Description

A student is attending a school with a high first-time pass rate on the NCLEX®. Which student statement articulates a belief that the nursing student has about faculty in the program?

1. Expect high academic standards from their students
2. Are concerned with job placement of their graduates
3. Are most concerned with the successful licensure of each student
4. Work hard to make sure students are successful

Correct Answer: 3

Rationale 1: The option expresses an attitude. Attitudes are mental positions or feelings that continue over time. This option describes how the student feels about the faculty.

Rationale 2: The option expresses an attitude. Attitudes are mental positions or feelings that continue over time. This option describes how the student feels about the faculty.

Rationale 3: Beliefs are interpretations or conclusions that people accept as true. They are based more on faith than fact and may or may not be true. Stating that faculty is more concerned with licensure would be a belief that the student has. It may or may not be true and it may be something that the student believes only for a short time—for example, until the student has had experiences with more of the faculty than just a few.

Rationale 4: The option expresses an attitude. Attitudes are mental positions or feelings that continue over time. This option describes describe how the student feels about the faculty.

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members

AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession

NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Discuss the advocacy role of the nurse.

MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing.

Page Number: 73

Question 2

Type: MCSA

A nurse manager has a staff nurse who observes certain religious holidays. The manager tries to make sure that these observances can be met if possible. Which value is the manager practicing?

1. Human dignity
2. Social justice
3. Autonomy
4. Altruism

Correct Answer: 4

Rationale 1: Human dignity is respect for the inherent worth and uniqueness of individuals and populations. That is not the value described here.

Rationale 2: Social justice is upholding moral, legal, and humanistic principles. That is not the value described here.

Rationale 3: Autonomy is the right to self-determination, and professional practice reflects autonomy when the nurse respects patients’ rights to make decisions about their health care. That is not the value described here.

Rationale 4: Altruism is a concern for the welfare and well-being of others. A professional behavior of this value is demonstrating understanding of the cultures, beliefs, and perspectives of others.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members

AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession

NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions.

MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing.

Page Number: 74

Question 3

Type: MCSA

Parents of a terminally ill child have decided to remove their child from life support, a decision that has met with little positive support. Which nursing action demonstrates autonomy regarding the parents’ decision?

1. Showing respect for the family
2. Respecting the parents’ decision
3. Referring the parents to social services
4. Asking to be assigned to a different client

Correct Answer: 2

Rationale 1: A nurse can show respect for the family without respecting the decision of the parents.

Rationale 2: Autonomy is the right to self-determination, and professional practice reflects autonomy when the nurse respects patients’ rights to make decisions about their health care.

Rationale 3: Referring the parents to another entity points to feelings of unease about the parents’ choice.

Rationale 4: Asking to be assigned to another client does not honor the right of patients and families to make decisions about health care.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members

AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession

NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions.

MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing.

Page Number: 74

Question 4

Type: MCSA

A nurse is working with a local agency to provide care to the inadequately insured by helping to staff an after-hours clinic. Which professional value is the nurse demonstrating?

1. Human dignity
2. Altruism
3. Social justice
4. Integrity

Correct Answer: 3

Rationale 1: Human dignity is respect for the worth and uniqueness of individuals and populations. That is not the value described here.

Rationale 2: Altruism is concern for the welfare and well-being of others. That is not the value described here.

Rationale 3: Social justice is upholding moral, legal, and humanistic principles. This value is demonstrated in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality health care.

Rationale 4: Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice. That is not the value described here.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members

AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession

NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. When presented with an ethical situation, identify the moral issues and principles involved.

MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing.

Page Number: 74

Question 5

Type: MCSA

A nurse mistakenly gave a client who was NPO a morning breakfast tray. After realizing the mistake, the nurse notified the physician as well as the client; explained the consequences of this mistake, which included a delay in the client’s scheduled procedure; and documented the situation in the client’s medical record. What did this nurse demonstrate?

1. Altruism
2. Integrity
3. Social justice
4. Human dignity

Correct Answer: 2

Rationale 1: Altruism is a concern for the welfare and well-being of others. That is not the value described here.

Rationale 2: Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice.

Rationale 3: Social justice is upholding moral, legal, and humanistic principles. That is not the value described here.

Rationale 4: Human dignity is respect for the worth and uniqueness of individuals and populations. That is not the value described here.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models.

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 74

Question 6

Type: MCSA

A pregnant client says her main concern is that her baby will be born healthy, even though she admits to drinking alcohol on a regular basis. With what should the nurse realize this client is struggling?

1. Values transmission
2. Values clarification
3. Morals
4. Ethics

Correct Answer: 2

Rationale 1: Values transmission means that values are learned through observation and experience and are influenced by sociocultural environment and traditions.

Rationale 2: Behavior that indicates unclear values includes ignoring a health professional’s advice, such as using alcohol during pregnancy.

Rationale 3: Morals refer to personal standards of what is right and wrong.

Rationale 4: Ethics refers to the practices or beliefs of a certain group.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members

AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession

NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Discuss common ethical issues currently facing health care professionals.

MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing.

Page Number: 74

Question 7

Type: MCSA

A client who has been blinded as result of an injury informs the rehabilitation staff of planning to return to her counseling practice and working full-time. The nurse should realize that this client is demonstrating which aspect of values clarification?

1. Choosing
2. Prizing
3. Acting
4. Clarifying

Correct Answer: 3

Rationale 1: Choosing is a cognitive action. Beliefs are chosen freely without outside pressure, from among alternatives, and after reflecting and considering consequences. That is not the aspect of values clarification described in the stem.

Rationale 2: Prizing is an affective action where chosen beliefs are prized and cherished. That is not the aspect of values clarification described in the stem.

Rationale 3: The “acting” component of values clarification is a behavioral action in which chosen beliefs are affirmed to others, incorporated into one’s behavior, and repeated consistently in one’s life. Stating the intention to return to prior employment on a full-time basis would be an affirmation of the client’s plan.

Rationale 4: Clarifying values is the process in which choosing, prizing, and acting are accomplished. That is not the aspect of values clarification described in the stem.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members

AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession

NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions.

MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing.

Page Number: 74

Question 8

Type: MCSA

A client has been complaining of pain, even though the nurse has given the client the maximum amount of medication as ordered by the physician. Which action demonstrates the nurse’s respect for the client’s autonomy?

1. Telling the client that he will have to “tough it out”
2. Calling the physician for further orders
3. Telling co-workers that this client has no pain tolerance
4. Believing the client is drug seeking

Correct Answer: 2

Rationale 1: This option does not exemplify the nurse’s respect for or consideration of the client’s situation.

Rationale 2: Honoring the principle of autonomy means that the nurse respects the client’s right to make decisions, treating others with consideration and not as impersonal sources of knowledge or training. Believing the client continues to have pain would be an example of treating with consideration. For whatever reason, this particular client is not responding to the medication ordered by the physician, and other medications or treatment should be initiated.

Rationale 3: This option does not exemplify the nurse’s respect for or consideration of the client’s situation.

Rationale 4: This option does not exemplify the nurse’s respect for or consideration of the client’s situation.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members

AACN Essentials Competencies: VIII. 3. Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession

NLN Competencies: Teamwork; Ethical Comportment; Value and respect the perspectives, attributes, and expertise of all health team members, including the patient/family

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values.

MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing.

Page Number: 76

Question 9

Type: MCSA

A client has chosen to discontinue hemodialysis. His family is not supportive of his decision. Which statement should the nurse make that demonstrates the theory of principles-based reasoning?

1. “This client is of sound mind and is capable of making his own decisions regarding health care. It really is his decision to make.”
2. “I need to try and help the family understand the client’s decision so they can work through this situation together.”
3. “This client’s health is so deteriorated that the treatment is not saving his life. It is prolonging the ultimate outcome, which is his death.”
4. “The client understands his decision and the advanced stage of his disease. If he quits treatment, he will die.”

Correct Answer: 1

Rationale 1: Principles-based theories stress individual rights, such as autonomy. The client has the ability to make the decision and it is his right to autonomy to do that.

Rationale 2: Caring theories, or relationship theories, stress courage, generosity, commitment, and the need to nurture and maintain relationships. Caring theories promote the common good or the welfare of the group. Trying to help the family understand the client’s decision is an example of a caring-based theory in practice.

Rationale 3: Consequence-based theories look at the outcomes of an action in judging whether that action is right or wrong.

Rationale 4: Consequence theories are exemplified by the nurse looking at the outcomes of the client’s decision.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Discuss the advocacy role of the nurse.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 76

Question 10

Type: MCSA

The administration of a hospital, along with nursing services, is planning to incorporate a struggling private clinic into the infrastructure of the hospital. Although relocating the clinic may cause transportation difficulty for some clients, keeping the clinic running will allow current employees as well as clients the continued benefit of the clinic. Which moral framework did the hospital leadership use to make this decision?

1. Teleological theory
2. Deontological theory
3. Utilitarianism
4. Caring theory

Correct Answer: 3

Rationale 1: Teleological theories look at the outcomes of an action and judge it to be right or wrong.

Rationale 2: Deontological theories, which are principles based, emphasize individual rights, duties, and obligations. In this situation, numerous people are involved with the clinic, not just one person.

Rationale 3: Utilitarianism views a good act as one that brings the most good and the least harm for the greatest number of people. Continuing to provide a service, even though it has to be relocated, is better than discontinuing something that clients continue to use and employees depend on.

Rationale 4: Caring theories stress courage, generosity, commitment, and the need to nurture and maintain relationships.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 76

Question 11

Type: MCSA

A decision has been made for an older client to receive aggressive cancer therapy despite knowing that the therapy will actually be more harmful than the disease and subject the client to harmful chemicals. With which ethical principle is this nurse caring for this client struggling?

1. Autonomy
2. Justice
3. Beneficence
4. Nonmaleficence

Correct Answer: 4

Rationale 1: Autonomy refers to the right to make one’s own decisions. That is not what the nurse is having an ethical dilemma about.

Rationale 2: Justice is often referred to as fairness. That is not what the nurse is having an ethical dilemma about.

Rationale 3: Beneficence means “doing good.” In this case the benefits are not known, making the harm more real. Although aggressive cancer therapy is difficult to endure and given the age of the client, this case suggests beneficence, but there is a more appropriate option available.

Rationale 4: Nonmaleficence is the duty to “do no harm.” Doing intentional harm is never acceptable in nursing. Placing a client at risk of harm is what is depicted in this scenario, and it occurs as a known consequence of a nursing intervention or some other type of treatment. It is unknown how much therapy will be of benefit to the client or whether it will actually do more harm.

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Discuss common ethical issues currently facing health care professionals.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 76

Question 12

Type: MCSA

The nurse needs to insert an intravenous access device into a toddler who is crying and scared. The parent asks if the procedure is painful. When practicing veracity, what should the nurse respond to the parent?

1. “I won’t lie to you. It may be easier for you if you step out until we get the line in.”
2. “We’ll take every care not to hurt your child.”
3. “It shouldn’t be too bad and I’ll be quick.”
4. “We do this all the time, so don’t worry.”

Correct Answer: 1

Rationale 1: Veracity refers to telling the truth. Even though telling the truth may frighten the parent, starting an IV on a frightened, scared, ill child is a difficult task. Because of the child’s developmental stage, any explanation given by the nurse won’t be understood. Being honest with the parent will help the nurse gain trust and will outweigh any benefits that may be gained by downplaying the situation.

Rationale 2: Saying that the nurse will everything possible not to hurt the child will not negate the fact that it will hurt. A needle going into a vein is not a comfortable procedure.

Rationale 3: Saying that the nurse will perform the task quickly is not a sufficient answer to the parent. A needle going into a vein is not a comfortable procedure. The nurse really doesn’t know how bad it will hurt the child.

Rationale 4: Telling the parent not to worry is pointless.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 77

Question 13

Type: MCSA

A student nurse accidentally left the call light outside the reach of an older client. Another nurse discovered the situation and was able to rectify the matter before something happened. The student apologizes and states the need to double check for call light placement before leaving a client’s room. What behavior did the student demonstrate?

1. Justice
2. Fidelity
3. Responsibility
4. Accountability

Correct Answer: 4

Rationale 1: Justice is being fair. That it not the value exhibited by the student nurse.

Rationale 2: Fidelity means to be faithful to agreements and promises. That it not the value exhibited by the student nurse.

Rationale 3: Responsibility refers to the liability associated with the performance of the duties of a particular role. The student had the responsibility to provide safe care to the client (i.e., make sure the call light was within reach) but did not follow through with it. That it not the value exhibited by the student nurse.

Rationale 4: Accountability means “answering to oneself and others for one’s own actions.” By admitting that double checking should be done, the student showed accountability.

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3. When presented with an ethical situation, identify the moral issues and principles involved.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 77

Question 14

Type: MCSA

The nurse is reviewing the ANA (American Nurses Association) Code of Ethics for Nurses. What should the nurse identify as a characteristic of this code?

1. It is a formal statement.
2. It contains the same standards as legal standards.
3. It is shared by group members.
4. It reflects legal judgments.
5. It serves as a standard for professional actions.

Correct Answer: 5

Rationale 1: A code of ethics is a formal statement of a group’s ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession.

Rationale 2: A code of ethics is a formal statement of a group’s ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession.

Rationale 3: A code of ethics is a formal statement of a group’s ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession.

Rationale 4: A code of ethics is a formal statement of a group’s ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession.

Rationale 5: A code of ethics is a formal statement of a group’s ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral (not legal) judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 78

Question 15

Type: MCSA

A 20-year-old client with Down syndrome is diagnosed with an illness. Even though the client is able to live in an assisted environment and work part-time for a local bookstore, the parents of the client are adamant about not initiating a course of treatment whose side effects are unknown with Down syndrome clients. According to the nursing code of ethics, to whom is the nurse’s first loyalty?

1. The client
2. The parent
3. The physician
4. The nurse

Correct Answer: 1

Rationale 1: The nurse’s first loyalty is to the client. Conflicts among obligations to families, physicians, employing institutions, and clients may arise because of the nurse’s unique position. It is not always easy to determine which action best serves the client’s needs.

Rationale 2: The nurse’s first loyalty is to the client. Conflicts among obligations to families, physicians, employing institutions, and clients may arise because of the nurse’s unique position. It is not always easy to determine which action best serves the client’s needs.

Rationale 3: The nurse’s first loyalty is to the client. Conflicts among obligations to families, physicians, employing institutions, and clients may arise because of the nurse’s unique position. It is not always easy to determine which action best serves the client’s needs.

Rationale 4: The nurse’s first loyalty is to the client. Conflicts among obligations to families, physicians, employing institutions, and clients may arise because of the nurse’s unique position. It is not always easy to determine which action best serves the client’s needs.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Discuss the advocacy role of the nurse.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 78

Question 16

Type: MCSA

A hospice nurse has been working closely with a client who, on several occasions, has asked about guidance and support in ending her life. What information should the nurse use when making an ethical and moral decision about this client’s request?

1. Passive euthanasia is an easy decision to arrive at.
2. Legal issues are not the same as moral or ethical ones.
3. Active euthanasia is supported in the Code for Nurses.
4. Assisted suicide is illegal in all states.

