1, NursingPast&Present Chapter learning objective: Delineate the forces and trends affecting contemporary nursing practice. Chapter page reference: p. 24 Heading: Increased Use of Nursing Assistive Personnel Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Collaboration Difficulty: Easy Feedback 1 All of the options may be disadvantages to using NAPs, but making decisions based on another’s information is the greatest drawback because of the potential for negatively affecting patient care. Treatment decisions based on incorrect information may cause harm to the patient. 2 All of the options may be disadvantages to using NAPs, but making decisions based on another’s information is the greatest drawback because of the potential for negatively affecting patient care. Treatment decisions based on incorrect information may cause harm to the patient. 3 All of the options may be disadvantages to using NAPs, but making decisions based on another’s information is the greatest drawback because of the potential for negatively affecting patient care. Treatment decisions based on incorrect information may cause harm to the patient. 10 | P a g e4 All of the options may be disadvantages to using NAPs, but making decisions based on another’s information is the greatest drawback because of the potential for negatively affecting patient care. Treatment decisions based on incorrect information may cause harm to the patient. PTS: 1 CON: Collaboration 14. An older adult patient is diagnosed with type 1 diabetes mellitus (DM). The patient can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for this patient? 1) Acute care facility 2) Ambulatory care facility 3) Extended care facility 4) Assisted living facility ANS: 4 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Chapter page reference: p. 16 Heading: Extended Care Facilities Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Acute care facilities focus on preventing illnesses and treating acute problems. These facilities include physicians’ offices, clinics, and diagnostic centers. 2 Ambulatory care facilities provide outpatient care. Clients live at home or in nonhospital settings and come to the site for care. Ambulatory care facilities include private health and medical offices, clinics, surgery centers, and outpatient therapy centers. 3 4 Extended care facilities typically provide long-term care, rehabilitation, wound care, and ongoing monitoring of patient conditions. Assisted living facilities are intended for those who are able to perform self-care activities but who require assistance with meals, housekeeping, or medications. PTS: 1 CON: Patient-Centered Care 15. The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model is the nurse implementing? 1) Functional 2) Primary 3) Case method 4) Team ANS: 3 11 | P a g eChapter number and title: 1, Nursing Past & Present Chapter learning objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Chapter page reference: p. 15 Heading: What Models of Care Are Used to Provide Nursing Care? Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 When the functional nursing model is employed, care is compartmentalized and each task is assigned to a staff member with the appropriate knowledge and skills. 2 In primary nursing, one nurse plans the care for a group of patients around the clock. The primary nurse assesses the patient and develops the plan of care. When that nurse is working, he or she provides care for those patients for whom he or she is responsible. In his or her absence, the associate nurses deliver care. Although the nurse in this case could possibly be a primary nurse, there are not enough data to confidently infer that. 3 The nurse is following the case method model of nursing care. In this model, one nurse cares for one patient during a single shift. 4 If the team nursing approach is utilized, a licensed nurse (RN or LVN) is paired with a nursing assistant. The pair is then assigned to a group of patients. PTS: 1 CON: Patient-CenteredCare 16. Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors affecting healthcare? 1) Social worker 2) Occupational therapist 3) Physician’s assistant 4) Technologist ANS: 1 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Chapter page reference: p. 17 Heading: Who Are the Members of the Interprofessional Healthcare Team? Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Collaboration Difficulty: Moderate Feedback 1 The social worker coordinates services and counsels patients about financial, housing, marital, and family issues affecting healthcare. 2 The occupational therapist helps patients regain function and independence in 12 | P a g eactivities of daily living. 3 Physician’s assistants work under the physician’s direction to diagnose certain diseases and injuries. 4 Technologists provide a variety of specific functions in hospitals, diagnostic centers, and emergency care. For example, laboratory technologists aid in the diagnosis and treatment of patients by examining blood, urine, tissue, and body fluids. Radiology technologists perform x-rays and other diagnostic testing. PTS: 1 CON: Collaboration 17. Which type of managed care allows patients the greatest choice of providers, medications, and medical devices? 