Correct Answer: 2

Rationale 1: Passive euthanasia involves the withdrawal of extraordinary means of life support and is never an easy decision.

Rationale 2: Determining whether an action is legal is only one aspect of deciding whether it is ethical. Legality and morality are not one and the same. The nurse must know and follow the legal statutes of the profession and boundaries within the state before making any decision.

Rationale 3: Active euthanasia and assisted suicide are in violation of the Code for Nurses, according to the position statement by the ANA.

Rationale 4: Some states and countries have laws permitting assisted suicide for clients who are severely ill, are near death, and wish to commit suicide.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Discuss common ethical issues currently facing health care professionals.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 82

Question 17

Type: MCSA

A client with terminal cancer is refusing food and fluids, and pushes the caregiver’s hands away when attempts are made to feed the client or offer any kind of fluid. The family is considering placing a gastrostomy tube because they feel the client is “starving to death.” What should the nurse do?

1. Honor the family’s wishes and have them sign a consent form.
2. Talk to the physician so he or she can move forward with the family’s wishes.
3. Honor the client’s refusal and help the family come to terms with the situation.
4. Take the case to the hospital’s ethics committee.

Correct Answer: 3

Rationale 1: Clients, not their families, should make decisions about their own health care and treatment.

Rationale 2: The physician may or may not be involved, but not to disregard the client’s refusal.

Rationale 3: A nurse is morally obligated to withhold food and fluids if it is determined to be more harmful to administer them than to withhold them. The nurse must also honor competent patients’ refusal of food and fluids. This position is supported by the ANA’s Code of Ethics for Nurses, through the nurse’s role as a client advocate and through the moral principle of autonomy. Clients, not their families, should make decisions about their own health care and treatment. In this case, the client has made a decision and it should be honored.

Rationale 4: An ethics committee is usually considered when there is an ethical dilemma and more input is needed to make a decision. In this case, the client has made a decision.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. When presented with an ethical situation, identify the moral issues and principles involved.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 78

Question 18

Type: MCSA

A client with a sexually transmitted illness (STI) asks the nurse to not tell anyone about the diagnosis. According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, what must the nurse do?

1. Honor the client’s wishes.
2. Not disclose any information to anyone.
3. Respect the client’s privacy and confidentiality.
4. Communicate only necessary information.

Correct Answer: 4

Rationale 1: Nurses should not make promises to keep necessary information private.

Rationale 2: Nurses are entrusted with sensitive information that, at times, must be revealed to other health care personnel in order to provide appropriate health care.

Rationale 3: Nurses are entrusted with sensitive information that, at times, must be revealed to other health care personnel in order to provide appropriate health care. Clients must be able to trust that their information is secure and will only be shared with appropriate entities.

Rationale 4: HIPAA includes standards that protect the confidentiality, integrity, and availability of data as well as standards that define appropriate disclosures of identifiable health information and patient rights protection. Nurses are entrusted with sensitive information that, at times, must be revealed to other health care personnel in order to provide appropriate health care. In this case, the nurse may be required to report information to the state health department.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Knowledge; HIPAA

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Discuss common ethical issues currently facing health care professionals.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 83

Question 19

Type: MCSA

The nurse learns that a home care client is diluting prescribed nutritional supplements because of the cost. What should the nurse do to advocate for this client?

1. Help the client look for available community resources that may be of assistance.
2. Tell the client that she needs to take the prescribed amount.
3. Report the situation to the physician.
4. Weigh the client on a weekly basis to monitor weight gain or loss.

Correct Answer: 1

Rationale 1: Resource allocation and financial considerations are major issues in home health care. When clients are in their own home, they operate from their own values and client autonomy must be respected. Community resources may be of benefit for this client to be able to afford the proper supplement at the correct dose or to provide assistance in other financial areas so the client has the treatment needs met.

Rationale 2: The client already knows she should take the prescribed amount.

Rationale 3: Telling the physician will not help to solve the situation.

Rationale 4: Weighing the client merely assesses the need, which has already been established.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Discuss the advocacy role of the nurse.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 83

Question 20

Type: MCMA

The nurse is reviewing the preamble of the International Council of Nurses Code of Ethics. On which responsibilities should the nurse focus when reviewing this preamble?

Standard Text: Select all that apply.

1. Promote health.
2. Restore health.
3. Inform the public about minimum standards of nursing conduct.
4. Provide self-regulation in the profession.
5. Prevent illness.
6. Alleviate suffering.

Correct Answer: 1, 2, 5, 6

Rationale 1: Promotion of health is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics.

Rationale 2: Restoration of health is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics.

Rationale 3: Informing the public about minimum standards of nursing conduct is not one of the fundamental responsibilities of nurses that is included in the preamble of the International Council of Nurses Code of Ethics.

Rationale 4: Providing self-regulation in the profession is not one of the fundamental responsibilities of nurses that is included in the preamble of the International Council of Nurses Code of Ethics.

Rationale 5: Preventing illness is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics.

Rationale 6: The alleviation of suffering is one of the fundamental responsibilities of nurses according to the International Council of Nurses Code of Ethics.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 78

Question 21

Type: MCMA

The nurse manager determines that a staff nurse demonstrates understanding of the professional responsibility to advocate for a client’s health, safety, and rights. What did the manager observe to come to this conclusion about the staff nurse?

Standard Text: Select all that apply.

1. Reporting a medication error that he was responsible for making
2. Notifying the unit manager that a nurse is showing signs of being under the influence of alcohol
3. Being sure the computer screen is not visible to visitors when charting
4. Asking the client to explain in her own words the purpose of the research project she asked to act in as a participant
5. Calling the health care provider to clarify a confusing prescription for a client’s pain

Correct Answer: 2, 3, 4, 5

Rationale 1: This is more reflective of the nurse’s responsibility and accountability for personal nursing practice.

Rationale 2: The nurse advocates for client health and safety when reporting the impaired nurse.

Rationale 3: The nurse advocates for client rights when protecting confidentiality.

Rationale 4: The nurse advocates for client health and safety when protecting the participants in a research project.

Rationale 5: The nurse advocates for client health and safety when clarifying confusing orders or questionable medical practices.

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5. Discuss the advocacy role of the nurse.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 83

Question 22

Type: SEQ

The nurse is addressing an ethical issue. In which order should the nurse implement the steps of this decision-making process?

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Interviewing the client regarding details of the problem

Choice 2. Discussing the various results of the identified possible actions to resolve the problem

Choice 3. Determining what, if any, ethical issues exist

Choice 4. Determining whether affected parties are in ethical conflict

Choice 5. Assessing all involved parties concerning their ethical beliefs regarding the problem

Correct Answer: 1, 3, 5, 4, 2

Rationale 1: Gathering additional information to clarify the situation is the first step in this model.

Rationale 2: Identifying the range of actions with anticipated outcomes is the final step in this process among the available options.

Rationale 3: Identifying the ethical issues in the situation occurs immediately after the information concerning the problem is obtained.

Rationale 4: Identifying value conflicts occurs after information has been gathered, after it is determined that an ethical problem exists, and after affected individuals are assessed for their ethical beliefs.

Rationale 5: Identifying moral positions of key individuals involved occurs after information has been gathered and it is determined that an ethical problem exists.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 81

[New Questions: ]

Question 23

Type: MCMA

A client with lung disease is strongly urged to stop smoking but likes to smoke and does not know what to do. In what order should the nurse take the following actions to help this client clarify values?

Standard Text: Click and drag the options below to move them up or down.

1. Choose freely.
2. List alternatives.
3. Affirm the choice.
4. Act with a pattern.
5. Examine consequences of choices.
6. Examine feelings about the choice.

Correct Answer: 2, 5, 1, 6, 3, 4

Rationale 1: The nurse should ask if the client has a say in the decision in the third step of the process.

Rationale 2: In the first step of the process, the nurse should help the client list alternatives so that the client is aware of all alternative actions.

.

Rationale 3: The nurse needs to ask how the client affirmed the choice by asking if the choice was discussed with others in the fifth step of the process.

Rationale 4: The final step is to find out if the client has acted with a pattern or consistently performs an action in a certain way.

Rationale 5: In the second step of the process, consequences of all choices need to be examined so that the client has thought about possible results of each action.

Rationale 6: In the fourth step of the process, the nurse needs to examine the client’s feelings about the choice. Some clients may not feel satisfied with their decision.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Explain how nurses use knowledge of values to make ethical decisions and to assist clients in clarifying their values.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 74

Question 24

Type: MCMA

The school of nursing professor is preparing a classroom activity to assist the students in acquiring professional values. Which actions should the professor select for this assignment?

Standard Text: Select all that apply.

1. Discuss codes of ethics with the students.
2. Recommend that the students avoid ethical issues.
3. Encourage the students to discuss experiences.
4. Invite other professors to participate in a discussion.
5. Have the students interview each other about experiences.

Correct Answer: 1, 3, 4, 5

Rationale 1: Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers.

Rationale 2: Ethical issues cannot be avoided in nursing or health care. This is not a viable approach for the professor to use.

Rationale 3: Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers.

Rationale 4: Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers.

Rationale 5: Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers.

.

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care

AACN Essentials Competencies: VIII. 1. Demonstrate the professional standards of moral, ethical, and legal conduct

NLN Competencies: Context and Environment; Practice; apply ethical decision making models

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Explain how values, moral frameworks, and codes of ethics affect moral decisions.

MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.

Page Number: 74

Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 07

Question 1

Type: MCSA

A nurse educator is explaining primary health care (PHC) and the extension of its boundaries beyond traditional health care services to a group of community members. What issues related to PHC should the nurse include in this discussion?

1. Distribution and participation
2. Environment, agriculture, and housing
3. Consumerism and governmental subsidies
4. Low life expectancies and high mortality rates among children

Correct Answer: 2

Rationale 1: PHC involves issues of the environment, agriculture, and housing. It also involves other social, economic, and political issues such as poverty, transportation, unemployment, and economic development to sustain the population. Distribution and participation are two of the five principles incorporated in PHC. Consumerism and governmental subsidies are not part of the PHC makeup. Low life expectancies and high mortality rates among children are two concerns about health care that led to the global health strategy of primary health care.

Rationale 2: PHC involves issues of the environment, agriculture, and housing. It also involves other social, economic, and political issues such as poverty, transportation, unemployment, and economic development to sustain the population. Distribution and participation are two of the five principles incorporated in PHC. Consumerism and governmental subsidies are not part of the PHC makeup. Low life expectancies and high mortality rates among children are two concerns about health care that led to the global health strategy of primary health care.

Rationale 3: PHC involves issues of the environment, agriculture, and housing. It also involves other social, economic, and political issues such as poverty, transportation, unemployment, and economic development to sustain the population. Distribution and participation are two of the five principles incorporated in PHC. Consumerism and governmental subsidies are not part of the PHC makeup. Low life expectancies and high mortality rates among children are two concerns about health care that led to the global health strategy of primary health care.

Rationale 4: PHC involves issues of the environment, agriculture, and housing. It also involves other social, economic, and political issues such as poverty, transportation, unemployment, and economic development to sustain the population. Distribution and participation are two of the five principles incorporated in PHC. Consumerism and governmental subsidies are not part of the PHC makeup. Low life expectancies and high mortality rates among children are two concerns about health care that led to the global health strategy of primary health care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: <objective id=”ch07os01obj01″ label=”1″><inst>1. </inst><para>Discuss factors influencing health care reform.</para></objective>

MNL Learning Outcome: 1.2.4. Compare the frameworks of care.

Page Number: 106

Question 2

Type: MCSA

After a community was hit by a tornado, the nurses of the local Red Cross Chapter helped to make sure people had adequate food and clothing. Which function of community were these nurses focused on restoring?

1. Social control
2. Social interparticipation
3. Mutual support
4. Distribution of goods and services

Correct Answer: 4

Rationale 1: Social control refers to the way in which order is maintained in a community.

Rationale 2: Social interparticipation refers to community activities that are designed to meet people’s needs for companionship.

Rationale 3: Mutual support refers to the community’s ability to provide resources at a time of illness or disaster.

Rationale 4: Production, distribution, and consumption of goods and services are the means by which the community provides for the economic needs of its members. It includes supplying food and clothing as well as providing water, electricity, police and fire protection, and the disposal of refuse.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Discuss competencies community-based nurses need for practice, including the Pew Health Professions Commission recommendations for health competencies for future health practitioners.

MNL Learning Outcome: 1.2.4. Compare the frameworks of care.

Page Number: 108

Question 3

Type: MCSA

A nurse is helping to set up an elder social group at a local senior center where residents can come to play cards or participate in structured activities three times a week. In which community function is this nurse working?

1. Socialization
2. Social control
3. Social interparticipation
4. Mutual support

Correct Answer: 3

Rationale 1: Socialization refers to the process of transmitting values, knowledge, culture, and skills to others.

Rationale 2: Social control refers to the way in which order is maintained in a community.

Rationale 3: Social interparticipation refers to community activities that are designed to meet people’s needs for companionship.

Rationale 4: Mutual support refers to the community’s ability to provide resources at a time of illness or disaster.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Differentiate community-based nursing from traditional institutional-based nursing.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 108

Question 4

Type: MCSA

The nurse is explaining the difference between community and population to a group of community members. What should the nurse use as an example for population?

1. Commuters on the subway
2. A grade school class
3. Graduating nursing students
4. A group of employees at a local plant

Correct Answer: 1

Rationale 1: A population is composed of people who share some common characteristic, but who do not necessarily interact with each other—as people on a subway might behave. They are all riding, but not really interacting.

Rationale 2: A community is a group of people or a social system in which the members interact formally or informally and form networks that operate for the benefit of all people in the community. A grade school class is a community.

Rationale 3: A community is a group of people or a social system in which the members interact formally or informally and form networks that operate for the benefit of all people in the community. Graduating nursing students is an example of a community.

Rationale 4: A community is a group of people or a social system in which the members interact formally or informally and form networks that operate for the benefit of all people in the community. Employees at a local plant are an example of a community.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 108

Question 5

Type: MCSA

When completing a community assessment, the community health nurse will take several aspects into account. What is the first stage of this assessment that the nurse will complete?

1. Learn about the people in the community.
2. Understand the major illnesses present in the community.
3. Identify the boundaries of the community.
4. Make sure resources are available in the community.

Correct Answer: 1

Rationale 1: The first stage in assessment is to learn about the people in the community. When completing a community assessment, the nurse needs to focus on a much larger “client”—which is the whole community.

Rationale 2: Understanding the major illnesses present in the community is not a part of the community assessment.

Rationale 3: Identifying boundaries is part of a community assessment; however, it is not the first stage.

Rationale 4: Community resources include types of dwellings, education system, safety and transportation services, politics and government, health and social services, communication, economics, and recreation.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe various community-based health care frameworks, including integrated health care systems, community initiatives and conditions, and case management.

MNL Learning Outcome: 1.2.4. Compare the frameworks of care.

Page Number: 108

Question 6

Type: MCSA

While completing a community assessment, the nurse needs to learn the location of main health facilities and the number of who receive welfare. Where should the nurse access this information?

1. Police department
2. City health planning board
3. County health department
4. State census data

Correct Answer: 3

Rationale 1: The police department has statistics regarding incidence of crime, vandalism, and drug addiction. Rationale 2: The city health planning board has information about health needs and practices.

Rationale 3: The county health department would be able to supply information about location of health facilities, occupational health programs, numbers of health professionals, numbers of welfare recipients, and so on.

Rationale 4: The state census data describe population composition and characteristics.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role.

MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.

Page Number: 109

Question 7

Type: MCSA

The new community health nurse is compiling information about the community and wants to understand more about services to maintain and promote health. What entity should the nurse access to learn this information?

1. Chamber of commerce
2. Public and university libraries
3. Recreational directors
4. Teachers and school nurses

Correct Answer: 4

Rationale 1: The chamber of commerce can supply statistics about employment, major industries, and primary occupations.

Rationale 2: Public and university libraries contain district social and cultural research reports.

Rationale 3: Recreational directors provide information about programs and participation levels.

Rationale 4: Teachers and school nurses provide information about the incidence of children’s health problems and information on facilities and services to maintain and promote health.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role.

MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.

Page Number: 109

Question 8

Type: MCSA

A client in the ambulatory clinic asks if there are any community programs to help with health and wellness issues. What should the nurse access to locate these types of activities?

1. Online computer services
2. Recreational directors
3. Local newspapers
4. Telephone book

Correct Answer: 3

Rationale 1: Online computer services may provide access to public documents related to community health.

Rationale 2: Recreational directors have information about programs provided and participation levels.

Rationale 3: Local newspapers contain information—including date and time—about community activities related to health and wellness, such as health lectures or health fairs.

Rationale 4: The telephone book would include the location of social, recreational, and health organizations, as well as committees and facilities.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Describe the role of the nurse in providing continuity of care.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 109

Question 9

Type: MCSA

Several nurses at the county health department are involved in planning community health. In order to create a plan that will be acceptable to members of the community, who else should be involved in this venture?

1. As many people from the community as possible
2. Physicians and other nurses
3. Members of the chamber of commerce and governing board of the community
4. Just the nurses at the county health department

Correct Answer: 1

Rationale 1: A broadly based planning group is most likely to create a plan that is acceptable to members of the community. People who are involved in planning become educated about problems, resources, and interrelationships within the system. Responsibility for planning at the community level is usually broadly based and needs to include as many of the community partners as possible.

Rationale 2: Physicians and other nurses may not understand the community’s health needs.

Rationale 3: Members of the chamber of commerce and community governing board may not understand the community’s health needs.

Rationale 4: The nurses may not understand the community’s health needs. The plan should include members of the community so that all members are represented and have a voice in planning.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 10. Collaborate with others to develop an intervention plan that takes into account determinants of health, available resources, and the range of activities that contribute to health and prevention of illness, injury, disability and premature death

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Describe various community-based health care frameworks, including integrated health care systems, community initiatives and conditions, and case management.

MNL Learning Outcome: 1.2.4. Compare the frameworks of care.

Page Number: 109

Question 10

Type: MCSA

After implementing health promotion activities and plans to prioritize health problems, the community must evaluate the effectiveness of the interventions. Which groups should be involved in this process?

1. Health care providers at the community level
2. Hospital and clinic personnel who administered health care needs
3. Health care providers, consumers, community leaders, and politicians
4. Those consumers who were directly affected by the services provided

Correct Answer: 3

Rationale 1: Because community health is usually a collaborative process between health providers, community leaders, politicians, and consumers, all may be involved in the evaluation process. Often, the community health nurse is the agent of evaluation, collecting and assessing data that determine the effectiveness of implemented programs.

Rationale 2: Because community health is usually a collaborative process between health providers, community leaders, politicians, and consumers, all may be involved in the evaluation process. Often, the community health nurse is the agent of evaluation, collecting and assessing data that determine the effectiveness of implemented programs.

Rationale 3: Because community health is usually a collaborative process between health providers, community leaders, politicians, and consumers, all may be involved in the evaluation process. Often, the community health nurse is the agent of evaluation, collecting and assessing data that determine the effectiveness of implemented programs.

Rationale 4: Because community health is usually a collaborative process between health providers, community leaders, politicians, and consumers, all may be involved in the evaluation process. Often, the community health nurse is the agent of evaluation, collecting and assessing data that determine the effectiveness of implemented programs.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role.

MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.

Page Number: 109

Question 11

Type: MCSA

A large community clinic provides health education, illness prevention, acute care, screening, and rehabilitation and health promotion services for the chronically ill. What should the community health nurse identify this approach to health care as being?

1. Community-based setting
2. Integrated health care system
3. Wellness center
4. Community outreach center

Correct Answer: 2

Rationale 1: Community-based settings are provided in county and state health departments and may include day-care centers, senior centers, storefront clinics, homeless shelters, and the like.

Rationale 2: An integrated health care system makes all levels of care available in an integrated form, including primary care (education and illness prevention), secondary care (acute care and screening), and tertiary care (rehabilitation and services for the chronically ill).

Rationale 3: A wellness center provides services such as health promotion, maintenance education, counseling, and screening.

Rationale 4: Community outreach centers are small, freestanding clinics providing services similar to those traditionally provided by large public health clinics, but focused on a narrower population.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: VII. 13. Use evaluation results to influence the delivery of care, deployment of resources, and to provide input into the development of policies to promote health and prevent disease

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Describe various community-based health care frameworks, including integrated health care systems, community initiatives and conditions, and case management.

MNL Learning Outcome: 1.2.4. Compare the frameworks of care.

Page Number: 109

Question 12

Type: MCSA

A parish health nurse is working with a particular congregation in setting up a support program for shut-ins within the congregation who are not able to come to regular prayer services. In which role is this nurse functioning?

1. Counselor
2. Educator
3. Referral source
4. Facilitator

Correct Answer: 4

Rationale 1: A counselor discusses health issues and problems with individuals and makes home, hospital, and nursing home visits as needed.

Rationale 2: An educator works to support individuals through health education activities that promote an understanding of the relationship between values, attitudes, lifestyle, faith, and well-being.

Rationale 3: A referral source is a liaison to other congregations and community resources.

Rationale 4: A facilitator recruits and coordinates volunteers within the congregation and develops support groups.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team

AACN Essentials Competencies: VI. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education and licensure requirements)

NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of health care team members, including overlaps

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe the role of the nurse in providing continuity of care.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 111

Question 13

Type: MCSA

A parish nurse is helping a group of new parents within the congregation find appropriate health care providers within the community who specialize in infant/child and family health care needs. In which role is the nurse functioning?

1. Health educator
2. Referral source
3. Facilitator
4. Integrator

Correct Answer: 2

Rationale 1: A health educator supports individuals through health education activities that promote understanding of the relationship between values, attitudes, lifestyle, faith, and well-being.

Rationale 2: A referral source acts as a liaison to other congregational and community resources. Helping new parents find appropriate sources for health care would be an example of a referral source.

Rationale 3: A facilitator recruits and coordinates volunteers within the congregation and develops support groups.

Rationale 4: An integrator brings the entities of faith and health together.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team

AACN Essentials Competencies: VI. 1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education and licensure requirements)

NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of health care team members, including overlaps

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe the role of the nurse in providing continuity of care.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 111

Question 14

Type: MCSA

A public health nurse is working with a group of home health nurses in an isolated, mountainous region where access to smaller communities and individuals is quite difficult, especially in the winter and early spring—seasons when the health needs of these individuals are quite high. The public health nurse has set up video conferencing and video clinics for these home health nurses regarding various client teaching and health promotion activities. What activity did the public health nurse conduct?

1. Community-based nursing
2. Parish nursing
3. Telenursing
4. Collaborative health care

Correct Answer: 3

Rationale 1: Community-based nursing is nursing care directed toward specific individuals.

Rationale 2: Parish nursing focuses on integrating aspects of faith and members of a particular congregation and health care or nursing needs.

Rationale 3: Telehealth projects use communication and information technology to provide health information and health care services to people in rural, remote, or underserviced areas. Video conferences and video clinics enable health care workers to provide distant consultation to assess and treat ambulatory clients who have a variety of health care needs. Telenursing enables nurses to provide client teaching and health promotion to distant clients.

Rationale 4: Collaborative health care describes a process of teamwork in providing comprehensive health care.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: VI. B. 5. Employ communication technologies to coordinate care for patients

AACN Essentials Competencies: IV. 2. Use telecommunication technologies to assist in effective communication in a variety of healthcare settings

NLN Competencies: Quality and Safety; Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Describe various community-based health care frameworks, including integrated health care systems, community initiatives and conditions, and case management.

MNL Learning Outcome: 1.2.4. Compare the frameworks of care.

Page Number: 111

Question 15

Type: MCSA

Several nurses are working with other health care providers to provide care for a group of community members who have complications of diabetes mellitus and require extensive dressing changes and comprehensive education. In what capacity are the nurses and care providers working?

1. Collaboration
2. Case management
3. Health promotion
4. Health education

Correct Answer: 1

Rationale 1: Collaboration means a collegial working relationship with other health care providers to supply patient care. Collaborative practice requires the discussion of diagnoses and management in the delivery of care.

Rationale 2: Case management involves one person overseeing the needs and requirements of a particular individual’s health.

Rationale 3: Health promotion activities include disease prevention and healthy lifestyle interventions.

Rationale 4: Health education would be included in this particular situation but collaboration is a more inclusive definition of what is occurring with these individuals and the care they require.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team

AACN Essentials Competencies: VI. 2. Use inter-and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care

NLN Competencies: Quality and Safety; Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role.

MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.

Page Number: 112

Question 16

Type: MCSA

A nurse is working in collaboration with a group of health care providers in a community clinic setting. They have defined a problem and now are focusing on objectives and considering various viewpoints presented by the group. Which collaboration competency is this nurse demonstrating?

1. Mutual respect
2. Trust
3. Communication
4. Decision making

Correct Answer: 4

Rationale 1: Mutual respect occurs when two or more people show or feel honor or esteem toward one another.

Rationale 2: Trust occurs when a person is confident in the actions of another person.

Rationale 3: Communication is necessary in effective collaboration. It occurs only if the involved parties are committed to understanding each other’s professional roles and appreciating each other as individuals.

Rationale 4: Decision making involves shared responsibility for the outcome. The team must follow specific steps of the decision-making process, beginning with a clear definition of the problem. Team decision making must be directed at the objectives of the effort and requires full consideration and respect for various and diverse viewpoints.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: II. B. 4. Function competently within own scope of practice as a member of the health care team

AACN Essentials Competencies: VI. 2. Use inter-and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care

NLN Competencies: Quality and Safety; Practice; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe various community-based health care frameworks, including integrated health care systems, community initiatives and conditions, and case management.

MNL Learning Outcome: 1.2.4. Compare the frameworks of care.

Page Number: 112

Question 17

Type: MCSA

The nurse case manager’s office is in a cluster of offices that share a fax machine. Which action by the nurse ensures that HIPAA requirements are met?

1. Have the client sign a consent form for information to be released.
2. Have sending agencies call ahead before any information is sent.
3. Do not utilize the fax machine; depend on the mail system.
4. Take relevant information over the phone.

Correct Answer: 2

Rationale 1: Signing a consent form for information to be released is necessary to share information, but this would not ensure the privacy aspect of HIPAA—only the disclosure aspect.

Rationale 2: Case manager nurses need to maintain vigilance to protect the privacy of client health care information when sending and receiving messages. In this case, having the sending agency call prior to faxing information would alert the nurse to collect the information from the fax machine at the time it is received, securing that information so others do not have access to it.

Rationale 3: Sending information through the mail takes time and does not ensure the privacy of the information.

Rationale 4: Phone conversations and information taken during the conversation must be protected and taken in a secured way to ensure HIPAA privacy aspects have not been breached.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: VI. B. 5. Employ communication technologies to coordinate care for patients

AACN Essentials Competencies: IV. 8. Uphold ethical standards related to data security, regulatory requirements, confidentiality and clients’ right to privacy

NLN Competencies: Context and Environment; Knowledge; principles of informed consent, confidentiality, patient self-determination

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Explain essential aspects of collaborative health care: definitions, objectives, benefits, and the nurse’s role.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 113

Question 18

Type: MCSA

The nurse is helping in discharge planning of a client who needs extensive rehabilitation and is on a complicated medication schedule. Which individual should the nurse include in this client’s plan?

1. Client’s spouse
2. Physician
3. Pharmacist
4. Social worker

Correct Answer: 1

Rationale 1: Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and health care professionals the opportunity to plan care and set goals. Involving the client’s spouse would be important in this situation because of the complexity of the client’s situation.

Rationale 2: Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and health care professionals the opportunity to plan care and set goals The physician, pharmacist, and social worker may also be included, but by their own decision—not necessarily by the nurse’s invitation.

Rationale 3: Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and health care professionals the opportunity to plan care and set goals. The physician, pharmacist, and social worker may also be included, but by their own decision—not necessarily by the nurse’s invitation.

Rationale 4: Effective discharge planning necessitates health team conferences and family conferences and gives the client, family, and health care professionals the opportunity to plan care and set goals. The physician, pharmacist, and social worker may also be included, but by their own decision—not necessarily by the nurse’s invitation.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe the role of the nurse in providing continuity of care.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 114

Question 19

Type: MCSA

A client is getting ready to go home from an intermediate care facility following surgery and a lengthy recovery period. On which item should the home health nurse focus to determine effectiveness of discharge teaching?

1. Activity restrictions
2. Follow-up appointment dates
3. Return demonstration of dressing change
4. Signs of complications

Correct Answer: 3

Rationale 1: Activity restrictions are important; however, it would not be possible for the client to demonstrate the expectation to the nurse.

Rationale 2: Knowing when to follow up with a health care provider is important; however, it would not be possible for the client to demonstrate the expectation to the nurse.

Rationale 3: Clients need teaching before discharge that includes information about medications, dietary and activity restrictions, signs of complications that need to be reported to the physician, follow-up appointments, and where supplies can be obtained. Clients, and perhaps caregivers, also need to demonstrate safe performance of any necessary treatments. Clients need help to understand their situation, to make health care decisions, and to learn new health behaviors. All the options would be important for the client to retain, but to determine whether the task of changing the dressing was learned, the client would have to demonstrate the skill back to the nurse.

Rationale 4: Signs of complications are important; however, it would not be possible for the client to demonstrate the expectation to the nurse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7. Describe the role of the nurse in providing continuity of care.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 115

New Questions:

Question 20

Type: MCMA

A multi-organization medical system is designing a community-based facility to support the health care needs of members who live in an urban area. What should the medical system keep in mind when designing the new facility?

Standard text: Select all that apply.

1. Affordable
2. Easy to travel to the facility
3. A focus on the needs of mothers and children
4. Many services available to meet community members’ needs
5. Communication of care needs to the community members’ other health care providers

Correct Answer: 1, 2, 4, 5

Rationale 1: To be effective, a community-based health care system needs to be affordable.

Rationale 2: To be effective, a community-based health care system needs to provide easy access to care.

Rationale 3: To be effective, a community-based health care system needs to focus on the needs of all community members and not just on mothers and children.

Rationale 4: To be effective, a community-based health care system needs to be flexible in responding to the care needs of individuals and families.