1) Health maintenance organization 2) Integrated delivery network 3) Preferred provider organization 4) Employment-based private insurance ANS: 3 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Chapter page reference: p. 19 Heading: Managed Care Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Patient-Centered CareDifficulty: Moderate Feedback 1 Health maintenance organizations allow patients to choose a primary care provider within the organization to coordinate their care. This type of program will only reimburse medical care when patients have first obtained a referral from their primary providers. 2 Integrated delivery networks combine providers, healthcare facilities, pharmaceuticals, and services into one system, and patients must remain within the system to receive care. 3 Preferred provider organizations are a form of managed care that allows patients greater choice of providers, medications, and medical devices within the designated list. 4 Employment-based private insurance is not a managed care organization. PTS: 1 CON: Patient-Centered Care 18. A patient who underwent a total abdominal hysterectomy is assisted out of bed as soon as her vital signs are stable. Which item is directing this intervention? 1) Critical pathway 2) Nursing care plan 3) Case manager 4) Traditional care model 13 | P a g eANS: 1 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Delineate the forces and trends affecting contemporary nursing practice. Chapter page reference: p. 20 Heading: Work Redesign Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Health Care System Difficulty: Easy Feedback 1 This patient’s care is most likely being directed by a critical pathway. A critical pathway is a multidisciplinary approach to care that sequences interventions over a length of stay for a given case type such as total abdominal hysterectomy. Using this model, the patient can be assisted out of bed as soon as her vital signs are stable. 2 The nursing care plan guides nursing care but cannot specify when the patient can get out of bed postoperatively without a physician’s order. 3 When case management is used, care is coordinated by the case manager across the healthcare setting, but the case manager does not direct each care intervention. 4 Using the traditional model, the nurse would have to obtain a physician’s order to assist the patient out of bed after surgery. PTS: 1 CON: HealthCareSystem 19. Which member of the healthcare team typically serves as the case manager? 1) Occupational therapist 2) Physician 3) Physician’s assistant 4) Registered nurse ANS: 4 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Name nine expanded roles for nursing. Chapter page reference: p. 9 Heading: Table 1-1 Roles and Functions of the Nurse Integrated Processes: Caring Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Collaboration Difficulty: Easy Feedback 1 The occupational therapist, physician, and physician’s assistant all serve on the healthcare team and take direction from the case manager. 2 The occupational therapist, physician, and physician’s assistant all serve on the healthcare team and take direction from the case manager. 3 The occupational therapist, physician, and physician’s assistant all serve on the 14 | P a g ehealthcare team and take direction from the case manager. 4 Typically, registered nurses serve as case managers for patients with specific diagnoses. Their role is coordinator of care across the healthcare system. PTS: 1 CON: Collaboration 20. Which is considered a primary care service? 1) Providing wound care 2) Administering childhood immunizations 3) Providing drug rehabilitation 4) Outpatient hernia repair ANS: 2 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Chapter page reference: p. 17 Heading: How Is Healthcare Categorized? Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Health Care System Difficulty: Easy Feedback 1 Wound care is an example of a tertiary care service. 2 Primary care services focus on health promotion and disease prevention; administering childhoodimunizationsisone such service. 3 Drug rehabilitation is an example of a tertiary care service. 4 Outpatient hernia repair surgery is an example of a secondary care service. PTS: 1 CON: Health Care System 21. Which nursing activities represent direct care? Choose all that apply 1) Administering a medication 2) Documenting an assessment 3) Participating in a care conference 4) Making work assignments for the shift ANS: 1 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Name nine expanded roles for nursing. Chapter page reference: p. 15 Heading: Who Are the Recipients of Nursing Care? Integrated Processes: Nursing Process – Implementation Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Professionalism Difficulty: Easy Feedback 1 Direct care involves personal interaction between the nurse and clients (e.g., 15 | P a g egiving medications, dressing a wound, or teaching a client about medicines or care). 2 Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing). 