Rationale 5: To be effective, a community-based health care system needs to promote care between and among health care agencies through improved communication mechanisms.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Differentiate community health care settings from traditional settings.

MNL Learning Outcome: 1.2.4. Compare the frameworks of care.

Page Number: 108

Question 21

Type: MCMA

The community health nurse is identifying approaches to support a community’s health care needs. Which programs should the nurse select to support community-based health care?

Standard Text: Select all that apply.

1. Smoking cessation classes
2. Personal safety classes for women
3. Blood pressure measurement clinic
4. Outpatient clinic for minor ailments
5. Allergy injection clinic on weekends

Correct Answer: 1, 2, 3

Rationale 1: Community-based care is holistic and involves a broad range of services designed not only to restore health but also to promote health, prevent illness, and protect the public. This would include smoking cessation classes.

Rationale 2: Community-based care is holistic and involves a broad range of services designed not only to restore health but also to promote health, prevent illness, and protect the public. This would include personal safety classes for women.

Rationale 3: Community-based care is holistic and involves a broad range of services designed not only to restore health but also to promote health, prevent illness, and protect the public. This would include blood pressure measurement clinics.

Rationale 4: The traditional health care system focuses on the ill and injured. An outpatient clinic for minor ailments would be a traditional health care program.

Rationale 5: The traditional health care system focuses on the ill and injured. An allergy clinic on weekends would be a traditional health care program.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Differentiate community health care settings from traditional settings.

MNL Learning Outcome: 1.2.4. Compare the frameworks of care.

Page Number: 107

Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 11

Question 1

Type: MCSA

The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process?

1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients.

Correct Answer: 3

Rationale 1: Delivery of organized care is not part of the nursing process, although each phase is interrelated.

Rationale 2: The nursing process is not part of the medical model, as nurses treat the client’s response to the disease or problem.

Rationale 3: The purpose of the nursing process is to identify a client’s health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.

Rationale 4: The nursing process is individualized for each client’s care plan. It is not about standardizing care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Describe the phases of the nursing process.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 155

Question 2

Type: MCSA

While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working?

1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation

Correct Answer: 1

Rationale 1: Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.

Rationale 2: Diagnosis is identifying the client’s response to the problem. Implementation is what the nurse does to help the client reach a goal, and then the goal is evaluated.

Rationale 3: Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.

Rationale 4: The goal of the intervention is evaluated, but that is not what is being described in this scenario.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify the four major activities associated with the assessing phase.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 159

Question 3

Type: MCSA

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says “leave me alone.” Which subjective data should the nurse document?

1. Restlessness
2. “Leave me alone”
3. Not talkative
4. Pale and diaphoretic

Correct Answer: 2

Rationale 1: Restlessness is observable so it is not subjective data.

Rationale 2: Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the client’s sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations.

Rationale 3: Not being talkative is observable so it is not subjective data.

Rationale 4: Paleness with diaphoresis is observable so this is not subjective data.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 160

Question 4

Type: MCSA

Family of a client demonstrating confusion state that this is not the client’s usual behavior. How should the nurse document this data?

1. Inference
2. Subjective data
3. Objective data
4. Secondary subjective data

Correct Answer: 3

Rationale 1: Inference is making a judgment, and that is not what is described in the question.

Rationale 2: The information provided by the spouse is not subjective because it is an observation by someone familiar with the client’s usual behavior.

Rationale 3: Information supplied by family members, significant others, or other health professionals are considered subjective if it is not based on fact. Because this information is factual, in that the spouse is able to provide the nurse with information about the client’s routine behavior and patterns, this is objective data.

Rationale 4: The information provided by the spouse is not subjective because it is an observation by someone familiar with the client’s usual behavior.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 160

Question 5

Type: MCSA

The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the client’s pain. Which phase of the nursing process is this nurse implementing?

1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation

Correct Answer: 3

Rationale 1: Assessment is gathering data, and this is not what is described in the question.

Rationale 2: Diagnosis is identifying patterns and making inferences, and this is not what is described in the question.

Rationale 3: Implementation is that part of the nursing process in which the nurse applies knowledge to perform interventions.

Rationale 4: Evaluation is making criterion-based evaluations, and this is not what is described in the question.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe the phases of the nursing process.

MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the nursing process.

Page Number: 159

Question 6

Type: MCSA

A new client has been admitted to the care area. How soon should the nurse plan to complete a physical assessment on this patient?

1. 1 hour
2. 12 hours
3. 48 hours
4. 24 hours

Correct Answer: 4

Rationale 1: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 1 hour.

Rationale 2: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 12 hours.

Rationale 3: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within a specific time period, but not 48 hours.

Rationale 4: The Joint Commission requires that each client have an initial assessment consisting of a history and physical performed and documented within 24 hours of admission as an inpatient.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10. Contrast various frameworks used for nursing assessment.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 159

Question 7

Type: MCSA

The nurse is admitting an infant to the care area. The parents and grandmother are present. What should the nurse use as the best source of data for this client?

1. Medical record from the child’s birth
2. Grandmother
3. Parents
4. Admitting physician

Correct Answer: 3

Rationale 1: The baby’s birth record is able to provide necessary information, but not to the same extent as the parents.

Rationale 2: Although the grandmother can support the parents during this time and may be able to offer some helpful information, she would not be the best source.

Rationale 3: The best source of data is usually the client, unless the client is too ill, young, or confused to communicate clearly. The parents would be able to provide the nurse with the most accurate, current information regarding the baby (diet, schedule, symptoms, etc.).

Rationale 4: The admitting physician will be able to provide necessary information, but not to the same extent as the parents.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 161

Question 8

Type: MCSA

A newly admitted client is angry because nursing staff continue to ask the same questions. What should the nurse respond to this client?

1. “In order to make sure all of your information is complete, I need to ask these questions.”
2. “You’re right. Let me know if there’s anything you need right now.”
3. “I’ll be done shortly, just give me a few more minutes.”
4. “You shouldn’t be upset. We’re only doing our jobs.”

Correct Answer: 2

Rationale 1: Before asking more questions, the nurse should review what is already at hand.

Rationale 2: Repeated questioning can be stressful and annoying, especially for hospitalized clients, and cause concern about the lack of communication among health professionals. The nurse should review previous records that contain data about the client’s occupation, religion, and marital status, as well as take time to review all the information the previous nurse collected. Validating the client’s feelings is always a good idea and helps to build rapport between the nurse and client.

Rationale 3: This option does not address the client’s legitimate concern, nor does it acknowledge the client’s feelings.

Rationale 4: Telling the client “we’re only doing our jobs” is belittling to the client and doesn’t offer a therapeutic response.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe important aspects of the interview setting.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 163

Question 9

Type: MCSA

The nurse documents: “Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. Is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse.” Which method of data collection does this documentation demonstrate?

1. Examining
2. Interviewing
3. Listening
4. Observing

Correct Answer: 4

Rationale 1: Examining is the major method used in the physical health assessment.

Rationale 2: Interviewing is used mainly while taking the nursing health history.

Rationale 3: Listening is only one part of observing.

Rationale 4: Observation is a conscious, deliberate skill that is developed through effort and with an organized approach. Observation occurs whenever the nurse is in contact with the client or support persons.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 10

Type: MCSA

A nurse has worked in the trauma critical care area for several years. Which noise may become indiscriminate for this particular nurse?

1. A client with audible breathing
2. Moaning of a client in pain
3. Whirring of ventilators
4. Co-orkers discussing their clients’ conditions

Correct Answer: 3

Rationale 1: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurse’s part). Listening to a client’s breathing helps the nurse become attentive to changes in breathing patterns.

Rationale 2: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurse’s part). A client’s moans of pain should never become easy to listen to.

Rationale 3: The noises of machines and other equipment noises—except alarms—would be easy to ignore, as these are the usual, normal sounds of the unit.

Rationale 4: Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurse’s part). Listening to coworkers discuss other clients on the unit is helpful in case the nurse has to attend to any one of them.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10. Contrast various frameworks used for nursing assessment.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 165

Question 11

Type: SEQ

A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority).

Standard Text: Click and drag the options below to move them up or down.

Choice 1. The family is at the bedside.

Choice 2. The IV pump is running on battery.

Choice 3. The ECG monitor shows tachycardia.

Choice 4. The client reports being restless.

Choice 5. O₂ tubing is not attached to wall regulator.

Correct Answer: 3, 4, 5, 2, 1

Rationale 1: Has no apparent bearing on client’s symptoms

Rationale 2: Indicates an issue worth observing

Rationale 3: Indicates an objective cardiac symptom

Rationale 4: Indicates a subjective symptom

Rationale 5: Indicates a possible cause of the client’s symptoms

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify the purpose of assessing.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 12

Type: MCSA

During an initial interview, the client says “I don’t understand why I have to have surgery; I’m really not that sick or in pain right now.” How should the nurse respond to the client?

1. “It’s OK to be worried. Surgery is a big step.”
2. “What kind of questions do you have about your surgery?”
3. “I think these are things you should be asking your doctor.”
4. “Have you had surgery before?”

Correct Answer: 2

Rationale 1: Simply noting the concern, without dealing with it, can leave the impression that the nurse does not care about the client’s concerns or dismisses them as unimportant.

Rationale 2: The nurse should use a combination of directive and nondirective approaches during the interview to determine areas of concern for the client.

Rationale 3: Passing the questions off for the doctor would leave the impression that the nurse does not care about the client’s concerns or dismisses them as unimportant.

Rationale 4: A closed question (Have you had surgery before?) does not allow the client to offer much information, besides yes/no or one-word answers.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 13

Type: MCSA

The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use?

1. “How would you describe your sleep pattern?”
2. “Can you describe your coughing pattern?”
3. “Is there anything that makes your breathing worse?”
4. “What medications are you on?”

Correct Answer: 1

Rationale 1: Open-ended questions invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. They specify only the broad topic to be discussed. Open-ended questions invite long answers—longer than one or two words.

Rationale 2: Closed questions can be answered with short, factual, and specific information.

Rationale 3: Closed questions can be answered with short, factual, and specific information.

Rationale 4: Closed questions can be answered with short, factual, and specific information.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 14

Type: MCSA

The nurse is assessing a client’s level of pain. Which open-ended question should the nurse use for this situation?

1. “Is your pain worse at night?”
2. “What brought you to the clinic?”
3. “How has the pain impacted your life?”
4. “You’re feeling down about having pain, aren’t you?”

Correct Answer: 3

Rationale 1: Closed questions can be answered with one or two words.

Rationale 2: A neutral question is open-ended and is used in nondirective interviews, which is what would be used if the nurse didn’t understand the reason for the client’s visit.

Rationale 3: An open-ended question would be beneficial to explore more about the client’s experience and should be asked with a “how” or “what.”

Rationale 4: A leading question is usually closed and directs the client’s answer (the nurse stating how the client is feeling, for example).

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of each.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 164

Question 15

Type: MCSA

A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, what should the nurse do?

1. Sit next to the client, a few feet apart.
2. Sit behind a desk.
3. Stand at the side of the client’s chair.
4. Stand at the counter to take notes during the interview.

Correct Answer: 1

Rationale 1: A seating arrangement in which the client and nurse are seated in chairs, a few feet apart, at right angles to each other and with no table between, creates a less formal atmosphere, with the nurse and client feeling on equal terms. This would allow for more comfort and relaxation during the interview phase.

Rationale 2: Sitting behind a desk creates a formal arrangement that suggests a business meeting between a superior and subordinate.

Rationale 3: Standing and looking down at a client who is in a chair risks intimidating the client.

Rationale 4: Standing and taking notes infers that the nurse is not really interested in the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe important aspects of the interview setting.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 165

Question 16

Type: MCSA

A client in the emergency department has a non-life-threatening wound. The unit is busy with other clients, families, and people in the waiting room. How should the nurse conduct an interview with this client?

1. Have the client wait until the department quiets down, as the wound is not too serious.
2. Tell the client to wait in the waiting room and fill out the paperwork.
3. Draw curtains around the client and nurse to provide as much privacy as possible.
4. Make sure the client’s back is to the rest of the room so as not to be heard by passersby.

Correct Answer: 3

Rationale 1: Having the client wait may cause an unnecessary delay in treatment.

Rationale 2: Having the client wait and fill out paperwork may cause an unnecessary delay in treatment.

Rationale 3: The interview setting should be in a well-lighted, well-ventilated room that is relatively free of noise, movements, and distractions in order to encourage communication. The interview should also take place in an area where others cannot overhear or see the client if possible. In this situation, at least pulling a privacy curtain will help keep the client from view of others in the department.

Rationale 4: Making sure the client’s back is to the rest of the room is not acceptable.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Compare directive and nondirective approaches to interviewing.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 165

Question 17

Type: MCSA

A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this client’s interview?

1. As soon as the client gets to the floor
2. After the client has settled in and been oriented to the room
3. When the family is available to help
4. After the client has been medicated

Correct Answer: 2

Rationale 1: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal.

Rationale 2: After the client has been oriented to the bathroom and nurse call light, the nurse should start the interview process. In this situation, the nurse may have to pace the interview according to the client’s comfort level.

Rationale 3: Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal.

Rationale 4: Medication may affect the client’s ability to think clearly, so getting as much information as quickly as possible is important.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. Describe important aspects of the interview setting.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 165

Question 18

Type: MCSA

A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client?

1. Have a member of the housekeeping staff who speaks the same language translate.
2. Use the translation services supplied by the hospital.
3. Make sure a family member who does speak English is available.
4. Conduct the interview using hand gestures.

Correct Answer: 2

Rationale 1: Nurses must be cautious when asking family members, client visitors, or agency nonprofessional staff to assist with translation. Issues of confidentiality or gender mismatch can interfere with effective communication.

Rationale 2: Live translation is preferred because the client can then ask questions for clarification. Many large facilities are establishing their own translator services for the languages commonly spoken in their geographical regions.

Rationale 3: Nurses must be cautious when asking family members, client visitors, or agency nonprofessional staff to assist with translation. Issues of confidentiality or gender mismatch can interfere with effective communication.

Rationale 4: Using hand gestures is not an appropriate way to communicate with a client when other options are available.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 166

Question 19

Type: MCSA

The nurse is greeting a newly admitted client. What statement should the nurse make to establish rapport with this client?

1. “Hello, I’m your nurse and I’ll be taking care of you today.”
2. “You’re lucky—there are no students on the unit today.”
3. “Good morning, is there anything you need right now?”
4. “Hi. If you need anything, put on your call light.”

Correct Answer: 1

Rationale 1: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner. Making introductions, especially offering the use of name, is especially good in establishing rapport.

Rationale 2: Telling a hospitalized client he or she is lucky is probably not the best therapeutic comment.

Rationale 3: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner.

Rationale 4: Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 166

Question 20

Type: MCSA

The nurse has just completed an admission interview with a new client. Which nursing statement indicates that the interview is in the closing phase?

1. “I’m going to set up your physical assessment now. Do you have any questions?”
2. “Tell me more about how you feel.”
3. “Could you give examples of what types of other treatments you’ve had?”
4. “Is there anything you’re worried about?”