3 Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing). 4 Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing). PTS: 1 CON: Professionalism 22. An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, the patient lived at home with her spouse and managed their activities of daily living (ADLs) very well. The hospital is ready to discharge the patient because the recommended length of stay in a hospital has been exceeded. However, she cannot walk or perform ADLs independently. She requires lengthy physical therapy and further monitoring of medications and both physical and mental status. To which type of facility should the patient be transferred? 1) Nursing home 2) Rehabilitation center 3) Outpatient therapy center 4) None of these; she should receive home healthcare ANS: 2 Chapter number and title: 1, NursingPast&Present Chapter learning objective: Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulation, and financing of healthcare. Chapter page reference: p. 16 Heading: Extended Care Facilities Integrated Processes: Nursing Process – Planning Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 A nursing home provides custodial care for those people who cannot live on their own but who are not sick enough to require hospitalization. It provides a room, custodial care, and opportunity for recreation. 2 A skilled nursing facility primarily provides skilled nursing care for patients who can be expected to improve with treatment. For example, a patient who no longer needs hospitalization may transfer to a skilled nursing facility, such as a rehabilitation center, to get skilled care until able to return home. 3 This patient cannot ambulate or perform ADLs, so outpatient therapy and home care would not be appropriate. 4 This patient cannot ambulate or perform ADLs, so outpatient therapy and home care would not be appropriate. 16 | P a g ePTS: 1 CON: Patient-Centered Care 23. A high school graduate desires to become a registered nurse in order to work in a community setting. In which type of program should this student enroll? 1) RN-BSN 2) Associate degree 3) Diploma program 4) Baccalaureate degree ANS: 4 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Differentiate between the various forms of nursing education. Chapter page reference: p. 11 Heading: How Do Nurses’ Educational Paths Differ? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Professionalism Difficulty: Easy Feedback 1 Nurses who have already received basic nursing education, passed the NCLEX-RN® examination, and now desire to earn a baccalaureate degree would enter an RN-BSN program. 2 Associate program nurses are prepared to provide direct patient care. 3 Diploma program nurses are prepared to provide direct patient care. 4 Baccalaureate degree nurses are prepared to address complex clinical situations, provide direct patient care, work incommunitycare, apply research findings, and enter graduate education. PTS: 1 CON: Professionalism 24. A practicing registered nurse wants to become a staff development educator. Which type of education should this nurse investigate? 1) Master’s degree 2) Doctoral degree 3) Baccalaureate degree 4) Continuing education ANS: 1 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Differentiate between the various forms of nursing education. Chapter page reference: p. 11 Heading: How Do Nurses’ Educational Paths Differ? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Professionalism Difficulty: Easy Feedback 1 Master’s degree programs prepare RNs to function in a more independent and 17 | P a g eautonomous role, such as nurse educator. 2 Baccalaureate and master’s degrees are required before entrance to a doctoral program. Courses of study in doctoral programs include practice or research. 3 Baccalaureate degree nurses are prepared to address complex clinical situations, provide direct patient care, work in community care, apply research findings, and enter graduate education. 4 Continuing education courses do not prepare nurses for a particular role. PTS: 1 CON: Professionalism 25. In preparation for relocating to another state the nurse contacts the state board of nursing to obtain the necessary transfer of nursing license. Where will the nurse learn about continuing education requirements for the new state of practice? 1) State board of nursing 2) The Joint Commission 3) School of original nursing education 4) Human resource department at new place of employment ANS: 1 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Differentiate between the various forms of nursing education. Chapter page reference: p. 11 Heading: How Do Nurses’ Educational Paths Differ? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Professionalism Difficulty: Easy Feedback 1 The state board of nursing notifies nurses about continuing education requirements and will notify nurses of any changes in the requirements. 2 The Joint Commission is a regulatory body that does not license nurses. 3 The school of original nursing education will not notify registered nurses about continuing education requirements for licensure. 