Correct Answer: 1

Rationale 1: Closing the interview is important for maintaining the rapport and trust between the client and nurse as well as to facilitate future interactions. The closing should contain an offer for questions, conclusions, plans for the next meeting, and a summary to verify accuracy.

Rationale 2: This would be part of the body of the interview—questions designed to gather the most information about the situation.

Rationale 3: This would be part of the body of the interview—questions designed to gather the most information about the situation.

Rationale 4: This would be part of the body of the interview—questions designed to gather the most information about the situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 167

Question 21

Type: MCSA

During an assessment interview, the client states that an elective surgical procedure will not be done because it does not fit into the client’s life goals. Into which of Gordon’s functional health patterns should the nurse identify this client’s comment?

1. Cognitive/perceptual pattern
2. Coping/stress-tolerance pattern
3. Health-perception/health-management pattern
4. Value/belief pattern

Correct Answer: 4

Rationale 1: Cognitive perceptual patterns describe sensory-perceptual and cognitive patterns.

Rationale 2: Coping/stress-tolerance patterns describe the client’s general coping pattern and the effectiveness of the patterns in terms of stress tolerance.

Rationale 3: Health-perception/health-management pattern describes the client’s perceived pattern of health and well-being and how health is managed.

Rationale 4: The value/belief pattern describes the patterns of values, beliefs (including spiritual), and goals that guide the client’s choices or decisions. The client in this situation has decided against a surgical procedure because it doesn’t coincide with the client’s beliefs and goals.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10. Contrast various frameworks used for nursing assessment.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 170

Question 22

Type: MCSA

The nurse suspects that a client with a history of injuries is a victim of abuse. What did the nurse use to come to this conclusion?

1. Observation of cues
2. Validation
3. Inference
4. Judgment

Correct Answer: 3

Rationale 1: Cues are subjective or objective data that can be directly observed by the nurse.

Rationale 2: Validation is the act of “double-checking” or verifying data to confirm that they are accurate and factual.

Rationale 3: Inferences are the nurse’s interpretations of conclusions made based on the cues, which in this case would be the frequent visits to the emergency department and the client’s injuries. Data must be based on cues, and the nurse must be careful not to jump to conclusions.

Rationale 4: Judgment is not part of validation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7. Compare directive and nondirective approaches to interviewing.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 172

Question 23

Type: MCMA

The nurse is reviewing the nursing process with a first-year nursing student. What should the nurse explain as being the purpose of the diagnosis phase?

Standard Text: Select all that apply.

1. Develop a list of problems.
2. Identify client strengths.
3. Develop a plan.
4. Specify goals and outcomes.
5. Identify problems that can be prevented.

Correct Answer: 1, 2, 5

Rationale 1: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems.

Rationale 2: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems.

Rationale 3: Developing a plan is part of the planning phase.

Rationale 4: Specifying goals and outcomes is part of the planning phase.

Rationale 5: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Describe the phases of the nursing process.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 156

Question 24

Type: MCSA

The nurse decides to seek wound care alternatives for a client’s stasis ulcer that is not healing after treatment for 2 weeks. In which phase of the nursing process is the nurse functioning?

1. Diagnosis
2. Implementation
3. Evaluation
4. Assessment

Correct Answer: 3

Rationale 1: Diagnosis is problem identification.

Rationale 2: Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case.

Rationale 3: Evaluation is measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement. Activities of evaluation include judging whether goals/outcomes have been achieved and making decisions about problem status. The client’s wound is not healing and the nurse decides to modify the nursing interventions.

Rationale 4: Assessment is collecting and organizing data.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1. Describe the phases of the nursing process.

MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of the client.

Page Number: 156

Question 25

Type: MCSA

While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time?

1. Initial assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed assessment

Correct Answer: 3

Rationale 1: Initial assessment is performed within a specific time after admission to a health care agency.

Rationale 2: Problem-focused assessment is an ongoing process integrated with nursing care.

Rationale 3: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems.

Rationale 4: Time-lapsed assessment occurs several months after the initial assessment to compare the client’s current status to baseline data previously obtained.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 161

Question 26

Type: MCSA

Unlicensed assistive personnel measure a newly admitted client’s vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data?

1. Retake the vital signs.
2. Call the physician.
3. Continue with the physical assessment as soon as possible.
4. Report the findings to the charge nurse.

Correct Answer: 1

Rationale 1: Guidelines for validating assessment data that are out of normal range include repeating the measurements, using another piece of equipment as needed to confirm abnormalities, or asking someone else to collect the same data. In this situation, the nurse needs to be sure that the vital signs are accurate.

Rationale 2: Calling the physician would be premature.

Rationale 3: The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated.

Rationale 4: Reporting the findings to the charge nurse before they have been validated would be premature.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 171

Question 27

Type: MCMA

A nurse is performing an initial assessment on a new admission. What information should the nurse consider as being a part of the database?

Standard Text: Select all that apply.

1. Reports from physical therapy the client received as an outpatient
2. Documentation of the nurse’s physical assessment
3. Physician’s orders
4. A list of current medications
5. Information about the client’s cultural preferences
6. Discharge instructions

Correct Answer: 1, 2, 4, 5

Rationale 1: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician’s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

Rationale 2: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician’s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

Rationale 3: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician’s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. It would not include the physician’s orders for this admission, or discharge instructions.

Rationale 4: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician’s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Current medications would be a part of this database.

Rationale 5: The database is all the information about a client. It includes the nursing health history, physical assessment, cultural preferences, the physician’s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

Rationale 6: The database is all the information about a client. It includes the nursing health history, physical assessment, the physician’s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. It would not include discharge instructions.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify three methods of data collection, and give examples of how each is useful.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 160

Question 28

Type: MCMA

The nurse is conducting an interview with a new client. Which actions indicate that the nurse is implementing effective communication guidelines?

Standard Text: Select all that apply.

1. Looking directly at the client to ensure good eye contact
2. Managing the conversation to avoid periods of silence
3. Providing personal experiences to help the client focus
4. Sitting in a chair next to the client who is in bed
5. Keeping arms unfolded and in a relaxed position

Correct Answer: 1, 4, 5

Rationale 1: Communication guidelines for a therapeutic interview would include establishing eye contact, as doing so shows interest and a focus on the client.

Rationale 2: Communication guidelines for a therapeutic interview would not include the avoidance of silence, as silence has therapeutic value.

Rationale 3: Communication guidelines for a therapeutic interview would not include personal experiences or opinions, as they can be viewed as a form of pressure by the client.

Rationale 4: Communication guidelines for a therapeutic interview would include sitting at the client’s eye level, as doing so helps create a sense of equality between the nurse and client.

Rationale 5: Communication guidelines for a therapeutic interview would include assuming a relaxed posture, as doing so conveys a nonthreatening environment.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. Describe important aspects of the interview setting..

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 165

Question 29

Type: MCMA

The nurse manager observes a staff nurse perform actions within the nursing process. Which activities did the manager observe the nurse perform?

Standard Text: Select all that apply.

1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature
2. Advocating for a client who is mentally incapable of expressing her needs
3. Deciding to increase a client’s nasal oxygen based on his current pulse oxygenation levels
4. Documenting all clients’ pain level responses after the administration of pain medication
5. Attending in-services on a new hydraulic lift to be used to support safe client care

Correct Answer: 1, 2, 3, 4

Rationale 1: The nursing process has distinctive characteristics that include being dynamic so as to respond to clients’ ever-changing needs.

Rationale 2: The nursing process has distinctive characteristics that include being client-centered, as evidenced by actions such as acting as the client’s advocate.

Rationale 3: The nursing process has distinctive characteristics that include decision making that enables the nurse to respond to the changing health status of the client.

Rationale 4: The nursing process has distinctive characteristics that include universal applicability of care.

Rationale 5: This is a nursing responsibility but not necessarily a characteristic of the nursing process.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 02 Identify major characteristics of the nursing process.

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Identify major characteristics of the nursing process.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 158

New Questions:

Question 30

Type: MCMA

The nurse is completing a health history with a newly admitted client. What information should the nurse include when asking about the history of the client’s present illness?

Standard text: Select all that apply.

1. Allergies
2. Immunization record
3. When the symptoms started
4. Exact location of the problem
5. Things that aggravate the problem

Correct Answer: 3, 4, 5

Rationale 1: Allergies is a part of the past history.

Rationale 2: Immunization record is a part of the past history.

Rationale 3: When the symptoms started is a part of the history of present illness.

Rationale 4: The location of the problem is a part of the history of present illness.

Rationale 5: Things that aggravate the problem is a part of the history of present illness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10. Contrast various frameworks used for nursing assessment.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 162

Question 31

Type: MCMA

The nurse manager observes a new graduate nurse complete assessment activities for a newly admitted client. Which actions indicate that the graduate needs assistance with the assessment process?

Standard Text: Select all that apply.

1. Reviews client record
2. Establishes a database
3. Performs nursing actions
4. Reviews nursing literature
5. Determines client’s strengths, risks, and problems

Correct Answer: 3, 5

Rationale 1: Reviewing client records is a part of the assessment phase of the nursing process.

Rationale 2: Establishing a database is a part of the assessment phase of the nursing process.

Rationale 3: Performing nursing actions is a part of the implementation phase of the nursing process.

Rationale 4: Reviewing nursing literature is a part of the assessment phase of the nursing process.

Rationale 5: Determining the client’s strengths, risks, and problems is a part of the diagnosis phase of the nursing process.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4. Identify the four major activities associated with the assessing phase.

MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process.

Page Number: 158

Kozier & Erb’s Fundamentals of Nursing, 9/E
Chapter 19

Question 1

Type: MCSA

A nurse is helping a hospice client who has had difficulty with making end-of-life decisions. The nurse has encouraged the client to focus on her self-worth, her accomplishments, and having positive self-esteem in order to process through some of these decisions. The nurse is helping the client to achieve balance in which component?

1. Environmental
2. Physical
3. Mental
4. Spiritual

Correct Answer: 3

Rationale 1: Environmental aspects include physical, biologic, economic, social, and political conditions.

Rationale 2: Physical aspects include optimal functioning of all body systems.

Rationale 3: Mental aspects include feelings of self-worth, a positive identity, a sense of accomplishment, and the ability to appreciate and create. In terms of optimal wellness, balance consists of mental, physical, emotional, spiritual, and environmental components. Each component needs to be balanced, and a sense of equality among the components is needed.

Rationale 4: Spiritual aspects involve moral values, a meaningful purpose in life, and a feeling of connectedness to others and a divine source.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Give examples of healing environments.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 296

Question 2

Type: MCSA

A home health nurse is working with a client who has had to quit his job after a serious injury and whose future employability is uncertain. The client states that his life has no meaning or purpose anymore and that he feels lonely and abandoned. What is an appropriate nursing diagnosis for this client?

1. Body Image Disturbance
2. Health-Seeking Behavior
3. Altered Family Processes
4. Spiritual Distress

Correct Answer: 4

Rationale 1: Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death. The NANDA label Spiritual Distress is defined as disruption of the life principle that pervades one’s biological and psychosocial nature. The feelings the client expresses have little to do with his body image.

Rationale 2: Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death. The NANDA label Spiritual Distress is defined as disruption of the life principle that pervades one’s biological and psychosocial nature. The client is not expressing the desire to increase his level of well-being.

Rationale 3: Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death. The NANDA label Spiritual Distress is defined as disruption of the life principle that pervades one’s biological and psychosocial nature. The feelings the client expresses have little to do with family processes.

Rationale 4: Spirituality is that which gives people meaning and purpose in their lives. It involves finding significant meaning in the entirety of life, including illness and death. The NANDA label Spiritual Distress is defined as disruption of the life principle that pervades one’s biological and psychosocial nature. The feelings the client expresses have little to do with his body image or family processes, and he is not expressing the desire to increase his level of well-being.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Describe the basic concepts of alternative practices.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 296

Question 3

Type: MCSA

The nurse is working with a client who, during her interview, expresses feelings of groundedness. The nurse interprets this to mean that the client

1. is full of energy.
2. feels connected to her reality.
3. is focused on her center of energy.
4. feels “down in the dumps.”

Correct Answer: 2

Rationale 1: Energy is viewed as the force that integrates the body, mind, and spirit and doesn’t relate to groundedness.

Rationale 2: Grounding relates to one’s connection with reality. Being grounded suggests stability, security, independence, having a solid foundation, and living in the present.

Rationale 3: Centering refers to the process of bringing oneself to the center or middle and doesn’t relate to groundedness.

Rationale 4: This relates more closely with sadness or depression than groundedness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Give examples of healing environments.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 296

Question 4

Type: MCSA

After having a difficult time saying “no” when asked to work yet another overtime shift, the nurse begins to feel overwhelmed and irritable. As a method to most effectively promote self-healing, what should this nurse do?

1. Clarify values and beliefs.
2. Set realistic goals.
3. Learn to manage stress.
4. Challenge the belief that others always come first.

Correct Answer: 4

Rationale 1: Identification of things that are important, meaningful, and valuable is part of clarifying values and beliefs and may help, but there is a more specific option available.

Rationale 2: Identifying and setting goals may help, but there is a more specific option available.

Rationale 3: Stress management may help, but there is a more specific option available.

Rationale 4: Overwork and overinvolvement leave little time for fulfillment of personal needs. Nurses need to learn to ask for what they need and avoid feelings of selfishness when not responding to someone else’s needs.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Give examples of healing environments.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 296

Question 5

Type: MCSA

During an interview assessment, the client states a belief in nutritional lifestyle counseling and that the body’s vital energy circulates through the body, which can be manipulated through specific anatomical points. Which type of healing practice should the nurse identify that this patient is following?

1. Traditional Chinese medicine
2. Native American healing
3. Ayurveda
4. Curanderismo

Correct Answer: 1

Rationale 1: Traditional Chinese medicine (TCM) is based on the premise that the body’s vital energy or qi circulates through pathways and meridians and can be accessed and manipulated through specific anatomical points along the surface of the body. Practitioners use a variety of ancient methods, including acupuncture, acupressure, herbal medicine, massage, heat therapy, qigong, t’ai chi, and nutritional counseling.

Rationale 2: Native American healing is very connected to spirituality, and health is viewed as a balance or harmony of body and mind.

Rationale 3: Ayurveda emphasizes the interdependence of the health of the individual and the quality of societal life.

Rationale 4: Curanderismo is a cultural healing tradition found in Latin American cultures and utilizes Western biomedical beliefs, treatment, and practices.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe the basic principles of health care practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 297

Question 6

Type: MCSA

The client asks whether herbal medicines are a “good idea.” What should the nurse respond?

1. “Things found in nature are always healthy.”
2. “If your doctor didn’t prescribe it, don’t take it.”
3. “Are there specific ones you’re wondering about?”
4. “Everything is good in moderation.”

Correct Answer: 3

Rationale 1: Not all plant life is beneficial.

Rationale 2: There are cautions and contraindications with some herbal preparations and over-the-counter (OTC) as well as prescription drugs. The use of such treatments may be helpful but should be discussed with a health care provider in order to minimize the risk of interactions.

Rationale 3: Not all plant life is beneficial. Nurses must be open to exploring and discussing their clients’ uses of and questions regarding herbal medicine. There are cautions and contraindications with some herbal preparations and over-the-counter (OTC) as well as prescription drugs. The most important role the nurse plays in regard to herbal medicine is to find out what the client is taking and at what dosage, and have a full list of the client’s prescription medications as well as anything taken that is OTC.

Rationale 4: Not all plant life is beneficial. This option is not a sufficient answer to the client’s question.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Give examples of healing environments.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 298

Question 7

Type: MCSA

A client comes to the family planning clinic for follow-up and is currently taking an oral contraceptive. During the interview assessment, the client states she has been using some “natural medicines.” Which herbal preparation should alert the nurse to a possible interaction with oral contraceptives?

1. Valerian
2. Echinacea
3. Garlic
4. Milk thistle

Correct Answer: 4

Rationale 1: Valerian may increase the sedative effects of antianxiety medication.

Rationale 2: Echinacea may reduce the effectiveness of immunosuppressants.

Rationale 3: Garlic may cause a need for an increased dose of antihypertensives.

Rationale 4: Milk thistle reduces the effectiveness of oral contraceptives.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 299

Question 8

Type: MCSA

A client who has a long-standing history of depression has been on a prescribed antidepressant for several months and states that he has also been trying St. John’s wort. Which vital sign should the nurse assess for possible adverse effects?

1. Temperature
2. Respiratory rate
3. Oxygen saturation
4. Pulse rate

Correct Answer: 4

Rationale 1: St. John’s wort would not affect the hypothalamus.

Rationale 2: St. John’s wort would not affect the respiratory system.

Rationale 3: St. John’s wort would not affect the respiratory system.

Rationale 4: St. John’s wort may potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 299

Question 9

Type: MCSA

During a clinic appointment, a client prescribed medication for glaucoma reports vision problems. When taking a medication history, which herbal preparation should the nurse identify as being problematic for this client?

1. Ginseng
2. Echinacea
3. Valerian
4. St. John’s wort

Correct Answer: 1

Rationale 1: Ginseng may interact with caffeine and cause irritability and may also decrease the effectiveness of glaucoma medication.

Rationale 2: Echinacea may reduce the effectiveness of immunosuppressants but does not appear to affect glaucoma medication.

Rationale 3: Valerian may increase the sedative effects of antianxiety medication but does not appear to affect glaucoma medication.

Rationale 4: St. John’s wort may potentiate antidepressant medications, causing severe agitation, nausea, confusion, and possible cardiac problems.

Global Rationale:

Learning Outcome: 10 Teach clients the uses and safety precautions regarding alternative therapies.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 299

Question 10

Type: MCSA

A client diagnosed with hypertension has had well-controlled follow-up of her blood pressure for the past 6 months. At today’s clinic appointment, the client’s blood pressure is 98/58. The client insists she has been taking her prescribed antihypertensive medication as prescribed, but also added an “herbal” tablet because she heard it was supposed to be good for her. Which is most likely interfering with the client’s antihypertensive?

1. Valerian
2. Milk thistle
3. Ginseng
4. Garlic

Correct Answer: 4

Rationale 1: Valerian may increase the sedative effects of antianxiety medication but does not appear to affect antihypertensive medication.

Rationale 2: Milk thistle reduces the effectiveness of oral contraceptives but does not appear to affect antihypertensive medication.

Rationale 3: Ginseng may decrease the effectiveness of glaucoma medications but does not appear to affect antihypertensive medication.

Rationale 4: Garlic reduces high blood pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 299

Question 11

Type: MCSA

The nurse is preparing to assess a group of assigned clients with chronic illnesses who use essential oils. For which health problem should the nurse particularly assess the clients?

1. Hypertension
2. Cardiac problems
3. Asthma
4. Cancer

Correct Answer: 3

Rationale 1: This type of alternative therapy does not appear to affect blood pressure.

Rationale 2: This type of alternative therapy does not appear to affect the cardiac system.

Rationale 3: Some oils can trigger bronchial spasms, so persons with asthma should consult their primary health care provider before using oils.

Rationale 4: This type of alternative therapy does not appear to affect cancer.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 299

Question 12

Type: MCSA

A client with degenerative joint disease comes to the clinic and states that he has been reading a lot about essential oils that are helpful for “stomach problems.” The nurse should offer the client information about the use of which oil?

1. Chamomile
2. Eucalyptus
3. Lavender
4. Tea tree

Correct Answer: 1

Rationale 1: Chamomile oil soothes muscle aches, sprains, and swollen joints and is helpful as a GI antispasmodic.

Rationale 2: Eucalyptus feels cool to the skin and warm to muscles; decreases fever; relieves pain; and acts as an anti-inflammatory, antiseptic, antiviral, and expectorant to the respiratory system in a steam inhalation. It can also boost the immune system.

Rationale 3: Lavender oil is calming and is used as a sedative for insomnia. It may be massaged around the temples for headache, inhaled to speed recovery from colds or flu, and massaged into the chest to decrease congestion. It can also be used to heal burns.

Rationale 4: Tea tree oil is good for athlete’s foot as an antifungal. It can be used to soothe insect bites, stings, cuts, and wounds. It can be bathed in for yeast infection, and drops on a handkerchief can be used for coughs or congestion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Teach clients the uses and safety precautions regarding complementary and alternative therapies.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 300

Question 13

Type: MCMA

A client asks the nurse about chiropractic medicine. What should the nurse explain as being among the goals of this type of health intervention?

Standard Text: Select all that apply.

1. Improvement of blood and lymph flow through the body
2. Stimulation of specific points to help with pain relief, cures certain illnesses, and promote wellness
3. Reduce or eliminate pain
4. Correct spinal dysfunction
5. Preventive maintenance

Correct Answer: 3, 4, 5

Rationale 1: Massage therapy improves blood flow and lymph fluid through the body.

Rationale 2: Acupressure and acupuncture are techniques of applying pressure or stimulation to specific points on the body in order to relieve pain, cure certain illnesses, and promote wellness.

Rationale 3: The first clinical goal of chiropractic care is to reduce or eliminate pain.

Rationale 4: By correcting spinal dysfunction, biomechanical balance is restored to the body to reestablish shock absorption, leverage, and range of motion. Muscles and ligaments are strengthened by spinal rehabilitative exercises to increase resistance to further injury.

Rationale 5: Preventive maintenance of chiropractic medicine ensures that the problem does not recur.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Discuss the principles of naturopathic medicine.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 301

Question 14

Type: MCSA

A client who resides in a long-term care facility has no family or visitors. Her only social contacts are with the staff. The client is confined to bed and is not able to communicate verbally. As part of the client’s care plan, the nurses provide massage therapy three times a week. What is the main benefit of this intervention for this client?

1. Stretch and loosen the muscles
2. Speed the removal of metabolic waste products
3. Help satisfy the need for caring and nurturing touch
4. Relieve pain

Correct Answer: 3

Rationale 1: Massage would be an appropriate intervention to address this option but it is not the main benefit the client will experience.

Rationale 2: Massage would be an appropriate intervention to address this option but it is not the main benefit the client will experience.

Rationale 3: Because she has no family, no visitors, and her only contacts are with the staff, this client will benefit at the emotional level, as massage satisfies the need for caring and nurturing touch. It also increases feelings of well-being, decreases mild depression, enhances self-image, reduces levels of anxiety, and increases awareness of mind–body connection.

Rationale 4: Massage would be an appropriate intervention to address this option but it is not the main benefit the client will experience.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Discuss the principles of naturopathic medicine.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 301

Question 15

Type: MCSA

A client visits a clinic that integrates Western medicine with complementary therapies. Which therapies might the client utilize and believe to keep the flow of qi at a therapeutic level?

1. Acupressure and reflexology
2. Therapeutic touch and Reiki
3. Aromatherapy and naturopathic remedies
4. Chiropractic and massage therapy

Correct Answer: 1

Rationale 1: Reflexology and acupressure are treatments rooted in the traditional Eastern philosophy that qi, or life energy, flows through the body along pathways known as meridians. When the flow of energy becomes blocked or congested, people experience discomfort or pain on a physical level. They may feel frustrated or irritable on an emotional level and may experience a sense of vulnerability or lack of purpose in life on a spiritual level.

Rationale 2: Therapeutic touch and Reiki use the hands to alter the bio-field or energy field.

Rationale 3: Aromatherapy and naturopathic remedies utilize essential oils and plants for health benefits.

Rationale 4: Chiropractic and massage therapy are examples of manual healing methods.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6. Identify the role of manual healing methods in health and illness.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 301

Question 16

Type: MCSA

A client reports feelings of spiritual anguish and depression as a result of experiencing numerous somatic complaints that make the client feel like “everything is out of order.” Which nursing diagnosis should the nurse identify for this client?

1. Energy-field disturbance
2. Powerlessness
3. Hopelessness
4. Anxiety

Correct Answer: 1

Rationale 1: Energy-field disturbance is defined as a state in which a disruption of the flow of energy surrounding a person’s being results in a disharmony of the body, mind, or spirit.

Rationale 2: Powerlessness is defined as a perception that one’s own actions will not significantly affect an outcome.

Rationale 3: Hopelessness is a subjective state in which an individual sees no alternatives or personal choices available and is unable to mobilize energy on his or her own behalf.

Rationale 4: Anxiety is defined as a vague, uneasy feeling, the source of which is often nonspecific or unknown to the individual.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Identify the role of manual healing methods in health and illness.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 301

Question 17

Type: MCSA

A client undergoing chemotherapy becomes very anxious and stressed just before the treatments. Which would be an appropriate therapy for this person to learn?

1. Meditation
2. Aromatherapy
3. Homeopathy
4. Yoga

Correct Answer: 1

Rationale 1: Meditation is a general term for a wide range of practices that involve relaxing the body and easing the mind. Meditation is a process that individuals can use to calm themselves, cope with stress, and, for those with spiritual inclinations, feel as one with God or the universe.

Rationale 2: Aromatherapy is the use of essential oils that, when absorbed into the body, produce physiologic or psychologic benefit.

Rationale 3: Homeopathy is a self-healing system in which doses of natural compounds stimulate a person’s self-healing capacity.

Rationale 4: Yoga includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 303

Question 18

Type: MCSA

A client has been undergoing therapy as a victim of severe emotional abuse. The goal of the client’s therapy is to gain self-control of the situation, improve self-esteem, and become self-sufficient. Which application should the nurse suggest become a part of the client’s therapy sessions?

1. Yoga
2. Meditation
3. Hypnotherapy
4. Guided imagery

Correct Answer: 3

Rationale 1: Yoga includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment.

Rationale 2: Meditation is a general term for a wide range of practices that involve relaxing the body and easing the mind.

Rationale 3: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous.

Rationale 4: Guided imagery is a state of focused attention, much like hypnosis, that encourages changes in attitudes, behavior, and physiologic reactions.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 303

Question 19

Type: MCSA

A client has been diagnosed with post-traumatic stress syndrome and has difficulty sleeping because of recurrent nightmares. In working with this client to overcome the problem, what should the nurse implement as part of therapy?

1. Guided imagery
2. Hypnotherapy
3. Yoga
4. Meditation

Correct Answer: 1

Rationale 1: Guided imagery is a state of focused attention that encourages changes in attitudes, behavior, and physiologic reactions. Guided imagery can help people learn how to stop troublesome thoughts and focus on images that promote relaxation and decrease the negative impact of stressors.

Rationale 2: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous.

Rationale 3: Yoga includes ethical models for behavior and mental and physical exercises aimed at producing spiritual enlightenment.

Rationale 4: Meditation is a general term for a wide range of practices that relax the body and help ease the mind.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 303

Question 20

Type: MCSA

A nurse who works in a busy neonatal intensive care unit has been having difficulty with concentration after a long day’s work. Which therapy should the nurse consider doing to help with this problem?

1. Guided imagery
2. Hypnotherapy
3. Qigong
4. Aromatherapy

Correct Answer: 3

Rationale 1: Guided imagery is a state of focused attention that encourages changes in attitudes, behavior, and physiologic reactions.

Rationale 2: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous.

Rationale 3: Qigong is a Chinese discipline consisting of breathing and mental exercises combined with body movements. The softness of movements develops energy without nervousness. The slowness of movements quiets the mind and develops one’s powers of awareness and concentration.

Rationale 4: Aromatherapy is the use of essential oils that, when absorbed into the body, produce physiologic or psychologic well-being.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qigong, and tai chi have in common.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 304

Question 21

Type: MCSA

A nurse working on an Alzheimer’s unit notes that just before the supper hour, many of the residents become more anxious and confused—exhibiting typical “sundowner’s syndrome”—making the evening meal an unpleasant ordeal. As a method to try to decrease their turmoil during this time, which therapy should the nurse introduce into the daily routine?

1. Biofeedback
2. Music therapy
3. Pilates
4. Spiritual therapy

Correct Answer: 2

Rationale 1: Biofeedback is a relaxation technique that uses electronic equipment to amplify the electrochemical energy produced by body responses.

Rationale 2: Quiet, soothing music without words is often used to induce relaxation. Music therapy can be used in a variety of settings, without much added cost and with little extra work on the part of staff. In this particular setting, the music may help to soothe the residents and promote a sense of balance or harmony on the unit.

Rationale 3: Pilates is a method of physical movement and exercises designed to stretch, strengthen, and balance the body.

Rationale 4: Spiritual therapy includes prayer and faith practices to promote healing.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify the role of manual healing methods in health and illness.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 305

Question 22

Type: MCSA

A client comes to the clinic with a chief complaint of feeling “dirty inside” and asks the nurse how colonics would work to improve the client’s overall well-being. What should the nurse respond to this client?

1. “Colonics is a dangerous and not useful technique that no one should try.”
2. “There is much controversy about colonics. What do you know about it?”
3. “This is a good way to get rid of toxins in your system.”
4. “You’d better ask your doctor about this.”

Correct Answer: 2

Rationale 1: Although colon cleansing is a controversial method of detoxification, and there tends to be no middle group in the beliefs about the usefulness of colonics, that option does not appropriately address the client’s concerns.

Rationale 2: Although colon cleansing is a controversial method of detoxification, establishing a baseline regarding the client’s knowledge regarding the process is most appropriate.

Rationale 3: Colonics is the procedure for washing the inner wall of the colon by filling it with water or herbal solutions and then draining it. Colon cleansing is a controversial method of detoxification and the issue requires further discussion.

Rationale 4: This option defers the client’s concerns to the doctor, which is inappropriate because the nurse should be prepared to discuss the issue with the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Identify types of detoxification therapies.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 306

Question 23

Type: MCSA

A client was in a motor vehicle crash where he sustained injury to his spinal cord that has resulted in difficulty with balance and holding his posture. Which should the nurse suggest the client consider?

1. Animal-assisted therapy
2. Hypnotherapy
3. Chelation therapy
4. Detoxification

Correct Answer: 1

Rationale 1: Therapeutic horseback riding, a type of animal-assisted therapy, is the use of the rhythmic movement of the horse to increase sensory processing and improve posture, balance, and mobility in people with movement dysfunctions.

Rationale 2: Hypnotherapy is an advanced form of relaxation and can be used to help people gain self-control, improve self-esteem, and become more autonomous.

Rationale 3: Chelation therapy is the introduction of chemicals into the bloodstream that bind with heavy metals in the body.