4 The Human Resources department at the new place of employment will not notify or track continuing education requirements for the nursing staff. PTS: 1 MULTIPLE RESPONSE 26. Which are examples of a health-promotion activity? Select all that apply. 1) Helping a client develop a plan for a low-fat, low-cholesterol diet 2) Disinfecting an abraded knee after a child falls off a bicycle 3) Administering a tetanus vaccination after an injury from a car accident 4) Distributing educational brochures about the benefits of exercise 5) Administering a measles, mumps, rubella (MMR) immunization to a toddler at 15 months of age CON: Professionalism 18 | P a g eANS: 1, 4, 5 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Discuss issues related to healthcare reform. Chapter page reference: p. 18 Heading: Nursing and Health Promotion Integrated Processes: Nursing Process – Implementation Client Need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Health Promotion Difficulty: Moderate Feedback 1. 2. 3. 4. 5. PTS: 1 This is correct. Health promotion includes strategies that promote positive lifestyle changes, such a developing a healthy diet. This is incorrect. Disinfecting an abraded knee is a treatment/intervention for an injury. This is incorrect. Administering a vaccination is a disease-prevention and treatment activity. This is correct. Health promotion includes strategies that promote positive lifestyle changes. This is correct. Primary care focuses on health promotion and disease prevention. Activities include health education and immunizations for infectious diseases. CON: Health Promotion 27. The nurse registers to attend an in-service education program. What should the nurse expect this program to provide? Select all that apply. 1) Review of new policies 2) Introduction to new equipment 3) Credit toward a professional nursing degree 4) Continuing education hours for license renewal 5) Enhancement of competency in knowledge, skills, and attitudes ANS: 1, 2, 5 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Differentiate between the various forms of nursing education. Chapter page reference: p.11 Heading: How Do Nurses’ Educational Paths Differ? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1. 2. In-service education is institution specific and provides information about policy changes. In-service education is institution specific and provides information about the use of new equipment. 19 | P a g e3. 4. 5. PTS: 1 In-service education does not provide credit toward a professional nursing degree. In-service education does not count toward meeting the continuing education requirement for licensure or renewal. In-service education is designed to enhance continuing competence in knowledge, skills, and attitudes. CON: Professionalism 28. The nurse manager prepares information on the regulations of nursing practice for a group of new nursing employees. Which information should the manager include in this presentation? Select all that apply. 1) Laws 2) Standards of practice 3) Facility policies and procedures 4) The Joint Commission regulations 5) Professional organization guidelines ANS: 1, 2, 5 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Explain how nursing practice is regulated. Chapter page reference: p. 13 Heading: How Is Nursing Practice Regulated? Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Professionalism Difficulty: Easy Feedback 1. 2. 3. 4. 5. PTS: 1 Laws regulate the practice of nursing Standards of practice regulate the practice of nursing Facility policies and procedures do not regulate the practice of nursing. The Joint Commission regulations are not used to regulate the practice of nursing. Guidelines from professional organizations regulate the practice of nursing CON: Professionalism 29. The nursing instructor provides a program on the state board of nursing for students preparing to graduate from a school of nursing. What should the instructor emphasize about the role of the state boards of nursing? Select all that apply. 1) Approve nursing education programs 2) Define the scope of practice for nursing 3) Develop rules and regulations for nursing practice 4) Provide guidance on knowledge, skills, and attitudes 5) Publish statements of duties for competent performance ANS: 1, 2, 3 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Explain how nursing practice is regulated. Chapter page reference: p. 13 20 | P a g eHeading: How Is Nursing Practice Regulated? Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Professionalism Difficulty: Easy Feedback 1. 2. 3. 4. 5. PTS: 1 Each state board of nursing is responsible for approving nursing education programs. Each state board of nursing is responsible for defining the scope of practice for nursing. Each state board of nursing is responsible for developing rules and regulations for guidance to nurses. Standards provide a guide to the knowledge, skills, and attitudes (KSAs) that nurses must incorporate into their practice to provide safe, quality care. Standards are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently. CON: Professionalism 30. The nurse reviews standards of professional practice every 3 to 4 months. Why does the nurse complete this review? Select all that apply. 1) Judge own performance 2) Develop an improvement plan 3) Incorporate into evaluationtols 4) Educate the public about nursing 5) Understand employer expectations ANS: 1, 2, 5 Chapter number and title: 1, Nursing Past & Present Chapter learning objective: Explain how nursing practice is regulated. Chapter page reference: p. 13 Heading: How Is Nursing Practice Regulated? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Professionalism Difficulty: Moderate Feedback 1. 2. 3. 4. 5. PTS: 1 Practicing nurses use the standards to judge their own performance. Practicing nurses use the standards to develop an improvement plan. Employers may incorporate the standards into annual employee evaluation tools. Professional organizations use the standards to educate the public about nursing. Practicing nurses use the standards to understand employers’ expectations. CON: Professionalism 21 | P a g eChapter 2. Critical Thinking & the Nursing Process MULTIPLE CHOICE 1. Which characteristic do the various definitions of critical thinking have in common? 1) Requires reasoned thought 2) Asks the questions “why?” or “how?” 3) Is a hierarchical process 4) Demands specialized thinking skills ANS: 1 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: Give one definition and one example of critical thinking. Chapter page reference: p. 28 Heading: What Is Critical Thinking? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 The definitions listed in the text as well as definitions in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor hierarchical. That means that the steps involved in critical thinking are not necessarily sequential, where mastery of one step is necessary to proceed to the next. Critical thinking isapurposeful, dynamic, analytic process that contributes to reasoned decisions and sound contextual judgments. 2 This is not a characteristic that the various definitions of critical thinking have in common. 3 This is not a characteristic that the various definitions of critical thinking have in common. 4 This is not a characteristic that the various definitions of critical thinking have in common. PTS: 1 CON: Patient-Centered Care 2. A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. The nurse should have a critical attitude because it helps the manager to do which item? 1) Consider all the possible advantages and disadvantages. 2) Maintain an open mind about the proposed change. 3) Apply the nursing process to the situation. 4) Make a decision based on past experience with documentation. ANS: 2 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: List and discuss seven attitudes of the critical thinker. Chapter page reference: p. 29 Heading: Why Is Critical Thinking Important for Nurses? 22 | P a g eIntegrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Communication Difficulty: Easy Feedback 1 A critical attitude does not allow the manger to consider all the possible advantages and disadvantages. 2 A critical attitude enables the person to think fairly and keep an open mind. 3 A critical attitude does not allow the manger to apply the nursing process to the situation. 4 A critical attitude does not allow the manger to make a decision based on past experience with documentation. PTS: 1 CON: Communication 3. The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first? 1) Assessment 2) Diagnosis 3) Plan outcomes 4) Plan interventions ANS: 1 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: Describethesixoverlapping and interdependent phases of the nursing process. Chapter page reference: p. 33 Heading: What Is the Nursing Process? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Assessment is the first step of the nursing process. 2 The nursing diagnosis is derived from the data gathered during assessment. 3 Nursing outcomes are derived from the diagnosis. 4 Nursing interventions are derived from the outcomes. PTS: 1 CON: Patient-Centered Care 4. Which is an example of theoretical knowledge? 1) A nurse uses sterile technique to catheterize a patient. 2) Room air has an oxygen concentration of 21%. 3) Glucose monitoring machines should be calibrated daily. 4) An irregular apical heart rate should be compared with the radial pulse. ANS: 2 23 | P a g eChapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: List the four types of nursing knowledge discussed in this chapter. Chapter page reference: p. 33 Heading: What Are the Different Kinds of Nursing Knowledge? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This is an example of practical knowledge—what to do and how to do it. 2 Theoretical knowledge consists of research findings, facts, principles, and theories. The oxygen concentration of room air is a scientific fact. 3 This is an example of practical knowledge—what to do and how to do it. 4 This is an example of practical knowledge—what to do and how to do it. PTS: 1 CON: Patient-Centered Care 5. Which is an example of practical knowledge? 1) The tricuspid valve is between the right atrium and ventricle of the heart. 