Rationale 4: Detoxification is based on the belief that physical impurities and toxins must be cleared from the body to achieve better health.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Discuss uses of animals, prayer, and humor as treatment modalities.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 306

Question 24

Type: MCSA

A client living in a long-term care center has been withdrawn and subdued, and does not eat in the dining room because of embarrassment about her physical decline. What might the nurse suggest that provides opportunities for unconditional love, achievement of trust, responsibility, and empathy toward others?

1. Chelation therapy
2. Animal-assisted therapy
3. Meditation
4. Pilates

Correct Answer: 2

Rationale 1: Chelation therapy is the introduction of chemicals into the bloodstream that bind with heavy metals in the body.

Rationale 2: Animal-assisted therapy is defined as the use of specifically selected animals as a treatment modality in health and human service settings. The contributions include opportunities for affection, achievement of trust, responsibility, and empathy toward others. Pets in long-term care facilities become so perceptive that they actually gravitate to the rooms of people who are most isolated or depressed.

Rationale 3: Meditation is a wide range of practices that relax the body and heal the mind.

Rationale 4: Pilates is a method of physical movement and exercise designed to stretch, strengthen, and balance the body.

Global Rationale:

Page Reference:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Discuss uses of animals, prayer, and humor as treatment modalities.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 306

Question 25

Type: MCMA

The nurse is reviewing systems of healing that emphasize client responsibility, client education, disease prevention, or natural substances that stimulate a person’s self-healing capacity. On which systems is the nurse focusing?

Standard Text: Select all that apply.

1. Naturopathic medicine
2. Homeopathic medicine
3. Aromatherapy
4. Chiropractic
5. Hypnosis

Correct Answer: 1, 2, 3, 4

Rationale 1: Naturopathic medicine is a self-healing system that utilizes remedies to stimulate a person’s self-healing capacity.

Rationale 2: Homeopathy is a self-healing system that utilizes remedies to stimulate a person’s self-healing capacity.

Rationale 3: Aromatherapy is the use of essential oils of plants in which the odor or fragrance, when applied or in proximity to the body, results in physiologic or psychologic benefit.

Rationale 4: Chiropractic is a type of manual healing method.

Rationale 5: Hypnosis is not considered a system of healing.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe the basic concepts of alternative practices.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 299, 300

Question 26

Type: MCMA

The nurse is teaching a client regarding the use of herbal preparations. Which statements should the nurse include in this teaching?

Standard Text: Select all that apply.

1. “Echinacea might reduce the effectiveness of the immunosuppressant medications you’ve been prescribed since your transplant.”
2. “Gingko could affect the results of your aspirin therapy.”
3. “Ginger could be contraindicated because you are taking anticoagulant medications.”
4. “With your history of glaucoma, I don’t believe you should be supplementing with ginseng.”
5. “St. John’s wort is a safe supplement when being medicated for depression.”

Correct Answer: 1, 2, 3, 4

Rationale 1: Although it is believed by some to enhance the immune system, echinacea can reduce the effectiveness of immunosuppressants.

Rationale 2: Gingko can increase the anticoagulant effects of aspirin and anticoagulant medications.

Rationale 3: Ginger can increase the anticoagulant effects of aspirin and anticoagulant medications.

Rationale 4: Ginseng can decrease the effectiveness of glaucoma medications.

Rationale 5: St. John’s wort can potentiate antidepressant medications, causing severe agitation and nausea.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Explain how herbs are similar to many prescription drugs.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 299

Question 27

Type: MCMA

The nurse is instructing a client on meditation and relaxation. Which information should the nurse include in this teaching?

Standard Text: Select all that apply.

1. “Perform these techniques at least 2 hours after eating so as to concentrate all your body’s energies.”
2. “Practice these techniques in a comfortable, upright position.”
3. “Remember to relax your muscles after you have successfully tightened a muscle group.”
4. “Find a quiet, peaceful place to meditate.”
5. “Set aside 60 minutes daily for meditation and relaxation.”

Correct Answer: 1, 2, 3, 4

Rationale 1: Ideally, choose the early morning or evening, and wait at least 2 hours after eating so that complete energy is devoted to meditation rather than to digestive demands.

Rationale 2: Avoid a lying position, because it increases the tendency to fall asleep.

Rationale 3: Progressively tighten and relax each muscle group in the body.

Rationale 4: A quiet, comfortable place, devoid of distractions, is helpful.

Rationale 5: Practice these techniques daily for 10- to 20-minute periods.

Global Rationale:

Learning Outcome: 06 Identify the role of manual healing methods in health and illness.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Identify the role of manual healing methods in health and illness.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 303

New Questions:

Question 28

Type: MCMA

A client tells the nurse about an appointment to see an Ayurveda health care practitioner for a specific chronic health problem. What should the nurse instruct the client to expect when visiting this practitioner?

Standard Text: Select all that apply.

1. A diet
2. Sitting in a sweat lodge
3. An exercise program
4. Acupuncture treatment
5. A list of herbal preparations

Correct Answer: 1, 3, 5

Rationale 1: Specific lifestyle interventions are a major preventive and therapeutic approach in Ayurveda. Each person is prescribed an individualized diet.

Rationale 2: Sweat lodges are a part of Native American healing.

Rationale 3: Specific lifestyle interventions are a major preventive and therapeutic approach in Ayurveda. Each person is prescribed an individualized exercise program.

Rationale 4: Acupuncture is an approach used in Chinese medicine.

Rationale 5: In Ayurveda, herbal preparations are added to the diet for preventive or regenerative purposes as well as for the treatment of specific disorders.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Describe the basic principles of health care practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 297

Question 29

Type: MCMA

While completing a health history and assessment, the nurse suspects that a client of Latino descent uses curanderismo for health care. What client information did the nurse use to make this determination?

Standard Text: Select all that apply.

1. The client stated that the health care provider prescribes specific herbs.
2. The client stated that the same health care provider helped in the delivery of all of her children.
3. The client stated that small needles are inserted along certain parts of the body to help with healing.
4. The client stated that the health care provider visits the home to pray with the family members
5. The client stated that specific areas of the body are pressed by the health care provider to increase energy.

Correct Answer: 1, 2, 4

Rationale 1: Curanderismo is a cultural healing tradition found in Latin America and among many Latinos in the United States. Healers are called curanderos (men) and curanderas (women) and may specialize as herbalists.

Rationale 2: Curanderismo is a cultural healing tradition found in Latin America and among many Latinos in the United States. Healers are called curanderos (men) and curanderas (women) and may specialize as midwives.

Rationale 3: The use of small needles describes acupuncture, which is a Chinese medicine approach.

Rationale 4: Curanderismo is a cultural healing tradition found in Latin America and among many Latinos in the United States. Healers are called curanderos (men) and curanderas (women) and may utilize religious rituals, cleansing rites, and prayers in their healing practices.

Rationale 5: Pressing areas of the body describes acupressure, which is not a part of curanderismo.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience

AACN Essentials Competencies: IX. 17. Develop a beginning understanding of complementary and alternative modalities and their role in health care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3. Describe the basic principles of health care practices such as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo.

MNL Learning Outcome: 1.3.4. Consider complementary and alternative therapy in the promotion of health.

Page Number: 298

Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 27

Question 1

Type: MCSA

The nurse has completed client teaching regarding medication administration. Which client statement best illustrates compliance?

1. “I’m glad to know about my medications. It makes taking them a lot easier.”
2. “I already knew most of what you told me.”
3. “I think you should have waited until I was ready to go home. Maybe I’d remember better.”
4. “If I take my medications as prescribed, I’ll feel better.”

Correct Answer: 1

Rationale 1: Compliance is best illustrated when the person recognizes and accepts the need to learn, then follows through with appropriate behaviors that reflect learning. Learning about the medications helps the client understand why they’re prescribed and improves the possibility for following the prescribed regimen.

Rationale 2: Statements of prior knowledge do not necessarily lead to compliance.

Rationale 3: Following the advice of the health care prescriber does not necessarily lead to compliance.

Rationale 4: Following the advice of the health care prescriber does not necessarily lead to compliance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1. Discuss the importance of the teaching role of the nurse.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 2

Type: MCSA

A nurse is planning a community health education project that deals with organ donation, and the target audience is a group of adults. When following andragogy concepts, the nurse should make sure that the teaching includes which information?

1. Past statistics about organ donors
2. Written pamphlets
3. Directions about how to become an organ donor
4. Information on how this group can influence their children

Correct Answer: 3

Rationale 1: An adult is more oriented to learning when the material is useful immediately, not sometime in the future.

Rationale 2: Written information may or may not be helpful, depending on what types of learners are included in the group.

Rationale 3: An adult is more oriented to learning when the material is useful immediately, not sometime in the future. For this audience, giving clear directions on how to become an organ donor would be more helpful than past information and future activities such as influencing their children.

Rationale 4: For this audience, giving clear directions on how to become an organ donor would be more helpful than past information and future activities such as influencing their children.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Compare and contrast andragogy, pedagogy, and geragogy.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 3

Type: MCSA

The nurse is instructing a client on self-administration of a subcutaneous injection. The nurse is using which theoretical construct of learning?

1. Thorndike’s behaviorism
2. Skinner’s positive reinforcement
3. Pavlov’s conditioning response
4. Bandura’s imitation

Correct Answer: 4

Rationale 1: Edward Thorndike originally advanced the theory of behaviorism and maintained that learning should be based on the learner’s behavior.

Rationale 2: Skinner focused his work on conditioning behavioral responses to a stimulus that causes the response or behavior.

Rationale 3: Pavlov focused his work on conditioning behavioral responses to a stimulus that causes the response or behavior.

Rationale 4: Bandura claims that most learning comes from observation and instruction. Imitation is the process by which individuals copy or reproduce what they have observed.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Discuss the learning theories of behaviorism, cognitivism, and humanism and how nurses can use each of these theories.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 4

Type: MCSA

A nursing student is presenting a teaching project to the class using each of Bloom’s domains. The student has several activities included in the project. Which activity is an example of the affective domain?

1. Each member of the class must identify two attitudinal changes that have occurred in their lives since beginning their nursing education.
2. All members must list the technical skills they’ve learned.
3. Members must demonstrate a favorite nursing skill at the end of the class period.
4. Members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class.

Correct Answer: 1

Rationale 1: The affective domain of Bloom’s theory of learning is also known as the “feeling” domain. It includes emotional responses to tasks such as feelings, emotions, interests, attitudes, and appreciations.

Rationale 2: Listing technical skills and reading or summarizing information is part of the “thinking” domain, which includes knowing, comprehending, application, analysis, synthesis, and evaluation.

Rationale 3: The psychomotor domain is the “skill” domain and includes hands-on motor skills such as demonstration.

Rationale 4: Listing technical skills and reading or summarizing information is part of the “thinking” domain, which includes knowing, comprehending, application, analysis, synthesis, and evaluation.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Describe the three learning domains.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 5

Type: MCSA

A client is practicing using an incentive spirometer after surgery. The nurse has explained the use, demonstrated how it works, and also given the rationale for the client to continue to use this device. When mastering the use of this device, the client will demonstrate learning in which of Bloom’s domains?

1. Cognitive
2. Psychomotor
3. Affective
4. Imitation

Correct Answer: 2

Rationale 1: Cognitive abilities include the “thinking” process that begins with knowing, comprehending, and applying knowledge.

Rationale 2: The psychomotor domain is the “skill” domain and includes motor skills, such as being able to use an incentive spirometer.

Rationale 3: The affective domain involves attitudes or emotional responses and includes feelings, emotions, interests, and appreciations.

Rationale 4: Imitation is not one of Bloom’s domains of learning.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3. Describe the three learning domains.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 440

Question 6

Type: MCSA

A nurse is presenting teaching sessions to a group of residents in a home for long-term physical rehabilitation. Which client exhibits the highest motivation?

1. An individual who has been struggling with following nursing directives regarding discharge goals
2. The client who has just moved in and is already waiting for discharge
3. A client who is excited to learn about his new prosthesis
4. A client who has been there the longest and is a great “coach” for newcomers

Correct Answer: 3

Rationale 1: Clients who struggle with rules or following prescribed courses of treatment are not motivated to learn the best reason for their particular plan of action. They may be “bucking” the system.

Rationale 2: The client who is already waiting to go home may be motivated for that, but not to the extent of being ready to learn how to achieve this end.

Rationale 3: Motivation is the desire to learn and influences how quickly and to what extent a person learns. It is generally greatest when a person recognizes a need and believes the need will be met through learning. The client who is excited to learn about his prosthesis understands that learning about it will help take his recovery to a high level.

Rationale 4: Motivation must be experienced by the client, not by someone else (as in being a “coach” for newcomers).

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 441

Question 7

Type: MCSA

A nurse is working in a neonatal intensive care unit, teaching parents how to care for their tiny babies while they are still in the hospital. Which statement by a parent reflects a readiness to learn?

1. “I’m so afraid I’ll hurt my baby with all these tubes.”
2. “I want to make sure my spouse is here, in case I don’t hear everything that’s said.”
3. “When my baby is just a little bigger, I’ll be able to handle him.”
4. “You’ll give us written instructions before we go home, correct?”

Correct Answer: 2

Rationale 1: Statements about fear of the situation need to be addressed so the fear will not inhibit the learning process.

Rationale 2: Readiness to learn is the demonstration of behaviors or cues that reflect a learner’s motivation, desire, and ability to learn at a specific time. The client who wants the spouse involved is demonstrating motivation and willingness, but also wants support from the spouse as well.

Rationale 3: Wanting to wait until the baby is older reflects uncertainty and possibly fear and should be addressed before learning can occur.

Rationale 4: Wanting to wait until discharge reflects uncertainty and possibly fear and should be addressed before learning can occur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 441

Question 8

Type: MCSA

The nurse is instructing a client on self-administration of insulin. Which statement regarding feedback will be most beneficial to the client?

1. “You know, there are children who can learn to do this.”
2. “Maybe it would be better if we taught your spouse to help you with this.”
3. “Next time, dart the needle in your skin, instead of pushing it in.”
4. “If you don’t learn this, you can’t be discharged.”

Correct Answer: 3

Rationale 1: Ridicule or sarcasm can lead to withdrawal from learning, as in reminding an adult client that a child can perform the task or of not being discharged until the skill is learned.

Rationale 2: Statements about having somebody else learn the technique may also cause the learner to avoid the teaching moment and to avoid learning the technique altogether.

Rationale 3: Feedback should be meaningful to the learner and should support the desired behavior through praise, positively worded corrections, and suggestions of alternative methods.

Rationale 4: Ridicule or sarcasm can lead to withdrawal from learning, as in reminding an adult client that a child can perform the task or of not being discharged until the skill is learned.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 442

Question 9

Type: MCSA

A home health client having difficulty keeping his medication schedule organized says “There are so many pills and the names are all confusing to me. I don’t even understand what they’re for.” What should the nurse do?

1. Help the client remember color and size in relationship to dosing time.
2. Write out the generic and trade name of all the pills for the client.
3. Fill a pill bar and tell the client not to worry, and just take the pills according to that system.
4. Have the physician talk to the client about his medications.