2) The pancreas does not produce enough insulin in type 1 diabetes. 3) When assessing the abdomen, you should auscultate before palpating. 4) Research shows pain medication given intravenously acts faster than by other routes. ANS: 3 Chapter number and title: 2, CriticalThinking&theNursing Process Chapter learning objective: List the four types of nursing knowledge discussed in this chapter. Chapter page reference: p. 33 Heading: What Are the Different Kinds of Nursing Knowledge? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 The others are examples of theoretical knowledge, anatomy (tricuspid valve), fact (type 1 diabetes), and research (IV pain medication). 2 The others are examples of theoretical knowledge, anatomy (tricuspid valve), fact (type 1 diabetes), and research (IV pain medication). 3 Practical knowledge is knowing what to do and how to do it, such as how to do an assessment. 4 The others are examples of theoretical knowledge, anatomy (tricuspid valve), fact (type 1 diabetes), and research (IV pain medication). PTS: 1 CON: Patient-Centered Care 6. Which is an example of self-knowledge if thought or stated by the nurse? 1) “I know that I should take the client’s apical pulse for 1 minute before giving 24 | P a g edigoxin.” 2) “I know that I should follow the client’s wishes even though it is not what I would want.” 3) “I know that I have religious beliefs that may make it difficult to take care of some clients.” 4) “I know that I need to honor the client’s request not to discuss his health concern with the family.” ANS: 3 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: List the four types of nursing knowledge discussed in this chapter. Chapter page reference: p. 33 Heading: What Are the Different Kinds of Nursing Knowledge? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 Taking the pulse is an example of practical knowledge. 2 Following client wishes and honoring client requests are examples of ethical knowledge. 3 Self-knowledge is being aware of your religious and cultural beliefs and values. 4 Following client wishes and honoring client requests are examples of ethical knowledge. PTS: 1 CON: Patient-CenteredCare 7. Which is the most important reason for nurses to be critical thinkers? 1) Nurses need to follow policies and procedures. 2) Nurses work with other healthcare team members. 3) Nurses care for clients who have multiple health problems. 4) Nurses have to be flexible and work variable schedules. ANS: 3 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: Explain how critical thinking is used in the nursing process. Chapter page reference: p. 29 Heading: Why Is Critical Thinking Important for Nurses? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do not necessarily require critical thinking. 2 Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do 25 | P a g enot necessarily require critical thinking. 3 Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. 4 Following policies and procedures does not necessarily require critical thinking, and working with others or being flexible and working different schedules do not necessarily require critical thinking. PTS: 1 CON: Patient-Centered Care 8. The nurse administering pain medication every 4 hours is an example of which aspect of patient care? 1) Assessment data 2) Nursing diagnosis 3) Patient outcome 4) Nursing intervention ANS: 4 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: Describe the six overlapping and interdependent phases of the nursing process. Chapter page reference: p. 33 Heading: What Is the Nursing Process? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 An example of assessment data might be, “Patient reports pain is a 5 on a 1 to 10 scale.” 2 The nursing diagnosis would be Pain. 3 The nurse might define the patient outcome in this scenario as, “The patient will state the level of pain is less than 4.” 4 Interventions are activities that will help the patient achieve a goal, such as administering pain-relieving medication. PTS: 1 CON: Patient-Centered Care 9. Which differentiates a nursing diagnosis from a medical diagnosis? 1) Terminology for the client’s disease or injury 2) A part of the client’s medical diagnosis 3) The client’s presenting signs and symptoms 4) A client’s response to a health problem ANS: 4 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: Describe the six overlapping and interdependent phases of the nursing process. Chapter page reference: p. 33 Heading: What Is the Nursing Process? 26 | P a g eIntegrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 This does not differentiate a nursing diagnosis from a medical diagnosis. 2 This does not differentiate a nursing diagnosis from a medical diagnosis. 3 This does not differentiate a nursing diagnosis from a medical diagnosis. 4 A nursing diagnosis is the client’s response to actual or potential health problems. PTS: 1 CON: Patient-Centered Care 10. Which statement about the nursing process is correct? 1) It was developed from the ANA Standards of Care. 2) It is a problem-solving method to guide nursing activities. 3) It is a linear process with separate, distinct steps. 4) It involves care that only the nurse will give. ANS: 2 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: Describe the six overlapping and interdependent phases of the nursing process. Chapter page reference: p. 33 Heading: What Is the Nursing Process? Integrated Processes: NursingProcess Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 The ANA organizes its Standards of Care around the nursing process, but the process was not developed from the standards. 2 The nursing process is a problem-solving process that guides nursing actions. 3 The nursing process is cyclical and involves care the nurses give or delegate to other members of the healthcare team. 4 The nursing process is cyclical and involves care the nurses give or delegate to other members of the healthcare team. PTS: 1 CON: Patient-Centered Care 11. What do critical thinking and the nursing process have in common? 1) They are both linear processes used to guide one’s thinking. 2) They are both thinking methods used to solve a problem. 3) They both use specific steps to solve a problem. 4) They both use similar steps to solve a problem. ANS: 2 Chapter number and title: 2, Critical Thinking & the Nursing Process 27 | P a g eChapter learning objective: Explain how critical thinking is used in the nursing process. Chapter page reference: p. 29 Heading: Why Is Critical Thinking Important for Nurses? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Patient-Centered Care Difficulty: Easy Feedback 1 Neither method of thinking is linear. 2 Critical thinking and the nursing process are ways of thinking that can be used in problem solving (although critical thinking can be used beyond problem-solving applications). 3 The nursing process has specific steps; critical thinking does not. 4 The nursing process has specific steps; critical thinking does not. PTS: 1 CON: Patient-Centered Care 12. A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. Which action must the nurse implement to develop a nursing diagnosis? 1) Analyze the assessment data 2) Consult standards of care 3) Decide which interventions are appropriate 4) Ask the client’s perceptions of her health problem ANS: 1 Chapter number and title: 2, CriticalThinking&theNursing Process Chapter learning objective: Describe the six overlapping and interdependent phases of the nursing process. Chapter page reference: p. 33 Heading: What Is the Nursing Process? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The basis of the nursing diagnosis is the assessment data. 2 Standards of care are referred to when establishing nursing interventions. 3 Customizing interventions personalizes nursing care. 4 Asking the client about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment. PTS: 1 CON: Patient-Centered Care 13. The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. The nurse ensured the nursing assistive personnel changed the patient’s position every 2 hours. In the evaluation phase of the nursing process, which would the nurse do first? 28 | P a g e1) Determine whether she has gathered enough assessment data. 2) Judge whether the interventions achieved the stated outcomes. 3) Follow up to verify that care for the nursing diagnosis was given. 4) Decide whether the nursing diagnosis was accurate for the patient’s condition. ANS: 2 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: Describe the six overlapping and interdependent phases of the nursing process. Chapter page reference: p. 33 Heading: What Is the Nursing Process? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Application [Applying] Concept: Patient-Centered Care Difficulty: Moderate Feedback 1 The nurse would not implement this action first in the evaluation phase of the nursing process. 2 The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the nursing process steps and revising the care plan. 3 The nurse would not implement this action first in the evaluation phase of the nursing process. 4 The nurse would not implement this action first in the evaluation phase of the nursing process. PTS: 1 CON: Patient-Centered Care 14. In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. Which best describes these activities? 1) Full-spectrum nursing 2) Critical thinking 3) Nursing process 4) Nursing knowledge ANS: 1 Chapter number and title: 2, Critical Thinking & the Nursing Process Chapter learning objective: Name and describe the main concepts of the full-spectrum nursing model. Chapter page reference: p. 34 Heading: What Is Full-Spectrum Nursing? Integrated Processes: Nursing Process Client Need: Safe and Effective Care Environment: Management of Care Cognitive level: Comprehension [Understanding] Concept: Patient-Centered Care 29 | P a g eDifficulty: Easy Feedback 1 Full-spectrum nursing involves the use of critical thinking, nursing knowledge, nursing process, and patient situation. 2 Although critical thinking is important for planning and delivering nursing care, it does not reflect all the nurse has demonstrated. 3 Although the nursing process is important for planning and delivering nursing care, it d