Correct Answer: 1

Rationale 1: Learning is facilitated by material that is logically organized and proceeds from the simple to the complex. This helps the learner comprehend new information, apply it to previous learning, and form new understandings. Naming the pills by color and size and dosing time helps the client move from that level to learning what each medication is for and why he is taking it—simple to complex.

Rationale 2: Learning generic and trade names is memorization and may not make sense for this client.

Rationale 3: Filling a pill box or bar is not helping the client learn about his meds; it merely puts them into an order without information.

Rationale 4: Nurses must rely on their own creativity and resourcefulness, not depend on physician input.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 442

Question 10

Type: MCSA

At the end of a busy clinical day a staff nurse asks the instructor if a student would like to administer a Z-track injected medication. This is a skill that the students have not yet been exposed to yet. What should the instructor respond to the staff nurse that supports timing and learning environment?

1. “It will take me a moment to explain the procedure to the students because we’ve not practiced this, but I’ll find somebody to administer it.”
2. “Would it be OK if the students observed today? Then, we’ll do it next time we’re here.”
3. “We’re leaving now, but thanks for asking.”
4. “I’ll check with the students and see if one of them would like to volunteer.”

Correct Answer: 2

Rationale 1: After a busy day in the clinical area, students may not be ready for the learning experience, even though it would be a good opportunity for them. Taking time to explain the procedure first might put the learning moment in the wrong time and environment, and the students may not retain the information as best they could.

Rationale 2: Allowing them to observe the staff nurse, then coming back when they are more refreshed would allow a better learning experience for the students.

Rationale 3: Simply declining the opportunity doesn’t make for good rapport with the staff nurse.

Rationale 4: Allowing a student to simply volunteer puts the instructor’s license at risk, especially if it is a skill the student has not learned or practiced.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 442

Question 11

Type: MCSA

A client with an incision necessitating a complex dressing change is being discharged and will require continued dressings at home. Which statement by the client indicates a need to postpone teaching?

1. “It’s going to take time for me to understand this whole thing.”
2. “Let’s make sure my spouse is around before you start explaining.”
3. “I wish my doctor would have explained this more in depth.”
4. “I’m feeling nauseous, but go ahead and start anyway.”

Correct Answer: 4

Rationale 1: This statement shows interest as well as realism in attitude toward learning. The nurse should be attentive to cues that may enhance the learning experience, such as amount of time spent on the process.

Rationale 2: This statement shows interest as well as realism in attitude toward learning. The nurse should be attentive to cues that may enhance the learning experience, such as having the spouse available to learn along with the client.

Rationale 3: This statement shows interest as well as realism in attitude toward learning. The nurse should be attentive to cues that may enhance the learning experience, such as giving thorough explanations about the rationale for the treatment.

Rationale 4: Learning can be inhibited by physiologic events such as illness, pain, or sensory deficits. The client must be able to concentrate and apply adequate energy to the learning or the learning itself will be impaired. If the client is experiencing nausea, the nurse should first try to reduce this symptom before beginning the teaching session.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 442

Question 12

Type: MCSA

A nurse is working with the family of a child who is hospitalized with asthma. The family members speak little English, and the child is being sent home on nebulizer treatments as well as an inhaler. In addition to enlisting an interpreter to help with the language barrier, the nurse should

1. provide written instructions before discharge.
2. address any healing beliefs the family has.
3. make sure the child comes back for the follow-up appointment.
4. make sure the parents can set up the treatments for their child.

Correct Answer: 2

Rationale 1: It is important to provide written material, but the first priority is ascertaining any belief conflicts that may interfere with the treatment.

Rationale 2: If the prescribed treatment conflicts with the client/family’s cultural healing beliefs, the client may not be compliant with the recommended treatments. To be effective, nurses must deal directly with any conflicts and differing values held by the client.

Rationale 3: If the prescribed treatment conflicts with the client/family’s cultural healing beliefs, the client may not be compliant with the recommended treatments.

Rationale 4: The client who does not understand will learn little, and providing an interpreter to assist with communication is extremely important in this situation. However, if the prescribed treatment conflicts with the client/family’s cultural healing beliefs, the client may not be compliant with the recommended treatments.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person’s development

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Discuss strategies to use when teaching clients of different cultures.

MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.

Page Number: 443

Question 13

Type: MCSA

A client who is legally blind requires vitamin B₁₂ injections every 2 weeks and insists on self-administration. What is the best way for the nurse to assist this client?

1. Teach the spouse to draw up the medication, then the client can give the injection.
2. Make sure that the injection is scheduled during a visit, so the nurse can supervise.
3. Prefill syringes with the correct dose, so the client can use them for self-administration.
4. Schedule the client’s clinic appointments in accordance with the dosing schedule, then give the injection when the client is at the clinic.

Correct Answer: 3

Rationale 1: Teaching a spouse is demeaning and does not support the client’s wishes for independence.

Rationale 2: Scheduling injections and visits to coincide is demeaning and does not support the client’s wishes for independence.

Rationale 3: Clients who have visual impairment may need the assistance of a support person or creative care in order to remain compliant with their treatment. Because the client insists on self-administration, prefilling syringes (and keeping them away from light and heat) would be a plausible solution. The client is concerned with independence, and allowing the client to maintain that would be quite important.

Rationale 4: Scheduling injections and visits to coincide when the dose is due is demeaning and does not support the client’s wishes for independence.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Assess learning needs of learners and the learning environment..

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 443

Question 14

Type: MCSA

A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the client’s motivation to learn?

1. Demonstrating the finger stick on the nurse
2. Offering to do the procedure for the client each time it is scheduled
3. Teaching the client’s support system how to perform the procedure
4. Encouraging the client’s participation each time the procedure is performed

Correct Answer: 4

Rationale 1: Demonstrating the procedure on the nurse may or may not help the client become interested in the learning process.

Rationale 2: Offering to do the procedure only allows the client’s current state of mind to continue.

Rationale 3: Giving the responsibility to someone else does not encourage the client to learn it.

Rationale 4: Nurses can increase a client’s motivation in several ways, including encouragement of self-direction and independence.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify factors that affect learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 447

Question 15

Type: MCSA

The nurse is working with a group of older clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that

1. information given to this group is written at a third-grade level.
2. teaching includes a variety of approaches.
3. information includes pictures.
4. there is ample time for teaching.

Correct Answer: 4

Rationale 1: The average reading ability of many American adults is at the fifth-grade level. Information provided to this group should be presented at the fifth- to sixth-grade reading level.

Rationale 2: A variety of approaches should be included regardless of the audience, as people learn by different methods.

Rationale 3: A variety of approaches should be included regardless of the audience, as people learn by different methods.

Rationale 4: When working with the older population, the nurse must realize that increased time for teaching is necessary because processing of information is slower. Health literacy skills are often limited in older adults.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Discuss the implications of low health literacy skills.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 446

Question 16

Type: MCSA

A client being discharged after a myocardial infarction has been prescribed several new medications and a low-fat diet. The client states: “I’m never going to understand what to do, when to do it, and why I should be doing all these things.” Which nursing diagnosis should the nurse formulate for this client?

1. Health-Seeking Behavior related to desire to prevent heart problems
2. Deficient Knowledge (diet and medication regimen) related to inexperience
3. Noncompliance related to situational factors
4. Risk for Myocardial Infarction related to deficient knowledge

Correct Answer: 2

Rationale 1: Health-Seeking Behavior is a diagnostic label used when the client is seeking health information.

Rationale 2: The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has identified a learning need, as in this case. The area of deficiency (diet and medication regimen) should always be included in the diagnosis.

Rationale 3: Noncompliance is used when the client or caregiver fails to follow a plan, which is too early to tell in this case.

Rationale 4: Risk for Myocardial Infarction is not a NANDA label. If a risk exists, the label could be Risk for Noncompliance related to deficient knowledge.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 448

Question 17

Type: MCSA

The nursing diagnosis Readiness for Enhanced Knowledge (Nutrition) related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. What would be an appropriate outcome for this client?

1. Client will understand the importance of eating healthy.
2. Client will be able to lose weight.
3. Client will list foods that are nutritionally sound, low fat, and high fiber.
4. Client will appreciate the value of using the Food Guide Pyramid.

Correct Answer: 3

Rationale 1: Learning outcomes, like client outcomes, must be specific and observable so they can be measured. Words like “understand” are not measurable and are not observable.

Rationale 2: “Be able to lose weight” is not specific enough, and with the information given, it is not known if that is really what the client wants to attain.

Rationale 3: Learning outcomes, like client outcomes, must be specific and observable so they can be measured.

Rationale 4: Words like “appreciate” are not measurable and are not observable.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 451

Question 18

Type: MCSA

A home health nurse is working with a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority?

1. Client will be able to set up and administer a nebulizer treatment by the end of the day.
2. Client will have increased activity level by the end of the week.
3. Client will be able to do activities of daily living (ADLs) without shortness of breath in 3 days.
4. Client will have a positive attitude about the diagnosis by the end of the month.

Correct Answer: 1

Rationale 1: Learning outcomes state the client behavior and are ranked according to priority. Nurses can use theoretical frameworks such as Maslow’s hierarchy of needs to establish priorities. In this case, the physiological need of learning how to administer medication takes priority over activity and attitudinal needs.

Rationale 2: This outcome cannot be measured.

Rationale 3: In this case, the physiological need of learning how to administer medication takes priority over activity needs.

Rationale 4: In this case, the physiological need of learning how to administer medication takes priority over attitudinal needs.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Identify nursing diagnoses, outcomes, and interventions that reflect the learning needs of clients.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 452

Question 19

Type: MCMA

A school nurse is putting together a program for adolescents about positive lifestyle choices. What should the nurse keep in mind when preparing content to present to this age group?

Standard Text: Select all that apply.

1. Based on learning outcomes
2. Current
3. Adjusted to the adolescent client
4. Based on sources available within the school system
5. Consistent with the teaching topics

Correct Answer: 1, 2, 3, 5

Rationale 1: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be based on learning outcomes.

Rationale 2: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be current.

Rationale 3: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be adjusted to the learner’s age.

Rationale 4: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be selected with consideration of how much time and what resources are available for teaching.

Rationale 5: Nurses can select among many sources of information, including books, nursing journals, and other nurses and physicians. Whatever sources the nurse chooses, content should be consistent with the information that the nurse is teaching.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 452

Question 20

Type: MCSA

The nurse is going to be working with a client who has a permanent colostomy and is ready to go home within the next several days. When organizing the teaching/learning experience, the nurse should

1. start from the beginning and proceed through all material.
2. break up sessions into shortened time periods.
3. discover what the learner knows before proceeding with further teaching.
4. make sure the client’s spouse is present before the teaching session begins.

Correct Answer: 3

Rationale 1: Going over information already taught and learned isn’t practicing good time management for the nurse or the client.

Rationale 2: Unless the client has attention problems or may be elderly, breaking up the sessions may not be necessary.

Rationale 3: Nurses should save time in constructing their own teaching sessions and should follow basic guidelines when sequencing the learning experience. The nurse should find out what the learner knows, and then proceed to the unknown. This gives the learner confidence. This information can be elicited either by asking questions or by having the client take a pretest or fill out a form.

Rationale 4: Having the spouse present is always a good idea, but may not be possible all the time.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 453

Question 21

Type: MCSA

A client needs discharge teaching regarding the use of a walker before going home. The client’s room is small and adjacent to a soda machine and small lounge area. In planning a teaching session, which is the best thing the nurse can do?

1. Wait until just prior to discharge, then do the teaching in the hospital lobby.
2. Close the door to the client’s room and make sure there is no clutter on the floor before the teaching session begins.
3. Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the client’s room.
4. Make sure a physical therapist is available to do the teaching and can see the client before discharge.

Correct Answer: 3

Rationale 1: Noise or interruptions can interfere with concentration, whereas a comfortable environment can promote learning. The hospital lobby does not provide privacy and can be noisy. There also would be little time to reinforce any teaching needs that might be necessary.

Rationale 2: Noise or interruptions can interfere with concentration, whereas a comfortable environment can promote learning.

Rationale 3: Going to a larger area and then evaluating the learning by watching the client ambulate back to the room would be the best way to implement teaching in this particular situation.

Rationale 4: Not all hospitals have a physical therapist available to help implement teaching for clients.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Assess learning needs of learners and the learning environment.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 454

Question 22

Type: MCSA

A community health nurse runs a clinic that provides health screening to mainly Mexican American and Native American clients. The nurse wants to have a class on smoking cessation for interested adults of this group. In order to adjust to their time orientation, what is the best action of the nurse?

1. Make sure that the classes are held at specific times.
2. Begin classes when a group of clients are gathered.
3. Mail letters ahead of time to make sure clients are informed about the upcoming class.
4. Make posters and place them in areas of the community frequented by these groups.

Correct Answer: 2

Rationale 1: Cultures with a predominant orientation to the present include the Mexican American and Navajo Native American. Schedules have to be very flexible in present-oriented societies.

Rationale 2: The nurse must be quite flexible, treat the culture’s beliefs with respect, and not expect that cultural practices will change to reflect the nurse’s needs.

Rationale 3: Time constraints are not significant for cultures that are oriented to the present, so advertising about specific classes may not be effective.

Rationale 4: Time constraints are not significant for cultures that are oriented to the present, so advertising about specific classes may not be effective.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and community in a person’s development

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Discuss strategies to use when teaching clients of different cultures.

MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.

Page Number: 457

Question 23

Type: MCSA

At the completion of a teaching session, the nurse wants to evaluate the effectiveness of instruction. In a situation where the client was learning a bandaging technique, which would be the most effective evaluation?

1. Shared by the nurse and client
2. A return demonstration by the client
3. When the nurse is satisfied that the client can complete the technique
4. If the wound heals

Correct Answer: 1

Rationale 1: Both the client and the nurse should evaluate the learning experience. The client can tell the nurse what was helpful and provide a demonstration that shows mastery of the skill. The nurse needs to evaluate whether the client has an understanding of the rationale behind the technique.

Rationale 2: Using only the return demonstration is one sided. The evaluation is of the bandaging technique, and it may or may not be covering a wound.

Rationale 3: Focusing on the nurse’s satisfaction with the client’s performance is one sided.

Rationale 4: The evaluation is of the bandaging technique, and it may or may not be covering a wound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.B. 15. Communicate care provided and needed at each transition in care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 13. Identify methods to evaluate learning.

MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.

Page Number: 458

Question 24

Type: MCMA

The nurse has completed a teaching session for a client with a tracheostomy. Documentation of the session should include what information?

Standard Text: Select all that apply.

1. Diagnosed learning needs
2. Supplies required
3. Client outcomes
4. Need for additional teaching
5. Topics taught

Correct Answer: 1, 3, 4, 5

Rationale 1: The parts of the teaching process that should be documented in the client’s chart include diagnosed learning needs.

Rationale 2: The parts of the teaching process that should be documented in the client’s chart include resources provided.

Rationale 3: The parts of the teaching process that should be documented in the client’s chart include client outcomes.

Rationale 4: The parts of the teaching process that should be documented in the client’s chart include need for additional teaching.

Rationale 5: The parts of the teaching process that should be documented in the client’s chart include topics taught.

Global Rationale: