Kozier And Erbs Fundamentals Of
Nursing 10th Edition Berman Test Bank:
Chapter 01
question 1
Type: SEQ
The nurse is reviewing historic events in nursing for a presentation to be provided to new nursing
students. In which chronological order should the nurse present these events? Begin with the
earliest (1) and end with the most recent (5).
Standard Text: Click and drag the options below to move them up or down.
Choice 1. The Order of Deaconesses opens a small hospital in Kaiserswerth, Germany.
Choice 2. The Knights of St. Lazarus dedicate themselves to the care of people with leprosy,
syphilis, and chronic skin conditions.
Choice 3. Harriet Tubman provides care to slaves fleeing on the Underground Railroad.
Choice 4. The Cadet Nurse Corps is established.
Choice 5. Florence Nightingale administers to soldiers during the Crimean War.
Correct Answer: 2, 1, 5, 3, 4
Rationale 1: In 1836, Theodore Fliedner reinstituted the Order of Deaconesses and opened a small
hospital and training school in Kaiserswerth, Germany, where Florence Nightingale received her
training.
Rationale 2: Religion played a significant role in the development of nursing. The crusades saw the
formation of several orders of knights who provided care to the sick and injured, including the
Knights of St. Lazarus.
Rationale 3: During the American Civil War (1861–1865), Harriet Tubman (among other nurses)
administered to the care of slaves and injured soldiers.
Rationale 4: World War II casualties created an acute shortage of care, and the Cadet Nurse Corps
was established in response to the shortage of nurses.
Rationale 5: During the Crimean War (1854–1856), Ms. Nightingale administered to the solders
following a request by Sir Sidney Herbert of the British War Department.
Cognitive Level: Application
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
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AACN Essentials Competencies: I. 9. Value the ideal of lifelong learning to support excellence in
nursing practice
NLN Competencies: Knowledge and Science; Knowledge; The state of science in nursing
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, influencing
the development of nursing.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 3
Question 2
Type: MCSA
The nurse is caring for a nurse who provided care to soldiers during the Vietnam War. What
information in this patient’s history should the nurse use to understand the patient’s nursing career?
1. The patient was still a student when serving in the war.
2. The patient’s first patient care experiences were during a time of war.
3. The patient decided to leave the profession after serving in the war.
4. The patient contracted long-term illnesses from being overseas in a war.
Correct Answer: 2
Rationale 1: During the Vietnam War, approximately 11,000 American military women stationed in
Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from
nursing school, making them the youngest group of medical personnel ever to serve in wartime.
Rationale 2: During the Vietnam War, approximately 11,000 American military women stationed in
Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from
nursing school, making them the youngest group of medical personnel ever to serve in wartime.
Rationale 3: During the Vietnam War, approximately 11,000 American military women stationed in
Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from
nursing school, making them the youngest group of medical personnel ever to serve in wartime.
There is no evidence that the patient did not continue in the role of a nurse after the war.
Rationale 4: During the Vietnam War, approximately 11,000 American military women stationed in
Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from
nursing school, making them the youngest group of medical personnel ever to serve in wartime.
There is no evidence that the patient contracted long-term illnesses from serving in the war.
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.
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: I. 9. Value the ideal of lifelong learning to support excellence in
nursing practice
NLN Competencies: Knowledge and Science; Knowledge; The state of science in nursing
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, influencing
the development of nursing.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 4
Question 3
Type: MCSA
The nurse is reviewing public health and health promotion roles for available for nurses. To which
leader should the nurse attribute the development of these roles?
1. Clara Barton
2. Lillian Wald
3. Mary Brewster
4. Florence Nightingale
Correct Answer: 4
Rationale 1: Florence Nightingale’s vision of nursing included public health and health promotion
roles for nurses, but it was only partly addressed in the early days of nursing. Her focus tended to be
on developing the profession within the hospitals. Clara Barton is noted for establishing the
American Red Cross. She persuaded Congress to ratify the Treaty of Geneva in 1882 so that the
Red Cross could perform humanitarian efforts in times of peace. Lillian Wald is considered the
founder of public health nursing. She and Mary Brewster were the first to offer trained nursing
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services to the poor in the New York slums and developed the Visiting Nurse Service, along with the
Henry Street Settlement.
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Rationale 2: Florence Nightingale’s vision of nursing included public health and health promotion
roles for nurses, but it was only partly addressed in the early days of nursing. Her focus tended to be
on developing the profession within the hospitals. Clara Barton is noted for establishing the
American Red Cross. She persuaded Congress to ratify the Treaty of Geneva in 1882 so that the
Red Cross could perform humanitarian efforts in times of peace. Lillian Wald is considered the
founder of public health nursing. She and Mary Brewster were the first to offer trained nursing
services to the poor in the New York slums and developed the Visiting Nurse Service, along with the
Henry Street Settlement.
Rationale 3: Florence Nightingale’s vision of nursing included public health and health promotion
roles for nurses, but it was only partly addressed in the early days of nursing. Her focus tended to be
on developing the profession within the hospitals. Clara Barton is noted for establishing the
American Red Cross. She persuaded Congress to ratify the Treaty of Geneva in 1882 so that the
Red Cross could perform humanitarian efforts in times of peace. Lillian Wald is considered the
founder of public health nursing. She and Mary Brewster were the first to offer trained nursing
services to the poor in the New York slums and developed the Visiting Nurse Service, along with the
Henry Street Settlement.
Rationale 4: Florence Nightingale’s vision of nursing included public health and health promotion
roles for nurses, but it was only partly addressed in the early days of nursing. Her focus tended to be
on developing the profession within the hospitals. Clara Barton is noted for establishing the
American Red Cross. She persuaded Congress to ratify the Treaty of Geneva in 1882 so that the
Red Cross could perform humanitarian efforts in times of peace. Lillian Wald is considered the
founder of public health nursing. She and Mary Brewster were the first to offer trained nursing
services to the poor in the New York slums and developed the Visiting Nurse Service, along with the
Henry Street Settlement.
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: I. 9. Value the ideal of lifelong learning to support excellence in
nursing practice
NLN Competencies: Knowledge and Science; Knowledge; The state of science in nursing
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, influencing
the development of nursing.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 6
Question 4
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Type: MCSA
The nurse has been asked to participate on the hospital’s Shared Governance Committee. To which
nurse leader should the nurse attribute the ability for nurses to control the profession?
1. Mary Breckinridge
2. Lavinia Dock
3. Margaret Higgins Sanger
4. Virginia Henderson
Correct Answer: 2
Rationale 1: Mary Breckinridge established the Frontier Nursing Service.
Rationale 2: Lavinia Dock was a feminist, writer, and activist. She participated in protest movements
for women’s rights that resulted in passage of the 19th Amendment, which allowed women the right
to vote. In addition, Dock campaigned for legislation to allow nurses, rather than physicians, to
control their profession.
Rationale 3: Margaret Higgins Sanger is considered the founder of Planned Parenthood.
Rationale 4: Virginia Henderson was one of the first modern nurses to define nursing.
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: I. 9. Value the ideal of lifelong learning to support excellence in
nursing practice
NLN Competencies: Knowledge and Science; Knowledge; The state of science in nursing
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 1. Discuss historical factors and nursing leaders, female and male, influencing
the development of nursing.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 7
Question 5
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Type: MCSA
While a nurse is conducting a health assessment, the individual asks why the term “patient” is being
used. What should the nurse explain about the implication of the term “patient”?
1. The person is seeking assistance because of illness.
2. The individual is proactive in his or her health care needs.
3. The person is a collaborator in his or her care.
4. The individual is using a service or commodity.
Correct Answer: 1
Rationale 1: The word patient comes from a Latin word meaning “to suffer” or “to bear.” Usually,
people become patients when they seek assistance because of illness or for surgery. Some nurses
believe that the wordpatient implies passive acceptance of the decisions and care of health
professionals, which would be opposite of being proactive in one’s health care needs. The
term client presents the recipient of health care as a collaborator in that care, along with the people
who are providing service. A consumer is an individual, a group of people, or a community that uses
a service or commodity.
Rationale 2: The word patient comes from a Latin word meaning “to suffer” or “to bear.” Usually,
people become patients when they seek assistance because of illness or for surgery. Some nurses
believe that the wordpatient implies passive acceptance of the decisions and care of health
professionals, which would be opposite of being proactive in one’s health care needs. The
term client presents the recipient of health care as a collaborator in that care, along with the people
who are providing service. A consumer is an individual, a group of people, or a community that uses
a service or commodity.
Rationale 3: The word patient comes from a Latin word meaning “to suffer” or “to bear.” Usually,
people become patients when they seek assistance because of illness or for surgery. Some nurses
believe that the wordpatient implies passive acceptance of the decisions and care of health
professionals, which would be opposite of being proactive in one’s health care needs. The
term client presents the recipient of health care as a collaborator in that care, along with the people
who are providing service. A consumer is an individual, a group of people, or a community that uses
a service or commodity.
Rationale 4: The word patient comes from a Latin word meaning “to suffer” or “to bear.” Usually,
people become patients when they seek assistance because of illness or for surgery. Some nurses
believe that the wordpatient implies passive acceptance of the decisions and care of health
professionals, which would be opposite of being proactive in one’s health care needs. The
term client presents the recipient of health care as a collaborator in that care, along with the people
who are providing service. A consumer is an individual, a group of people, or a community that uses
a service or commodity.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
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Client Need Sub: Management of Care
QSEN Competencies: II.C. 3. Value the perspectives and expertise of all health team members
AACN Essentials Competencies: I. 9. Value the ideal of lifelong learning to support excellence in
nursing practice
NLN Competencies: Knowledge and Science; Knowledge; The state of science in nursing
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Describe how the definition of nursing has evolved since Florence Nightingale.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 13
Question 6
Type: MCSA
The nurse is creating a community education program on health promotion and wellness. Which
topic should the nurse use for this program?
1. Prenatal and infant care
2. Prevention of sexually transmitted disease
3. Exercise class for clients who have had a stroke
4. Home accident prevention
Correct Answer: 4
Rationale 1: Wellness is a process that engages in activities and behaviors that enhance quality of
life and maximize personal potential. This involves individual and community activities to enhance
healthy lifestyles, such as improving nutrition and physical fitness, preventing drug and alcohol
misuse, restricting smoking, and preventing accidents in the home and workplace. The goal of
illness prevention is to maintain optimal health by preventing disease, which would include
immunization, prenatal and infant care, and prevention of sexually transmitted disease. Teaching
clients about recovery activities, such as exercises that accelerate recovery after a stroke, would
focus on health restoration.
Rationale 2: Wellness is a process that engages in activities and behaviors that enhance quality of
life and maximize personal potential. This involves individual and community activities to enhance
healthy lifestyles, such as improving nutrition and physical fitness, preventing drug and alcohol
misuse, restricting smoking, and preventing accidents in the home and workplace. The goal of
illness prevention is to maintain optimal health by preventing disease, which would include
immunization, prenatal and infant care, and prevention of sexually transmitted disease. Teaching
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clients about recovery activities, such as exercises that accelerate recovery after a stroke, would
focus on health restoration.
Rationale 3: Wellness is a process that engages in activities and behaviors that enhance quality of
life and maximize personal potential. This involves individual and community activities to enhance
healthy lifestyles, such as improving nutrition and physical fitness, preventing drug and alcohol
misuse, restricting smoking, and preventing accidents in the home and workplace. The goal of
illness prevention is to maintain optimal health by preventing disease, which would include
immunization, prenatal and infant care, and prevention of sexually transmitted disease. Teaching
clients about recovery activities, such as exercises that accelerate recovery after a stroke, would
focus on health restoration.
Rationale 4: Wellness is a process that engages in activities and behaviors that enhance quality of
life and maximize personal potential. This involves individual and community activities to enhance
healthy lifestyles, such as improving nutrition and physical fitness, preventing drug and alcohol
misuse, restricting smoking, and preventing accidents in the home and workplace. The goal of
illness prevention is to maintain optimal health by preventing disease, which would include
immunization, prenatal and infant care, and prevention of sexually transmitted disease. Teaching
clients about recovery activities, such as exercises that accelerate recovery after a stroke, would
focus on health restoration.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9. Describe the expanded career roles of nurses and their functions..
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 14
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Question 7
Type: MCSA
The nurse is offering free occult blood screening at a community health fair. Which level of practice
is the nurse providing?
1. Promoting health and wellness
2. Illness prevention
3. Restoring health
4. Rehabilitation
Correct Answer: 3
Rationale 1: Restoring health focuses on the ill client, and it extends from early detection (such as
checking for occult blood in feces) through helping the client during the recovery period. Health
promotion and wellness activities enhance the quality of life and maximize personal potential.
Rehabilitation is an activity of health restoration.
Rationale 2: Restoring health focuses on the ill client, and it extends from early detection (such as
checking for occult blood in feces) through helping the client during the recovery period. Health
promotion and wellness activities enhance the quality of life and maximize personal potential.
Rehabilitation is an activity of health restoration.
Rationale 3: Restoring health focuses on the ill client, and it extends from early detection (such as
checking for occult blood in feces) through helping the client during the recovery period. Health
promotion and wellness activities enhance the quality of life and maximize personal potential.
Rehabilitation is an activity of health restoration.
Rationale 4: Restoring health focuses on the ill client, and it extends from early detection (such as
checking for occult blood in feces) through helping the client during the recovery period. Health
promotion and wellness activities enhance the quality of life and maximize personal potential.
Rehabilitation is an activity of health restoration.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
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NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8. Describe the roles of nurses.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 14
Question 8
Type: MCSA
The nurse has starting working in a state other than the one in which the nursing education program
was located. Which of the following should the nurse consult in order to understand the implications
of this change of venue?
1. American Nurses Association (ANA)
2. National League for Nursing (NLN)
3. National Council of State Boards of Nursing (NCSBN)
4. Nurse State Practice Act
Correct Answer: 4
Rationale 1: Nurse practice acts regulate the practice of nursing in the United States and Canada.
Each state and each province has its own act. Nurses are responsible for knowing their state’s nurse
practice act, as it governs their practice. The ANA is the professional organization of nursing, the
NLN is responsible for accrediting schools of nursing, and the NCSBN handles licensure of
professional nurses.
Rationale 2: Nurse practice acts regulate the practice of nursing in the United States and Canada.
Each state and each province has its own act. Nurses are responsible for knowing their state’s nurse
practice act, as it governs their practice. The ANA is the professional organization of nursing, the
NLN is responsible for accrediting schools of nursing, and the NCSBN handles licensure of
professional nurses.
Rationale 3: Nurse practice acts regulate the practice of nursing in the United States and Canada.
Each state and each province has its own act. Nurses are responsible for knowing their state’s nurse
practice act, as it governs their practice. The ANA is the professional organization of nursing, the
NLN is responsible for accrediting schools of nursing, and the NCSBN handles licensure of
professional nurses.
Rationale 4: Nurse practice acts regulate the practice of nursing in the United States and Canada.
Each state and each province has its own act. Nurses are responsible for knowing their state’s nurse
practice act, as it governs their practice. The ANA is the professional organization of nursing, the
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NLN is responsible for accrediting schools of nursing, and the NCSBN handles licensure of
professional nurses.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members
AACN Essentials Competencies: V. 5. Describe state and national statues, rules and regulations
that authorize and define professional nursing practice
NLN Competencies: Context and Environment; Knowledge; scope of practice considerations
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7. Identify the purposes of nurse practice acts and standards of professional
nursing practice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 15
Question 9
Type: MCSA
A seasoned nurse is a mentor for a new graduate. Which of the standards of professional
performance is the seasoned nurse practicing?
1. Collaboration
2. Leadership
3. Collegiality
4. Evaluation
Correct Answer: 3
Rationale 1: Collegiality describes interaction with and contributions to the professional
development of peers and colleagues, which is what a mentoring relationship would involve.
Collaboration involves working with the client, the family, and others in the conduct of nursing
practice. Leadership provides direction in a professional practice setting, and evaluation involves a
comparison between one’s own nursing practice and professional practice standards.
Rationale 2: Collegiality describes interaction with and contributions to the professional
development of peers and colleagues, which is what a mentoring relationship would involve.
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Collaboration involves working with the client, the family, and others in the conduct of nursing
practice. Leadership provides direction in a professional practice setting, and evaluation involves a
comparison between one’s own nursing practice and professional practice standards.
Rationale 3: Collegiality describes interaction with and contributions to the professional
development of peers and colleagues, which is what a mentoring relationship would involve.
Collaboration involves working with the client, the family, and others in the conduct of nursing
practice. Leadership provides direction in a professional practice setting, and evaluation involves a
comparison between one’s own nursing practice and professional practice standards.
Rationale 4: Collegiality describes interaction with and contributions to the professional
development of peers and colleagues, which is what a mentoring relationship would involve.
Collaboration involves working with the client, the family, and others in the conduct of nursing
practice. Leadership provides direction in a professional practice setting, and evaluation involves a
comparison between one’s own nursing practice and professional practice standards.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members
AACN Essentials Competencies: V. 5. Describe state and national statues, rules and regulations
that authorize and define professional nursing practice
NLN Competencies: Context and Environment; Knowledge; Code of Ethics; regulatory and
professional standards
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10. Discuss the criteria of a profession and the professionalization of nursing.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 18
Question 10
Type: MCSA
The nurse ensures that a patient is covered during a bath. In which nursing role is the nurse
functioning?
1. Caregiver
2. Communicator
3. Teacher
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4. Client advocate
Correct Answer: 1
Rationale 1: The caregiver role includes those activities that assist the client physically and
psychologically while preserving the client’s dignity. As a communicator, the nurse identifies client
problems, then communicates these verbally or in writing to other members of the health team. As a
teacher, the nurse helps clients learn about their health and the health care procedures they need to
perform to maintain or restore their health. A client advocate acts to protect clients and represents
their needs and wishes to other health professionals.
Rationale 2: The caregiver role includes those activities that assist the client physically and
psychologically while preserving the client’s dignity. As a communicator, the nurse identifies client
problems, then communicates these verbally or in writing to other members of the health team. As a
teacher, the nurse helps clients learn about their health and the health care procedures they need to
perform to maintain or restore their health. A client advocate acts to protect clients and represents
their needs and wishes to other health professionals.
Rationale 3: The caregiver role includes those activities that assist the client physically and
psychologically while preserving the client’s dignity. As a communicator, the nurse identifies client
problems, then communicates these verbally or in writing to other members of the health team. As a
teacher, the nurse helps clients learn about their health and the health care procedures they need to
perform to maintain or restore their health. A client advocate acts to protect clients and represents
their needs and wishes to other health professionals.
Rationale 4: The caregiver role includes those activities that assist the client physically and
psychologically while preserving the client’s dignity. As a communicator, the nurse identifies client
problems, then communicates these verbally or in writing to other members of the health team. As a
teacher, the nurse helps clients learn about their health and the health care procedures they need to
perform to maintain or restore their health. A client advocate acts to protect clients and represents
their needs and wishes to other health professionals.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members
AACN Essentials Competencies: V. 5. Describe state and national statues, rules and regulations
that authorize and define professional nursing practice
NLN Competencies: Context and Environment; Knowledge; Code of Ethics; regulatory and
professional standards
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8. Describe the roles of nurses.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
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Page Number: 15
Question 11
Type: MCSA
A client wishes to discontinue cancer treatment. If acting as the client advocate, which statement
should the nurse make to the client’s physician?
1. “The client is making his own decision.”
2. “The client would benefit from additional information about treatment options.”
3. “The family must be involved in this decision.”
4. “Let’s educate the family about the consequences of this decision.”
Correct Answer: 1
Rationale 1: A client advocate acts to protect the client and may represent the client’s needs and
wishes to other health professionals, such as relaying the client’s wishes for information to the
physician. Providing additional information to the client about treatment options and bringing the
family into the decision-making process would be examples of the nurse acting as teacher or
counselor.
Rationale 2: A client advocate acts to protect the client and may represent the client’s needs and
wishes to other health professionals, such as relaying the client’s wishes for information to the
physician. Providing additional information to the client about treatment options and bringing the
family into the decision-making process would be examples of the nurse acting as teacher or
counselor.
Rationale 3: A client advocate acts to protect the client and may represent the client’s needs and
wishes to other health professionals, such as relaying the client’s wishes for information to the
physician. Providing additional information to the client about treatment options and bringing the
family into the decision-making process would be examples of the nurse acting as teacher or
counselor.
Rationale 4: A client advocate acts to protect the client and may represent the client’s needs and
wishes to other health professionals, such as relaying the client’s wishes for information to the
physician. Providing additional information to the client about treatment options and bringing the
family into the decision-making process would be examples of the nurse acting as teacher or
counselor.
.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
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QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members
AACN Essentials Competencies: VI. 2. Use inter- and intraprofessional communication and
collaborative skills to deliver evidence-based, patient-centered care
NLN Competencies: Context and Environment; Knowledge; principles of informed consent,
confidentiality, patient self-determination
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8. Describe the roles of nurses.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 15
Question 12
Type: MCSA
The nurse has accepted a position as a case manager. What should the nurse expect to perform
when functioning in this role?
1. Managing a client’s hospital stay
2. Delegating activities to other nurses
3. Evaluating the performance of ancillary workers
4. Identifying areas of client concern or problems
Correct Answer: 1
Rationale 1: The case manager oversees the care of a specific caseload or may act as the primary
nurse to provide some level of direct care to the client and family. Responsibilities may vary from
managing acute hospitalizations to managing high-cost clients or case types. Delegating activities to
other nurses and evaluating the performance of ancillary workers are responsibilities of the nurse
manager. Identifying areas of researchable problems would fall to the research consumer.
Rationale 2: The case manager oversees the care of a specific caseload or may act as the primary
nurse to provide some level of direct care to the client and family. Responsibilities may vary from
managing acute hospitalizations to managing high-cost clients or case types. Delegating activities to
other nurses and evaluating the performance of ancillary workers are responsibilities of the nurse
manager. Identifying areas of researchable problems would fall to the research consumer.
Rationale 3: The case manager oversees the care of a specific caseload or may act as the primary
nurse to provide some level of direct care to the client and family. Responsibilities may vary from
managing acute hospitalizations to managing high-cost clients or case types. Delegating activities to
other nurses and evaluating the performance of ancillary workers are responsibilities of the nurse
manager. Identifying areas of researchable problems would fall to the research consumer.
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Rationale 4: The case manager oversees the care of a specific caseload or may act as the primary
nurse to provide some level of direct care to the client and family. Responsibilities may vary from
managing acute hospitalizations to managing high-cost clients or case types. Delegating activities to
other nurses and evaluating the performance of ancillary workers are responsibilities of the nurse
manager. Identifying areas of researchable problems would fall to the research consumer.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care team members
AACN Essentials Competencies: VII. 4. Use behavioral change techniques to promote health and
manage illness
NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8. Describe the roles of nurses.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 16
Question 13
Type: MCSA
The manager identifies that a nurse is practicing professionalism. What did the manager observe to
come to this conclusion?
1. Recognizing characteristics considered to be professional
2. Maintaining specific character and spirit
3. Learning about the influences of Florence Nightingale
4. Promising to uphold the standards of the profession
Correct Answer: 2
Rationale 1: Professionalism refers to professional character, spirit, or methods. It is a set of
attributes and a way of life that implies responsibility and commitment. Florence Nightingale
influenced nursing professionalism a great deal, but simply learning about her influence does not
constitute professionalism because professionalism refers to a way of life. Professionalization is the
process of becoming professional, which is acquiring characteristics considered to be professional
and upholding the standards of a profession.
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Rationale 2: Professionalism refers to professional character, spirit, or methods. It is a set of
attributes and a way of life that implies responsibility and commitment. Florence Nightingale
influenced nursing professionalism a great deal, but simply learning about her influence does not
constitute professionalism because professionalism refers to a way of life. Professionalization is the
process of becoming professional, which is acquiring characteristics considered to be professional
and upholding the standards of a profession.
Rationale 3: Professionalism refers to professional character, spirit, or methods. It is a set of
attributes and a way of life that implies responsibility and commitment. Florence Nightingale
influenced nursing professionalism a great deal, but simply learning about her influence does not
constitute professionalism because professionalism refers to a way of life. Professionalization is the
process of becoming professional, which is acquiring characteristics considered to be professional
and upholding the standards of a profession.
Rationale 4: Professionalism refers to professional character, spirit, or methods. It is a set of
attributes and a way of life that implies responsibility and commitment. Florence Nightingale
influenced nursing professionalism a great deal, but simply learning about her influence does not
constitute professionalism because professionalism refers to a way of life. Professionalization is the
process of becoming professional, which is acquiring characteristics considered to be professional
and upholding the standards of a profession.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.C. 5. Respect the unique attributes that members bring to a team, including
variations in professional orientations and accountabilities
AACN Essentials Competencies: VIII. 4. Demonstrate professionalism, including attention to
appearance, demeanor, respect for self and others, and attention to professional boundaries with
patients and families as well as among caregivers
NLN Competencies: Context and Environment; Practice; Apply professional standards; show
accountability for nursing judgment and actions; develop advocacy skills
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 10. Discuss the criteria of a profession and the professionalization of nursing.
MNL Learning Outcome: 1.1.3. Consider how values impact the practice of nursing.
Page Number: 17
Question 14
Type: MCSA
The nurse is caring for several acutely ill patients. What nursing action demonstrates professional
autonomy?
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1. Delivering medications and prescribed treatments in a timely manner
2. Prioritizing client according to client needs
3. Communicating with peers when help is needed
4. Informing the supervisor about high acuity level and staff-to-client ratio
Correct Answer: 2
Rationale 1: Autonomy in nursing means independence at work, responsibility, and accountability
for one’s actions. Making decisions about which client requires care according to needs is an
example of autonomy. Carrying out physician orders would be an example of nursing care, but not
independence. Communication is important in any profession, as is making concerns known to
supervisors, but these are not examples of controlling activity—a hallmark of autonomy.
Rationale 2: Autonomy in nursing means independence at work, responsibility, and accountability
for one’s actions. Making decisions about which client requires care according to needs is an
example of autonomy. Carrying out physician orders would be an example of nursing care, but not
independence. Communication is important in any profession, as is making concerns known to
supervisors, but these are not examples of controlling activity—a hallmark of autonomy.
Rationale 3: Autonomy in nursing means independence at work, responsibility, and accountability
for one’s actions. Making decisions about which client requires care according to needs is an
example of autonomy. Carrying out physician orders would be an example of nursing care, but not
independence. Communication is important in any profession, as is making concerns known to
supervisors, but these are not examples of controlling activity—a hallmark of autonomy.
Rationale 4: Autonomy in nursing means independence at work, responsibility, and accountability
for one’s actions. Making decisions about which client requires care according to needs is an
example of autonomy. Carrying out physician orders would be an example of nursing care, but not
independence. Communication is important in any profession, as is making concerns known to
supervisors, but these are not examples of controlling activity—a hallmark of autonomy.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.C. 5. Respect the unique attributes that members bring to a team, including
variations in professional orientations and accountabilities
AACN Essentials Competencies: VIII. 4. Demonstrate professionalism, including attention to
appearance, demeanor, respect for self and others, and attention to professional boundaries with
patients and families as well as among caregivers
NLN Competencies: Context and Environment; Practice; Apply professional standards; show
accountability for nursing judgment and actions; develop advocacy skills
Nursing/Integrated Concepts: Nursing Process: Planning
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Learning Outcome: 8. Describe the roles of nurses.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 17
Question 15
Type: MCSA
The student nurse contacts a number of other students to create a study group. What behavior is the
student nurse demonstrating?
1. Governance
2. Socialization
3. Service orientation
4. Specialized education
Correct Answer: 2
Rationale 1: Governance is the establishment and maintenance of social, political, and economic
arrangements by which practitioners control their practice, working conditions, and professional
affairs.
Rationale 2: Socialization involves learning to behave, feel, and see the world in a manner similar to
other persons occupying the same role. The goal is to instill in others the norms, values, attitudes,
and behaviors deemed essential. One of the most powerful mechanisms of professional socialization
is interacting with fellow students and becoming bound together by feelings of mutual cooperation,
support, and solidarity.
Rationale 3: Service orientation differentiates nursing from an occupation pursued primarily for
profit.
Rationale 4: Specialized education is an important aspect of professional status and is focused on
the course of study and curriculum particular to the profession.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.C. 5. Respect the unique attributes that members bring to a team, including
variations in professional orientations and accountabilities
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AACN Essentials Competencies: VIII. 4. Demonstrate professionalism, including attention to
appearance, demeanor, respect for self and others, and attention to professional boundaries with
patients and families as well as among caregivers
NLN Competencies: Context and Environment; Practice; Apply professional standards; show
accountability for nursing judgment and actions; develop advocacy skills
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8. Describe the roles of nurses.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 17
Question 16
Type: MCSA
The nursing instructor is explaining the present economic challenges in health care to students in a
community health course. What should the instructor emphasize as being important for the students
to be aware of?
1. Passage of the Affordable Care Act
2. Consumer presence on the boards of nursing associations and regulatory agencies
3. Diagnostic-related groups (DRGs)
4. Advances in science and technology
Correct Answer: 1
Rationale 1: With the passage of the Affordable Care Act (ACA) in 2010, health care delivery shifted
in focus from acute care to primary preventive care and treatment of chronic conditions using health
care teams and information technology. Other forces include consumer demands, family structure,
and science and technology. DRGs are a classification system that categorically establishes
pretreatment billing based on diagnosis. Although this is an aspect of economic factors affecting
nursing, it is not the underlying cause of more personnel being employed in community-based
settings.
Rationale 2: With the passage of the Affordable Care Act (ACA) in 2010, health care delivery shifted
in focus from acute care to primary preventive care and treatment of chronic conditions using health
care teams and information technology. Other forces include consumer demands, family structure,
and science and technology. DRGs are a classification system that categorically establishes
pretreatment billing based on diagnosis. Although this is an aspect of economic factors affecting
nursing, it is not the underlying cause of more personnel being employed in community-based
settings.
Rationale 3: With the passage of the Affordable Care Act (ACA) in 2010, health care delivery shifted
in focus from acute care to primary preventive care and treatment of chronic conditions using health
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care teams and information technology. Other forces include consumer demands, family structure,
and science and technology. DRGs are a classification system that categorically establishes
pretreatment billing based on diagnosis. Although this is an aspect of economic factors affecting
nursing, it is not the underlying cause of more personnel being employed in community-based
settings.
Rationale 4: With the passage of the Affordable Care Act (ACA) in 2010, health care delivery shifted
in focus from acute care to primary preventive care and treatment of chronic conditions using health
care teams and information technology. Other forces include consumer demands, family structure,
and science and technology. DRGs are a classification system that categorically establishes
pretreatment billing based on diagnosis. Although this is an aspect of economic factors affecting
nursing, it is not the underlying cause of more personnel being employed in community-based
settings.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A. 4. Recognize contributions of other individuals and groups in helping
patient/family achieve health goals
AACN Essentials Competencies: V. 6.Explore the impact of socio-cultural, economic, legal and
political factors influencing healthcare delivery and practice
NLN Competencies: Context and Environment; Knowledge; Health care economic policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12. Describe factors influencing contemporary nursing practice.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 19
Question 17
Type: MCSA
The community health nurse is caring for teenage mothers and their children. For what should the
nurse assess these patients when determining their degree of vulnerability?
1. Distance separation from their nuclear families
2. Increased levels of poverty
3. Raising children without the support of family
4. The normal difficulties of adolescence
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Correct Answer: 4
Rationale 1: Teenage mothers have the normal needs of teenagers as well as those of new
mothers, with motherhood compounding the difficulties of adolescence. Although many teenage
mothers are raising children alone, without the support of the baby’s father or perhaps their own
families, and many live in poverty, all are vulnerable because of their age.
Rationale 2: Teenage mothers have the normal needs of teenagers as well as those of new
mothers, with motherhood compounding the difficulties of adolescence. Although many teenage
mothers are raising children alone, without the support of the baby’s father or perhaps their own
families, and many live in poverty, all are vulnerable because of their age.
Rationale 3: Teenage mothers have the normal needs of teenagers as well as those of new
mothers, with motherhood compounding the difficulties of adolescence. Although many teenage
mothers are raising children alone, without the support of the baby’s father or perhaps their own
families, and many live in poverty, all are vulnerable because of their age.
Rationale 4: Teenage mothers have the normal needs of teenagers as well as those of new
mothers, with motherhood compounding the difficulties of adolescence. Although many teenage
mothers are raising children alone, without the support of the baby’s father or perhaps their own
families, and many live in poverty, all are vulnerable because of their age.
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. 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; Knowledge; family dynamics
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9. Describe the expanded career roles of nurses and their functions.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 19
Question 18
Type: MCSA
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A client tells the nurse about research information on the Internet to learn more about a new health
problem. What should the nurse respond to this client?
1. “Information from the Internet isn’t always accurate.”
2. “It’s best to check this information with your physician.”
3. “Bring your information to the clinic so we can go through it together.”
4. “I’d prefer you rely on information you haven’t received from our office.”
Correct Answer: 3
Rationale 1: Nurses may need to interpret Internet sources of information to clients and their
families. Although not all Internet-based information is accurate, some may be high quality and valid.
Nurses need to become information brokers so they, not just the physician, can help clients access
and evaluate information to determine its usefulness.
Rationale 2: Nurses may need to interpret Internet sources of information to clients and their
families. Although not all Internet-based information is accurate, some may be high quality and valid.
Nurses need to become information brokers so they, not just the physician, can help clients access
and evaluate information to determine its usefulness.
Rationale 3: Nurses may need to interpret Internet sources of information to clients and their
families. Although not all Internet-based information is accurate, some may be high quality and valid.
Nurses need to become information brokers so they, not just the physician, can help clients access
and evaluate information to determine its usefulness.
Rationale 4: Nurses may need to interpret Internet sources of information to clients and their
families. Although not all Internet-based information is accurate, some may be high quality and valid.
Nurses need to become information brokers so they, not just the physician, can help clients access
and evaluate information to determine its usefulness.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: VI.A. 4. Describe examples of how technology and information management
are related to the quality and safety of patient care
AACN Essentials Competencies: IV. 6. Evaluate data from all relevant sources, including
technology, to inform the delivery of care
NLN Competencies: Knowledge and Science; Knowledge; Electronic databases; literature retrieval;
evaluating data for validity and reliability; evidence and best practices for nursing
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 9. Describe the expanded career roles of nurses and their functions.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 20
Question 19
Type: MCSA
The nurse practitioner is working with a staff nurse to change the plan of care for a client with a
terminal illness. In which areas of nursing practice are these nurses functioning?
1. Promoting health and wellness
2. Preventing illness
3. Restoring health
4. Caring for the dying
Correct Answer: 4
Rationale 1: Promoting health and wellness may involve individual and community activities to
enhance healthy lifestyles, such as improving nutrition and physical fitness, preventing drug and
alcohol misuse, restricting smoking, and preventing accidents and injury in the home and workplace.
Rationale 2: The goal of illness prevention programs is to maintain optimal health by preventing
disease.
Rationale 3: Restoring health focuses on the ill client, and it extends from early detection of disease
through helping the client during the recovery period.
Rationale 4: Caring for the dying involves comforting and caring for people of all ages who are
dying. It includes helping clients be as comfortable as possible until death and helping support
persons cope with death.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.B. 7. Initiate effective treatments to relieve pain and suffering in light of
patient values, preferences and expressed needs
AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of endof-life and palliative care issues, such as symptom management, support of rituals, and respect for
patient and family preferences
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NLN Competencies: Context and Environment; Ethical Comportment; Examine personal beliefs,
values, and biases with regard to respect for persons, human dignity, equality, and justice; explore
ideas of nurse caring and compassion
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 6. Identify the four major areas of nursing practice.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 14
Question 20
Type: MCSA
The nurse is scheduled to attend a continuing education program to learn about the latest urinary
catheterization care. Which type of credential should the nurse expect to earn after attending this
program?
1. None because this program is designed to enhance a skill
2. Advanced degree
3. Certification as a renal nurse
4. Credit hours toward an advanced degree
Correct Answer: 1
Rationale 1: The term continuing education (CE) refers to formalized experiences designed to
enhance the knowledge or skills of practicing professionals. Compared to advanced educational
programs, which result in an academic degree, CE courses tend to be more specific and shorter.
Participants may receive certificates of completion or specialization.
Rationale 2: The term continuing education (CE) refers to formalized experiences designed to
enhance the knowledge or skills of practicing professionals. Compared to advanced educational
programs, which result in an academic degree, CE courses tend to be more specific and shorter.
Participants may receive certificates of completion or specialization.
Rationale 3: The term continuing education (CE) refers to formalized experiences designed to
enhance the knowledge or skills of practicing professionals. Compared to advanced educational
programs, which result in an academic degree, CE courses tend to be more specific and shorter.
Participants may receive certificates of completion or specialization.
Rationale 4: The term continuing education (CE) refers to formalized experiences designed to
enhance the knowledge or skills of practicing professionals. Compared to advanced educational
programs, which result in an academic degree, CE courses tend to be more specific and shorter.
Participants may receive certificates of completion or specialization.
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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: VIII. 13. Articulate the value of pursuing practice excellence,
lifelong learning and professional engagement to foster professional growth and development
NLN Competencies: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep
professional knowledge current
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Explain the importance of continuing nursing education.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 12
Question 21
Type: MCSA
The nurse is planning to apply to graduate school to earn a master’s degree in nursing. On what
should the nurse expect the program’s curriculum to focus?
1. An advanced leadership role
2. Case manager
3. Wound care specialist
4. Intravenous therapy specialist
Correct Answer: 1
Rationale 1: The emphasis of master’s degree programs is on preparing nurses for advanced
leadership roles in administration, clinical, or teaching.
Rationale 2: The emphasis of master’s degree programs is on preparing nurses for advanced
leadership roles in administration, clinical, or teaching. A case manager does not necessarily need to
have a master’s degree.
Rationale 3: The emphasis of master’s degree programs is on preparing nurses for advanced
leadership roles in administration, clinical, or teaching. A wound care specialist does not necessarily
need a master’s degree..
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Rationale 4: The emphasis of master’s degree programs is on preparing nurses for advanced
leadership roles in administration, clinical, or teaching An intravenous therapy specialist does not
necessarily need a master’s degree.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member
AACN Essentials Competencies: VIII. 13. Articulate the value of pursuing practice excellence,
lifelong learning and professional engagement to foster professional growth and development
NLN Competencies: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep
professional knowledge current
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 3. Describe the different types of educational programs for nurses.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 11
Question 22
Type: MCSA
The staff nurse is considering membership in the National League for Nurses. What should the
nurse expect as a member of this organization?
1. Members that are non-nurses
2. Assistance with getting into graduate school
3. Opportunities to be awarded scholarships
4. Assistance with finding employment
Correct Answer: 1
Rationale 1: The NLN is an organization of both individuals and agencies. Its objective is to foster
the development and improvement of all nursing services and nursing education. People who are
not nurses but have an interest in nursing services can be members of the league.
Rationale 2: The NLN is an organization of both individuals and agencies. Its objective is to foster
the development and improvement of all nursing services and nursing education. People who are
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not nurses but have an interest in nursing services can be members of the league. The league does
not offer assistance with getting into graduate school.
Rationale 3: The NLN is an organization of both individuals and agencies. Its objective is to foster
the development and improvement of all nursing services and nursing education. People who are
not nurses but have an interest in nursing services can be members of the league. The league does
not provide scholarships.
Rationale 4: The NLN is an organization of both individuals and agencies. Its objective is to foster
the development and improvement of all nursing services and nursing education. People who are
not nurses but have an interest in nursing services can be members of the league. The league does
not provide assistance with finding employment.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member
AACN Essentials Competencies: VIII. 13. Articulate the value of pursuing practice excellence,
lifelong learning and professional engagement to foster professional growth and development
NLN Competencies: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep
professional knowledge current
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 13. Explain the functions of national and international nurses’ associations..
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 22
Question 23
Type: MCSA
The nurse is consulting other professionals as well as educating, supporting, and managing a
client’s chemotherapy regimen. In which role is this nurse functioning?
1. Nurse practitioner
2. Clinical nurse specialist
3. Nurse educator
4. Nurse entrepreneur
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Correct Answer: 2
Rationale 1: A clinical nurse specialist has an advanced degree or expertise and is considered to be
an expert in a specialized area of practice (oncology in this case). The nurse provides direct client
care, educates others, consults, conducts research, and manages care. A nurse practitioner has an
advanced education, is a graduate of a nurse practitioner program, and usually deals with
nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is
responsible for classroom and often clinical teaching. A nurse entrepreneur usually has an advanced
degree, manages a health-related business, and may be involved in education, consultation, or
research.
Rationale 2: A clinical nurse specialist has an advanced degree or expertise and is considered to be
an expert in a specialized area of practice (oncology in this case). The nurse provides direct client
care, educates others, consults, conducts research, and manages care. A nurse practitioner has an
advanced education, is a graduate of a nurse practitioner program, and usually deals with
nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is
responsible for classroom and often clinical teaching. A nurse entrepreneur usually has an advanced
degree, manages a health-related business, and may be involved in education, consultation, or
research.
Rationale 3: A clinical nurse specialist has an advanced degree or expertise and is considered to be
an expert in a specialized area of practice (oncology in this case). The nurse provides direct client
care, educates others, consults, conducts research, and manages care. A nurse practitioner has an
advanced education, is a graduate of a nurse practitioner program, and usually deals with
nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is
responsible for classroom and often clinical teaching. A nurse entrepreneur usually has an advanced
degree, manages a health-related business, and may be involved in education, consultation, or
research.
Rationale 4: A clinical nurse specialist has an advanced degree or expertise and is considered to be
an expert in a specialized area of practice (oncology in this case). The nurse provides direct client
care, educates others, consults, conducts research, and manages care. A nurse practitioner has an
advanced education, is a graduate of a nurse practitioner program, and usually deals with
nonemergency acute or chronic illness and provides primary ambulatory care. The nurse educator is
responsible for classroom and often clinical teaching. A nurse entrepreneur usually has an advanced
degree, manages a health-related business, and may be involved in education, consultation, or
research.
Cognitive Level: Analysis
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member
AACN Essentials Competencies: VIII. 13. Articulate the value of pursuing practice excellence,
lifelong learning and professional engagement to foster professional growth and development
NLN Competencies: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep
professional knowledge current
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Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Discuss the evolution of nursing education and entry into professional nursing
practice..
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 16
Question 24
Type: MCSA
A staff nurse is serving as a preceptor for nursing students. In which level of Benner’s proficiency is
this nurse practicing?
1. Stage II
2. Stage III
3. Stage IV
4. Stage V
Correct Answer: 3
Rationale 1: Stage IV is a proficiency stage. The person has 3 to 5 years of experience and has a
holistic understanding of the client, which improves decision making and focuses on long-term goals.
Stage II is advanced beginner. The person demonstrates marginally acceptable performance. Stage
III is competent. The nurse has 2 or 3 years of experience and demonstrates organizational/planning
abilities. Stage V is considered expert. Performance is fluid, flexible, and highly proficient. The expert
nurse no longer requires rules, guidelines, or maxims to connect an understanding of the situation to
appropriate action. This person has highly intuitive and analytic abilities in new situations.
Rationale 2: Stage IV is a proficiency stage. The person has 3 to 5 years of experience and has a
holistic understanding of the client, which improves decision making and focuses on long-term goals.
Stage II is advanced beginner. The person demonstrates marginally acceptable performance. Stage
III is competent. The nurse has 2 or 3 years of experience and demonstrates organizational/planning
abilities. Stage V is considered expert. Performance is fluid, flexible, and highly proficient. The expert
nurse no longer requires rules, guidelines, or maxims to connect an understanding of the situation to
appropriate action. This person has highly intuitive and analytic abilities in new situations.
Rationale 3: Stage IV is a proficiency stage. The person has 3 to 5 years of experience and has a
holistic understanding of the client, which improves decision making and focuses on long-term goals.
Stage II is advanced beginner. The person demonstrates marginally acceptable performance. Stage
III is competent. The nurse has 2 or 3 years of experience and demonstrates organizational/planning
abilities. Stage V is considered expert. Performance is fluid, flexible, and highly proficient. The expert
nurse no longer requires rules, guidelines, or maxims to connect an understanding of the situation to
appropriate action. This person has highly intuitive and analytic abilities in new situations.
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Rationale 4: Stage IV is a proficiency stage. The person has 3 to 5 years of experience and has a
holistic understanding of the client, which improves decision making and focuses on long-term goals.
Stage II is advanced beginner. The person demonstrates marginally acceptable performance. Stage
III is competent. The nurse has 2 or 3 years of experience and demonstrates organizational/planning
abilities. Stage V is considered expert. Performance is fluid, flexible, and highly proficient. The expert
nurse no longer requires rules, guidelines, or maxims to connect an understanding of the situation to
appropriate action. This person has highly intuitive and analytic abilities in new situations.
Cognitive Level: Analysis
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member
AACN Essentials Competencies: VIII. 13. Articulate the value of pursuing practice excellence,
lifelong learning and professional engagement to foster professional growth and development
NLN Competencies: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep
professional knowledge current
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 11. Discuss Benner’s levels of nursing proficiency.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 18
Question 25
Type: MCMA
The nurse is explaining the definition of being a nurse to a new nursing assistant. Which themes
should the nurse include when talking with the assistant?
Standard Text: Select all that apply.
1. Adaptive
2. Client-centered
3. Goal-directed according to the needs of the client
4. Diagnosis and treatment of disease
5. An art
6. A science
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Correct Answer: 1, 2, 5, 6
Rationale 1: Adaptive; client-centered; art; science; holistic; caring; concerned with health
promotion, health maintenance, and health restoration; and a helping profession are themes that are
common to many definitions formulated about nursing. In 1973, the American Nurses Association
(ANA) described nursing practice as goal-oriented and adaptable to the needs of the individual, the
family, and the community (not just the client). In 1980, the ANA’s definition was changed to
“Nursing is the diagnosis and treatment of the human responses to actual or potential health
problems.” Diagnosis and treatment of disease is a definition of the medical model.
Rationale 2: Adaptive; client-centered; art; science; holistic; caring; concerned with health
promotion, health maintenance, and health restoration; and a helping profession are themes that are
common to many definitions formulated about nursing. In 1973, the American Nurses Association
(ANA) described nursing practice as goal-oriented and adaptable to the needs of the individual, the
family, and the community (not just the client). In 1980, the ANA’s definition was changed to
“Nursing is the diagnosis and treatment of the human responses to actual or potential health
problems.” Diagnosis and treatment of disease is a definition of the medical model.
Rationale 3: Adaptive; client-centered; art; science; holistic; caring; concerned with health
promotion, health maintenance, and health restoration; and a helping profession are themes that are
common to many definitions formulated about nursing. In 1973, the American Nurses Association
(ANA) described nursing practice as goal-oriented and adaptable to the needs of the individual, the
family, and the community (not just the client). In 1980, the ANA’s definition was changed to
“Nursing is the diagnosis and treatment of the human responses to actual or potential health
problems.” Diagnosis and treatment of disease is a definition of the medical model.
Rationale 4: Adaptive; client-centered; art; science; holistic; caring; concerned with health
promotion, health maintenance, and health restoration; and a helping profession are themes that are
common to many definitions formulated about nursing. In 1973, the American Nurses Association
(ANA) described nursing practice as goal-oriented and adaptable to the needs of the individual, the
family, and the community (not just the client). In 1980, the ANA’s definition was changed to
“Nursing is the diagnosis and treatment of the human responses to actual or potential health
problems.” Diagnosis and treatment of disease is a definition of the medical model.
Rationale 5: Adaptive; client-centered; art; science; holistic; caring; concerned with health
promotion, health maintenance, and health restoration; and a helping profession are themes that are
common to many definitions formulated about nursing. In 1973, the American Nurses Association
(ANA) described nursing practice as goal-oriented and adaptable to the needs of the individual, the
family, and the community (not just the client). In 1980, the ANA’s definition was changed to
“Nursing is the diagnosis and treatment of the human responses to actual or potential health
problems.” Diagnosis and treatment of disease is a definition of the medical model.
Rationale 6: Adaptive; client-centered; art; science; holistic; caring; concerned with health
promotion, health maintenance, and health restoration; and a helping profession are themes that are
common to many definitions formulated about nursing. In 1973, the American Nurses Association
(ANA) described nursing practice as goal-oriented and adaptable to the needs of the individual, the
family, and the community (not just the client). In 1980, the ANA’s definition was changed to
“Nursing is the diagnosis and treatment of the human responses to actual or potential health
problems.” Diagnosis and treatment of disease is a definition of the medical model.
Cognitive Level: Applying
Testsbanknursing.com
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.C. 2. Appreciate importance of intra- and inter-professional collaboration.
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: Knowledge and Science; Knowledge; Relationships between
knowledge/science and excellence in nursing
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Describe how the definition of nursing has evolved since Florence Nightingale.
MNL Learning Outcome: 1.2.4. Compare the frameworks of care.
Page Number: 13
Question 26
Type: MCSA
A registered nurse is supervising several LPNs who provide patient care. Which responsibility should
the registered nurse expect to complete?
1. Evaluating the care provided to the client
2. Administering intramuscular (IM) medications
3. Performing dressing changes
4. Delegating appropriate tasks to unlicensed client care providers (such as a nurse’s aide)
Correct Answer: 1
Rationale 1: The RN has the knowledge and skill to make more sophisticated nursing judgments,
and is responsible for assessing the client’s condition, planning care, and evaluating the effect of the
care provided.
Rationale 2: LPNs practice under the supervision of an RN in a hospital, nursing home,
rehabilitation center, or home health agency, and usually provide basic, direct technical care to
clients that can include the administration of scheduled IM medications if the institution includes that
in the LPN’s job description.
Rationale 3: LPNs practice under the supervision of an RN in a hospital, nursing home,
rehabilitation center, or home health agency, and usually provide basic, direct technical care to
clients that can include dressing changes.
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Rationale 4: LPNs practice under the supervision of an RN in a hospital, nursing home,
rehabilitation center, or home health agency, and usually provide basic, direct technical care to
clients that can include appropriate delegation of tasks to unlicensed client care providers.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.C. 2. Appreciate importance of intra- and inter-professional collaboration.
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: Knowledge and Science; Knowledge; Relationships between
knowledge/science and excellence in nursing
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8. Describe the roles of nurses.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 9
Question 27
Type: MCSA
A faculty member is speaking to prospective students interested in enrolling in the BSN program at
the university. What should the faculty member emphasize as a major incentive for students to
select a BSN program over an ADN program?
1. Ability to work in critical care areas
2. Easier transition to graduate school
3. Better opportunity for career advancement
4. Liberal arts education
Correct Answer: 3
Rationale 1: RNs, regardless of their education level, can work in critical care areas.
Rationale 2: There are some programs offering RN-to-MSN completion studies at this point in time.
Rationale 3: The nurse who holds a baccalaureate degree enjoys greater autonomy, responsibility,
participation in institutional decision making, and career advancement.
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Rationale 4: A liberal arts education is also a positive point, although not as major of an incentive.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care 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: Knowledge and Science; Knowledge; Relationships between
knowledge/science and excellence in nursing
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Discuss the evolution of nursing education and entry into professional nursing
practice.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 11
Question 28
Type: MCSA
The ANA’s proposal for entry level for professional practice initiated debate among nurses. Which
nurse would be at greatest risk if the ANA proposal were implemented?
1. An RN with an associate degree who has a head nurse position
2. An RN with a BSN who is a staff nurse
3. An RN with a diploma who works overtime
4. An RN with an associate degree who is currently in school
Correct Answer: 1
Rationale 1: According to the ANA’s proposal, only the baccalaureate graduate would be licensed
under the legal title registered nurse. The graduate with an associate degree or diploma would be
considered an associate nurse. If the ANA proposal were implemented, nurses who are currently
licensed and educated in associate degree or diploma programs would have to be considered under
a grandfather clause, provided that their performance met established standards. If an institution
required a minimum of a baccalaureate degree for the position of head nurse, an RN who was
currently employed as a head nurse but who did not hold a baccalaureate degree would have no
guarantee of retaining that position.
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Rationale 2: According to the ANA’s proposal, only the baccalaureate graduate would be licensed
under the legal title registered nurse. The graduate with an associate degree or diploma would be
considered an associate nurse. If the ANA proposal were implemented, nurses who are currently
licensed and educated in associate degree or diploma programs would have to be considered under
a grandfather clause, provided that their performance met established standards. If an institution
required a minimum of a baccalaureate degree for the position of head nurse, an RN who was
currently employed as a head nurse but who did not hold a baccalaureate degree would have no
guarantee of retaining that position.
Rationale 3: According to the ANA’s proposal, only the baccalaureate graduate would be licensed
under the legal title registered nurse. The graduate with an associate degree or diploma would be
considered an associate nurse. If the ANA proposal were implemented, nurses who are currently
licensed and educated in associate degree or diploma programs would have to be considered under
a grandfather clause, provided that their performance met established standards. If an institution
required a minimum of a baccalaureate degree for the position of head nurse, an RN who was
currently employed as a head nurse but who did not hold a baccalaureate degree would have no
guarantee of retaining that position.
Rationale 4: According to the ANA’s proposal, only the baccalaureate graduate would be licensed
under the legal title registered nurse. The graduate with an associate degree or diploma would be
considered an associate nurse. If the ANA proposal were implemented, nurses who are currently
licensed and educated in associate degree or diploma programs would have to be considered under
a grandfather clause, provided that their performance met established standards. If an institution
required a minimum of a baccalaureate degree for the position of head nurse, an RN who was
currently employed as a head nurse but who did not hold a baccalaureate degree would have no
guarantee of retaining that position.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.A. 2. Describe scopes of practice and roles of health care 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: Knowledge and Science; Knowledge; Relationships between
knowledge/science and excellence in nursing
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7. Identify the purposes of nurse practice acts and standards of professional
nursing practice.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 11
Question 29
Testsbanknursing.com
Type: SEQ
A nurse is considering additional education to become a nurse researcher. To prepare for this role
the nurse is reviewing the evolution of research in nursing. In which order should the nurse review
this information? Put these events in chronological order, starting with the earliest (1) and
proceeding to the most recent (4):
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Centers for nursing research established
Choice 2. Research focused on the study of nursing education
Choice 3. Early stage of development
Choice 4. Studies focused on the knowledge behind nursing practice
Choice 5. Research focused on practice-related issues
Correct Answer: 3, 1, 2, 4, 5
Rationale 1: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing
research was at a very early stage of development. In the 1950s, increased federal funding and
professional support helped establish centers for nursing research. Most early research was directed
at the study of nursing education. In the 1960s, studies were often related to the nature of the
knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on
practice-related issues.
Rationale 2: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing
research was at a very early stage of development. In the 1950s, increased federal funding and
professional support helped establish centers for nursing research. Most early research was directed
at the study of nursing education. In the 1960s, studies were often related to the nature of the
knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on
practice-related issues.
Rationale 3: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing
research was at a very early stage of development. In the 1950s, increased federal funding and
professional support helped establish centers for nursing research. Most early research was directed
at the study of nursing education. In the 1960s, studies were often related to the nature of the
knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on
practice-related issues.
Rationale 4: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing
research was at a very early stage of development. In the 1950s, increased federal funding and
professional support helped establish centers for nursing research. Most early research was directed
at the study of nursing education. In the 1960s, studies were often related to the nature of the
knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on
practice-related issues.
Rationale 5: Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing
research was at a very early stage of development. In the 1950s, increased federal funding and
Testsbanknursing.com
professional support helped establish centers for nursing research. Most early research was directed
at the study of nursing education. In the 1960s, studies were often related to the nature of the
knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on
practice-related issues.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Defining the relationships between
research and science building, and between research and EBP
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9. Describe the expanded career roles of nurses and their functions.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 17
Question 30
Type: MCSA
A high school graduate is considering entering a nursing program that offers a baccalaureate
degree. What organization accreditation should the nurse use to help select a nursing program?
1. NLN (National League for Nursing)
2. CCNE (Commission on Collegiate Nursing Education)
3. NCLEX® (National Council Licensure Examination)
4. NCSBN (National Council of State Boards of Nursing)
Correct Answer: 2
Rationale 1: The CCNE accredits baccalaureate- and graduate-degree nursing programs. The NLN
accredits nursing programs at all levels, including LVN and LPN. Both of these offer voluntary
accreditation. The NCLEX® is the licensure examination administered by each state, and the
NCSBN is the council to which all state boards of nursing belong.
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Rationale 2: The CCNE accredits baccalaureate- and graduate-degree nursing programs. The NLN
accredits nursing programs at all levels, including LVN and LPN. Both of these offer voluntary
accreditation. The NCLEX® is the licensure examination administered by each state, and the
NCSBN is the council to which all state boards of nursing belong.
Rationale 3: The CCNE accredits baccalaureate- and graduate-degree nursing programs. The NLN
accredits nursing programs at all levels, including LVN and LPN. Both of these offer voluntary
accreditation. The NCLEX® is the licensure examination administered by each state, and the
NCSBN is the council to which all state boards of nursing belong.
Rationale 4: The CCNE accredits baccalaureate- and graduate-degree nursing programs. The NLN
accredits nursing programs at all levels, including LVN and LPN. Both of these offer voluntary
accreditation. The NCLEX® is the licensure examination administered by each state, and the
NCSBN is the council to which all state boards of nursing belong.
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member
AACN Essentials Competencies: VIII. 13. Articulate the value of pursuing practice excellence,
lifelong learning and professional engagement to foster professional growth and development
NLN Competencies: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep
professional knowledge current
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Discuss the evolution of nursing education and entry into professional nursing
practice.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies
Page Number: 21
[New Questions: ]
Question 31
Type: MCMA
The student nurse is reviewing the code of ethics prior to beginning a clinical assignment. On what
areas should the nurse focus when providing client care?
Standard Text: Select all that apply.
1. Support lifelong learning.
2. Ensure the safety of all clients.
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3. Maintain client confidentiality.
4. Provide care in a professional manner.
5. Collaborate with students and faculty.
Correct Answer: 2, 3, 4
Rationale 1: Lifelong learning would be a personal goal or plan.
Rationale 2: When providing care, the student nurse should focus on client safety.
Rationale 3: When providing care, the student nurse should focus on client confidentiality.
Rationale 4: When providing care, the student should ensure professionalism.
Rationale 5: Collaboration with students and faculty would promote professional development.
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; Code of Ethics; regulatory and
professional standards
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7. Identify the purposes of nurse practice acts and standards of professional
nursing practice.
MNL Learning Outcome: 1.1.4. Consider how ethics impact the practice of nursing.
Page Number: 17
Question 32
Type: MCMA
The nurse is interested in specializing in forensics. What should the nurse expect to learn prior to
assuming the role of a forensics nurse?
Standard Text: Select all that apply.
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1. Knowledge about the legal system
2. Approaches to collecting evidence
3. Budgeting, staffing, and planning programs
4. Information necessary when providing testimony in court
5. Training in identification, evaluation, and documentation of injuries
Correct Answer: 1, 2, 4, 5
Rationale 1: The forensic nurse provides specialized care for individuals who are victims and/or
perpetrators of trauma. Forensic nurses have knowledge of the legal system and skills in injury
identification, evaluation, and documentation. After tending to the client’s medical needs, the forensic
nurse collects evidence, provides medical testimony in court, and consults with legal authorities.
Rationale 2: The forensic nurse provides specialized care for individuals who are victims and/or
perpetrators of trauma. Forensic nurses have knowledge of the legal system and skills in injury
identification, evaluation, and documentation. After tending to the client’s medical needs, the forensic
nurse collects evidence, provides medical testimony in court, and consults with legal authorities.
Rationale 3: Budgeting, staffing, and planning programs are functions of a nurse administrator.
Rationale 4: The forensic nurse provides specialized care for individuals who are victims and/or
perpetrators of trauma. Forensic nurses have knowledge of the legal system and skills in injury
identification, evaluation, and documentation. After tending to the client’s medical needs, the forensic
nurse collects evidence, provides medical testimony in court, and consults with legal authorities.
Rationale 5: The forensic nurse provides specialized care for individuals who are victims and/or
perpetrators of trauma. Forensic nurses have knowledge of the legal system and skills in injury
identification, evaluation, and documentation. After tending to the client’s medical needs, the forensic
nurse collects evidence, provides medical testimony in court, and consults with legal authorities.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: II.B. 2. Initiate plan for self-development as a team member
AACN Essentials Competencies: VIII. 13. Articulate the value of pursuing practice excellence,
lifelong learning and professional engagement to foster professional growth and development
NLN Competencies: Quality and Safety; Ethical Comportment; Engage in lifelong learning to keep
professional knowledge current
Nursing/Integrated Concepts: Nursing Process: Planning
Testsbanknursing.com
Learning Outcome: 9. Describe the expanded career roles of nurses and their functions.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 16
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Chapter 02
Question 1
Type: SEQ
The nurse is reviewing the history of research in nursing care for a school project. In which
chronological order should the nurse place the events that occurred in nursing research? Start with
the earliest (1) to the most recent (4):
Standard Text: Click and drag the options below to move them up or down.
Choice 1. The National Center for Nursing Research was created.
Choice 2. The National Institute for Nursing Research was created.
Choice 3. The journal Nursing Research was established.
Choice 4. End-of-life/palliative care research was conducted.
Correct Answer: 2, 3, 1,4
Rationale 1: The journal Nursing Research was established in 1952. The National Center for
Nursing Research was created in 1985 at the National Institutes of Health (NIH). In 1993, it was
promoted to the National Institute for Nursing Research (NINR). End-of-life/palliative care was
identified at NINR as an area of research for 2000–2004.
Rationale 2: The journal Nursing Research was established in 1952. The National Center for
Nursing Research was created in 1985 at the National Institutes of Health (NIH). In 1993, it was
promoted to the National Institute for Nursing Research (NINR). End-of-life/palliative care was
identified at NINR as an area of research for 2000–2004.
Rationale 3: The journal Nursing Research was established in 1952. The National Center for
Nursing Research was created in 1985 at the National Institutes of Health (NIH). In 1993, it was
promoted to the National Institute for Nursing Research (NINR). End-of-life/palliative care was
identified at NINR as an area of research for 2000–2004.
Rationale 4: The journal Nursing Research was established in 1952. The National Center for
Nursing Research was created in 1985 at the National Institutes of Health (NIH). In 1993, it was
promoted to the National Institute for Nursing Research (NINR). End-of-life/palliative care was
identified at NINR as an area of research for 2000–2004.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
Testsbanknursing.com
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Apply the steps of change used in implementing evidence-based practice.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 27
Question 2
Type: MCSA
A nursing student is assigned to develop a research question using a quantitative approach. Which
question should the student write that demonstrates this approach?
1. How do siblings react to a new baby of a second marriage after divorce of their parents?
2. What dressing selections work best for a wound dehiscence?
3. What support do terminal cancer clients find least beneficial in hospice care?
4. Does expression of client spirituality affect recovery time?
Correct Answer: 2
Rationale 1: Qualitative research most often explores the subjective experiences of human beings.
Rationale 2: Quantitative research is often viewed as “hard” science. It progresses through
systematic, logical steps to collect information under controlled conditions. The information is
analyzed using statistical procedures.
Rationale 3: Qualitative research most often explores the subjective experiences of human beings.
Rationale 4: Qualitative research most often explores the subjective experiences of human beings.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
Testsbanknursing.com
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Differentiate the quantitative approach from the qualitative approach in
nursing research.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 28
Question 3
Type: MCSA
A client has agreed to participate in a research study. Which action would constitute risk of harm to
this client?
1. Withholding information about the study
2. Suggesting that participation would greatly benefit the client’s financial situation
3. Giving the client false information about his or her participation
4. Providing the client’s name as a participant in the study
Correct Answer: 4
Rationale 1: Risk of harm to a research subject is exposure to the possibility of injury, which could
involve physical or psychological injury such as loss of confidentiality or loss of privacy. Withholding
information or giving false information would be a violation of full disclosure. Participants should feel
free from coercion or undue influence to participate in a study or this would be a violation against the
right of self-determination.
Rationale 2: Risk of harm to a research subject is exposure to the possibility of injury, which could
involve physical or psychological injury such as loss of confidentiality or loss of privacy. Withholding
information or giving false information would be a violation of full disclosure. Participants should feel
free from coercion or undue influence to participate in a study or this would be a violation against the
right of self-determination.
Rationale 3: Risk of harm to a research subject is exposure to the possibility of injury, which could
involve physical or psychological injury such as loss of confidentiality or loss of privacy. Withholding
information or giving false information would be a violation of full disclosure. Participants should feel
free from coercion or undue influence to participate in a study or this would be a violation against the
right of self-determination.
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Rationale 4: Risk of harm to a research subject is exposure to the possibility of injury, which could
involve physical or psychological injury such as loss of confidentiality or loss of privacy. Withholding
information or giving false information would be a violation of full disclosure. Participants should feel
free from coercion or undue influence to participate in a study or this would be a violation against the
right of self-determination.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: III.C. 2. Value the need for ethical conduct of research and quality
improvement
AACN Essentials Competencies: III. 3. Advocate for the protection of human subjects in the conduct
of research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7. Describe the nurse’s role in protecting the rights of human participants in
research.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 34
Question 4
Type: MCSA
A nursing instructor is researching the implementation of assigning study guides for homework
points and the effect this has on the students’ test grades. The instructor reports group data for
published research. Which research right did the instructor implement?
1. Right of full disclosure
2. Right of privacy
3. Right of self-determination
4. Risk of harm
Correct Answer: 2
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Rationale 1: The right of full disclosure is the act of making clear the client’s role in a research
situation.
Rationale 2: Within the right to privacy, confidentiality is to be maintained, which means that any
information a participant relates will not be made public, and investigators must inform research
participants about the measures to provide for these rights. Such measures may include the use of
code numbers or reporting only group or aggregate data in published research.
Rationale 3: The right of self-determination means that participants should feel free from undue
influence.
Rationale 4: Risk of harm is exposure to the possibility of injury going beyond everyday situations.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.C. 2. Value the need for ethical conduct of research and quality
improvement
AACN Essentials Competencies: III. 3. Advocate for the protection of human subjects in the conduct
of research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 7. Describe the nurse’s role in protecting the rights of human participants in
research.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 34
Question 5
Type: MCSA
The nurse researcher is considering whether the findings of a project may present uncertain results
in the clinical area. Upon which criteria is the researcher reflecting?
1. Significance
2. Researchability
3. Confidentiality
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4. Variables
Correct Answer: 2
Rationale 1: Significance deals with whether the research problem has the potential to contribute to
nursing science by enhancing nursing care.
Rationale 2: Researchability means that the problem can be subjected to scientific investigation. If a
significant problem produces ambiguity or uncertainty in clinical situations, it may not be appropriate
to research.
Rationale 3: Confidentiality is one of the research participant’s rights.
Rationale 4: Quantitative research problems address relationships between independent and
dependent variables.
.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 2. Apply the steps of change used in implementing evidence-based practice.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 29
Question 6
Type: MCSA
A nurse researcher is considering the use of various nonpharmacological distraction techniques that
have shown success for behavior control in troubled adolescents. Which criteria is this researcher
considering to use?
1. Significance
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2. Researchability
3. Feasibility
4. Interest
Correct Answer: 1
Rationale 1: The research problem has significance if it has the potential to contribute to nursing
science by enhancing client care, testing or generating a theory, or resolving a day-to-day clinical
problem. If the adolescents are showing improved behavior, then these techniques have significance
in enhancing client care.
Rationale 2: Researchability means that the problem can be subjected to scientific investigation,
without ambiguity or uncertainty.
Rationale 3: Feasibility pertains to the time and material as well as human resources needed to
investigate a problem or question.
Rationale 4: Interest can be a factor for successful completion, depending on the attitude of the
researcher.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 31
Question 7
Type: MCSA
Testsbanknursing.com
The nurse educator develops the research question “Do students who study in groups score better
on the NCLEX® exam when compared to students who study independently?” Which phrase should
the educator identify as the dependent variable?
1. Number of students in a study group
2. NCLEX® scores of both groups
3. Students’ college GPAs
4. Time between graduation and sitting for the NCLEX®
Correct Answer: 2
Rationale 1: This option is an example of an independent variable, or something that can cause or
have an influence on the dependent variable.
Rationale 2: The dependent variable is the behavior, characteristic, or outcome that the researcher
wishes to explain or predict. The independent variable is the presumed cause of or influence on the
dependent variable. In this situation, the prediction is the success on NCLEX®.
Rationale 3: This option is an example of an independent variable, or something that can cause or
have an influence on the dependent variable.
Rationale 4: The option is an example of an independent variable, or something that can cause or
have an influence on the dependent variable.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 30
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Question 8
Type: MCSA
The nurse has defined a research problem. What action should the nurse take next?
1. Formulate a hypothesis.
2. Define variables.
3. Review the literature.
4. Select a design.
Correct Answer: 3
Rationale 1: Before progressing with the research design, the researcher determines what is known
and not known about the problem. A thorough review of the literature provides the foundation on
which to build new knowledge. Next, a hypothesis is formulated, variables are defined, and the
research design is selected.
Rationale 2: Before progressing with the research design, the researcher determines what is known
and not known about the problem. A thorough review of the literature provides the foundation on
which to build new knowledge. Next, a hypothesis is formulated, variables are defined, and the
research design is selected.
Rationale 3: Before progressing with the research design, the researcher determines what is known
and not known about the problem. A thorough review of the literature provides the foundation on
which to build new knowledge. Next, a hypothesis is formulated, variables are defined, and the
research design is selected.
Rationale 4: Before progressing with the research design, the researcher determines what is known
and not known about the problem. A thorough review of the literature provides the foundation on
which to build new knowledge. Next, a hypothesis is formulated, variables are defined, and the
research design is selected.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Testsbanknursing.com
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 30
Question 9
Type: MCSA
The nurse researcher is testing the effects of a new dressing preparation on certain participants,
while continuing to use older but more familiar products on others. Which type of research design is
the nurse using?
1. Quasi-experimental
2. Experimental
3. Nonexperimental
4. Pilot study
Correct Answer: 2
Rationale 1: Quasi-experimental design is when the investigator manipulates the independent
variable but without either randomization or control.
Rationale 2: Experimental design is one in which the investigator manipulates the independent
variable by administering an experimental treatment to some participants while withholding it from
others. This would be the situation if some of the participants were exposed to new products while
others were not.
Rationale 3: In a nonexperimental design, the investigator does no manipulation of the independent
variable.
Rationale 4: A pilot study is a test study before the actual one begins and is not a type of research
design.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
Testsbanknursing.com
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Differentiate the quantitative approach from the qualitative approach in
nursing research.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 30
Question 10
Type: MCSA
A researcher is conducting a study with single-parent families within a school system. What sample
is the researcher using?
1. The school system
2. Children
3. Parents
4. Single-parent families
Correct Answer: 4
Rationale 1: The school system would be more representative of the population, which includes all
possible members of the group who meet the criteria for the study.
Rationale 2: The children would be more representative of the population, which includes all
possible members of the group who meet the criteria for the study.
Rationale 3: The parents would be more representative of the population, which includes all
possible members of the group who meet the criteria for the study.
Rationale 4: The sample is the segment of the population from which the data will actually be
collected—in this case, single-parent families.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
Testsbanknursing.com
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 30
Question 11
Type: MCSA
The nurse researcher is using an instrument that provides similar results each time it’s implemented.
Which term should the researcher use to describe the quality of this instrument?
1. Validity
2. Reliability
3. Consistency
4. Variability
Correct Answer: 2
Rationale 1: Validity is the degree to which an instrument measures what it is supposed to measure.
Rationale 2: Reliability is the degree of consistency with which an instrument measures a concept or
variable. If it is reliable, repeated measurement of the same variable should yield similar or nearly
similar results.
Rationale 3: Consistency is a component of reliability.
Rationale 4: Variability does not describe instrument measurement, but variances in data.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
Testsbanknursing.com
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 30
Question 12
Type: MCSA
The student nurse is examining the dispersion of data in a research study. Which measurements
should this student expect to review?
1. Mean, median, and mode
2. Range, variance, and standard deviation
3. Mean, range, and standard deviation
4. Measures of central tendency
Correct Answer: 2
Rationale 1: Measures of variability indicate the degree of dispersion or spread of the data. They
include the range, variance, and standard deviation. Measures of central tendency describe the
center of distribution of the data, denoting where most of the subjects lie. They include the mean,
median, and mode.
Rationale 2: Measures of variability indicate the degree of dispersion or spread of the data. They
include the range, variance, and standard deviation. Measures of central tendency describe the
center of distribution of the data, denoting where most of the subjects lie. They include the mean,
median, and mode.
Rationale 3: Measures of variability indicate the degree of dispersion or spread of the data. They
include the range, variance, and standard deviation. Measures of central tendency describe the
center of distribution of the data, denoting where most of the subjects lie. They include the mean,
median, and mode.
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Rationale 4: Measures of variability indicate the degree of dispersion or spread of the data. They
include the range, variance, and standard deviation. Measures of central tendency describe the
center of distribution of the data, denoting where most of the subjects lie. They include the mean,
median, and mode.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 31
Question 13
Type: MCSA
After the data have been analyzed, the nurse realizes that the probability has a value of less than
.05. What should this finding indicate to the nurse?
1. Statistically significant
2. Statistically insignificant
3. Chance occurrences
4. Generalized
Correct Answer: 1
Rationale 1: If findings in a research study are statistically significant—which means they did not
occur by chance—the probability value is less than .05, the acceptable level of significance.
Rationale 2: Values greater than .05 are considered to be statistically insignificant and there is a
greater probability that the results were due to chance occurrences.
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Rationale 3: Values greater than .05 are considered to be statistically insignificant and there is a
greater probability that the results were due to chance occurrences.
Rationale 4: It is not known what the generalized findings would be.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 31
Question 14
Type: MCSA
The nursing student completes a literature review on evidence-based practice (EBP). Which action
indicates that the student understands EBP?
1. Presenting a paper about EBP
2. Repositioning a client at risk for skin breakdown every 2 hours
3. Explaining EBP to fellow students
4. Trying to find other problems to implement EBP
Correct Answer: 2
Rationale 1: Presenting papers or explaining what EBP is to someone else does not demonstrate
the ability to put into practice that which is learned.
Rationale 2: In evidence-based practice, the nurse integrates research findings with clinical
experience, the client’s preferences, and available resources in planning and implementing care.
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Evidence-based practice would support frequent repositioning to prevent skin breakdown in an atrisk client, demonstrating that this student is able to incorporate research into practice.
Rationale 3: Explaining what EBP is to someone else does not demonstrate the ability to put into
practice that which is learned.
Rationale 4: Attempting to find other problems to implement EBP does not demonstrate the ability to
put into practice that which is learned.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Describe research-related roles and responsibilities for nurses
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 26
Question 15
Type: MCSA
A group of nurses is researching how care providers of Stage I/II Alzheimer’s clients use prior coping
skills in dealing with their current situation. Which qualitative research tradition are these nurses
using?
1. Grounded theory
2. Ethnography
3. Phenomenology
4. Substantive dimension
Correct Answer: 3
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Rationale 1: Grounded theory is research to understand social structures and social processes.
Rationale 2: Ethnography is research that provides a framework to focus on the culture of a group of
people.
Rationale 3: Phenomenology is research that investigates people’s life experiences and how they
interpret those experiences. Using prior coping skills (life experiences) and applying them to current
situations in order to interpret the process of Alzheimer’s disease is an example of phenomenology.
Rationale 4: Substantive dimension is not a research tradition, rather a way to critique research
reports.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Differentiate the quantitative approach from the qualitative approach in
nursing research.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 29
Question 16
Type: MCSA
The nurse is evaluating the results of a study prior to implementing its findings into practice. Which
action should the nurse take when scientifically validating the research results?
1. Scrutinizing how the study was conceptualized, designed, and conducted in order to make a
judgment about the overall quality of its findings
2. Assessing how the study’s findings compare to findings from other studies about the problem
3. Determining how the study’s findings will transfer from the research conditions to the clinical
practice conditions in which they will be used
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4. Identifying practical or feasibility considerations that need to be addressed when applying the
findings in practice
Correct Answer: 1
Rationale 1: Scientific validation is a thorough critique of a study for its conceptual and
methodological integrity. This means scrutinizing how the study was conceptualized, designed, and
conducted in order to make a judgment about the overall quality of its findings.
Rationale 2: Comparative analysis involves assessing study findings for their implementation
potential. Three factors are considered: (1) how the study’s findings compare to findings from other
studies about the problem, (2) how the study’s findings will transfer from the research conditions to
the clinical practice conditions in which they will be used, and (3) practical or feasibility
considerations that need to be addressed when applying the findings in practice.
Rationale 3: Comparative analysis involves assessing study findings for their implementation
potential. Three factors are considered: (1) how the study’s findings compare to findings from other
studies about the problem, (2) how the study’s findings will transfer from the research conditions to
the clinical practice conditions in which they will be used, and (3) practical or feasibility
considerations that need to be addressed when applying the findings in practice.
Rationale 4: Comparative analysis involves assessing study findings for their implementation
potential. Three factors are considered: (1) how the study’s findings compare to findings from other
studies about the problem, (2) how the study’s findings will transfer from the research conditions to
the clinical practice conditions in which they will be used, and (3) practical or feasibility
considerations that need to be addressed when applying the findings in practice.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6. Describe research-related roles and responsibilities for nurses.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 31
Question 17
Testsbanknursing.com
Type: MCSA
A nurse practitioner feels it is important to participate in nursing research. Which activity is most
appropriate for this nurse’s level of education and position?
1. Helping to identify clinical problems in direct client care
2. Using research findings to develop policies and procedures
3. Critically analyzing and interpreting research for application to practice
4. Participating in data collection
Correct Answer: 3
Rationale 1: All nurses, including new graduates, could help to identify clinical problems in direct
client care.
Rationale 2: Nurse managers would most likely use research findings to develop policies and
procedures and may not necessarily have an advanced degree.
Rationale 3: The nurse practitioner, having a graduate-level education as well as prior nursing
experience, would most likely be analyzing and interpreting research for application.
Rationale 4: All nurses, including new graduates, could participate in data collection.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Describe research-related roles and responsibilities for nurses.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 28
Question 18
Testsbanknursing.com
Type: MCMA
A nurse researcher is exploring and formulating research problems. Which criteria should the nurse
researcher consider in this process?
Standard Text: Select all that apply.
1. Significance
2. Confidentiality
3. Researchability
4. Design
5. Feasibility
6. Interest to the researcher
Correct Answer: 1, 3, 5, 6
Rationale 1: When formulating a research problem, significance (the potential to contribute to
nursing science by enhancing client care) should be considered, along with researchability (the
problem can be subjected to scientific investigation) and feasibility (the availability of time as well as
material and human resources, space, money, etc.). Because researchers spend much time and
energy while conducting a research project, it would also be important that they have genuine
interest in the project. Confidentiality is one of the rights of the participant in research, and design
focuses on how the research is done.
Rationale 2: Confidentiality is one of the rights of the participant in research.
Rationale 3: When formulating a research problem, researchability (the problem can be subjected to
scientific investigation) should be considered.
Rationale 4: Design focuses on how the research is done.
Rationale 5: When formulating a research problem, feasibility (the availability of time as well as
material and human resources, space, money, etc.) should be considered.
Rationale 6: Because researchers spend much time and energy while conducting a research
project, it would also be important that they have genuine interest in the project.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
Testsbanknursing.com
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 29
Question 19
Type: SEQ
The nurse is planning to use evidence-based practice to help guide the care of a client. In which
order should the nurse implement the steps of EBP?
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Design practice change.
Choice 2. Assess the need for a change in practice.
Choice 3. Integrate and maintain change in practice.
Choice 4. Implement and evaluate the change.
Choice 5. Critically analyze the evidence.
Choice 6. Locate the best evidence.
Correct Answer: 2, 6, 5, 1, 4, 3
Rationale 1: The nurse should first assess the need for a change in practice. Then the best
evidence should be located. The evidence should then be analyzed prior to designing a change in
practice. The change should be implemented and then evaluated. Finally, the change in practice
should be integrated and maintained.
Rationale 2: The nurse should first assess the need for a change in practice. Then the best
evidence should be located. The evidence should then be analyzed prior to designing a change in
practice. The change should be implemented and then evaluated. Finally, the change in practice
should be integrated and maintained.
Rationale 3: The nurse should first assess the need for a change in practice. Then the best
evidence should be located. The evidence should then be analyzed prior to designing a change in
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practice. The change should be implemented and then evaluated. Finally, the change in practice
should be integrated and maintained.
Rationale 4: The nurse should first assess the need for a change in practice. Then the best
evidence should be located. The evidence should then be analyzed prior to designing a change in
practice. The change should be implemented and then evaluated. Finally, the change in practice
should be integrated and maintained.
Rationale 5: The nurse should first assess the need for a change in practice. Then the best
evidence should be located. The evidence should then be analyzed prior to designing a change in
practice. The change should be implemented and then evaluated. Finally, the change in practice
should be integrated and maintained.
Rationale 6: The nurse should first assess the need for a change in practice. Then the best
evidence should be located. The evidence should then be analyzed prior to designing a change in
practice. The change should be implemented and then evaluated. Finally, the change in practice
should be integrated and maintained.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 26
Question 20
Type: MCMA
The nurse educator is reviewing concerns about the use of research for evidence-based practice.
What particular concerns should the nurse highlight when discussing the use of research with the
students?
Standard Text: Select all that apply.
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1. When evidence-based practice is done appropriately, the process often becomes cost-prohibitive.
2. The research environment results in strictly constructed and controlled circumstances.
3. There is a “best” solution or practice for any specific research question.
4. Evidence-based practice is most applicable to physiological problems.
5. Research evidence can be flawed when applied to various cultures and ethnic groups.
Correct Answer: 2, 3, 4, 5
Rationale 1: Research might be expensive in many incidences but not in all cases, and cost is not
recognized as a negative factor at this time.
Rationale 2: Research is often done under very controlled circumstances, which is very different
from the real world of health care delivery.
Rationale 3: Research evidence suggests that there is one best solution to a problem for all clients.
This limited perspective stifles creativity.
Rationale 4: EBP appears to have greater relevance for physiological problems than for
psychological, social, or spiritual ones.
Rationale 5: Implementing EBP may not take into consideration organizational culture and ethnic
characteristics.
.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Describe limitations in relying on research as the primary source of evidence
for practice.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
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Page Number: 27
[New Questions: ]
Question 21
Type: MCMA
The nurse using evidence-based practice to guide care has identified a study in which the findings
would be appropriate to address a client’s health care need. What actions should the nurse take
before implementing these findings?
Standard text: Select all that apply.
1. Ask the client if the findings can be used.
2. Immediately apply the findings to client care.
3. Examine how the findings fit with the client’s health needs.
4. Determine if resources are available to implement the findings.
5. Identify organization policies to support or address the findings.
Answer: 1, 3, 4, 5
Rationale 1: Integrate the findings with clinical expertise and client/family preferences and values.
Each nurse must determine how the evidence fits with the clinical condition of the client, available
resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be
established.
Rationale 2: Evidence must not be automatically applied to the care of individual clients.
Rationale 3: Integrate the findings with clinical expertise and client/family preferences and values.
Each nurse must determine how the evidence fits with the clinical condition of the client, available
resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be
established.
Rationale 4: Integrate the findings with clinical expertise and client/family preferences and values.
Each nurse must determine how the evidence fits with the clinical condition of the client, available
resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be
established.
Rationale 5: Integrate the findings with clinical expertise and client/family preferences and values.
Each nurse must determine how the evidence fits with the clinical condition of the client, available
resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be
established.
Cognitive Level: Applying
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Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Explain the relationship between research and evidence-based nursing
practice.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 26
Question 22
Type: MCMA
The nurse researcher is determining the best way to formulate a research problem. What should the
nurse identify if implementing the PICO format?
Standard text: Select all that apply.
1. Intervention to use
2. Problem of interest
3. Comparison of treatments
4. Outcome of the treatments
5. Individuals to perform actions
Answer: 1, 2, 3, 4
Rationale 1: When using the PICO format, the nurse should identify the problem of interest,
consider interventions to use, compare the interventions, and determine the outcome of the
interventions. The individuals to perform the actions are not identified when using the PICO format.
Rationale 2: When using the PICO format, the nurse should identify the problem of interest,
consider interventions to use, compare the interventions, and determine the outcome of the
interventions. The individuals to perform the actions are not identified when using the PICO format.
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Rationale 3: When using the PICO format, the nurse should identify the problem of interest,
consider interventions to use, compare the interventions, and determine the outcome of the
interventions. The individuals to perform the actions are not identified when using the PICO format.
Rationale 4: When using the PICO format, the nurse should identify the problem of interest,
consider interventions to use, compare the interventions, and determine the outcome of the
interventions. The individuals to perform the actions are not identified when using the PICO format.
Rationale 5: When using the PICO format, the nurse should identify the problem of interest,
consider interventions to use, compare the interventions, and determine the outcome of the
interventions. The individuals to perform the actions are not identified when using the PICO format.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes
AACN Essentials Competencies: III. 1. Explain the interrelationships among theory, practice and
research
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and
methods of scientific inquiry
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Outline the steps of the research process.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 30
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Chapter 03
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 03
Question 1
Type: MCSA
Nursing students have been assigned to develop their own theory of nursing. What should they
include in their theory, often referred to as the metaparadigm for nursing?
1. Society, medicine, nursing, and biology
2. Patient, facility, health, and nursing
3. Organization, discipline, nursing, and client
4. Client, environment, health, and nursing
Correct Answer: 4
Rationale 1: These options do not include the “pattern” associated with the four concepts that
comprise a metaparadigm.
Rationale 2: These options do not include the “pattern” associated with the four concepts that
comprise a metaparadigm.
Rationale 3: These options do not include the “pattern” associated with the four concepts that
comprise a metaparadigm.
Rationale 4: Four major concepts—person (or client), environment, health, and nursing—can be
superimposed on almost any theoretical work in nursing. They are collectively referred to as a
metaparadigm for nursing.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Differentiate the terms theory, concept, conceptual framework, paradigm, and
metaparadigm for nursing.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 38
Question 2
Type: MCSA
Nursing students are researching how cultural practices affect the dying process of terminal cancer
clients. For their research, which theory will the students most likely explore?
1. Critical theory
2. Midlevel theories
3. Grand theories
4. Stability models
Correct Answer: 1
Rationale 1: Critical theory research used in nursing helps explain how structures such as race,
gender, sexual orientation, and economic class affect patient experiences and health outcomes. In
this scenario (the influences of culture on the dying process), research on critical theory would
help in understanding how these structures affect the human experience of death.
Rationale 2: Midlevel theories focus on exploring concepts such as pain, self-esteem, and learning.
Rationale 3: Grand theories are only occasionally used in nursing research. The stability model
describes the dominant view of nursing theories.
Rationale 4: The stability model describes the dominant view of nursing theories.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
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NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical
practice.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 39
Question 3
Type: MCSA
A nurse is caring for a client with a severe head trauma. Each shift, the nurse pays attention to the
lighting, atmosphere, and surroundings the client is exposed to. The nurse is functioning according
to the assumptions of which nursing theorist?
1. Dorothea Orem
2. Martha Rogers
3. Florence Nightingale
4. Jean Watson
Correct Answer: 3
Rationale 1: Dorothea Orem’s theory focused on self-care and doesn’t apply here.
Rationale 2: Rogers’s theory is the science of unitary human beings and doesn’t apply here.
Rationale 3: Florence Nightingale defined nursing more than 100 years ago as “the act of utilizing
the environment of the patient to assist him in his recovery.” Attending to the client’s surroundings,
including the lighting and atmosphere, is being attentive to the client’s environment. Deficiencies in
environmental factors (especially air, water, drainage, cleanliness, and light) have produced lack of
health or illness.
Rationale 4: Jean Watson defined nursing in relationship to caring and doesn’t apply here.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
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QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 40
Question 4
Type: MCSA
Nursing staff members from an acute psychiatric unit have been asked to establish a nurse theorist
they can easily identify with in their practice. Understanding the importance of developing a
therapeutic relationship between themselves and their clients, especially in this unit, to which theorist
would they most likely be drawn?
1. Florence Nightingale
2. Hildegard Peplau
3. Jean Watson
4. Dorothea Orem
Correct Answer: 2
Rationale 1: Florence Nightingale’s theory focused on environmental controls.
Rationale 2: Hildegard Peplau, a psychiatric nurse, introduced a theory in which a therapeutic
relationship between the nurse and client is central.
Rationale 3: Jean Watson’s theory has caring as its central theme.
Rationale 4: Dorothea Orem’s theory focused on self-care deficit.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
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Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 40
Question 5
Type: MCSA
During a hospital stay, the client has taken control of her recovery and rehabilitation and is utilizing
available resources for her needs. In which level of Peplau’s model should the nurse determine that
this patient is functioning?
1. Orientation
2. Identification
3. Exploitation
4. Resolution
Correct Answer: 3
Rationale 1: Orientation is the first phase, in which the client seeks help and the nurse provides the
client with understanding and assistance.
Rationale 2: Identification is the second phase, in which the client assumes dependence,
interdependence, or independence in relation to the nurse.
Rationale 3: The nurse–client relationship is described in four phases, according to Peplau’s
interpersonal relations model. The exploitation phase occurs when the client derives full value from
what the nurse offers through the relationship, using available services based on self-interest and
needs. Power shifts from the nurse to the client.
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Rationale 4: The last phase is resolution, in which old needs and goals are put aside and new ones
adopted.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 40
Question 6
Type: MCSA
A Department of Nursing within a medical center is adopting the theory that is founded on 14
fundamental needs of individuals. Which nurse theorist is this department using to guide client care?
1. Dorothea Orem
2. Florence Nightingale
3. Martha Rogers
4. Virginia Henderson
Correct Answer: 4
Rationale 1: Dorothea Orem’s theory on self-care deficit does not contain 14 fundamental needs.
Rationale 2: Florence Nightingale’s theory centered around the client’s environment does not contain
14 fundamental needs.
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Rationale 3: Martha Rogers related her theory to multiple scientific disciplines, and it does not
contain 14 fundamental needs.
Rationale 4: Henderson conceptualized the nurse’s role as assisting sick or healthy individuals to
gain independence in meeting 14 fundamental needs, from breathing normally to discovering the
curiosity that leads to normal development and health.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 40
Question 7
Type: MCSA
A nurse has implemented the use of noncontact therapeutic touch. Which theorist is the nurse using
as a basis for this intervention?
1. Florence Nightingale
2. Martha Rogers
3. Virginia Henderson
4. Rosemarie Parse
Correct Answer: 2
Rationale 1: Rogers states that humans are dynamic energy fields. Nurses applying Rogers’s theory
seek to promote interaction between the two energy fields. The use of noncontact therapeutic touch
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is based on the concept of human energy fields. Nightingale’s theory centered on the client’s
environment. Henderson conceptualized the nurse’s role as assisting individuals to gain
independence in meeting 14 fundamental needs. Rosemarie Parse’s theory revolves around human
becoming.
Rationale 2: Rogers states that humans are dynamic energy fields. Nurses applying Rogers’s theory
seek to promote interaction between the two energy fields. The use of noncontact therapeutic touch
is based on the concept of human energy fields. Nightingale’s theory centered on the client’s
environment. Henderson conceptualized the nurse’s role as assisting individuals to gain
independence in meeting 14 fundamental needs. Rosemarie Parse’s theory revolves around human
becoming.
Rationale 3: Rogers states that humans are dynamic energy fields. Nurses applying Rogers’s theory
seek to promote interaction between the two energy fields. The use of noncontact therapeutic touch
is based on the concept of human energy fields. Nightingale’s theory centered on the client’s
environment. Henderson conceptualized the nurse’s role as assisting individuals to gain
independence in meeting 14 fundamental needs. Rosemarie Parse’s theory revolves around human
becoming.
Rationale 4: Rogers states that humans are dynamic energy fields. Nurses applying Rogers’s theory
seek to promote interaction between the two energy fields. The use of noncontact therapeutic touch
is based on the concept of human energy fields. Nightingale’s theory centered on the client’s
environment. Henderson conceptualized the nurse’s role as assisting individuals to gain
independence in meeting 14 fundamental needs. Rosemarie Parse’s theory revolves around human
becoming.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 41
Question 8
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Type: MCSA
The nurse is teaching health and wellness principles to junior high students. According to Orem’s
theory, which category of self-care requisite is the nurse using to guide this teaching?
1. Universal
2. Developmental
3. Health deviation
4. Deficit
Correct Answer: 2
Rationale 1: Universal requisites are common to all people and include nutrition, hydration,
elimination, and rest.
Rationale 2: Developmental requisites result from maturation or are associated with conditions or
events, such as adjusting to a change in body image (adolescent maturation, in this case) or to the
loss of a spouse.
Rationale 3: Health deviation requisites result from illness, injury, or disease or its treatment. They
include actions such as seeking health care assistance, carrying out prescribed therapies, and
learning to live with the effects of illness or treatment.
Rationale 4: Self-care deficit is not a self-care requisite, but it results when self-care agency is not
adequate to meet the known self-care demand.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical
practice.
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MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 41
Question 9
Type: MCSA
The nurse is caring for clients in Stage II/III Alzheimer’s disease. If Orem’s theory is applied, which
type of nursing system should the nurse use when providing client care?
1. Supportive
2. Educative
3. Partly compensatory
4. Wholly compensatory
Correct Answer: 4
Rationale 1: Supportive systems (developmental) are designed for persons who need to learn to
perform self-care measures and need assistance to do so. This would not be attainable for this
group of clients.
Rationale 2: Educative systems (developmental) are designed for persons who need to learn to
perform self-care measures and need assistance to do so. This would not be attainable for this
group of clients.
Rationale 3: Partly compensatory systems are designed for individuals who are unable to perform
some, but not all, self-care activities. Because the clients are in the end stage of the disease, their
ability to care for themselves is greatly diminished. Some would not be able to care for themselves at
all.
Rationale 4: Wholly compensatory systems are required for individuals who are unable to control
and monitor their environment and process information. This would describe clients with Stage II/III
Alzheimer’s—those who need constant supervision and at some point in the near future, total care
with all activities of daily living (ADLs).
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
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AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 41
Question 10
Type: MCSA
A nurse educator incorporates stress, power, authority, and personal space along with other
concepts and considers these concepts essential knowledge for use by nurses. From which theorist
is the educator applying principles into the curriculum?
1. Dorothea Orem
2. Imogene King
3. Jean Watson
4. Hildegard Peplau
Correct Answer: 2
Rationale 1: Orem’s theory focuses on self-care/self-care deficit and is not applicable here.
Rationale 2: Imogene King’s theory of goal attainment is based on 15 concepts from nursing
literature she selected as essential knowledge for use by nurses: self, role, perception,
communication, interaction, transaction, growth and development, stress, time, personal space,
organization, status, power, authority, and decision making.
Rationale 3: Jean Watson’s theory centers on caring interaction and is not applicable here.
Rationale 4: Hildegard Peplau’s theory centers on the use of a therapeutic relationship between the
nurse and client and is not applicable here.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
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QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 41
Question 11
Type: MCSA
The nurse is applying Neuman’s systems model during client care. Which response should the nurse
identify as an intrapersonal stressor to a client?
1. Inadequate health insurance coverage
2. Family members who quarrel frequently about the client’s care
3. Adverse reaction to medication
4. Expectations regarding rehab
Correct Answer: 3
Rationale 1: Extrapersonal stressors are those that occur outside the person
(e.g., financial/insurance concerns).
Rationale 2: Interpersonal stressors are those that occur between individuals (e.g., family members
who quarrel).
Rationale 3: Neuman categorizes stressors as intrapersonal when they occur within the individual
(e.g., a drug reaction).
Rationale 4: Neuman categorizes stressors as interpersonal when they occur between individuals
(e.g., expectations regarding rehabilitation).
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
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Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 42
Question 12
Type: MCSA
A client is being seen in the clinic for the final follow-up appointment after an extensive course of
rehabilitation. According to Neuman’s model, which level of intervention should the nurse realize this
patient is experiencing?
1. Primary prevention
2. Secondary prevention
3. Resistant prevention
4. Tertiary prevention
Correct Answer: 4
Rationale 1: Primary prevention focuses on protecting the normal line of defense and strengthening
the flexible line of defense.
Rationale 2: Secondary prevention focuses on strengthening internal lines of resistance, reducing
the reaction, and increasing resistance factors.
Rationale 3: Secondary prevention focuses on strengthening internal lines of resistance, reducing
the reaction, and increasing resistance factors.
Rationale 4: According to Neuman’s model, nursing interventions focus on retaining or maintaining
system stability and are carried out on three preventive levels: primary, secondary, and tertiary.
Tertiary prevention focuses on readaptation and stability and protects reconstitution or return to
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wellness following treatment. A final follow-up appointment following extensive rehabilitation would
be an example of tertiary prevention.
.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 42
Question 13
Type: MCSA
A client with a postoperative infection is afebrile but still receiving IV antibiotics. The nurse should
realize that this client is receiving which level of prevention?
1. Primary
2. Secondary
3. Tertiary
4. Critical
Correct Answer: 2
Rationale 1: Primary prevention focuses on protecting the normal line of defense and strengthening
the flexible line of defense.
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Rationale 2: Secondary prevention focuses on strengthening internal lines of resistance (fighting the
infection with IV antibiotics), reducing the reaction, and increasing resistance factors. The fact that
the client is now afebrile shows that the treatment is working to improve the client’s condition.
Rationale 3: Tertiary prevention focuses on readaptation and stability and protects reconstitution or
return to wellness following treatment.
Rationale 4: Critical prevention is not part of Neuman’s model.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 42
Question 14
Type: MCSA
A group of nursing students is helping to set up an immunization clinic. In which level of prevention
are these students functioning?
1. Educational
2. Primary
3. Secondary
4. Tertiary
Correct Answer: 2
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Rationale 1: Educational is not one of Neuman’s levels of prevention.
Rationale 2: Primary prevention focuses on protecting the normal line of defense. Providing
immunizations would be doing just that—protecting the body’s normal response to disease by
helping it to build antibodies.
Rationale 3: Secondary prevention focuses on strengthening internal lines of resistance.
Rationale 4: Tertiary prevention focuses on readaptation and stability.
.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 42
Question 15
Type: MCSA
The nurse is preparing to complete a spiritual assessment with a client. Which theorist should the
nurse review before completing this assessment?
1. Roy
2. Neuman
3. Nightingale
4. Peplau
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Correct Answer: 1
Rationale 1: Sr. Callista Roy’s work focuses on the increasing complexity of person and environment
and the relationship between and among persons, the universe, and what can be considered a
supreme being or God. She uses characteristics of “creation spirituality” in her work and philosophy.
Rationale 2: Neuman developed her model based on the individual’s relationship to stress.
Rationale 3: Nightingale’s theory focuses on environmental manipulation.
Rationale 4: Peplau’s theory centers on the therapeutic relationship between nurse and client.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 42
Question 16
Type: MCSA
The nurse observes a client working to include the spouse in the treatment and recovery process
of an illness. Which of Roy’s modes
should the nurse recognize that this client is demonstrating?
1. Physiologic
2. Self-concept
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3. Role function
4. Interdependence
Correct Answer: 4
Rationale 1: The physiologic mode involves the body’s basic physiologic needs and ways of
adapting with regard to function of the body’s systems.
Rationale 2: The self-concept mode includes the physical self and the personal self.
Rationale 3: The role function mode is determined by the need for social integration and refers to the
performance of duties based on given positions within society.
Rationale 4: The goal of Roy’s model is to enhance life processes through adaptation in four
adaptive modes. The interdependence mode involves one’s relations with significant others and
support systems that provide help, affection, and attention. Involving a spouse with the treatment
and recovery process would be an example of this mode.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 43
Question 17
Type: MCSA
A client is experiencing metabolic acidosis, a condition that involves the body’s pH level, carbon
dioxide level, and bicarbonate balance. According to Roy’s model, to which mode should the nurse
realize that this client is responding?
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1. Physiologic
2. Self-concept
3. Role function
4. Interdependence
Correct Answer: 1
Rationale 1: The physiologic mode involves the body’s basic physiologic needs and ways of
adapting with regard to fluid and electrolytes, activity and rest, circulation and oxygen, nutrition and
elimination, protection, the senses, and neurologic and endocrine function. The pH level as well as
levels of the carbon dioxide and bicarbonate ion would be physiologic mechanisms at work in the
body.
Rationale 2: The self-concept mode includes the physical self and the personal self.
Rationale 3: The role function mode is determined by the need for social integration and refers to the
performance of duties based on given positions within society.
Rationale 4: The interdependence mode involves one’s relations with significant others and support
systems that provide help, affection, and attention.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 43
Question 18
Testsbanknursing.com
Type: MCSA
A nurse has agreed to delay a client’s treatment until the matriarch of the family can be present.
Understanding that this is an important consideration for this client’s cultural practices, which of
Leininger’s intervention modes is the nurse implementing?
1. Preservation and maintenance
2. Accommodation, negotiation
3. Restructuring
4. Repatterning
Correct Answer: 2
Rationale 1: The preservation and maintenance mode does not involve the scenario described here.
Rationale 2: By allowing flexibility in scheduling client treatment in order to allow for the client’s
family member to be present—which in this case is an important aspect of the family’s cultural
practices—the nurse accommodates the client’s needs.
Rationale 3: Restructuring does not involve the scenario described here.
Rationale 4: Repatterning does not involve the scenario described here.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 43
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Question 19
Type: MCSA
The nurse implements being authentically present to clients by supporting them in their beliefs and
helping to instill hopefulness in their recovery. Which theorist is the nurse using when performing
these actions?
1. Florence Nightingale
2. Hildegard Peplau
3. Jean Watson
4. Rosemarie Parse
Correct Answer: 3
Rationale 1: Nightingale’s theory involved environmental manipulation.
Rationale 2: Peplau focused on the therapeutic relationship between nurse and client.
Rationale 3: Jean Watson believes the practice of caring is central to nursing and has developed
nursing interventions referred to as clinical caritas processes. Of these, “being authentically present,
and enabling and sustaining the deep belief system and subjective life world of self and one-being
cared for” is an example.
Rationale 4: Parse developed the theory of human becoming.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical
practice.
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MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 44
Question 20
Type: MCSA
The nurse struggling with a demanding client focuses on experiencing a sense of true empathy for
the client’s situation. Which assumption of Parse’s human becoming theory is the nurse using?
1. Meaning
2. Rhythmicity
3. Intersubjectivity
4. Cotranscendence
Correct Answer: 4
Rationale 1: Meaning arises from a person’s interrelationship with the world.
Rationale 2: Rhythmicity is the movement toward greater diversity.
Rationale 3: Intersubjectivity is not one of Parse’s assumptions.
Rationale 4: Cotranscendence is the process of reaching out beyond the self, which would be what
the nurse in this scenario has implemented.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical
practice.
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MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 44
Question 21
Type: MCSA
When a client who had a stroke gives up all hope of any amount of recovery, the nurse solicits a visit
from a former stroke client who has physical limitations but has since gone back to work
and, through adaptation, can function independently at home. This nurse has fulfilled which role,
according to Parse?
1. Mobilizing transcendence
2. Synchronizing rhythm
3. Illuminating meaning
4. True presence
Correct Answer: 3
Rationale 1: Mobilizing transcendence is dreaming of possibilities and planning to reach them.
Rationale 2: Synchronizing rhythm involves leading through discussion to recognize harmony.
Rationale 3: According to Parse’s theory, illuminating meaning refers to uncovering what was and
what will be. In this situation, the stroke is what was, and the client who is now independent is what
could be for the nurse’s current client.
Rationale 4: Nurses must provide a “true presence” to their clients, but this is not a role in Parse’s
theory; it is a behavior.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Testsbanknursing.com
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical
practice.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 44
Question 22
Type: MCSA
The pediatric nurse implements Watson’s assumption regarding a caring environment. Which action
did the nurse take to implement this assumption?
1. Providing for all needs and cares of the nurse’s clients
2. Ensuring that a zone of professionalism is present between the nurse and client
3. Allowing the clients to have choices, as appropriate, in their care
4. Selecting games and activities that are age appropriate for the clients
Correct Answer: 3
Rationale 1: The nurse may not need to provide for all of the needs and cares of clients.
Rationale 2: Being conscientious of a zone of professionalism (i.e., keeping distant) would not be a
characteristic of caring according to Watson.
Rationale 3: A caring environment, according to Watson’s assumptions of caring, offers the
development of potential while allowing the person to choose the best action for the self at a given
point in time.
Rationale 4: Taking choices away from clients by making selections for them is not a good example
of true caring, as defined by Watson.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
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NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical
practice.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 44
Question 23
Type: MCMA
Nursing students have been studying the “stability model” of nurse theorists. What phrases or terms
should the students use to describe this model?
Standard Text: Select all that apply.
1. Dominant
2. Systems framework
3. Stress/adaptation framework
4. Martha Rogers’s theory
5. Caring/complexity framework
6. Callista Roy’s theory
Correct Answer: 1, 2, 3, 6
Rationale 1: The dominant view of nursing theories is considered the “stability model.“
Rationale 2: The dominant view of nursing theories is considered the “stability model,” and may
include systems as a framework.
Rationale 3: The dominant view of nursing theories is considered the “stability model,” and may
include stress/adaptation as a framework.
Rationale 4: The emerging view is considered the “growth model,” with theories using caring or
complexity as frameworks. This model includes the theory of Martha Rogers.
Rationale 5: The emerging view is considered the “growth model,” with theories using caring or
complexity as frameworks.
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Rationale 6: The dominant view of nursing theories is considered the “stability model” and may
include the theory of Callista Roy.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 42
Question 24
Type: MCMA
Grounding nursing research in theories from other disciplines is argued to be undesirable by some
scholars. What should the nurse identify as reasons why grounding theory is not desired?
Standard Text: Select all that apply.
1. It detracts from developing nursing as a separate discipline.
2. It makes nursing less relevant.
3. It helps bring a broader perspective and insight to nursing.
4. Other disciplines are not unique to the human condition.
5. Other disciplines get the benefit of nursing’s research.
Correct Answer: 1, 2, 5
Rationale 1: Some nursing scholars think that grounding research in theories from other disciplines
detracts from the development of nursing as a separate discipline.
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Rationale 2: Some nursing scholars think that grounding research in theories from other disciplines
makes nursing research less relevant.
Rationale 3: Some scholars believe that bringing insights and perspectives from other disciplines
helps to broaden values of the profession.
Rationale 4: Other disciplines are attentive to the human condition.
Rationale 5: Other disciplines regularly share research findings, and it does not detract from the
professional source.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 5. Identify one positive and one negative effect of using theory to understand
clinical practice.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 38
Question 25
Type: MCMA
The nurse is implementing Watson’s Assumptions of Caring philosophy. Which actions
demonstrate that the nurse is using this philosophy?
Standard Text: Select all that apply.
1. Asking the client to explain the impact that his culture and religion will have on required nursing
care
2. Asking clients when they prefer to be given the opportunity to bathe
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3. Feeling empathy toward the client’s loss of mobility as a result of a fractured hip
4. Always assuring that the client has an unobstructed view out his room’s window
5. Arranging to fulfill a client’s request to stay with him during a painful diagnostic test
Correct Answer: 2, 3, 5
Rationale 1: This is more relevant to Leininger’s Cultural Care Diversity and Universality Theory.
Rationale 2: Watson proposes that a caring environment offers the development of potential while
allowing the person to choose the best action for the self at a given point in time.
Rationale 3: Watson proposes that human caring in nursing is not just an emotion, concern, attitude,
or benevolent desire. Caring connotes a personal response such as empathy.
Rationale 4: This is more relevant to Roy’s Adaptation Model.
Rationale 5: Watson proposes that caring occasions involve action and choice by nurse and client. If
the caring occasion is transpersonal, the limits of openness expand, as do human capacities.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 44
Question 26
Type: MCMA
Testsbanknursing.com
The nurse is using the central concepts of nursing when providing client care. What actions is this
nurse performing?
Standard Text: Select all that apply.
1. Including a client’s family in discussions regarding the client’s discharge health needs
2. Assessing a physically dependent client’s spouse for indications of caregiver stress
3. Asking clients to define what “healthy and well” means to them
4. Suggesting wound care supplies with the priority of cost
5. Advocating for a client who is not responding to current pain control treatment
Correct Answer: 1, 2, 3, 5
Rationale 1: One of the recognized central concepts of nursing is that the recipients of nursing care
include individuals, families, groups, and communities.
Rationale 2: One of the recognized central concepts of nursing is that the nurse addresses the
client’s environmental surroundings, including people in the physical environment, such as families,
friends, and significant others, for unmet needs that ultimately affect the client.
Rationale 3: One of the recognized central concepts of nursing is that health is the degree of
wellness or well-being that the client experiences.
Rationale 4: Although important, economic frugality is not a central concept of nursing care.
Rationale 5: One of the recognized central concepts of nursing is that the nurse provides care on
behalf of, or in conjunction with, the client.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
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MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 38
Question 27
Type: MCMA
The nurse is planning client care while keeping in mind Orem’s self-care deficit theory. Which
methods of helping should the nurse include when determining the best care for the client?
Standard Text: Select all that apply.
1. Balancing rest
2. Teaching
3. Supporting
4. Guiding
5. Preventing hazards to life
Correct Answer: 2, 3, 4, 5
Rationale 1: Balancing rest and preventing hazards to life are part of the universal requisites of
Orem’s self-care needs.
Rationale 2: Orem’s self-care deficit theory explains not only when nursing is needed, but also how
people can be assisted through methods of helping that include teaching.
Rationale 3: Orem’s self-care deficit theory explains not only when nursing is needed, but also how
people can be assisted through methods of helping that include supporting.
Rationale 4: Orem’s self-care deficit theory explains not only when nursing is needed, but also how
people can be assisted through methods of helping that include guiding.
Rationale 5: Preventing hazards to life is part of the universal requisites of Orem’s self-care needs.
.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
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AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the major purpose of theory in the sciences and practice disciplines.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 41
[New Questions: ]
Question 28
Type: MCMA
After completing a health history the nurse reviews the content to determine metaparadigms that
contribute to the client’s health. Which metaparadigm should the nurse categorize as being a part of
the client’s environment?
Standard Text: Select all that apply.
1. Diet
2. Family
3. Friends
4. Blood pressure
5. Significant others
Correct Answer: 2, 3, 5
Rationale 1: Health is the degree of wellness or well-being that the client experiences. This can be
measured by diet and blood pressure.
Rationale 2: The environment is the internal and external surroundings that affect the client. This
includes people in the physical environment, such as families, friends, and significant others.
Rationale 3: The environment is the internal and external surroundings that affect the client. This
includes people in the physical environment, such as families, friends, and significant others.
Rationale 4: Health is the degree of wellness or well-being that the client experiences. This can be
measured by diet and blood pressure.
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Rationale 5: The environment is the internal and external surroundings that affect the client. This
includes people in the physical environment, such as families, friends, and significant others.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Identify the components of the metaparadigm for nursing.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 38
Question 29
Type: MCMA
The nurse is planning interventions for a client based upon Henderson’s fundamental needs. Which
interventions should the nurse include in the plan of care?
Standard Text: Select all that apply.
1. Sleep 4 to 5 hours each night.
2. Attend to spiritual needs as desired.
3. Wear clothing suitable for the weather.
4. Bathe and keep the body well-groomed.
5. Restrict fluids with an elevated body temperature.
Answer: 2, 3, 4
Rationale 1: Henderson did not limit the number of hours of sleep.
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Rationale 2: Henderson conceptualizes the nurse’s role as assisting sick or healthy individuals to
gain independence in meeting 14 fundamental needs, which include worshipping according to one’s
faith, selecting suitable clothes, and keeping the body clean and well-groomed.
Rationale 3: Henderson conceptualizes the nurse’s role as assisting sick or healthy individuals to
gain independence in meeting 14 fundamental needs, which include worshipping according to one’s
faith, selecting suitable clothes, and keeping the body clean and well-groomed.
Rationale 4: Henderson conceptualizes the nurse’s role as assisting sick or healthy individuals to
gain independence in meeting 14 fundamental needs, which include worshipping according to one’s
faith, selecting suitable clothes, and keeping the body clean and well-groomed.
Rationale 5: According to Henderson, food and liquids should be adequate for the individual.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A. 4. Read original research and evidence reports related to area of
practice
AACN Essentials Competencies: III. 2. Demonstrate an understanding of the basic elements of the
research process and models for applying evidence to clinical practice
NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to
promote quality and improve practices
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4. Identify the role of nursing theory in nursing education, research, and clinical
practice.
MNL Learning Outcome: 1.1.1. Explain the history of nursing theory and role of nursing theory in the
provision of nursing care.
Page Number: 40
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Chapter 04
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 04
Question 1
Type: MCSA
A client was given the wrong dose of medication and died. The case is being tried in court and
similar cases are used by the court in comparison to arrive at a decision. Which doctrine should the
nurse’s attorney explain is applied to this situation?
1. Common law
2. Public law
3. Administrative law
4. Stare decisis
Correct Answer: 4
Rationale 1: Common law is a type of law enacted by different entities.
Rationale 2: Public law is a type of law enacted by different entities.
Rationale 3: Administrative law is a type of law enacted by different entities.
Rationale 4: Stare decisis, “to stand by things decided,” is a doctrine courts adhere to when arriving
at a ruling in a particular case. The courts apply the same rules and principles applied in previous,
similar cases.
Cognitive Level: Application
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: V. 6. Explore the impact of socio-cultural, economic, legal and
political factors influencing healthcare delivery and practice.
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 1. List sources of law and types of laws.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 48
Question 2
Type: MCSA
The nurse is notified about new state practice act regulations. Which type of law should the nurse
expect to implement and enforce the nurse practice act regulations?
1. Statutory law
2. Administrative law
3. Common law
4. Public law
Correct Answer: 2
Rationale 1: Statutory laws are laws enacted by any legislative body.
Rationale 2: Administrative agencies are given authority to create rules and regulations to enforce
statutory law when the state legislature passes a statute. State boards of nursing write rules and
regulations to implement and enforce a nurse practice act, which was created through statutory law
but is enforced by administrative law.
Rationale 3: Common law refers to laws evolved from court decisions.
Rationale 4: Public law refers to the body of law that deals with relationships between individuals
and the government and governmental agencies.
Cognitive Level: Application
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: V. 6. Explore the impact of socio-cultural, economic, legal and
political factors influencing healthcare delivery and practice.
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including
HIPAA, for faculty, students, patients, and families
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Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. List sources of law and types of laws.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 48
Question 3
Type: MCSA
The admitting nurse explains the process of signing forms to allow for the client’s insurance
company to be billed for services. If the insurance fails to pay for services, the client is responsible
for payment. Which type of law did the nurse explain to the client?
1. Contract law
2. Tort law
3. Statutory law
4. Administrative law
Correct Answer: 1
Rationale 1: Contract law involves the enforcement of agreements among private individuals or the
payment of compensation for failure to fulfill the agreements. Signing a form prior to receipt of health
care services makes the client responsible for cost, regardless of insurance payment.
Rationale 2: Tort law defines and enforces duties and rights among private individuals that are not
based on contractual agreements.
Rationale 3: Statutory laws are laws enacted by any legislative body.
Rationale 4: Administrative laws give administrative agencies the authority to create rules and
regulations to enforce statutory laws.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: V. 6. Explore the impact of socio-cultural, economic, legal and
political factors influencing healthcare delivery and practice.
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NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. List sources of law and types of laws.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 48
Question 4
Type: MCSA
The nurse forgets to put the call light within the client’s reach and then leaves the room. The client
reaches for it and falls out of bed. With what should the nurse expect to be charged?
1. Assault
2. Battery
3. Negligence
4. Criminal intent
Correct Answer: 3
Rationale 1: Assault is the threat to touch another person unjustifiably.
Rationale 2: Battery is the willful touching of a person that may cause harm.
Rationale 3: Negligence is an example of a tort law. Negligence occurs when something is
accidental and harm results, as in this case. Another example of negligence would be if surgical
instruments or bandages are accidentally left in a client during surgery.
Rationale 4: Criminal intent implies preplanned actions that are illegal.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including
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HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10. Compare and contrast intentional torts (assault/battery, false imprisonment,
invasion of privacy, defamation) and unintentional torts (professional negligence).
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 49
Question 5
Type: MCSA
A client is suing the hospital for malpractice. Before the case goes to court, the attorney meets with
staff and reads the medical record. The nurse realizes that the attorney is performing which activity?
1. Burden of proof
2. Complaint
3. Discovery
4. Civil action
Correct Answer: 3
Rationale 1: Burden of proof falls to the plaintiff and is the duty to prove wrongdoing.
Rationale 2: A complaint is a document filed by a person (plaintiff) who claims that his or her legal
rights have been infringed on by one or more persons (defendants).
Rationale 3: Discovery is an effort by both parties to obtain all the facts of the situation. It occurs
before the trial.
Rationale 4: A civil action is a legal action that deals with the relationships among individuals in
society.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: V. 6. Explore the impact of socio-cultural, economic, legal and
political factors influencing healthcare delivery and practice.
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NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. List sources of law and types of laws.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 49
Question 6
Type: MCSA
Before applying for re-licensure, the nurse attends continuing education programs. Which action is
the nurse performing to adhere to the state board of nursing expectation?
1. Licensure
2. Competency
3. Credentialing
4. Certification
Correct Answer: 3
Rationale 1: Licensure is the process of granting a legal permit to practice or engage in a profession,
such as nursing.
Rationale 2: Competency is a level of acceptable performance, and credentialing ensures this in
licensure. Certification is also part of credentialing. It validates that an individual has met minimum
standards of nursing competency in a specialty area.
Rationale 3: Credentialing is the process of determining and maintaining competence in general
nursing practice. It is one way to maintain the professional standards of practice and accountability
for the members’ educational preparation.
Rationale 4: Certification validates that an individual has met minimum standards of nursing
competency in a specialty area.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
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AACN Essentials Competencies: V. 6. Explore the impact of socio-cultural, economic, legal and
political factors influencing healthcare
delivery and practice.
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare and contrast the state-based licensure model and the mutual
recognition model for multistate licensure.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 49
Question 7
Type: MCSA
The high school graduate desiring to attend nursing school reviews the schools for
accreditation. Which regulatory body’s actions is the student analyzing?
1. State board of nursing
2. NLNAC
3. CCNE
4. ANA
Correct Answer: 1
Rationale 1: All states require that all schools of nursing in the state are approved/accredited by the
state board of nursing.
Rationale 2: Some but not all states require that programs be both state approved and accredited by
a national accrediting agency such as NLNAC.
Rationale 3: Some but not all states require that programs be both state approved and accredited by
a national accrediting agency such as CCNE.
Rationale 4: Voluntary accreditation is not required by all states and is a means of informing the
public and prospective students that the nursing program has met certain criteria. The ANA
(American Nurses Association) is nursing’s professional organization.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
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Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: V. 6. Explore the impact of socio-cultural, economic, legal and
political factors influencing healthcare delivery and practice.
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Describe ways nurse practice acts, credentialing, standards of care, and
agency policies and procedures affect the scope of nursing practice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 51
Question 8
Type: MCSA
The nurse carries out a medication order, incorrectly written by the physician and subsequently filled
by the pharmacist. Who, in this situation, is legally liable for the action?
1. Physician
2. Pharmacist
3. Hospital
4. Nurse
Correct Answer: 4
Rationale 1: Even though the physician wrote the order incorrectly, the primary responsibility in
question is the administration of the medication, and so the responsibility is not the physician’s.
Rationale 2: Even though the pharmacist filled an incorrect order, the primary responsibility in
question is the administration of the medication, and so the responsibility is not the pharmacist’s.
Rationale 3: Assuming policies and procedures were written and accessible, the hospital is not
legally responsible in this case.
Rationale 4: The responsibility for the nursing activity—in this case, giving the medication—belongs
to the nurse. Liability is legal responsibility for one’s action. Even though the physician wrote the
order incorrectly and the pharmacist filled it, it was the nurse who carried it out, making that person
ultimately responsible for the action.
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Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: V. 6. Explore the impact of socio-cultural, economic, legal and
political factors influencing healthcare delivery and practice.
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7. Recognize the nurse’s legal responsibilities with selected aspects of nursing
practice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 53
Question 9
Type: MCSA
A hospital receives notice of being sued for an action performed by a nurse. The nurse
realizes that which doctrine is being implemented in this case?
1. Contractual relationship
2. Stare decisis
3. Respondeat superior
4. Res ipsa loquitur
Correct Answer: 3
Rationale 1: A contractual relationship is not a doctrine; it is what the nurse and hospital, for
example, enter into when the hospital hires the nurse as an employee.
Rationale 2: “To stand by things decided,” or stare decisis, is the same thing as following precedent,
or applying the same rules to a situation as were applied in similar situations.
Rationale 3: “Let the master answer,” or respondeat superior, means that the master (in this case
the hospital/employer) assumes responsibility for the conduct of the servant (the nurse) and can be
held responsible for the nurse’s failure to act in a competent way.
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Rationale 4: “The thing speaks for itself,” or res ipsa loquitur, is a doctrine in cases where harm
occurs but cannot be traced to a specific health care provider or standard.
.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: V. 6. Explore the impact of socio-cultural, economic, legal and
political factors influencing healthcare delivery and practice.
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 7. Recognize the nurse’s legal responsibilities with selected aspects of nursing
practice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 62
Question 10
Type: MCSA
A client being prepared for an invasive procedure questions some of the terminology in the consent
form. Which response should the nurse make?
1. “Just sign the form, and I’ll make sure your physician talks to you before he begins the procedure.”
2. “I’ll explain whatever you don’t understand.”
3. “You should have asked your physician when he was in here.”
4. “I’ll call your physician back in the room to answer your questions.”
Correct Answer: 4
Rationale 1: If the client has questions, he should not sign the form. These questions require the
physician’s attention before the consent is signed.
Rationale 2: If the client has questions, he should not sign the form, and it is not the nurse’s
responsibility to answer the questions.
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Rationale 3: Telling the client what he “should have” done is demeaning and not an appropriate
therapeutic response.
Rationale 4: Obtaining informed consent for specific medical treatment is the responsibility of the
person who is going to perform the procedure, in this case the physician. Informed consent suggests
that the client has been given complete information, including benefits, risks, and alternatives if the
treatment is not given. An element of informed consent is that the client must be given enough
information to be the ultimate decision maker. If not, it is the physician’s responsibility to make sure
the client’s understanding is clear. It is important that the person obtaining the consent (the physician
in this case) answer the client’s questions.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Describe the purpose and essential elements of informed consent.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 54
Question 11
Type: MCSA
The client presents her hand when the nurse makes this statement: “I need to start an IV so you can
get your antibiotics.” Which behavior did the client demonstrate?
1. Informed consent
2. Express consent
3. Implied consent
4. Compliance
Correct Answer: 3
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Rationale 1: Informed consent is an agreement by a client to accept a course of treatment or a
procedure after being provided complete information, including the benefits and risks of
treatment, and generally requires the client’s signature (written consent)
Rationale 2: Express consent may be either an oral or written agreement. In this case, there were
neither spoken words nor a written consent form for the IV initiation.
Rationale 3: Implied consent exists when the individual’s nonverbal behavior indicates agreement. In
this case, presenting the hand for IV initiation would be a nonverbal behavior indicating agreement
with the treatment.
Rationale 4: Compliance occurs when clients agree to follow the recommended treatment, usually by
their own actions as in taking prescribed medications or following a prescribed diet.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Describe the purpose and essential elements of informed consent.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 54
Question 12
Type: MCSA
An adult client who cannot read needs surgery and is competent to make his own decisions. What is
the best action that the nurse should take?
1. Tell the client in the nurse’s own words what the surgical procedure involves.
2. Read the consent form to the client and have the client state understanding.
3. Make sure the physician explains the procedure to the client.
4. Have a family member who can read sign the consent form.
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Correct Answer: 2
Rationale 1: Telling the client in words other than what is on the consent form is not appropriate, as
some meaning and information may be lost in the transfer.
Rationale 2: If a client cannot read, the consent form must be read to the client and the client must
state understanding before the form is signed.
Rationale 3: The physician should explain the procedure to the client, regardless of the client’s
literacy.
Rationale 4: Because the client is a competent adult, he must be the one giving consent. Illiteracy
does not make one incompetent.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Describe the purpose and essential elements of informed consent.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 55
Question 13
Type: MCSA
An older adult fell at home and fractured a hip, which requires surgical repair. After admittance to the
emergency department, the client was given sedation for pain before a surgical permit was signed.
What should be done to obtain consent?
1. The physician should have the client’s wife sign the consent form.
2. The physician should wait until the effects of the medication wear off and have the client sign the
form.
3. Because the client has been medicated, the nurse should thoroughly explain the consent form to
the client.
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4. This would be considered an emergency situation and consent would be implied.
Correct Answer: 1
Rationale 1: A client who is confused, disoriented, or sedated is not considered functionally
competent and a legal guardian or representative can provide or refuse consent for the client. In this
case, because the client was given medication that sedated him, the wife would be appropriate for
giving consent for the surgical procedure.
Rationale 2: Waiting until the effects of the medication wear off would not be in the best interest of
the client.
Rationale 3: Thorough explanation may or may not matter in this case because the client is
considered functionally incompetent. Besides, it is the physician’s responsibility to obtain informed
consent.
Rationale 4: Implied consent may be used in a medical emergency, but in this case, there is an
appropriate option available.
.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Describe the purpose and essential elements of informed consent.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 55
Question 14
Type: MCSA
A client is brought to the emergency department after being involved in a motor vehicle crash.
Although the client is conscious, her condition is critical and will require emergency surgery. The
client does not speak English. Which action should the nurse take?
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1. Read the consent form and have the client sign it anyway.
2. Explain the form to the best of the nurse’s ability using pictures and gestures.
3. Have the hospital interpreter explain the procedure.
4. Proceed with surgery, as implied consent would be the case in this situation.
Correct Answer: 3
Rationale 1: Reading the consent form to someone who doesn’t understand the words is pointless.
Rationale 2: There is a better option available than using pictures and gestures in the hope of
explaining the procedure.
Rationale 3: If the client does not speak the same language as the health professional who is
providing the information, an interpreter must be present.
Rationale 4: Implied consent indicates that the person understands what will be done.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Describe the purpose and essential elements of informed consent.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 55
Question 15
Type: MCSA
The nurse manager learns that vital signs delegated to unlicensed assistive personnel (UAP) were
not recorded accurately. With which care provider should the manager discuss this finding?
1. The UAP
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2. The nurse
3. Both the UAP and the nurse
4. The team leader
Correct Answer: 2
Rationale 1: Although taking vital signs was an appropriate task to delegate to the UAP, the
responsibility of the action—in this case, the inaction, as the vitals were recorded inaccurately—is
not fully assumed by the UAP.
Rationale 2: Although taking vital signs was an appropriate task to delegate to the UAP, the
responsibility of the action—in this case, the inaction, as the vitals were recorded inaccurately—
remains with the nurse.
Rationale 3: Although taking vital signs was an appropriate task to delegate to the UAP, the full
responsibility of the action—in this case, the inaction, as the vitals were recorded inaccurately—is
not shared by both the UAP and the nurse.
Rationale 4: Delegating this task was not the responsibility of the team leader and thus he or
she has no responsibility for this action.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7. Recognize the nurse’s legal responsibilities with selected aspects of nursing
practice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 57
Question 16
Type: MCSA
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A nurse is caring for a client in the emergency department (ED) who was brought in by her adult
child for vague, flu-like symptoms. While helping the client to change into a gown, the nurse notices
numerous bruises on the client’s back and arms. When questioned, the client
is distracted and ambiguous with her answers. Which action should the nurse take?
1. Report the situation to law enforcement.
2. Report the situation to social services.
3. Question the adult child who brought the client to the ED.
4. File a written report in the client’s chart.
Correct Answer: 2
Rationale 1: In this case, social services should be notified. Law enforcement would be notified if the
results of social services’ investigation warrant it.
Rationale 2: Nurses are considered mandated reporters. As a result, they must report any situation
when an injury is present and appears to be the result of abuse, neglect, or exploitation. The
situation described may or may not be one of abuse or neglect, but the nurse is required to report it
to the proper authorities. In this case, social services should be notified.
Rationale 3: Questioning the client’s adult child is appropriate, but the incident needs to be reported
regardless of the questioning.
Rationale 4: Documentation in the chart is extremely important, but this would be part of the nurse’s
notes, not a separate written report.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7. Recognize the nurse’s legal responsibilities with selected aspects of nursing
practice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
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Page Number: 57
Question 17
Type: MCSA
A nurse who has been a longtime employee of a hospital, providing bedside care to clients, was
seriously injured and is paralyzed from the shoulders down, with limited use of the upper arms.
Through rehabilitation, the nurse is able to mobilize with a wheelchair and has no cognitive or
psychological deficits. The nurse wants to return to the same position held prior to the injury. Under
the guidelines of the ADA, what should the hospital do?
1. The hospital is required to accommodate the nurse.
2. The hospital must find another job for the nurse.
3. The hospital should claim undue hardship to accommodate this nurse.
4. The hospital terminate the nurse’s employment.
Correct Answer: 3
Rationale 1: The act’s provisions state that the disabled must be able to perform the responsibilities
of the job with reasonable accommodations. With limited use of the upper arms, this nurse would not
be able to perform the tasks required of a nurse working at the bedside.
Rationale 2: With limited use of the upper arms, this nurse would not be able to perform the tasks
required of a nurse working at the bedside. However, the hospital could help find another position
that utilizes the nurse’s experience and desire to continue in the field of nursing, but this would have
to be a collaborative effort with the nurse and a reasonable request regarding the hospital’s needs
and resources.
Rationale 3: According to the ADA, it is the employer’s responsibility to provide reasonable
accommodations that would allow the person with a disability to perform the job satisfactorily. With
limited use of the upper arms, this nurse would not be able to perform the tasks required of a nurse
working at the bedside.
Rationale 4: Terminating employment may or may not occur, but not until all other options have been
explored.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
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NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Describe the purpose of the Americans with Disabilities Act.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 57
Question 18
Type: MCSA
A nurse on the unit notices that a co-worker exhibits a pattern of behavior suggestive of drug
abuse. What should the nurse do?
1. Report the situation to the unit charge nurse.
2. Send an anonymous letter to the director of nursing.
3. Let other co-workers know about the situation.
4. Report the situation, then let management take care of it.
Correct Answer: 1
Rationale 1: As a mandatory reporter, the nurse is required to report situations where co-workers are
suspected of impairment, which includes alcohol/drug abuse as well as mental illness. The nurse
should report the matter starting at the lowest possible level in the agency hierarchy. In this case, the
charge nurse would be appropriate.
Rationale 2: The nurse should take responsibility for the report by being open about it, not making an
anonymous report to the higher level of management.
Rationale 3: The nurse should obtain support from at least one other trustworthy person before filing
the report. This doesn’t mean telling the whole unit, which could be detrimental to both the nurse
reporting the incident and the co-worker.
Rationale 4: After the report is made, the nurse should see the problem through, not assume that
management will take care of the situation.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
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AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Discuss the impaired nurse and available diversion or peer assistance
programs.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 58
Question 19
Type: MCSA
A nurse’s co-worker makes a practice of telling offensive jokes or stories with a sexual undertone
during the shift. Which action should the nurse take first?
1. Ignore the co-worker and walk away.
2. Report the incident to the nurse manager.
3. Tell the co-worker to stop the activity because the conduct is offensive.
4. Ask to be scheduled opposite this co-worker.
Correct Answer: 3
Rationale 1: Ignoring the situation is not addressing the situation in an assertive manner.
Rationale 2: Reporting the incident to the nurse manager would be an appropriate second step if the
behavior doesn’t stop after the nurse’s approach.
Rationale 3: Nurses must develop skills of assertiveness to deter sexual harassment in the
workplace. Telling the co-worker to stop, and why, is the first step in putting an end to the situation.
Rationale 4: Asking to be scheduled opposite this person is not addressing the situation in an
assertive manner.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
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AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including
HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7. Recognize the nurse’s legal responsibilities with selected aspects of nursing
practice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 58
Question 20
Type: MCSA
A nurse who is opposed to abortion works in a hospital where abortions are performed. According to
the Supreme Court’s conscience clause, which action should the nurse take?
1. The nurse should not take action, because the nurse cannot interfere with a woman’s
constitutional right to privacy.
2. The nurse should voluntarily terminate employment.
3. The nurse should counsel women before they have an abortion.
4. The nurse should refuse to participate in abortions.
Correct Answer: 4
Rationale 1: The nurse cannot interfere with a woman’s right to privacy, which includes control over
her own body to the extent that she can abort her fetus.
Rationale 2: The conscience clause states that nurses, as well as other health care personnel, have
a right to refuse to participate in abortions.
Rationale 3: Counseling a woman prior to an abortion would not be an appropriate
action because the nurse has chosen to work in a hospital where these procedures are done.
Rationale 4: In Roe v. Wade and Doe v. Bolton, the Supreme Court upheld that a woman’s right to
privacy includes control over her own body to the extent that she can abort her fetus. Although the
nurse cannot interfere with this, the conscience clause states that nurses, as well as other health
care personnel, have a right to refuse to participate in abortions and hospitals have the right to deny
admission to abortion clients.
.
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Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7. Recognize the nurse’s legal responsibilities with selected aspects of nursing
practice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 59
Question 21
Type: MCSA
A client woke in the middle of the night, confused and unaware of the surroundings. Although the call
light was within reach, the client got out of bed unassisted, tripped on the bedside chair, and fell.
Which element of malpractice should the client’s attorney realize is missing in this case?
1. Foreseeability
2. Damages
3. Injury
4. Duty
Correct Answer: 1
Rationale 1: Foreseeability is the link between the nurse’s act and the injury suffered. The call light
was within reach, but the client did not use it and got out of bed unassisted. Nighttime confusion
occurs with some clients, but unless the nurse had knowledge or awareness that this would happen,
there was no link between the nurse’s action and the client’s fall.
Rationale 2: Damages may well be present, but these probably are not due to any action or inaction
on the nurse’s part.
Rationale 3: Injury may well be present, but this probably is not due to any action or inaction on the
nurse’s part.
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Rationale 4: Duty was addressed this case because the call light was within reach.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8. Discriminate between negligence and professional negligence/malpractice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 65
Question 22
Type: MCSA
A client scheduled for surgery has signed the consent form but refuses to have a Foley catheter
placed, saying “That’s not part of the surgery.” What should the nurse do?
1. Explain that this is part of the surgical prep and continue with the procedure.
2. Explain that the client has already signed the consent, and place the catheter.
3. Respect the client’s wishes and document accordingly.
4. Offer to call the physician.
Correct Answer: 3
Rationale 1: Battery exists when there is not consent, even if the client was not asked. In this case,
the client has the right to refuse other treatment surrounding pre- and post-op care.
Rationale 2: Battery exists when there is not consent, even if the client was not asked. In this case,
the client has the right to refuse other treatment surrounding pre- and post-op care.
Rationale 3: Consent is required before procedures are performed. Depending on the invasiveness
of the procedure, a written consent may be required. The client signed a consent form for surgery,
and the refusal for placement of a catheter should be respected. The nurse should document the
incident and not continue with the procedure.
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Rationale 4: Calling the physician is not inappropriate.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Describe the purpose and essential elements of informed consent.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 54
Question 23
Type: MCSA
The nurse documents in a client’s medical record: “The client is a drug addict and is always asking
for more medication than what is necessary.” With what might the nurse be charged?
1. Defamation
2. Slander
3. Libel
4. Incompetence
Correct Answer: 3
Rationale 1: Defamation is verbal communication that is false or made with a careless disregard for
the truth and that results in injury to the reputation of a person.
Rationale 2: Slander is defamation by the spoken word.
Rationale 3: Libel is defamation of character by means of print, writing, or pictures. Putting a
statement such as this in the client’s medical record is, first, making a diagnosis, which the nurse is
not qualified to do, and, second, making an assumption about the client’s need for medication, which
is a personal attitude about how the client responds.
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Rationale 4: Incompetence relates to the ineffective or improper execution of nursing tasks.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8. Discriminate between negligence and professional negligence/malpractice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 64
Question 24
Type: MCSA
The nurse is reviewing the Good Samaritan acts. For which situation should the nurse realize
that these laws apply?
1. Giving CPR to a client brought to the emergency department, when the client later is found to
have a “Do Not Resuscitate” order
2. Giving first aid to a child injured in a sporting event
3. Permitting a nursing student to try to insert an airway in an unconscious client
4. Leaving the scene of an emergency to call for help
5. Helping deliver the baby of a neighbor during a snowstorm
Correct Answer: 5
Rationale 1: The Good Samaritan acts are laws designed to protect health care providers against
claims of malpractice in cases of emergency, unless it can be shown that there was a gross
departure from the normal standard of care. Giving CPR would be considered a level of care
provided by any other reasonable person under similar circumstances. The fact that the client had a
DNR order was not apparent at the time of care rendered by the nurse. A nursing student trying to
insert an airway is not appropriate, as it would be above the level of care a student is able to do. A
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nurse should not leave the scene of an emergency until another qualified person takes over. The
nurse should have someone else call or go for additional help.
Rationale 2: The Good Samaritan acts are laws designed to protect health care providers against
claims of malpractice in cases of emergency, unless it can be shown that there was a gross
departure from the normal standard of care. Giving CPR would be considered a level of care
provided by any other reasonable person under similar circumstances. The fact that the client had a
DNR order was not apparent at the time of care rendered by the nurse. A nursing student trying to
insert an airway is not appropriate, as it would be above the level of care a student is able to do. A
nurse should not leave the scene of an emergency until another qualified person takes over. The
nurse should have someone else call or go for additional help.
Rationale 3: The Good Samaritan acts are laws designed to protect health care providers against
claims of malpractice in cases of emergency, unless it can be shown that there was a gross
departure from the normal standard of care. Giving CPR would be considered a level of care
provided by any other reasonable person under similar circumstances. The fact that the client had a
DNR order was not apparent at the time of care rendered by the nurse. A nursing student trying to
insert an airway is not appropriate, as it would be above the level of care a student is able to do. A
nurse should not leave the scene of an emergency until another qualified person takes over. The
nurse should have someone else call or go for additional help.
Rationale 4: The Good Samaritan acts are laws designed to protect health care providers against
claims of malpractice in cases of emergency, unless it can be shown that there was a gross
departure from the normal standard of care. Giving CPR would be considered a level of care
provided by any other reasonable person under similar circumstances. The fact that the client had a
DNR order was not apparent at the time of care rendered by the nurse. A nursing student trying to
insert an airway is not appropriate, as it would be above the level of care a student is able to do. A
nurse should not leave the scene of an emergency until another qualified person takes over. The
nurse should have someone else call or go for additional help.
Rationale 5: The Good Samaritan acts are laws designed to protect health care providers against
claims of malpractice in cases of emergency, unless it can be shown that there was a gross
departure from the normal standard of care. Giving CPR would be considered a level of care
provided by any other reasonable person under similar circumstances. The fact that the client had a
DNR order was not apparent at the time of care rendered by the nurse. A nursing student trying to
insert an airway is not appropriate, as it would be above the level of care a student is able to do. A
nurse should not leave the scene of an emergency until another qualified person takes over. The
nurse should have someone else call or go for additional help.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
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Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 12. Describe the laws and strategies that protect the nurse from litigation.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 67
Question 25
Type: MCMA
When providing client care the nurse demonstrates practices that are designed to provide legal
protections from liability. Which actions is the nurse demonstrating?
Standard Text: Select all that apply.
1. Checking the client’s name band prior to the administration of a preoperative medication
2. Asking for help when moving a comatose client because the client can not be safely handled by
one nurse
3. Attending an in-service on the appropriate use of a new piece of equipment used in the facility
4. Delegating only those tasks that he or she can’t personally perform
5. Reviewing the five rights of medication administration when the client states, “This doesn’t look
like my usual pill”
Correct Answer: 1, 2, 3, 5
Rationale 1: Legal protection for nurses is best assured by always checking the identity of the client
to make sure it is the right client.
Rationale 2: Legal protection for nurses is best assured by asking for assistance and/or supervision
in situations in which the nurse feels inadequately prepared.
Rationale 3: Legal protection for nurses is best assured by maintaining clinical competence.
Rationale 4: Delegation is a nursing responsibility that is designed to help provide quality and timely
nursing care, but that is not its sole focus.
Rationale 5: Legal protection for nurses is best assured by checking any order that a client
questions.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
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QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12. Describe the laws and strategies that protect the nurse from litigation.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 68
Question 26
Type: MCMA
The clinical nursing instructor determines that a nursing student understands the legal
responsibilities to clients when providing care. What did the instructor observe to come to this
conclusion?
Standard Text: Select all that apply.
1. Prepared to discuss the client’s medical diagnosis in pre-conference
2. Overheard stating, “My care is held to the same standards as that of the unit nurses”
3. Offers to stay with the client who is about to experience a painful diagnostic procedure
4. Addresses the staff and clients respectfully and by their full names
5. Asks for help with a dressing change involving techniques he or she has not yet performed alone
Correct Answer: 1, 2, 5
Rationale 1: Nursing students are held to the same standards as licensed nurses, and therefore
need to make sure that they are prepared to provide the necessary care to assigned clients.
Rationale 2: Nursing students are held to the same standards as licenses nursed, and therefore
need to make sure that they are prepared to provide the necessary care to assigned clients.
Rationale 3: Although offering to stay with a client during a painful procedure shows compassion, it
is not a behavior representative of legal responsibility.
Rationale 4: Although showing respect for staff and clients demonstrates professionalism, it is not a
behavior that is representative of legal responsibility.
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Rationale 5: It is important that nursing students ask for help or supervision in situations for which
they feel inadequately prepared.
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. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 13. Discuss the legal responsibilities of nursing students.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 70
[New Questions: ]
Question 27
Type: MCMA
While working a scheduled shift the nurse focuses on actions to protect the privacy of a client with
local notoriety. What actions should the nurse take at this time?
Standard Text: Select all that apply.
1. Secure the client’s medical record.
2. Review the client’s care with the media.
3. Remove the client’s name from the door.
4. Permit family to view the client’s record.
5. Fax the client’s lab values with a cover sheet.
Correct Answer: 1, 3, 5
Rationale 1: Actions to ensure the client’s privacy include securing the medical record.
Rationale 2: Sharing the client’s care with the media violates the client’s privacy.
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Rationale 3: Actions to ensure the client’s privacy include removing the client’s name from the door.
Rationale 4: Permitting family to view the client’s record violates the client’s privacy.
Rationale 5: Actions to ensure the client’s privacy include faxing information with a cover sheet.
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. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11. Describe the four specific areas of the Health Insurance Portability and
Accountability Act and their impact on nursing practice.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 66
Question 28
Type: MCMA
The nurse manager is concerned that a staff nurse’s care demonstrates gross negligence. What
actions did the manager use to make this determination?
Standard Text: Select all that apply.
1. Removed a client’s central line
2. Reconnected contaminated intravenous tubing to a client
3. Accessed the computerized documentation system with a password
4. Walked a client with a blood pressure of 70/58 mm Hg to the bathroom
5. Delegated nasotracheal suctioning for a client to unlicensed assistive personnel
Correct Answer: 1, 2, 4, 5
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Rationale 1: Gross negligence involves extreme lack of knowledge, skill, or decision making that the
person clearly should have known would put others at risk for harm. Removing a client’s central line
would be gross negligence.
Rationale 2: Gross negligence involves extreme lack of knowledge, skill, or decision making that the
person clearly should have known would put others at risk for harm. Reconnecting contaminated
intravenous tubing would be gross negligence.
Rationale 3: Accessing the computer documentation system with a password demonstrates
compliance with HIPAA.
Rationale 4: Gross negligence involves extreme lack of knowledge, skill, or decision making that the
person clearly should have known would put others at risk for harm. Walking a patient with an
unsafe blood pressure is gross negligence.
Rationale 5: Gross negligence involves extreme lack of knowledge, skill, or decision making that the
person clearly should have known would put others at risk for harm. Inappropriately delegating a skill
is gross negligence.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.A. 7. Explore ethical and legal implications of patient-centered care
AACN Essentials Competencies: VIII. 12. Act to prevent unsafe, illegal or unethical care practices
NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 9. Delineate the elements of professional negligence.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 62
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Chapter 05
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 05
Question 1
Type: MCSA
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
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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
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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:
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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
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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.
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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.
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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
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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.
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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.”
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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
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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
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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
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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.
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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
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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.
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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
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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.
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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.
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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?
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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Chapter 06
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 06
Question 1
Type: MCSA
The nurse is reviewing the Healthy People 2020 primary goals. Which plan should the nurse realize
is in alignment with one of the goals?
1. Providing free screening to schoolchildren
2. Opening a wellness clinic
3. Developing better insurance controls
4. Developing new pharmacological treatments
Correct Answer: 2
Rationale 1: Healthy People 2020 has four overarching goals: (1) Increase quality and years of
healthy life, (2) achieve health equity and eliminate health disparities, (3) create healthy
environments for everyone, and (4) promote health and quality life across the life span. Free
screening to schoolchildren is already being done in most states.
Rationale 2: Healthy People 2020 has four overarching goals: (1) Increase quality and years of
healthy life, (2) achieve health equity and eliminate health disparities, (3) create healthy
environments for everyone, and (4) promote health and quality life across the life span. Opening a
wellness clinic focuses on bettering health, which would be in line with goal 1.
Rationale 3: Healthy People 2020 has four overarching goals: (1) Increase quality and years of
healthy life, (2) achieve health equity and eliminate health disparities, (3) create healthy
environments for everyone, and (4) promote health and quality life across the life span.Developing
insurance control was a goal of health care reform during the Clinton administration.
Rationale 4: Ongoing development of pharmacological treatments is not a new initiative.
Cognitive Level: Analyzing
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
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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: Teamwork; Practice; Clarify roles and integrate the contributions of others who
play a role in helping the patient/family achieve health goals
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Differentiate health care services based on primary, secondary, and tertiary
disease prevention categories.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 89
Question 2
Type: MCSA
Several nurses are working to open a clinic that focuses on health promotion. Which activity should
the nurses expect to perform once this clinic opens?
1. Teaching biofeedback techniques for stress reduction
2. Providing immunization clinics
3. Evaluating regional industrial centers for environmental pollution
4. Teaching smoking cessation classes to adolescents
Correct Answer: 1
Rationale 1: Health promotion programs address nutrition, weight control, exercise, and stress
reduction. Health promotion activities emphasize the role of clients in maintaining their own health
and provide encouragement in maintaining the highest level of wellness they can achieve.
Rationale 2: Providing immunization clinics is an example of illness prevention, not health promotion.
Rationale 3: Evaluating industrial centers for pollution is an example of illness prevention, not health
promotion.
Rationale 4: Teaching smoking cessation classes is an example of illness prevention, not health
promotion.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the
diversity of human experience
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; apply health promotion/disease
prevention strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Differentiate health care services based on primary, secondary, and tertiary
disease prevention categories.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 89
Question 3
Type: MCSA
A client is in the end stages of cancer. Which type of service should the nurse consider as being the
best for this client?
1. Rehabilitation
2. Health restoration
3. Acute care
4. Palliative care
Correct Answer: 4
Rationale 1: Rehabilitation is a process of restoring ill or injured people to optimum and functional
levels of wellness, emphasizing the importance of assisting clients to function adequately in the
physical, mental, social, economic, and vocational areas of their lives. That is not the service this
client requires.
Rationale 2: Health restoration is service that helps bring ill or injured clients back to their former
state of health. That is not the service this client requires.
Rationale 3: Acute care is the typical service provided in a hospital. That is not the service this client
requires.
Rationale 4: Palliative care is service that provides comfort and treatment of symptoms. This type of
care is for clients who cannot be returned to health. It may be conducted in many settings, including
the home.
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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: 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; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in
this chapter.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 90
Question 4
Type: MCSA
Several nurses are looking for an agency to sponsor a program that would meet the needs of a
community group lacking in health promotion education. Which agency should the nurse approach to
fill this need?
1. State health department
2. Local health department
3. Local hospital
4. Federal government
Correct Answer: 2
Rationale 1: State health organizations are responsible for assisting the local health departments.
This is not the agency to provide the assistance the nurses are looking for.
Rationale 2: The local health department has the responsibility for developing programs to meet the
health needs of the people, providing the necessary staff and facilities to carry out those programs,
evaluating their effectiveness, and monitoring changing needs.
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Rationale 3: Local hospitals provide the majority of acute care services in a community. This is not
the agency to provide the assistance the nurses are looking for.
Rationale 4: The U.S. Department of Health and Human Services is an agency at the federal level
whose functions include conducting research and providing training in the health field, providing
assistance to communities in planning and developing health facilities, and
assisting states and local communities through financing and provision of trained personnel. This is
not the agency to provide the assistance the nurses are looking for.
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: 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; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in
this chapter.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 90
Question 5
Type: MCSA
The nurse is hired to provide care in a hospital that offers services in all specialty areas. How should
the nurse categorize this type of health care facility?
1. General hospital
2. Specialty hospital
3. Long-term care hospital
4. Short-term hospital
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Correct Answer: 1
Rationale 1: Hospitals are classified by the services they provide as well as by their ownership.
General hospitals admit clients requiring a variety of services, such as medical, surgical, obstetric,
pediatric, and psychiatric services.
Rationale 2: Hospitals are classified by the services they provide as well as by their ownership.
Some hospitals offer only specialty services, such as psychiatric or pediatric. This does not describe
the facility in this scenario.
Rationale 3: Hospitals are classified by the services they provide as well as by their ownership.
Long-term care hospitals provide services for longer periods—sometimes years or for the remainder
of the client’s life. This does not describe the facility in the scenario.
Rationale 4: Acute care (or short-term) hospitals provide assistance to clients whose illness and
need for hospitalization are relatively short term, such as several days. This does not describe the
facility in the stem.
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: 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; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in
this chapter.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 91
Question 6
Type: MCSA
A client being discharged from an acute care hospital requires IV antibiotics, is not able to complete
activities of daily living without assistance, and has no family available to assist in the recovery
phase. Which type of recommendation should the nurse make for this client?
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1. Stay in the hospital until the client is fully capable of self-care.
2. Remain in the hospital until the antibiotic course is completed.
3. Be discharged to an extended care facility.
4. Go to a nursing home.
Correct Answer: 3
Rationale 1: An acute care hospital stay is no longer required because the needs of the client could
be met in another facility.
Rationale 2: The antibiotic therapy and custodial care can be provided in a more suitable facility.
Rationale 3: Extended care facilities provide care for clients who require rehabilitation and custodial
care after discharge from an acute care hospital. Because this client still receives antibiotic therapy
and requires some custodial care, this type of facility can provide the best care until the client is
ready for discharge home.
Rationale 4: The client may require a nursing home or long-term care facility at some point, but it is
too early in the recovery to make this decision.
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: 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; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in
this chapter.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 92
Question 7
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Type: MCSA
An older client has no family in the same community, lives alone in a small house, and is having
greater difficulty with mobility due to advanced osteoarthritis. Cognitively, this client is alert, is able to
manage her own business matters, and does her own cooking, but does not enjoy “cooking for one.”
The home health nurse who visits has noticed that the client is losing weight and does not have as
much energy or interest in activities as on previous visits. What should the nurse recommend for this
client?
1. See a psychiatrist because the client appears to be depressed.
2. Check out joint replacement options for the osteoarthritis.
3. Start thinking about long-term care.
4. Consider moving to an assisted living facility.
Correct Answer: 4
Rationale 1: Diagnosing depression is outside the scope of nursing practice. Other interventions can
be implemented before this action is considered. It also does not meet the client’s immediate needs.
Rationale 2: Joint replacement may or may not be an option, but it would not be the nurse’s
responsibility to recommend this, nor does it meet the client’s immediate needs.
Rationale 3: This client does not show any indications of requiring long-term care at this point.
Rationale 4: Assisted living facilities offer meals, laundry services, nursing care, transportation, and
social activities to residents who are able to live relatively independently. They are intended to meet
the needs of people who are unable to remain at home but do not require hospital or nursing home
care. The client in this scenario has some physical limitations, but could benefit from socialization
and interaction with peers as well as having staff available to provide limited care and health
promotion activities.
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: 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; apply health promotion/disease prevention
strategies; apply health policy
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in
this chapter.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 92
Question 8
Type: MCSA
The spouse of a client diagnosed with Stage I/II Alzheimer’s disease must continue to work full-time.
The spouse tells the occupational health nurse that the client has started to wander outside the
house, forgets to turn off the stove after preparing food, and tries to drive the car if the keys are
available. What should the nurse recommend for this family?
1. The client should be placed in long-term care.
2. The spouse should consider early retirement.
3. The client should be placed in an adult day-care environment.
4. An increase in the client’s medications should be considered to slow the progress of the disease.
Correct Answer: 3
Rationale 1: Placing a client from an independent home situation to long-term care would be more
detrimental than a gradual progression of care.
Rationale 2: Telling the spouse to consider early retirement is neither therapeutic nor realistic.
Rationale 3: Day-care centers provide care and nutrition for adults who cannot be left at home alone
but do not need to be in an institution. These centers often provide care involving socializing,
exercise programs, and stimulation. Some provide counseling and physical therapy. Nurses who are
employed in day-care centers may provide medications, treatment, and counseling.
Rationale 4: Increasing medications is a decision that needs to be made by the client’s primary
caregiver, not the nurse, nor does it address the spouse’s concerns regarding care.
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
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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; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in
this chapter.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 93
Question 9
Type: MCSA
The spouse of a client referred to hospice care asks why the client needs the change in
services. How should the nurse respond to this question?
1. “So we can see if there’s any way to improve your spouse’s life.”
2. “There is no need for acute care any longer.”
3. “It’s best for your spouse to be cared for at home.”
4. “Hospice care is cheaper than acute care.”
Correct Answer: 1
Rationale 1: The central concept of the hospice movement is not saving life but improving or
maintaining the quality of life until death. Hospice care provides a variety of services given to the
terminally ill, their families, and support persons. The place of care varies, but includes home,
hospital, or skilled nursing facilities.
Rationale 2: Acute care may be warranted as the client’s condition changes.
Rationale 3: The place of hospice care varies, but includes home, hospital, or skilled nursing
facilities.
Rationale 4: Hospice care may well be cheaper, but this is not the main reason for referral to hospice
services.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
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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: 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; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in
this chapter.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 93
Question 10
Type: MCSA
A young adult client recovering from an injury that resulted in partial paralysis plans to
live independently as before the injury. Which referral should the nurse identify as being the best for
this client?
1. Paramedical technologist
2. Physical therapist
3. Occupational therapist
4. Case manager
Correct Answer: 3
Rationale 1: The term paramedical technologist includes laboratory technologists, radiological
technologists, and nuclear medicine technologists. This title is given to those professionals having
some connection with medicine. This referral would not meet the client’s needs regarding
independent living.
Rationale 2: A physical therapist helps clients regain physical strength and mobility. In this case, the
client would probably also see a physical therapist, but not for the focus on independent living.
Rationale 3: An occupational therapist assists clients with impaired function to gain the skills
necessary for activities of daily living. The therapist teaches skills that are therapeutic but at the
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same time provide fulfillment. Helping a client with paralysis learn to use equipment or different
methods of doing daily tasks will enable the client to be as independent as possible.
Rationale 4: A case manager’s role is to ensure that clients receive fiscally sound, appropriate care
in the best setting. This client may well have a case manager to coordinate all the necessary care,
but the question focuses on the return to independent living.
Cognitive Level: Analyzing
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: 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; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in
this chapter.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 94
Question 11
Type: MCSA
A nurse is interviewing a client at a clinic near a shelter for the homeless. Understanding the
increased risk a poor physical environment creates for this client, on what should the nurse focus
during the intake phase of the interview?
1. Lack of social support
2. Recent history of chills and body aches
3. Improper nutrition
4. Few personal resources
Correct Answer: 2
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Rationale 1: Lack of social support contributes to health problems in general.
Rationale 2: A poor physical environment results in increased susceptibility to infections. The client’s
recent history of chills and body aches should alert the nurse that this client may have an infection.
Rationale 3: Improper nutrition contributes to health problems in general.
Rationale 4: Few personal resources contributes to health problems in general.
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: 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: Assessment
Learning Outcome: 3. Identify the roles of various health care professionals.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 98
Question 12
Type: MCSA
A nurse is working in a clinic that emphasizes cost control, customer satisfaction, health promotion,
and preventive services. In which type of health system is this nurse providing care?
1. Managed care
2. Case management
3. Differentiated practice
4. Patient-focused care
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Correct Answer: 1
Rationale 1: Managed care describes a health care system whose goals are to provide costeffective, quality care that focuses on decreased costs and improved outcomes for groups of clients.
Rationale 2: Case management describes a range of models for integrating health care services for
individuals or groups. This is not the model described in the scenario.
Rationale 3: Differentiated practice is a system in which the best possible use of nursing personnel is
based on their educational preparation and resultant skill sets. This is not the model described in
the scenario.
Rationale 4: Patient-focused care is a delivery model that brings all services and care providers to
the client. This is not the model described in the scenario.
Cognitive Level: Analyzing
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: 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: Assessment
Learning Outcome: 4. Describe the factors that affect health care delivery.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 98
Question 13
Type: MCSA
The manager of a small clinic has cross-trained the nurses to provide basic nursing
care, and perform ECG testing, phlebotomy, and some respiratory therapy interventions. Which type
of care delivery model has the manager implemented?
1. Managed care
2. Case management
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3. Patient-focused care
4. Critical pathways
Correct Answer: 3
Rationale 1: Managed care focuses on cost-effective, quality care that results in decreased costs
and improved outcomes. This is not the model described in the scenario.
Rationale 2: Case management is a way to integrate health care services for individuals or groups
and involves multidisciplinary teams that assume collaborative responsibility for planning, assessing
needs, and coordinating, implementing, and evaluating care. This is not the model described in
the scenario.
Rationale 3: Client-focused care is a delivery model that provides services according to the clients’
needs. Rationale 4: Critical pathways are used to track the client’s progress in case management.
This is not the model described in the scenario.
Cognitive Level: Analyzing
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: 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: Evaluation
Learning Outcome: 5. Describe frameworks for the delivery of nursing care.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 100
Question 14
Type: MCSA
A new graduate nurse is looking for employment and is hoping to find a facility that utilizes nursing
personnel based on their educational preparation and skill set. In which type of facility should the
new graduate apply for a position?
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1. Patient-focused care
2. Shared governance
3. Differentiated practice
4. Managed care
Correct Answer: 3
Rationale 1: Patient-focused care is a delivery model that brings all services and care providers to
the client. This is not the model described in the scenario.
Rationale 2: Shared governance is an organizational model in which nursing staff are cooperative
with administrative personnel in making, implementing, and evaluating client care policies. This is
not the model described in the stem.
Rationale 3: Differentiated practice is a system in which the best possible use of nursing personnel is
based on their educational preparation and resultant skill sets. This model consists of specific job
descriptions for nurses according to their education or training.
Rationale 4: Managed care focuses on cost containment, consumer satisfaction, health promotion,
and preventive services. This is not the model described in the scenario.
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: 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: Assessment
Learning Outcome: 3. Identify the roles of various health care professionals.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 99
Question 15
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Type: MCSA
The nurse is considering leaving a position in an organization that utilized differentiated practice.
Which type of delivery system should the nurse consider as being the most similar to differentiated
practice?
1. Case method
2. Shared governance
3. Functional method
4. Team nursing
Correct Answer: 4
Rationale 1: The case method is a client-centered model where one nurse is assigned to and
responsible for the comprehensive care of a group of clients during a shift. In this method a client
has consistent contact with one nurse during a shift, but may have different nurses on other shifts.
This is not the model described in the scenario.
Rationale 2: Shared governance is an organizational model in which nursing staff are cooperative
with administrative personnel in making, implementing, and evaluating client care policies. This is
not the model described in the scenario.
Rationale 3: The functional nursing method focuses on the jobs to be completed. It is a task-oriented
approach in which personnel with less preparation than the professional nurse perform less complex
care requirements. This is not the model described in the scenario.
Rationale 4: Team nursing is the delivery of individualized nursing care to clients by a team led by a
professional nurse. The nursing team consists of registered nurses, licensed practical nurses, and
unlicensed assistive personnel. The registered nurse retains responsibility and authority for client
care but delegates appropriate tasks to the other team members. This enables nurses to progress
and assume roles and responsibilities appropriate for their level of experience, capability, and
education—much like the differentiated practice system.
Cognitive Level: Analyzing
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: 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
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Identify the roles of various health care professionals.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 99
Question 16
Type: MCSA
A seasoned RN is especially competent in knowledge of the computerized charting system in a
facility and is able to assume the team leader role on a regular basis. In which type of care delivery
system is this nurse most likely providing care?
1. Primary nursing
2. Team nursing
3. Differentiated practice
4. Case method
Correct Answer: 1
Rationale 1: Primary nursing is a system in which one nurse is responsible for total care of a number
of clients, 24 hours a day, 7 days a week. It is a method of providing comprehensive, individualized,
and consistent care. Primary nursing uses the nurse’s technical knowledge and management skills
in assessing and prioritizing each client’s needs, implementing the plan of care, and evaluating the
plan’s effectiveness.
Rationale 2: Team nursing is the delivery of individualized nursing care to clients by a team led by a
professional nurse and consisting of RNs, LPNs, and UAPs. This is not the model described in
the scenario.
Rationale 3: Differentiated practice is a system in which the best possible use of nursing personnel is
based on their education preparation and resultant skill sets. This is not the model described in
the scenario.
Rationale 4: The case method is also referred to as total care, in which one nurse is assigned to and
is responsible for the comprehensive care of a group of clients during an 8- or 12-hour shift. This is
not the model described in the scenario.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
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QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the
diversity of human experience
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: Assessment
Learning Outcome: 3. Identify the roles of various health care professionals.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 100
Question 17
Type: MCSA
A 68–year–old client is concerned about paying for extended hospitalization and expensive
medications to treat his health problem. What should the nurse respond to this client?
1. “Don’t worry. I’m sure everything will work out OK.”
2. “You need to focus on recovering, not worrying about finances.”
3. “Much of your care will be covered by Medicare.”
4. “I’ll have someone from the business office come and talk to you about your bill.”
Correct Answer: 3
Rationale 1: Ignoring the client’s concerns by telling him not to worry is not therapeutic
communication and does little, if anything, to confront the client’s concerns.
Rationale 2: Ignoring the client’s concerns by telling him not to worry is not therapeutic
communication and does little, if anything, to confront the client’s concerns.
Rationale 3: The Medicare amendment to the Social Security Act provided a national and state
health insurance program for older adults. By the mid-1970s, virtually everyone over 65 years of age
was protected by hospital insurance under Part A. In 1988, Congress expanded Medicare to include
extremely expensive hospital care, “catastrophic care,” and expensive drugs.
Rationale 4: Giving the concern to the business office is merely “passing the buck.” Nurses should
have some knowledge about the payment sources of their clients, especially those who have
automatic coverage with Medicare because of their age.
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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: 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: Implementation
Learning Outcome: 6. Compare various systems of payment for health care services.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 100
Question 18
Type: MCSA
A clinic in a rural area depends primarily on the services of a nurse practitioner. Which legislation
provided the opportunity for the nurse practitioner to have this position?
1. Medicare
2. Medicaid
3. Rural Health Clinics Act
4. National Health Planning and Resources Development Act
Correct Answer: 3
Rationale 1: Medicare provides insurance coverage for people over age 65. This is not the
legislation described in the scenario.
Rationale 2: Medicaid provides service to people who require financial assistance for health care.
This is not the legislation described in the scenario.
Rationale 3: In 1978, the Rural Health Clinics Act provided for the development of health care in
medically underserved rural areas. This act opened the door for nurse practitioners to provide
primary care.
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Rationale 4: The National Health Planning and Resources Development Act established health
systems agencies throughout the United States for the development of health care in medically
underserved rural areas. This is not the legislation described in the scenario.
Cognitive Level: Analyzing
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: 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: Evaluation
Learning Outcome: 5. Describe frameworks for the delivery of nursing care.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 93
Question 19
Type: MCSA
The nurse is reviewing the principles of the Affordable Care Act with a client. What information
should the nurse include when discussing the act with the client?
1. Individuals will be fined if they do not have health insurance.
2. Employers must offer health insurance if they meet identified requirements.
3. Insurance can be purchased through exchanges.
4. Individuals with preexisting health conditions cannot be denied health insurance coverage.
5. Health insurance is free.
Correct Answer: 1, 2, 3, 4
Rationale 1: A provision within the Affordable Care Act is that individuals will be fined if they do not
have health insurance.
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Rationale 2: A provision within the Affordable Care Act is that employers must offer health insurance
if they meet identified requirements.
Rationale 3: A provision within the Affordable Care Act is that insurance can be purchased through
exchanges.
Rationale 4: A provision within the Affordable Care Act is that individuals with preexisting health
conditions cannot be denied health insurance coverage.
Rationale 5: Health insurance is not free.
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: 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: Implementation
Learning Outcome: 5. Describe frameworks for the delivery of nursing care.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 100
Question 20
Type: MCSA
A client asks the nurse to explain the difference between an HMO and a PPO. What should the
nurse include when responding to the client?
1. “You’ll have good health care benefits, so don’t worry.”
2. “Both the HMO and PPO are covered by your employer, so it’s really not your concern.”
3. “Your PPO offered you a choice in your health care provider as well as services. Now, you will
choose a primary care provider who will evaluate your health and will coordinate all of your care.”
4. “You really should be happy about the HMO. You’ll pay little, if any, out-of-pocket expense.”
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Correct Answer: 3
Rationale 1: Telling the client not to worry does not address the client’s question, which is to explain
the difference.
Rationale 2: Telling the client not to worry does not address the client’s question, which is to explain
the difference.
Rationale 3: HMO plans emphasize wellness, and members choose a primary care provider who
evaluates their health status and coordinates their care. Clients are limited in their ability to select
health care providers and services, but available services are at minimal and predetermined cost to
the client. PPOs consist of a group of physicians that provide an insurance company or employer
with health services at a discounted rate. One advantage of the PPO is that it provides clients with a
choice of health care providers and services.
Rationale 4: Even though telling the client that she will have little out-of-pocket expense may be
truthful, it doesn’t answer the question.
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: 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: Implementation
Learning Outcome: 5. Describe frameworks for the delivery of nursing care.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 102
Question 21
Type: MCMA
The nurse is reviewing changes occurring within the health care industry. What should the nurse
identify as factors that have an effect on health care delivery?
Standard Text: Select all that apply.
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1. Increased use of complementary and alternative medicine
2. More knowledgeable consumers
3. Increase in the number of elderly
4. Decrease in chronic disease
5. Technological advances
6. Economics
Correct Answer: 2, 3, 5, 6
Rationale 1: Although there is an increase in complementary and alternative medicine use, this does
not affect how health care is delivered.
Rationale 2: With the improved availability of health-related information, consumers are more
knowledgeable, and play an active role in their health care.
Rationale 3: People over age 85 are projected to be the fastest-growing population in the United
States.
Rationale 4: Chronic illness is prevalent in this group.
Rationale 5: Technology related to health care is rapidly increasing, and includes improved
diagnostic procedures and equipment that permits early recognition of diseases.
Rationale 6: Inflation increases all costs, and paying for health care services is becoming a greater
problem.
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: 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: Assessment
Learning Outcome: 4. Describe the factors that affect health care delivery.
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MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 96
Question 22
Type: MCMA
A client in the hospital is concerned about the cost of receiving hospitalized care. What should the
nurse realize is causing the increase in the client’s medical expenses?
Standard Text: Select all that apply.
1. Health care of the older adult
2. Number of uninsured population
3. Changes in birth rate over last 20 years
4. Cost of prescription drugs
5. State of inflation
6. Amount of diagnosed chronic illnesses
Correct Answer: 1, 2, 4, 5, 6
Rationale 1: The total population is growing, especially the older adult segment that tends to have
greater health care needs compared to younger persons.
Rationale 2: The uninsured numbers are on the rise: 17% of persons under age 65.
Rationale 3: Birth rates have dropped in the last 20 years, and so do not have a major impact on
health care costs.
Rationale 4: The cost of prescription drugs is increasing, and represents 19% of total health care
expenditures in the United States.
Rationale 5: Inflation increases all costs.
Rationale 6: The total population is growing, especially the older adult segment that tends to have
diagnosed chronic illnesses.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
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QSEN Competencies: I.B. 3. Provide patient-centered care with sensitivity and respect for the
diversity of human experience
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: Assessment
Learning Outcome: 4. Describe the factors that affect health care delivery.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 96
Question 23
Type: MCMA
In order to comply with the U.S. Department of Health and Human Services’ most current
health care goals as stated in Healthy People 2020, what should the nurse do?
Standard Text: Select all that apply.
1. Plan a depression screening for senior citizens who regularly have lunch at the senior center.
2. Attend an educational in-service on the use of a new automated blood pressure monitor.
3. Advocate for psychiatric health care for those with no private insurance coverage.
4. Organize a park “cleanup day” to assure that the community’s children have a safe place to play.
5. Counsel older clients regarding programs available to assist them to live in their homes
independently.
Correct Answer: 1, 3, 4, 5
Rationale 1: The federal–government–funded Healthy People 2020 has as one of its primary goals
promoting health and quality life across the life span.
Rationale 2: This intervention is not directed toward the federal government’s primary health goals
as stated in Healthy People 2020.
Rationale 3: The federal–government–funded Healthy People 2020 has among its primary goals
achieving health equity and eliminating health disparities.
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Rationale 4: The federal–government–funded Healthy People 2020 has as one of its primary goals
creating healthy environments for everyone.
Rationale 5: The federal–government–funded Healthy People 2020 has as one of its primary goals
increasing quality and years of healthy life.
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: 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: Teamwork; Practice; Clarify roles and integrate the contributions of others who
play a role in helping the patient/family achieve health goals
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Differentiate health care services based on primary, secondary, and tertiary
disease prevention categories.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 89
Question 24
Type: MCMA
The nurse is reviewing sources of federal funding for health care services provided to clients. For
which clients should the nurse recognize as most likely having health care paid through a federal
funding source?
Standard Text: Select all that apply.
1. 35-year-old self-employed house painter
2. 72-year-old retired schoolteacher
3. 52-year-old nurse who runs the family farm
4. 29-year-old mentally challenged sheltered workshop employee
5. 40-year-old factory worker
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Correct Answer: 2, 4
Rationale 1: This patient would be on a private insurance plan like Blue Cross and Blue Shield.
Rationale 2: This patient would be on a federally funded insurance plan like Medicare.
Rationale 3: This patient would be on a private insurance plan like Blue Cross and Blue Shield.
Rationale 4: This patient would be on a federally funded insurance plan like Medicaid.
Rationale 5: This patient would be on a prepaid group plan: a health maintenance organization
(HMO).
Cognitive Level: Analyzing
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: 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: Assessment
Learning Outcome: 5. Describe frameworks for the delivery of nursing care.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 100
Question 25
Type: MCMA
The nurse is concerned that the hospital will not receive payment for care provided to a client. Which
client health problems are causing the nurse this concern?
Standard Text: Select all that apply.
1. Intravenous fluids were prescribed for 4 days.
2. X-rays of the left leg and left arm were prescribed.
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3. A stage II pressure ulcer developed on the client’s heels.
4. A urinary tract infection occurred because of an indwelling urinary catheter.
5. Physical therapy treatments were prescribed for 7 days for crutch walking.
Correct Answer: 3, 4
Rationale 1: There is no reason for intravenous fluids to not be paid.
Rationale 2: There is no reason for x-rays to not be paid.
Rationale 3: In efforts to decrease cost and encourage attention to preventable conditions, for
discharges occurring after October 1, 2008, hospitals no longer receive additional payment for cases
in which one of several identified preventable conditions was not present on admission. That is, the
case would be paid as though the secondary diagnosis were not present. Examples of hospitalacquired conditions (HACs) are pressure ulcers and urinary tract infections following catheterization.
Rationale 4: In efforts to decrease cost and encourage attention to preventable conditions, for
discharges occurring after October 1, 2008, hospitals no longer receive additional payment for cases
in which one of several identified preventable conditions was not present on admission. That is, the
case would be paid as though the secondary diagnosis were not present. Examples of hospitalacquired conditions (HACs) are pressure ulcers and urinary tract infections following catheterization.
Rationale 5: There is no reason for physical therapy treatments to not be paid.
Cognitive Level: Analyzing
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: 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; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6. Compare various systems of payment for health care services.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 101
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Question 26
Type: MCMA
The nurse is considering a position with a home health agency. What type of care should the nurse
realize will be provided when working for this type of agency?
Standard Text: Select all that apply.
1. Providing ventilatory support
2. Completing a health and wellness visit
3. Instructing about care of a surgical wound
4. Providing intravenous antibiotics once a day
5. Teaching about medications for self-management of diabetes
Correct Answer: 3, 4, 5
Rationale 1: Ventilatory support would be considered a critical illness and most likely not provided
through home care.
Rationale 2: A health and wellness visit can be conducted in a community clinic or health care
provider’s office. Home care would not be needed.
Rationale 3: Home health care nurses and other staff offer education to clients and families and also
provide comprehensive care to clients who are acutely, chronically, or terminally ill. This would
include teaching about surgical wound care.
Rationale 4: Home health care nurses and other staff offer education to clients and families and also
provide comprehensive care to clients who are acutely, chronically, or terminally ill. This would
include providing intravenous antibiotics daily.
Rationale 5: Home health care nurses and other staff offer education to clients and families and also
provide comprehensive care to clients who are acutely, chronically, or terminally ill. This would
include teaching about self-management of a disease process.
Cognitive Level: Analyzing
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
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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; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 2. Describe the functions and purposes of the health care agencies outlined in
this chapter.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 93
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Chapter 07
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.
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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: 1. Discuss factors influencing health care reform.
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.
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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
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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
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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
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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
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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
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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
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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
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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.
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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,
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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
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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.
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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 wellbeing.
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)
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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
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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.
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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
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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
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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
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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.
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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
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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.
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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
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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
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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
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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
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Chapter 08
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 08
Question 1
Type: MCMA
The nurse learns that two new home care agencies are opening in a community. What should the
nurse consider as reasons why home care agencies are increasing in numbers?
1. The need for custodial care
2. Third-party payers who support cost control measures
3. The increase in the older adult population
4. The decreasing need for acute care
5. The focus on the needs of the community
Correct Answer: 2, 3
Rationale 1: A common misconception about home health nursing is that it is custodial in its scope of
practice.
Rationale 2: Factors that have contributed to the growth of home care services include third-party
payers that favor home care to control costs.
Rationale 3: Factors that have contributed to the growth of home care services include the increase
in the older population.
Rationale 4: Acute care has not decreased, but the length of stay in acute care has.
Rationale 5: The focus of home health care nursing is individuals and their families.
Global Rationale:
Cognitive Level: Analyzing
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.
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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: Assessment
Learning Outcome: 2. Compare the characteristics of home health nursing to those of institutional
nursing care.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 118
Question 2
Type: MCSA
During orientation with a home care agency, the nurse is learning the difference in care delivery
between home health nursing and community nursing. What should the nurse understand as being
the focus of home health care nursing?
1. Individuals, families, and groups
2. The individual and his or her family
3. The terminally ill client and his or her family
4. The client in a home setting
Correct Answer: 2
Rationale 1: Community health nursing focuses on individuals, families, and aggregate groups.
Rationale 2: The focus of home health care nursing is individuals and their families.
Rationale 3: Hospice nursing supports the care of the dying client and the client’s family; this is not
the focus of home health nursing.
Rationale 4: A home setting identifies the location of home health nursing, but not the focus.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
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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. 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: Assessment
Learning Outcome: 2. Compare the characteristics of home health nursing to those of institutional
nursing care.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 118
Question 3
Type: MCSA
To help a home health client with a difficult medication regime, the nurse contacts the pharmacist for
ideas to facilitate the process. Which behavior did the nurse demonstrate when caring for this client?
1. Hands-on care
2. Direct care
3. Advocacy
4. Indirect care
Correct Answer: 4
Rationale 1: Hands-on care includes physical assessments, dressing changes, and managing IV
sites for therapies, which is not the scenario described here.
Rationale 2: Direct care is the same as hands-on care, which is not the scenario described here.
Rationale 3: Client advocacy is not the scenario described here.
Rationale 4: Indirect care is provided by the home health nurse to the client each time the nurse
consults with other health care providers about ways to improve nursing care for the client.
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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. 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: Assessment
Learning Outcome: 4. Describe the roles of the home health nurse.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 120
Question 4
Type: MCSA
A client being discharged needs physical therapy for progressive ambulation, wound care to treat a
postoperative wound, and assistance with the payment of hospital bills. Before the nurse contacts a
home care agency, who should write the order for the client to receive home care?
1. Physician
2. Nurse
3. Social worker
4. Physical therapist
Correct Answer: 1
Rationale 1: A client may be referred to home health care by providers, nurses, social workers, and
therapists, but home care cannot begin without a physician’s order and a physician-approved
treatment plan. This is a legal reimbursement requirement.
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Rationale 2: A client may be referred to home health care by providers, nurses, social workers, and
therapists, but home care cannot begin with a nurse’s order.
Rationale 3: A client may be referred to home health care by providers, nurses, social workers, and
therapists, but home care cannot begin with a social worker’s order.
Rationale 4: A client may be referred to home health care by providers, nurses, social workers, and
therapists, but home care cannot begin with a social worker’s order.
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. 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: 3. Describe the types of home health agencies, including referral and
reimbursement sources.
MNL Learning Outcome: 1.2.4. Compare the frameworks of care.
Page Number: 119
Question 5
Type: MCSA
During the first home care visit, the nurse determines that the client needs speech therapy, physical
therapy, and custodial care several times a week. When should the nurse schedule the client’s care
to begin?
1. As soon as the nurse completes the initial assessment
2. As soon as the client agrees to the care
3. When the physician signs the plan of care the nurse develops
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4. Within 48 hours of the nurse’s visit
Correct Answer: 3
Rationale 1: Completing the initial assessment identifies but does not initiate client care.
Rationale 2: The client agreeing to care indicates the client’s involvement in the process but does
not initiate care.
Rationale 3: At the initial visit, the nurse develops a plan of care that identifies the client’s needs.
This plan must by reviewed, approved, authorized, and signed by the attending physician before the
home health agency providers can continue with services.
Rationale 4: Care might begin within 48 hours but initiation is dependent on many other factors.
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. 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: 2. Compare the characteristics of home health nursing to those of institutional
nursing care.
MNL Learning Outcome: 1.2.4. Compare the frameworks of care.
Page Number: 119
Question 6
Type: MCSA
A home health client has a complicated case involving occupational therapy, respiratory therapy, a
dietitian, the nurse, and a nurse’s aide who provides assistance with bathing, housekeeping, and
grocery shopping. Which care provider should be prepared to coordinate this client’s care?
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1. Physician
2. Nurse
3. Social worker
4. Home health agency
Correct Answer: 2
Rationale 1: Case coordination is essential but is not a physician responsibility.
Rationale 2: Because clients often require the services of several professionals, case coordination is
essential and generally rests with the registered nurse.
Rationale 3: Case coordination is not the responsibility of a social worker.
Rationale 4: Case coordination is not the responsibility of a home health agency.
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. 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: 4. Describe the roles of the home health nurse.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 121
Question 7
Type: MCSA
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The nurse is hired to provide home care through a community agency that is operated by the state
health department and financed by taxes. In which type of agency is this nurse employed?
1. Institution based
2. Private
3. Not-for-profit
4. Official
Correct Answer: 4
Rationale 1: Institution-based agencies operate under a parent organization such as a hospital and
are funded by the same sources as the parent. That is not the situation described here.
Rationale 2: Private, proprietary agencies are for-profit organizations and are governed by either
individual owners or national corporations. That is not the situation described here.
Rationale 3: Not-for-profit or voluntary agencies are supported by donations, endowments, charities
such as the United Way, and third-party reimbursement. That is not the situation described here.
Rationale 4: Official or public agencies are operated by state or local governments and financed
primarily by tax funds.
Global Rationale:
Cognitive Level: Analyzing
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. 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: Assessment
Learning Outcome: 3. Describe the types of home health agencies, including referral and
reimbursement sources.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
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Page Number: 120
Question 8
Type: MCSA
While reviewing a health insurance plan, the nurse learns that a client has coverage for durable
medical equipment (DME). What care need should the nurse identify as being covered by the client’s
health plan?
1. Dressings and bandages
2. Medications
3. A hospital bed
4. Visits by the home health nurse
Correct Answer: 3
Rationale 1: Supplies that the client uses and cannot be reused are not considered DME.
Rationale 2: Supplies that the client uses and cannot be reused are not considered DME.
Rationale 3: Durable medical equipment (DME) ranges from hospital beds to bedside commodes to
ventilators and apnea monitors. Equipment that will not be “used up” is considered DME.
Rationale 4: Visits by the home health nurse are paid through a different aspect of the client’s health
care plan.
Global Rationale:
Cognitive Level: Analyzing
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. 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: Assessment
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Learning Outcome: 3. Describe the types of home health agencies, including referral and
reimbursement sources.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 120
Question 9
Type: MCSA
The nurse would like to admit a client to home health care, but is worried about insurance
reimbursement. What client action is causing the nurse to question if home care can be prescribed
for this client?
1. Lives with a spouse
2. Needs skilled care
3. Needs intermittent care
4. Drives a car for trips to the barber
Correct Answer: 4
Rationale 1: Living with a spouse is allowed for reimbursement by insurance companies.
Rationale 2: Needing skilled care is allowed for reimbursement by insurance companies.
Rationale 3: Needing intermittent care is allowed for reimbursement by insurance companies.
Rationale 4: Clients must meet certain criteria, including homebound status, except for occasional
outings. Barber trips are included as “occasional outings,” but the client is not the driver.
Global Rationale:
Cognitive Level: Analyzing
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. 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
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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 types of home health agencies, including referral and
reimbursement sources.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 120
Question 10
Type: MCSA
A client who has been the recipient of home health care has made the decision to discontinue
hemodialysis. The client understands all the consequences of this decision and is not supported by
his family. The nurse is meeting with the family to help them understand the significance of the
client’s decision and to help them support the client during this difficult time. In which role is the
nurse functioning?
1. Caregiver
2. Advocate
3. Educator
4. Counselor
Correct Answer: 2
Rationale 1: The home health nurse’s major role as caregiver is to assess and diagnose the client’s
actual and potential health problems. That is not the role described here.
Rationale 2: As a client advocate, the nurse explores and supports the client’s choices in health
care. Advocacy includes having discussions about the client’s rights, advance medical directives,
living wills, and durable power of attorney for health care. At times, the client’s views may vary from
those of other family members. In the event of conflict, the nurse ensures that the client’s rights and
desires are upheld.
Rationale 3: The educator role focuses on teaching illness care, prevention of problems, and
promotion of optimal wellness or well-being. That is not the role described here.
Rationale 4: Counselor is not a role for the home health nurse.
Global Rationale:
Cognitive Level: Analyzing
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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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Describe the roles of the home health nurse.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 120
Question 11
Type: MCSA
During a home visit, the client with terminal cancer undergoes respiratory arrest. The client has
agreed to a DNR (do not resuscitate) order; however, the spouse tells the nurse to call 911. What
action should the nurse take?
1. Assess vital signs.
2. Call 911.
3. Start CPR.
4. Remind the spouse of the client’s desires.
Correct Answer: 4
Rationale 1: Assessment of vital signs does not address the immediate situation.
Rationale 2: In the event of conflict between the client’s desires and the family’s wishes, the nurse,
being the client’s primary advocate, ensures that the client’s rights and desires are upheld. This is a
difficult situation, but the nurse is bound to the client’s desires. Calling 911 would not support the
client’s desires.
Rationale 3: In the event of conflict between the client’s desires and the family’s wishes, the nurse,
being the client’s primary advocate, ensures that the client’s rights and desires are upheld. This is a
difficult situation, but the nurse is bound to the client’s desires. Starting CPR would not support the
client’s desires.
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Rationale 4: In the event of conflict between the client’s desires and the family’s wishes, the nurse,
being the client’s primary advocate, ensures that the client’s rights and desires are upheld. This is a
difficult situation, but the nurse is bound to the client’s desires.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Describe the roles of the home health nurse.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 121
Question 12
Type: MCSA
During a home visit, the nurse explains the procedures for preventing infection in a central venous
access device to the spouse who watches while the nurse hooks the client to the medication
infusion. Which role is the nurse performing at this time?
1. Caregiver
2. Advocate
3. Educator
4. Coordinator
Correct Answer: 3
Rationale 1: The role of caregiver involves assessing and diagnosing actual or potential health
problems, planning care, and evaluating the client’s outcomes. That is not the role described here.
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Rationale 2: The advocate role ensures that the rights and desires of the client are upheld. That is
not the role described here.
Rationale 3: Education can be the most essential aspect of home care practice, the goal of which is
to help clients learn to manage as independently as possible. Involving the spouse in care and
educating the spouse along with the client promotes wellness and helps prevent problems.
Rationale 4: The home health nurse coordinates the activities of all other home health team
members involved in the client’s treatment plan. That is not the role described here.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Describe the roles of the home health nurse.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 121
Question 13
Type: MCSA
While assessing a client’s environment for safety concerns, the nurse finds that most of the rooms in
the house have only one outlet with various cords entering the outlet. When this concern is shared
with the client and spouse, they state that “this is the way we’ve lived for years.” What should the
nurse do?
1. Provide telephone numbers for local electricians.
2. Continue to persuade the client to have the home rewired.
3. Not bring the subject up again.
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4. Document the findings and the client and spouse’s response to the concern.
Correct Answer: 4
Rationale 1: Although not inappropriate, this option is not likely to be acted upon by the client.
Rationale 2: Home health nurses cannot expect to change a family’s living space and lifestyle, and
such an intervention may be resented by the client.
Rationale 3: The nurse has an obligation to bring safety issues to the client’s attention.
Rationale 4: Home health nurses cannot expect to change a family’s living space and lifestyle.
However, they can express concern when a situation suggests the possibility for injury. Nurses must
document information they provide and the family’s response to instruction as well as make ongoing
assessments about the family’s use of safety precautions.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.B. 10. Engage patients or designated surrogates in active partnerships that
promote health, safety and well-being, and self-care management
AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring
NLN Competencies: Quality and Safety; Practice; Encourage patients and families to communicate
their observations and concerns regarding safety
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home
care setting.
MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety.
Page Number: 121
Question 14
Type: MCSA
A home health client lives alone in a small apartment and has only one phone, which is a land line.
What safety recommendation should the visiting home health nurse make for this particular client?
1. Suggest that the client move to a nursing home or assisted living dwelling.
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2. Recommend that the client be enrolled in an emergency response system.
3. Enroll the client in a program that places all of the client’s vital medical information in one place for
emergency personnel.
4. Have the client post a list of emergency numbers (fire, police, ambulance) near the phone.
Correct Answer: 2
Rationale 1: Making suggestions for the client to relocate may be a possibility, but this might be
premature to suggest at this point.
Rationale 2: An emergency response system provides a small device with a help button that
attaches to the client’s wrist or is worn around the neck. The client can send a signal to a home
base that would indicate if the client is in trouble (i.e., has fallen or become ill) and can’t get to the
phone. This system is particularly useful for clients who live alone.
Rationale 3: Having all of the client’s medical information in one place is a helpful idea but does not
address the concern of effective means of communication.
Rationale 4: An emergency response system provides a small device with a help button that
attaches to the client’s wrist or is worn around the neck. The client can send a signal to a home
base that would indicate if the client is in trouble (i.e., has fallen or become ill) and can’t get to the
phone. This system is particularly useful for clients who live alone. Making suggestions for the client
to relocate may be a possibility, but this might be premature to suggest at this point. Having
emergency numbers in a visible spot is a helpful idea but does address the concern of effective
means of communication.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.B. 10. Engage patients or designated surrogates in active partnerships that
promote health, safety and well-being, and self-care management
AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring
NLN Competencies: Quality and Safety; Practice; Encourage patients and families to communicate
their observations and concerns regarding safety
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home
care setting.
MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety.
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Page Number: 122
Question 15
Type: MCSA
The home health nurse has scheduled a visit to a client who lives in a neighborhood that is known to
be unsafe because of gang activity. Before going to the client’s home, what should the nurse do?
1. Call for an escort.
2. Call the client to let the client know the nurse is on the way.
3. Ask if the client could meet the nurse at the agency.
4. Take a second nurse along on the visit.
Correct Answer: 1
Rationale 1: Some less desirable living locations pose safety concerns for the nurse. Many home
health agencies have contracts with security firms to escort nurses needing to see clients in
potentially unsafe neighborhoods. If there is no such firm for escort, the police can also provide
security for the nurse.
Rationale 2: Calling ahead to the client’s home is routine practice, regardless of where the client
lives.
Rationale 3: Having the client meet the nurse at the agency is inappropriate, especially if the client
meets the criteria for home care.
Rationale 4: Taking a second nurse along may not be a realistic intervention.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.B. 10. Engage patients or designated surrogates in active partnerships that
promote health, safety and well-being, and self-care management
AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring
NLN Competencies: Quality and Safety; Practice; Encourage patients and families to communicate
their observations and concerns regarding safety
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home
care setting.
MNL Learning Outcome: 4.1.4. Use the nursing process to maintain a safe and effective client care
environment.
Page Number: 122
Question 16
Type: MCSA
A home health nurse has a weekly visit to a client living in less than desirable cleanliness. The client
has a central venous access device and requires weekly infusion therapy. What is the best way for
the nurse to protect the client against infection?
1. Have the client wash her hands before the infusion begins.
2. Practice strict aseptic technique during the infusion process.
3. Help the client clean the room before starting the infusion.
4. Suggest that the client have a housekeeper come on the morning of the infusion.
Correct Answer: 2
Rationale 1: This intervention will not directly impact the minimization of the risk for
infection because the client is not performing the infusion.
Rationale 2: Infection control can present a challenge to the home health nurse, especially if the
home care facilities are not conducive to basic aseptic requirements. The most important ways to
prevent infection are making sure the site is clean, accessing the port following sterile procedure,
and following Standard Precautions while accessing the line.
Rationale 3: Even if the client’s environment is not clean, that doesn’t necessarily mean the client is
unclean. There is another option that will impact the risk of infection.
Rationale 4: Teaching about health practices that prevent infection is important, but the nurse cannot
expect to change the client’s lifestyle.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.B. 10. Engage patients or designated surrogates in active partnerships that
promote health, safety and well-being, and self-care management
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AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home
care setting.
MNL Learning Outcome: 4.1.4. Use the nursing process to maintain a safe and effective client care
environment.
Page Number: 123
Question 17
Type: MCMA
The nurse is concerned that the spouse of a home care client with multiple sclerosis is experiencing
caregiver role strain. What did the nurse observe to come to this conclusion?
1. The home appears cluttered.
2. The spouse expresses feelings of anger.
3. The spouse reports decreased energy.
4. The spouse reports that she is learning how to manage finances.
5. The client asks when the nurse will return for the next visit.
Correct Answer: 2, 3
Rationale 1: Evidence of caregiver role strain would be dramatic change in the home environment’s
appearance. Clutter would not be a dramatic change.
Rationale 2: Feelings of anger are evidence of caregiver role strain.
Rationale 3: Reports of declining physical energy and insufficient time for
caregiving indicate caregiver role strain.
Rationale 4: Learning how to manage finances is a positive statement and would not
indicate caregiver role strain.
Rationale 5: Asking when the nurse will make the next visit is not an indication of caregiver role
strain.
Global Rationale:
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Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.B. 10. Engage patients or designated surrogates in active partnerships that
promote health, safety and well-being, and self-care management
AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 7. Identify ways the nurse can recognize and minimize caregiver role strain.
MNL Learning Outcome: 4.1.4. Use the nursing process to maintain a safe and effective client care
environment.
Page Number: 123
Question 18
Type: MCSA
After completing an initial assessment, the nurse identifies teaching that the client will need. Why did
the nurse identify learning needs for this client?
1. Lack of knowledge related to health conditions and self-care
2. The fact that there is little time to complete education in the acute care setting
3. The fact that teaching someone who is willing to learn is easier in the home
4. The need for reimbursement for education by Medicare
Correct Answer: 1
Rationale 1: One of the most common health issues that nurses address with clients in home care
settings is lack of knowledge related to health conditions and self-care. Client education is
considered a skill reimbursed by Medicare.
Rationale 2: Although this may be true in some situations, it is not the reason that education is a
focus of home health nursing care. Not all home care clients come from acute care, and education is
still implemented in this setting.
Rationale 3: Not all home clients are willing or ready to learn, even though they are in their own
home environment.
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Rationale 4: Client education is considered a skill reimbursed by Medicare.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.B. 10. Engage patients or designated surrogates in active partnerships that
promote health, safety and well-being, and self-care management
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: 5. Identify the essential aspects of the home visit.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 124
Question 19
Type: MCSA
An older client being discharged from an acute care facility is prescribed home care. When should
the home care nurse see the client to understand needs for safety and mobility?
1. At the initial home visit, in order to see the client in the home environment
2. While the client is still a patient in the acute care hospital
3. After the client has been home for a few days and can help the nurse decide what is needed
4. When the spouse is available to assist in the assessment
Correct Answer: 2
Rationale 1: Once the client is at home, the need for the devices will be immediate and the client
may have to wait unnecessarily for the required items.
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Rationale 2: Assessment for the older client being discharged to home health should be initiated
while the client is in the hospital to determine the need for assistive devices or environmental
changes before the client returns home.
Rationale 3: Waiting a few days is a delay that is not beneficial for the client, who requires these
items upon arriving home.
Rationale 4: Waiting until the spouse is able to help is a delay that is not beneficial for the client, who
requires these items upon arriving home.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.B. 10. Engage patients or designated surrogates in active partnerships that
promote health, safety and well-being, and self-care management
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 settingsNLN Competencies: Context and Environment; Practice; conduct populationbased transcultural health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4. Describe the roles of the home health nurse.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 119
Question 20
Type: MCSA
A client has been receiving home care for several weeks. Which individual should the nurse realize
is responsible for ensuring that the client is receiving care at the appropriate times and in the
appropriate amounts?
1. Client
2. Nurse
3. Physician
4. Client’s spouse
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Correct Answer: 2
Rationale 1: Even though the client may become independent in self-care skills, assurance is not the
client’s responsibility.
Rationale 2: Even though the client and family may become independent in self-care skills, the home
health nurse still has the ultimate responsibility to ensure that the client is receiving the prescribed
therapy at the appropriate timed intervals. On subsequent home visits, the nurse observes the same
parameters assessed on the initial visit.
Rationale 3: Even though the physician has responsibilities to the client, assurance in this area is not
one of them.
Rationale 4: Even though family members may assume responsibility for a client’s care, it is not their
responsibility to assure appropriate care.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.B. 10. Engage patients or designated surrogates in active partnerships that
promote health, safety and well-being, and self-care management
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: 4. Describe the roles of the home health nurse.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 121
Question 21
Type: MCMA
The nurse is attending a seminar that focuses on the changes within the home health care industry.
Which statements that the nurse makes indicate an understanding of home care as a primary health
service delivery system?
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Standard Text: Select all that apply.
1. “It’s unfortunate that clients can be screened for illnesses in the privacy of their own home.”
2. “With people living well into their 70s and 80s, the healthcare system is being stressed
immensely.”
3. “The cost of acute hospital-based health care has become an economic burden to most people.”
4. “A client’s chronic cardiac problems can be monitored well with in-home health services.”
5. “It relieves so much stress when care can come to them instead of their going to the health
provider.”
Correct Answer: 2, 3, 4, 5
Rationale 1: Health preventative screening can be accomplished as a part of home care when
needed.
Rationale 2: Numerous factors have contributed to trend toward home health care; among
them is the increasing number of aging adult clients.
Rationale 3: Numerous factors have contributed to the trend toward home health care; among
them is rising health care costs.
Rationale 4: Numerous factors have contributed to the trend toward home health care; among
them is the growing emphasis on managing chronic illness.
Rationale 5: Numerous factors have contributed to the trend toward home health care; among
them is the growing emphasis on managing stress for the chronically ill.
Global Rationale:
Cognitive Level: Analyzing
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. 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
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Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 2. Compare the characteristics of home health nursing to those of institutional
nursing care.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 118
Question 22
Type: MCMA
The nurse is taking a tour of a home care agency as part of the interview process. Which services
should the nurse recognize as being provided through this health agency?
Standard Text: Select all that apply.
1. A case manager arranging services to meet the client’s need for physical therapy after a fall
2. A nurse educating the pregnant teenager on the signs of premature labor
3. A durable supply company delivering a wheelchair to a client with spina bifida
4. A nurse assessing the feet of a home–bound diabetic client
5. A grocery store delivering groceries to a client recovering from cancer surgery
Correct Answer: 1, 3, 4
Rationale 1: Home care today involves a wide range of health care professionals providing services,
such as physical therapy, in the home setting to people who are recovering from an acute illness or
injury, are disabled, or have a chronic condition.
Rationale 2: Pregnancy education would not be addressed in the home setting unless the pregnancy
required bed rest.
Rationale 3: Home care today involves a wide range of health care professionals providing services,
such as assistive devices, in the home setting to people who are recovering from an acute illness or
injury, are disabled, or have a chronic condition.
Rationale 4: Home care today involves a wide range of health care professionals providing services,
such as nursing care, in the home setting to people who are recovering from an acute illness or
injury, are disabled, or have a chronic condition.
Rationale 5: Home care does not include non-professional services such as grocery delivery.
Global Rationale:
Cognitive Level: Analyzing
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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. 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: Assessment
Learning Outcome: 1. Define home health care.
MNL Learning Outcome: 1.2.2. Recognize the functions of health care agencies.
Page Number: 119
New Questions:
Question 23
Type: MCMA
The nurse has two older parents who were recently hospitalized at the same time and are being
discharged home on the same day. What should the nurse do to ensure these family members
receive the highest quality of care in the home?
Standard Text: Select all that apply.
1. Call off from work to provide care to both parents.
2. Adjust his or her personal schedule to provide care to the parents.
3. Move in with the parents until conditions are stabilized.
4. Determine if custodial support is needed for the parents.
5. Find out when the home care nurse is scheduled to arrive.
Correct Answer: 4, 5
Rationale 1: A particular challenge exists when the nurse is in a position to be a caregiver to a family
member. The nurse may feel obligated to provide care, even when this is over and above regular
employment responsibilities. The nurse should not call off from work to provide care to both parents.
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Rationale 2: A particular challenge exists when the nurse is in a position to be a caregiver to a family
member. The nurse may feel obligated to provide care, even when this is over and above regular
employment responsibilities. The nurse should not adjust his or her personal schedule to provide
care to the parents.
Rationale 3: A particular challenge exists when the nurse is in a position to be a caregiver to a family
member. The nurse may feel obligated to provide care, even when this is over and above regular
employment responsibilities. Moving in with the parents should not be done.
Rationale 4: A particular challenge exists when the nurse is in a position to be a caregiver to a family
member. The nurse may feel obligated to provide care, even when this is over and above regular
employment responsibilities. The nurse must have the opportunity to step back and experience the
role and emotions of being a family member—not only those of being a nurse. Determining if
custodial support is needed would be appropriate because the nurse is unable to provide this level of
care.
Rationale 5: A particular challenge exists when the nurse is in a position to be a caregiver to a family
member. The nurse may feel obligated to provide care, even when this is over and above regular
employment responsibilities. The nurse must have the opportunity to step back and experience the
role and emotions of being a family member—not only those of being a nurse. Finding out when the
home care nurse is scheduled to arrive would be appropriate.
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. 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: 4. Describe the roles of the home health nurse.
MNL Learning Outcome: 1.2.1. Explore the various roles in nursing practice.
Page Number: 123
Question 24
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Type: MCMA
During a home visit, the nurse is concerned that a client recovering from hip replacement surgery is
at risk for falling in the home. What information from the home assessment did the nurse use to
come to this conclusion?
Standard Text: Select all that apply.
1. Laminated floors highly polished
2. Scatter rugs in the kitchen and bathroom
3. Smoke detector battery low in the bedroom
4. Cleaning solution placed in an unlabeled jar
5. Expired medication in the bathroom cabinet
Answer: 1, 2
Rationale 1: Highly polished floors can be a safety hazard and increase the client’s risk of falling.
Rationale 2: Scatter rugs are a safety hazard and can increase the client’s risk of falling.
Rationale 3: Although a safety hazard, a low smoke detector battery will not increase this client’s risk
of falling.
Rationale 4: Although a safety hazard, placing a caustic substance in an unlabeled jar will not
increase the client’s risk of falling.
Rationale 5: Although a safety hazard, expired medications will not increase the client’s risk of
falling.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I.B. 10. Engage patients or designated surrogates in active partnerships that
promote health, safety and well-being, and self-care management
AACN Essentials Competencies: II. 7. Promote factors that create a culture of safety and caring
NLN Competencies: Quality and Safety; Practice; Encourage patients and families to communicate
their observations and concerns regarding safety
Nursing/Integrated Concepts: Nursing Process: Evaluation
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Learning Outcome: 6. Discuss the safety and infection control dimensions applicable to the home
care setting.
MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety.
Page Number: 122
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Chapter 09
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 09
Question 1
Type: MCSA
The nurse needs to complete mandatory continuing education on client safety as part of a regulatory
requirement for the hospital. Which computerized approach should the nurse consider to complete
this required education?
1. Complete a computerized tutorial on client safety
2. Read information on safety from a web site
3. Review the online hospital policies about client safety
4. Complete a literature review on client safety
Correct Answer: 1
Rationale 1: Nursing has benefited from the computer revolution in the form of computer-assisted
instruction (CAI). Programs cover a variety of topics which allow almost instant access to
any content. Completion of CAI programs may also be an acceptable means of demonstrating
continuing education activities.
Rationale 2: Reading information from a web site does not necessarily indicate completion of
education on client safety.
Rationale 3: Reviewing policies online does not necessarily indicate completion of education on
client safety.
Rationale 4: Completing a literature review on client safety would not indicate that education on this
topic has been completed.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
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AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Describe the uses of computers and technology in nursing education.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 131
Question 2
Type: MCSA
A nurse manager is responsible for scheduling the staff of all units in a critical care hospital.
Which program should the manager use for computerized scheduling?
1. Database
2. Word processing
3. Graphics program
4. Spreadsheet
Correct Answer: 4
Rationale 1: A database is used to manage detailed information. That is not the application
described here.
Rationale 2: Word processing is one of the most commonly used computer applications. Documents
are checked for spelling and grammar, and individualized to include pictures, charts, and designs.
That is not the application described here.
Rationale 3: Graphics programs have become popular for their ability to create charts, tables, and
pictures. That is not the application described here.
Rationale 4: Spreadsheets are programs that can manipulate numbers. Data are arranged in
columns and rows. Spreadsheets are used for budgets and are useful for working with staffing,
scheduling, invoicing, research, and other analyses.
Global Rationale:
Cognitive Level: Applying
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Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Identify computer applications used in client assessment and care.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 130
Question 3
Type: MCSA
A client tells the nurse about researching on the Internet for information about a newly prescribed
medication. What should the nurse respond to the client?
1. “I’m glad you’re interested in your therapy.”
2. “Information on the Internet cannot be trusted. You should check with your pharmacist.”
3. “Your physician is the one you should be asking these kinds of questions.”
4. “Let’s look at some of the sites you’ve been visiting.”
Correct Answer: 4
Rationale 1: Although being involved in one’s care is desirable, there are concerns related to
information accessed on the Internet.
Rationale 2: This statement is not necessarily true, although there are concerns about information
accessed on the Internet.
Rationale 3: Although this statement isn’t incorrect, the client should be able to access reliable
information in order to be well informed.
Rationale 4: Thousands of health-related sites exist on the Internet, with new ones occurring daily.
There are no controls to ensure that information provided on these sites is accurate. Therefore, the
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nurse should help the client find reliable and accurate information. Clients are involved consumers.
Wanting more information about their medications, disease processes, and treatment options is
taking a proactive approach to their own care. It is appropriate to ask questions and seek
information from a variety of sources. However, nurses must assist clients in making sure the
information they gather is credible and accurate.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Identify computer applications used in client assessment and care.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 130
Question 4
Type: MCSA
The nurse wants to search for articles having to do with a client care problem. Which database
should the nurse use to find this information?
1. CINAHL
2. Google
3. ERIC
4. PsychINFO
Correct Answer: 1
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Rationale 1: The Cumulative Index to Nursing and Allied Health Literature (CINAHL) focuses on
nursing and allied health articles, including research. In this database, the user can search
systematically for articles that are related to nursing research, peer reviewed, published, and so on.
Rationale 2: Google search engine gives a variety of sites, both health-related and non-healthrelated, but there are no controls for accuracy with this database.
Rationale 3: The Educational Resources Information Center (ERIC) would include all areas of
academia, not just nursing.
Rationale 4: PsychINFO includes only psychological abstracts.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5. Identify the role of technology in each step of the research process.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 131
Question 5
Type: MCSA
A small nursing program has limited access to clinical sites, especially those with specialty areas.
What should the nurse educators consider as an option to allow students “hands-on” simulated
clinical experience in these areas?
1. A field trip to a larger nursing institution
2. Videos
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3. CAI
4. Workbook with written study guides
Correct Answer: 3
Rationale 1: Taking field trips might not be economically feasible.
Rationale 2: Videos also provide instruction, but not simulation.
Rationale 3: Computer-assisted instruction (CAI) helps students as well as nurses learn and
demonstrate learning. Programs cover topics from drug dosage calculations to ethical decision
making, drill and practice, simulation, and testing. CAI simulations can provide a virtual experience
for the student through a computer program.
Rationale 4: Written study guides allow for learning, but not “hands-on” experience.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Describe the uses of computers and technology in nursing education.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 131
Question 6
Type: MCSA
The nurse enrolled in graduate courses is able to continue studies while visiting abroad. What has
this nurse’s nursing school implemented to make this possible?
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1. Classroom technology
2. Distance learning
3. CAI
4. Informatics
Correct Answer: 2
Rationale 1: Classroom technology is just one piece of distance learning.
Rationale 2: Distance learning is a model to deliver information and class sessions via audio or video
transmission. The use of computers is required to offer this type of delivery in education.
Rationale 3: Computer-assisted instruction (CAI), a method to allow for practice and simulation via
CD-ROM, is only one component of distance learning.
Rationale 4: Nursing informatics is the science of using computer information systems in the practice
of nursing, not necessarily the education of nursing.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1. Describe the uses of computers and technology in nursing education.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 132
Question 7
Type: MCSA
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A nurse educator has taught the same courses for the past 5 years and each year implements a few
minor changes. Over this time, the educator has stored the grade data, including homework and
assignment scores, in order to track trends following the implemented changes. What is the educator
using to maintain this information?
1. Informatics
2. Student record management
3. Data warehousing
4. Management information system (MIS)
Correct Answer: 3
Rationale 1: Informatics is the use of computer technology in nursing practice.
Rationale 2: Student and course record management are programs that help maintain results of
students’ grades or attendance using spreadsheets.
Rationale 3: Data warehousing is the accumulation of large amounts of data that are stored over
time and can be examined for output in different types of reports (charts and tables).
Rationale 4: A management information system (MIS) is designed to facilitate the organization and
application of data used to manage an organization or department.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe the uses of computers and technology in nursing education.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
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Page Number: 132
Question 8
Type: MCSA
The nurse accesses previous hospitalization information to learn more about the client’s previous
health history. In what way is the availability of the client’s health information assisting with the
planning to address new care needs?
1. Ability to monitor quality
2. Access warehoused data (stored data)
3. Client sharing of knowledge that influences health
4. Constant availability of client health information
Correct Answer: 4
Rationale 1: There are at least four ways the EHR can improve health care. Accessing previous
hospitalization information is not being done to monitor quality.
Rationale 2: There are at least four ways the EHR can improve health care. Accessing previous
hospitalization information is not being done to support data warehousing.
Rationale 3: There are at least four ways the EHR can improve health care. Accessing previous
hospitalization information is not being done to share client information.
Rationale 4: There are at least four ways the EHR can improve health care. Accessing previous
hospitalization information is being done to review the client’s information to aid with planning for this
current hospitalization.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Discuss the advantages of and concerns about computerized client
documentation systems.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 134
Question 9
Type: MCSA
A client asks what is done to keep computerized personal health information confidential. How
should the nurse respond?
1. “Don’t worry; your information is always safe.”
2. “Information in our system requires a password to retrieve.”
3. “Our system was designed with a lot of input from nursing staff.”
4. “I can see why you’re worried, with all the computer hackers out there these days.”
Correct Answer: 2
Rationale 1: Information in a computer data system may not always be safe, and it would be
inappropriate for the nurse to say this.
Rationale 2: Maintaining privacy and security of data is a significant issue. One way that computers
can protect data is by the use of passwords—only those persons who have a legitimate need to
access the data receive the password.
Rationale 3: Nurses need to be involved with the design, implementation, and evaluation of clientbased patient records (CPRs) to maximize their use and effectiveness, but this does not ensure
security.
Rationale 4: Reminding the client that there is indeed cause for privacy concerns is not therapeutic.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
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AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Discuss the advantages of and concerns about computerized client
documentation systems.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 131
Question 10
Type: MCMA
The nurse is accessing information about standard classification of terms prior to documenting in a
client’s computerized clinical record. Which systems should the nurse consider using for this
documentation?
Standard Text: Select all that apply.
1. ANA
2. HIPAA
3. NANDA
4. The Omaha system
5. HHCC
6. NOC
Correct Answer: 3, 4, 5, 6
Rationale 1: The ANA has a position statement on privacy, confidentiality of medical records, and
the nurse’s role, but it is not one of the classification systems used in the United States.
Rationale 2: HIPAA is a piece of legislation that addressed privacy of and access to health records.
Rationale 3: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has
established guidelines for the use of nursing terminology by companies that are creating software
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programs for nursing application. In doing this, NIDSEC recognizes the classification systems that
include North American Nursing Diagnosis Association (NANDA) taxonomy.
Rationale 4: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has
established guidelines for the use of nursing terminology by companies that are creating software
programs for nursing application. In doing this, NIDSEC recognizes the classification systems that
include the Omaha System.
Rationale 5: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has
established guidelines for the use of nursing terminology by companies that are creating software
programs for nursing application. In doing this, NIDSEC recognizes the classification systems that
include the Home Health Care Classification (HHCC).
Rationale 6: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has
established guidelines for the use of nursing terminology by companies that are creating software
programs for nursing application. In doing this, NIDSEC recognizes the classification systems that
include the Nursing Outcomes Classification (NOC).
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. List ways technology may be used by nurse administrators in the areas of
human resources, facilities management, finance, quality assurance, and accreditation.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 135
Question 11
Type: MCMA
Testsbanknursing.com
The nurse educator is considering ways to impact the learning of students through the use of
computer technology. Which actions should the educator take to achieve this goal?
Standard Text: Select all that apply.
1. Assign distance learners to conduct a research study of current evidence-based articles on caring
for the diabetic client.
2. Expect that notification of clinical absences be provided by e-mail.
3. Require a clinical group to make daily reflective entries in an online journal.
4. Provide extra credit for academic work that is created on a computer as an electronic file.
5. Encourage the learners to access online NCLEX review questions as a way to assess their
classroom learning.
Correct Answer: 1, 3, 5
Rationale 1: Nursing education is supported by the use of computerized library services, especially
when learning is conducted using the distance learning model.
Rationale 2: This is not a learning-focused requirement but rather an organizational requirement.
Rationale 3: Nursing education is supported by the use of computerized documentation, such as
journaling, because it aids in organization, writing skills, and computer use.
Rationale 4: This is not an appropriate way to support learning except in an online learning
environment, in which case all assignments would be computer-generated.
Rationale 5: Nursing education is supported by the use of computerized testing options, as it helps
advance the learners’ comfort and skill with online testing.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe the uses of computers and technology in nursing education.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 132
Question 12
Type: MCMA
A nurse educator believes computers can enhance student learning. Which actions should the
instructor take to demonstrate this belief?
Standard Text: Select all that apply.
1. Allow students to research a nursing topic either by going to the library or via an online literature
search.
2. Require a student to remediate after a failed test by completing appropriate computer-assisted
instruction modules.
3. Use PowerPoint slides to reinforce complex concepts during classroom lectures.
4. Assign a collaborative group project to students enrolled in an online course.
5. Use computer-generated graphics to make written material less monotonous.
Correct Answer: 1, 2, 3, 4
Rationale 1: Computers enhance academics for students in at least four ways, including access to
nursing literature.
Rationale 2: Computers enhance academics for students in at least four ways, including computerassisted instruction modules.
Rationale 3: Computers enhance academics for students in at least four ways, including teaching
strategies employing PowerPoint presentations.
Rationale 4: Computers enhance academics for students in at least four ways, including online
collaborative projects.
Rationale 5: Any form of graphics—not necessarily computer-generated ones—would be effective in
this application.
Global Rationale:
Cognitive Level: Applying
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Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe the uses of computers and technology in nursing education.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 131
New Questions:
Question 13
Type: MCMA
The nurse is beginning a physical assessment of a client who is freelance computer information
technologist. On which areas should the nurse place particular emphasis during this assessment?
Standard Text: Select all that apply.
1. Vision
2. Hearing
3. Back flexibility
4. Hand range of motion
5. Range of motion of arms
Correct Answer: 1, 3, 4, 5
Rationale 1: There are many issues of concern related to frequent and extended use of computers
by clients of all ages. In particular, eye strain can occur from computer monitor viewing.
Rationale 2: There are many issues of concern related to frequent and extended use of computers
by clients of all ages. Hearing is not a concern with computer use.
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Rationale 3: There are many issues of concern related to frequent and extended use of computers
by clients of all ages. In particular, musculoskeletal damage is related to inadequate ergonomic
arrangement of desk chairs, surface height, and monitor placement.
Rationale 4: There are many issues of concern related to frequent and extended use of computers
by clients of all ages. In particular, repetitive motion injuries (especially of the hand) can occur with
extensive typing and use of the computer mouse.
Rationale 5: There are many issues of concern related to frequent and extended use of computers
by all clients of ages. In particular, musculoskeletal damage is related to inadequate ergonomic
arrangement of desk chairs, surface height, and monitor placement.
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: 2. Discuss the advantages of and concerns about computerized client
documentation systems.
MNL Learning Outcome: 4.3.2. Recognize factors that affect movement and immobility.
Page Number: 139
Question 14
Type: MCMA
The nurse is participating in the development of a research study. What elements of the computer
should the nurse ensure are in place before the study begins?
Standard Text: Select all that apply.
1. Computer speed adequate
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2. Print drivers installed
3. Word processing program
4. Computer storage capacity adequate
5. Appropriate software programs
Correct Answer: 1, 3, 4, 5
Rationale 1: Computer resources are an important component of the planning phase of any research
project. The speed must be adequate for the amount and type of data that will be collected.
Rationale 2: Installation of print drivers is not identified as a need prior to beginning a research
study.
Rationale 3: Computer resources are an important component of the planning phase of any research
project. Computerized word processing is an integral component in the publication and
dissemination of research.
Rationale 4: Computer resources are an important component of the planning phase of any research
project. The storage capacity must be adequate for the amount and type of data that will be
collected.
Rationale 5: Computer resources are an important component of the planning phase of any research
project. The proper software programs must be in place to manage and analyze the data.
Computerized word processing is also an integral component in the publication and dissemination of
research.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: VI. B. 2. Apply technology and information management tools to support safe
processes of care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5. Identify the role of technology in each step of the research process.
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MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 138
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Chapter 10
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 10
Question 1
Type: MCSA
The nurse is providing care to a group of clients. For which situation would the nurse’s use of critical
thinking be a priority?
1. Administering IV push meds to critically ill clients
2. Educating a home health client about treatment options
3. Teaching new parents car seat safety
4. Assisting an orthopedic client with the proper use of crutches
Correct Answer: 2
Rationale 1: Administering IV meds (even to critically ill clients) does not require much reasoning.
There are standard procedures to follow and, most of the time, clear answers about the rationale.
Rationale 2: Nurses who utilize good critical thinking skills are able to think and act in areas where
there are neither clear answers nor standard procedures. Treatment options, especially for the home
health client, can be extensive. There are many points to consider (good and bad), and choosing
between treatment options can cause conflict among family members. The nurse in this case must
use creativity, analysis based on science, and problem-solving skills—all of which contribute to
critical thinking skills.
Rationale 3: Teaching new parents about car seat safety does not require much reasoning. There
are standard procedures to follow and, most of the time, clear answers about the rationale.
Rationale 4: Teaching correct use of crutches does not require much reasoning. There are standard
procedures to follow and, most of the time, clear answers about the rationale.
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. 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: 1. Describe the significance of developing critical thinking abilities in order to
practice safe, effective, and professional nursing care.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 144
Question 2
Type: MCSA
A client recovering from a stroke does not want to perform prescribed shoulder exercises. What
should the nurse say to the client that demonstrates critical thinking with creativity?
1. “You’ll only get worse if you don’t do these exercises.”
2. “As soon as you get these into your routine, you’ll feel better.”
3. “Your physician wouldn’t have ordered these if they weren’t important.”
4. “Here’s a marker. See how many circles you can make on this board in 10 minutes.”
Correct Answer: 4
Rationale 1: Explaining the rationale for doing or not doing the exercises is not using creativity. It is
merely explaining the reason.
Rationale 2: This shows no creativity and merely dismisses the client’s concerns and feelings.
Rationale 3: This shows no creativity and merely dismisses the client’s feelings.
Rationale 4: Making the exercise routine into something more fun—such as a game, drawing a
picture, or even “decorating the walls,” for example—would raise a challenge to the client, take the
focus off the “why,” and still achieve the end result.
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. 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: Implementing
Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing
process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 145
Question 3
Type: MCSA
A student nurse resists when encouraged to be creative when providing client care. What should the
nurse educator say to encourage this student to be creative?
1. “Creativity allows unique solutions to unique problems.”
2. “Not all your answers are going to be from your textbook.”
3. “Creativity makes nursing more fun.”
4. “You’ll get bored if you don’t learn to be creative.”
Correct Answer: 1
Rationale 1: Creativity is thinking that results in the development of new ideas and products and is
the ability to develop and implement new and better solutions. When nurses incorporate creativity
into their thinking, they are able to find unique solutions to unique problems. Creativity does make
the nurse look beyond the answers found in the text, but it also brings originality and individuality to
nursing.
Rationale 2: This option does not address the reason creativity is a major component of critical
thinking, and appears to dismiss the student’s statement.
Rationale 3: This option doesn’t address the reason for creativity in nursing and merely trivializes its
importance.
Rationale 4: This option doesn’t address the reason for creativity in nursing and merely provides a
personal motive for creativity.
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. 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: Implementing
Learning Outcome: 1. Describe the significance of developing critical thinking abilities in order to
practice safe, effective, and professional nursing care.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 145
Question 4
Type: MCSA
The nurse educator assigns students an activity to implement Socratic questioning in their daily
lives. Which question provided by a student demonstrates this reasoning technique?
1. “What makes you think cramming for a test is an ineffective way to study?”
2. “What other ways of studying could you implement?”
3. “If you didn’t study for your test, what is the probability you will fail?”
4. “If you study all the unit outcomes, what effect will that have?”
Correct Answer: 1
Rationale 1: Socratic questioning is a technique one can use to look beneath the surface, recognize
and examine assumptions, search for inconsistencies, examine multiple points of view, and
differentiate what one knows from what one merely believes. Questions about evidence and reason
focus on just that (e.g., what evidence is there, how you know, what would change your mind).
Rationale 2: Asking about ways to study would be a question about the problem (studying), which is
not an example of Socratic questioning.
Rationale 3: Asking about the effects of studying is questioning about implications and
consequences, which is not an example of Socratic questioning.
Rationale 4: Asking about the effects of studying is questioning about implications and
consequences, which is not an example of Socratic questioning.
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. 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: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical
reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 146
Question 5
Type: MCSA
A client is experiencing a productive cough, audible coarse crackles, elevated temperature of
102.3°F, chills, and body aches. What did the nurse use to determine that this patient is
experiencing respiratory compromise?
1. Deductive reasoning
2. Inductive reasoning
3. Socratic questioning
4. Critical analysis
Correct Answer: 1
Rationale 1: Deductive reasoning is reasoning from the general to the specific. The nurse starts with
a framework and makes descriptive interpretations of the client’s condition in relation to the
framework. Productive cough, crackles, fever, and chills all point to problems with respiratory status.
Rationale 2: Inductive reasoning would be making a generalization from a set of facts or observation.
In this case, the nurse using inductive reasoning could presume that the client has bronchitis or a
bacterial respiratory infection.
Rationale 3: Socratic questioning looks beneath the surface and asks questions to come to a
conclusion about the situation; that is not what is described in this scenario.
Rationale 4: Critical analysis looks beneath the surface and asks questions to come to a conclusion
about the situation.
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. 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: 2. Describe the actions of clinical reasoning in the implementation of the nursing
process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 147
Question 6
Type: MCSA
A client with a PhD in epidemiology has been to numerous physicians and has had numerous
laboratory tests, all of which were abnormal, and exploratory surgery, but no one is able to explain
the etiology of his problem. The client also states that he has a rare form of a neurological
disorder. Which statement should the nurse make that demonstrates critical thinking?
1. “Why don’t you just tell your physician what you think you have?”
2. “Did you bring your prior tests and results with you, so we don’t repeat anything?”
3. “If you know what you have, what do you want from us?”
4. “Describe what tests you’ve had and explain the symptoms of this disorder.”
Correct Answer: 4
Rationale 1: Asking “why” questions make clients very defensive, and doing so does not utilize
critical thinking skills.
Rationale 2: Asking a “yes/no” question offers little other information, and doing so does not utilize
critical thinking skills.
Rationale 3: Asking the client what he wants does not help to find out more information about the
client’s situation or prior history, and doing so does not utilize critical thinking skills.
Rationale 4: In critical thinking, the nurse also differentiates statements of fact, inference, judgment,
and opinion. The nurse will have to ascertain the accuracy of information and evaluate the credibility
of the information sources.
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. 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: 2. Describe the actions of clinical reasoning in the implementation of the nursing
process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 147
Question 7
Type: MCSA
A nurse educator has always believed that lectures with focused outlines are the best way to present
theory content in class. A colleague, who teaches the same group of students, but a different
subject, utilizes group work and in-class activities to teach difficult content and finds that students
perform as well, or better, on their tests. The first educator in this situation is starting to rethink her
position. What behavior is the first educator demonstrating?
1. Integrity
2. Perseverance
3. Fair-mindedness
4. Humility
Correct Answer: 1
Rationale 1: Intellectual integrity requires that individuals apply the same rigorous standards of proof
to their own knowledge and beliefs as they apply to the knowledge and beliefs of others. Trying new
teaching techniques in the hope that students might respond positively shows that the first educator
is willing to question her own practices, just as she would question those of another.
Rationale 2: Perseverance is determination that enables critical thinkers to clarify concepts and sort
out related issues, in spite of difficulties and frustrations.
Rationale 3: Fair-mindedness is assessing all viewpoints with the same standards and not basing
judgments on personal or group bias or prejudice.
Rationale 4: Intellectual humility means having an awareness of the limits of one’s own knowledge.
Critical thinkers are willing to admit what they do not know, seek new information, and rethink their
conclusions in light of new knowledge.
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: Planning
Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing
process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 149
Question 8
Type: MCSA
The nurse who just moved from an urban area to a sparsely populated rural area understands that
certain customs and practices the nurse follows may be quite foreign to the people in the new
area. Which attitude of critical thinking is the nurse demonstrating?
1. Fair-mindedness
2. Insight into egocentricity
3. Intellectual humility
4. Intellectual courage to challenge the status quo and rituals
Correct Answer: 2
Rationale 1: Fair-mindedness means assessing all viewpoints with the same standards and not
basing judgments on personal or group bias or prejudice.
Rationale 2: Critical thinkers are open to the possibility that their personal biases or social pressures
and customs could unduly affect their thinking. They actively try to examine their own biases and
bring them to awareness each time they make a decision. Understanding that how things were done
and what practices were common may be completely different in the new surroundings is an
example of the nurse implementing this attitude.
Rationale 3: Intellectual humility means having an awareness of the limits of one’s own knowledge.
Rationale 4: Intellectual courage to challenge the status quo and rituals is taking a fair examination
of one’s own ideas or views, especially those to which one may have a strongly negative reaction.
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: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical
reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 148
Question 9
Type: MCSA
The nurse implements a quicker way to set up and initiate an intravenous infusion while still following
safe practice. Which attitude of critical thinking is this nurse practicing?
1. Independence
2. Intellectual courage to challenge the status quo or rituals
3. Integrity
4. Confidence
Correct Answer: 1
Rationale 1: Nurses who can think for themselves and consider different methods of performing
technical skills—not just the way they may have been taught in school—develop an attitude of
independence.
Rationale 2: Courage to challenge the status quo comes from recognizing that sometimes beliefs are
false or misleading. Integrity requires that individuals apply the same rigorous standards of proof to
their own knowledge and beliefs; that is not what is described in the scenario.
Rationale 3: Integrity requires that individuals apply the same rigorous standards of proof to their
own knowledge and beliefs; that is not what is described in the scenario.
Rationale 4: Confidence is the self–assurance to act on one’s own beliefs; that is not what is
described in the scenario.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
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: 1. Describe the significance of developing critical thinking abilities in order to
practice safe, effective, and professional nursing care.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 148
Question 10
Type: MCSA
The nurse questions the practice of administering rectal suppositories to residents in a long-term
care facility at bedtime, rather than earlier in the day. When told that this is the best time for staff and
that’s the routine that has been practiced for a long time, the nurse continues to research whether
there would be a better time, especially in the best interest of the residents. Which critical thinking
attitude is this nurse demonstrating?
1. Confidence
2. Perseverance
3. Curiosity
4. Integrity
Correct Answer: 3
Rationale 1: Confidence comes from cultivating reasoning and examining arguments. In this case,
the nurse did not reason anything out, but is asking questions.
Rationale 2: Perseverance happens from determination in clarifying concepts and sorting out related
issues, in spite of difficulties and frustrations. This nurse is asking questions, not making any
changes in spite of difficulties or frustrations.
Rationale 3: The internal conversation going on within the mind of a critical thinker is filled with
questions. The curious nurse may value tradition but is not afraid to examine traditions to be sure
they are still valid, as in this case. This nurse is asking valid questions.
Rationale 4: Integrity requires that individuals apply the same rigorous standards of proof to their
own knowledge and beliefs as they apply to the knowledge and beliefs of others.
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: Implementation
Learning Outcome: 1. Describe the significance of developing critical thinking abilities in order to
practice safe, effective, and professional nursing care.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 149
Question 11
Type: MCSA
A seasoned nurse uses past experiences and knowledge gained from previous care situations to
care for a client with complex health issues. Which attribute of critical thinking is this nurse
practicing?
1. Reflection
2. Context
3. Dialogue
4. Time
Correct Answer: 1
Rationale 1: Reflection involves being able to determine what data are relevant and to make
connections between that data and the decisions reached. The nurse reflects on previous clinical
experiences similar to this one and determines if the outcomes of care improved the clients’
conditions.
Rationale 2: Context is an essential consideration in nursing because care must always be
individualized, taking knowledge and applying it to real people, but that is not what is described in
the scenario.
Rationale 3: Dialogue is a purposed exchange of information, but that is not what is described in
the scenario.
Rationale 4: The attribute of time is a part of reflection.
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: Implementation
Learning Outcome: 5. Integrate strategies to enhance critical thinking and clinical reasoning as the
provider of nursing care.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 151
Question 12
Type: MCSA
While listening to a client describe current symptoms, the nurse considers the client’s entire
situation. Which attribute of critical thinking is the nurse practicing?
1. Reflection
2. Context
3. Dialogue
4. Time
Correct Answer: 2
Rationale 1: Reflection involves being able to determine what data are relevant and to make
connections between that data and the decisions reached.
Rationale 2: Context is being considerate of the whole situation—including relationships,
background, and environment—and its relevant to the current situation.
Rationale 3: Dialogue, which need not involve other persons, refers to the process of serving as both
teacher and student in learning from situations.
Rationale 4: Time emphasizes the value of using past learning in current situations that then guide
future actions.
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: Implementation
Learning Outcome: 1. Describe the significance of developing critical thinking abilities in order to
practice safe, effective, and professional nursing care.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 146
Question 13
Type: MCSA
A client complaining of shortness of breath has no pallor, cyanosis, or use of accessory muscles with
respirations. The client’s respiratory rate is 16 breaths per minute. The nurse is concerned that the
client’s report and the physical findings conflict. Which standard of critical thinking is the nurse
using?
1. Clarity
2. Accuracy
3. Logical reasoning
4. Significance
Correct Answer: 3
Rationale 1: Clarity provides examples. That is not the process described in the scenario.
Rationale 2: Accuracy is asking if something is true. That is not the process described in
the scenario.
Rationale 3: Logicalness would ask if the report follows from the evidence. In this case, it does not.
However, the nurse is still questioning, which shows she is engaged in critically thinking through the
situation.
Rationale 4: Significance is prioritizing the facts. That is not the process described in the scenario.
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: Assessment
Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing
process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 146
Question 14
Type: MCSA
The nurse enters the room of a critically ill child after sensing that “something” isn’t right. Once the
nurse determines the child is stable, the nurse continues to perform a check of all the lines and
equipment in the room and finds that the last IV solution hung by the previous nurse was not the
correct solution. Which problem–solving method did this nurse use?
1. Trial and error
2. Intuition
3. Judgment
4. Scientific method
Correct Answer: 2
Rationale 1: Trial and error is solving problems through a number of approaches until a solution is
found.
Rationale 2: Intuition is the understanding or learning of things without the conscious use of
reasoning. It is also known as sixth sense, hunch, instinct, feeling, or suspicion. Clinical experience
allows the nurse to recognize cues and patterns and begin to reach correct conclusions using
intuition. Finding no cause for concern in the physical assessment of the client, the nurse is not
satisfied and continues to assess the client’s surroundings, finding the error.
Rationale 3: Judgment is not part of problem solving.
Rationale 4: The scientific method requires that the nurse evaluate potential solutions to a given
problem in an organized, formal, and systematic approach.
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: 5. Integrate strategies to enhance critical thinking and clinical reasoning as the
provider of nursing care.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 146
Question 15
Type: MCSA
The nurse systematically tries a variety of products to help with healing of a client’s wound. Which
problem–solving method is the nurse using?
1. Intuition
2. Scientific method
3. Research process
4. Trial and error
Correct Answer: 4
Rationale 1: Intuition is the learning of things without conscious use of reasoning—also known as the
sixth sense, hunch, or instinct.
Rationale 2: The scientific method is a formalized, systematic, and logical approach to solving
problems.
Rationale 3: The research process is a formalized, systematic, and logical approach to solving
problems.
Rationale 4: Trial and error is solving problems by utilizing a number of approaches. Trial-and-error
methods can be dangerous in nursing because the client might suffer harm if an approach is
inappropriate. In this case, the client may not suffer harm, but there will be no way to know if one
product used is effective because the nurse is changing them on a daily basis.
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. 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: 2. Describe the actions of clinical reasoning in the implementation of the nursing
process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 148
Question 16
Type: MCSA
A client with unstable cardiac dysrhythmias has orders for medications, one of which is by oral route,
the other by IV delivery. The nurse realizes that the IV route would be fastest, but is also concerned
about the side effects that this drug may produce and the fact that the client has never taken the
drug, so any adverse effect is unknown. Which part of the decision-making process is the nurse
using?
1. Identify the purpose
2. Seek alternatives
3. Project
4. Implement
Correct Answer: 2
Rationale 1: Identifying the purpose, in this case, would be determining that the client needs
intervention to control the dysrhythmia.
Rationale 2: In this step, the decision maker (nurse) identifies possible ways to meet the criteria.
Alternatives considered are which by route to give a certain medication: IV versus oral. The nurse is
utilizing his experience, taking what he knows about cardiac problems and pharmacology, and will
make a selection based on that information.
Rationale 3: Projecting is when the nurse applies creative thinking and skepticism to determine what
might go wrong as a result of a decision and develops plans to prevent, minimize, or overcome any
problems.
Rationale 4: Implementation is taking the plan into action.
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. 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: 4. Describe the components of clinical reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 146
Question 17
Type: MCSA
Prior to providing client care, the nurse reviews previous shift charting and the responses to nursing
interventions. Which decision-making action is the nurse using?
1. Set the criteria
2. Examine alternatives
3. Implement
4. Evaluate the outcome
Correct Answer: 4
Rationale 1: Setting criteria is based on three questions: What is the desired outcome? What needs
to be preserved? What needs to be avoided?
Rationale 2: Examining alternatives ensures that there is an objective rationale in relation to the
established criteria for choosing one strategy over another.
Rationale 3: Implementation is putting a plan into action.
Rationale 4: In evaluating, the nurse determines the effectiveness of the plan and whether the initial
purpose was achieved. In this situation, the nurse wants to determine what worked on the previous
shift and what didn’t. This will help with deciding on interventions for the client during the shift.
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: 4. Describe the components of clinical reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 150
Question 18
Type: MCSA
Parents ask why invasive diagnostic tests were prescribed for their ill child. The nurse has just
gotten out of report and has not had a chance to review additional information. What should the
nurse respond to the parents?
1. “I’m not sure I can answer your question just now.”
2. “It’s a good idea to listen to what your physician wants.”
3. “Your child’s doctor is the best there is. I don’t see why you wouldn’t follow his advice.”
4. “Maybe you should get another opinion if you’re not comfortable with your doctor.”
Correct Answer: 1
Rationale 1: Suspending judgment means tolerating ambiguity for a time. If an issue is complex, it
may not be resolved quickly and judgment should be postponed. In this case, the nurse just doesn’t
have enough information to give a good answer to the parents. For a while, the nurse will need to
say “I don’t know” and be comfortable with that answer.
Rationale 2: Telling the parents to agree with the physician before the nurse knows all the facts
might be premature, even if he is the best physician in the area.
Rationale 3: Nurses should not give advice or counsel.
Rationale 4: It would be premature to tell the parents to get another opinion.
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: 4. Describe the components of clinical reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 146
Question 19
Type: MCSA
A client complaining of “extreme” low back pain is pale and diaphoretic and walks bent at the waist.
Before taking vital signs, the nurse suspects that the blood pressure and heart rate will be
elevated. What thought process did the nurse use to come to this conclusion?
1. Fact
2. Inference
3. Judgment
4. Opinion
Correct Answer: 2
Rationale 1: A fact can be verified through investigation. In this case, facts would be the elevated
pulse and blood pressure readings.
Rationale 2: Inferences are conclusions drawn from facts, going beyond facts to make a statement
about something that is not currently known. In this case, acute, severe pain will most likely cause
the blood pressure as well as pulse rate to be elevated as the body’s response to the painful
experience.
Rationale Judgment is evaluating facts and information that reflect values or other criteria; it is a type
of opinion. Because the nurse understands the pathophysiology of pain, thinking about changes in
vital signs is more than a judgment—it is an inference.
Rationale 4: Opinions are beliefs formed over time and include judgments that may fit facts or be in
error.
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. 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: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical
reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 146
Question 20
Type: MCSA
The nurse completes collecting data from a client and determines a list of problems. Which step in
the nursing process should the nurse perform next?
1. Assess
2. Diagnose
3. Plan
4. Evaluate
Correct Answer: 3
Rationale 1: Assessment is the process of collecting data.
Rationale 2: Diagnosing is putting a label on the problem.
Rationale 3: The planning portion of the nursing process involves setting criteria, weighting the
criteria, and seeking/examining alternatives when compared to the decision-making process.
Rationale 4: Evaluating is reviewing the outcome.
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. 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: 2. Describe the actions of clinical reasoning in the implementation of the nursing
process.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 148
Question 21
Type: MCSA
While caring for a client of a different culture, the nurse becomes disturbed when the client’s spouse
makes all the decisions about care and treatments. What behavior is this nurse demonstrating?
1. Inference
2. Judgment
3. Opinion
4. Evaluation
Correct Answer: 3
Rationale 1: Inferences are conclusions drawn from the facts, going beyond facts to make a
statement about something not currently known.
Rationale 2: Judgment is an evaluation of facts or information that reflects values or other criteria.
Rationale 3: Opinions are beliefs formed over time and include judgments that may fit facts or be in
error. In this case, the nurse may not understand that, culturally, this may be very appropriate and
fitting for this client. If this is the case, the nurse should not become disturbed by the spouse’s
attention.
Rationale 4: Evaluation is considering the results or outcome.
Global Rationale:
Cognitive Level: Analyzing
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. 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: Assessment
Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical
reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 147
Question 22
Type: MCSA
The staff nurse asks why unlicensed assistive personnel are responsible for stocking the unit
refrigerator with refreshments when dietary personnel place the items on the shelf in the kitchen.
What characteristic of critical thinking is this nurse demonstrating?
1. Curiosity
2. Clinical reasoning
3. Setting priorities
4. Developing rationales
Correct Answer: 4
Rationale 1: Curiosity is questioning the status quo. The curious nurse may value tradition but is not
afraid to examine traditions to be sure they are still valid.
Rationale 2: Clinical reasoning is the analysis of a clinical situation as it unfolds or develops.
Rationale 3: Setting priorities is determining what needs to be completed in a specific order to
support client care needs.
Rationale 4: Developing rationales is when the nurse transfers nursing knowledge to the clinical
situation to justify the plan of care.
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: Assessment
Learning Outcome: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical
reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 151
Question 23
Type: MCSA
A clinical instructor senses that a student has been struggling with clinical skills learned in lab. To
combat this, the educator pairs the student with a staff nurse who has clients with a variety of
treatments and cares. Which type of problem solving is the instructor using?
1. Trial and error
2. Intuition
3. Research process
4. Experience
Correct Answer: 2
Rationale 1: Trial and error uses a number of approaches until a solution is found.
Rationale 2: Intuition is the understanding or learning of things without the conscious use of
reasoning. It is also known as the sixth sense, hunch, instinct, feeling, or suspicion. In this case, the
educator has a sense that the student is struggling, although there are no real facts to support it.
Rationale 3: The research process is a systematic, analytical, and logical way to problem solve.
Rationale 4: Experience is part of intuition, but by itself, not a particular way to problem solve.
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: Implementation
Learning Outcome: 2. Describe the actions of clinical reasoning in the implementation of the nursing
process.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 148
Question 24
Type: MCMA
The nurse desires to improve critical thinking skills when providing client care. On which attributes
should the nurse focus when developing these skills?
Standard Text: Select all that apply.
1. Independence
2. Egocentricity
3. Intellectual humility
4. Fair-mindedness
5. Confidence
6. Perseverance
Correct Answer: 1, 3, 4, 5, 6
Rationale 1: Attributes that foster critical thinking include independence.
Rationale 2: Attributes that foster critical thinking include insight into egocentricity (which is open to
the possibility that biases or social pressures and customs can affect one’s thinking) but not
egocentricity itself.
Rationale 3: Attributes that foster critical thinking include intellectual humility.
Rationale 4: Attributes that foster critical thinking include fair-mindedness.
Rationale 5: Attributes that foster critical thinking include confidence.
Rationale 6: Attributes that foster critical thinking include perseverance.
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: 4. Describe the components of clinical reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 148
Question 25
Type: MCMA
During a clinical conference, a staff nurse states that critical thinking is essential when providing
client care. What additional statements should this nurse make to support the use of critical thinking?
Standard Text: Select all that apply.
1. “Patient acuity is so much greater than it was even 10 years ago.”
2. “Care delivery systems are only as good as the nurses delivering care.”
3. “Nurses have always relied on commonsense thinking to provide quality, appropriate nursing
care.”
4. “With health care being so expensive, nursing has to take on responsibility to keep the costs
controlled.”
5. “My practice involves caring for clients who require care that didn’t even exist when I went to
school.”
Correct Answer: 1, 2, 4, 5
Rationale 1: Patients are sicker, with multiple problems, and so nursing care requires a more critical
form of thinking in order to meet their nursing needs.
Rationale 2: Redesigning care delivery is useless if nurses don’t have the thinking skills required to
deal with today’s world.
Rationale 3: Although this might be true, medicine and nursing have evolved tremendously, and so
has the need for nurses to be critical thinkers.
Rationale 4: Consumers and payers demand to see evidence of benefits, efficiency, and results.
Rationale 5: Today’s progress often creates new problems that can’t be solved by old ways of
thinking.
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: 1. Describe the significance of developing critical thinking abilities in order to
practice safe, effective, and professional nursing care.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 144
Question 26
Type: MCMA
The nurse manager determines that a new staff nurse is demonstrating characteristics of a critical
thinker. What did the manager observe the nurse perform?
Standard Text: Select all that apply.
1. Listening with empathy to a client who recently has been diagnosed.
2. Waiting for the medical team to determine the focus of the client’s supportive care.
3. Questioning a medication order that does not appear to meet the client’s needs for pain
management.
4. Exhibiting a willingness to try alternate methods of addressing a client’s care needs.
5. Practicing nursing in a culturally competent fashion.
Correct Answer: 1, 3, 4, 5
Rationale 1: Empathetic listening shows the ability to imagine others’ feelings and difficulties, which
is characteristic of critical thinking.
Rationale 2: Proactive anticipation of consequences, planning ahead, and acting as opportunities
and events require are characteristic of real thinking.
Rationale 3: Courageously advocating for others demonstrates attributes characteristic of critical
thinking.
Rationale 4: Flexible changing of approaches as needed to get the best results is a characteristic of
critical thinking.
Rationale 5: Sensitivity to diversity, expressing appreciation of human differences related to values
and culture, is a characteristic of critical thinking.
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: 3. Discuss the attitudes and skills needed to develop critical thinking and clinical
reasoning.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Page Number: 146
New Questions:
Question 27
Type: MCMA
The staff nurse is helping a new graduate understand the relationship between care concepts and
planned interventions. What value would it be for the staff nurse to encourage the new graduate to
use a concept map?
Standard Text: Select all that apply.
1. Used to highlight key areas
2. Provides a visual representation
3. Can be quicker than taking notes
4. Takes years to study how to create
5. Aids in developing critical thinking
Correct Answer: 1, 2, 3, 5
Rationale 1: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear
relationships to represent critical thinking. A general benefit is that it highlights key areas.
Rationale 2: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear
relationships to represent critical thinking. Concept maps provide an opportunity to visualize things.
Rationale 3: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear
relationships to represent critical thinking. A general benefit of these maps is that they are quicker
than note taking.
Rationale 4: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear
relationships to represent critical thinking. It is easy to learn and does not take years of study.
Rationale 5: Concept mapping is a technique that uses a graphic depiction of nonlinear and linear
relationships to represent critical thinking. Also known as mind maps, concept maps are context
dependent and can be used to develop analytical skills. The attributes of the concept are linked,
making meaning of the concept they represent.
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: Planning
Learning Outcome: 6. Describe the process of concept mapping to enhance critical thinking and
clinical reasoning for the provision of nursing care.
MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing
process.
Chapter 11
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
Chapter 12
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 12
Question 1
Type: MCSA
After an assessment, the nurse reviews the list of client problems. For which problems should the
nurse create nursing diagnoses?
1. The ones that the nurse is licensed to treat
2. The ones that address other health professionals’ interventions
3. The ones that focus on the client’s primary illness
4. The ones that have standardized care available
Correct Answer: 1
Rationale 1: The domain of nursing diagnoses includes only those health states that nurses are
educated on and licensed to treat. A nursing diagnosis is a judgment made only after data collection.
Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk
factors, and areas of enhanced personal growth.
Rationale 2: A nursing diagnosis, although familiar to other health care professionals, is nursing
focused.
Rationale 3: The nursing diagnosis statement is specific to nursing and nurses and does not include
the medical diagnosis.
Rationale 4: The nursing diagnosis, like the plan of care, is specific to each individual client and the
client’s situation.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 177
Question 2
Type: MCSA
A client comes to the clinic seeking information and education regarding healthy lifestyles and eating
habits. Which type of diagnosis should the nurse select for this client?
1. Risk nursing diagnosis
2. Syndrome diagnosis
3. Wellness diagnosis
4. Actual diagnosis
Correct Answer: 3
Rationale 1: A risk diagnosis is a clinical judgment that a problem does not exist, but the presence of
risk factors indicates that a problem is likely to develop unless nurses intervene—that is not what is
described in this scenario.
Rationale 2: A syndrome diagnosis is associated with a cluster of other diagnoses—that is not what
is described in this scenario.
Rationale 3: A wellness diagnosis describes the human response to levels of wellness in an
individual. This client is seeking information about behavior changes and improvement to assist him
in making choices and changes to enhance his life.
Rationale 4: An actual diagnosis is a client problem that is present at the time of the nursing
assessment.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: II.B. 4. Function competently within own scope of practice as a member of the
health care team
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 1. Differentiate nursing diagnoses according to status.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 183
Question 3
Type: MCSA
A client who has been in a wheelchair for several years is currently experiencing problems with skin
breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select
for this client?
1. Syndrome diagnosis
2. Risk nursing diagnosis
3. Actual diagnosis
4. Wellness diagnosis
Correct Answer: 1
Rationale 1: A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses
(in this situation, Urinary elimination alteration, Impaired skin integrity, and Powerlessness).
Rationale 2: A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the
presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes.
Rationale 3: An actual diagnosis is a client problem that is present at the time of the nursing
assessment.
Rationale 4: A wellness diagnosis describes human responses to levels of wellness in an individual,
family, or community that has a readiness for enhancement.
Global Rationale:
Cognitive Level: Applying
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 1. Differentiate nursing diagnoses according to status.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 176
Question 4
Type: MCSA
The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the
NANDA label?
1. Must contain three components
2. Describes the health problem for which nursing therapy is given
3. Helps define medical diagnoses for nursing
4. Promotes a taxonomy of nursing
Correct Answer: 4
Rationale 1: The diagnosis contains three components: the problem and its definition, the etiology,
and the defining characteristics.
Rationale 2: The problem statement, or diagnostic label, describes the client’s health problem or
response for which nursing therapy is given.
Rationale 3: The nursing diagnosis is not equated with or defined by medical diagnoses.
Rationale 4: The purpose of the NANDA label is to define, refine, and promote a taxonomy of
nursing diagnostic terminology of general use to professional nurses. This label describes the health
problem or response by the client for which nursing therapy is given.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 2. Identify the components of a nursing diagnosis.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 176
Question 5
Type: MCSA
An experienced nurse has just walked into the room of a newly assigned client. Which observation
should the nurse use to include a new nursing diagnosis in this client’s plan of care?
1. The client’s eyes are closed.
2. The client’s skin is pale and mottled.
3. The client’s spouse is asleep in the chair next to the bed.
4. The television is on and the volume is turned up.
Correct Answer: 2
Rationale 1: Nurses draw on knowledge and experience to compare client data to standards and
norms and to identify significant and relevant observations. A sleeping client would not necessarily
be recognized as a significant or relevant observation.
Rationale 2: Nurses draw on knowledge and experience to compare client data to standards and
norms and to identify significant and relevant observations. An observation is considered significant
if it points to changes in the client’s health status or pattern, varies from norms of the client
population, or indicates a developmental delay. Pale, mottled skin could indicate coldness, a
problem with circulation, or even death.
Rationale 3: Nurses draw on knowledge and experience to compare client data to standards and
norms and to identify significant and relevant cues. A client’s spouse asleep in a chair would not
necessarily be recognized as a significant or relevant observation.
Rationale 4: Nurses draw on knowledge and experience to compare client data to standards and
norms and to identify significant and relevant cues. A television playing loudly would not necessarily
be recognized as a significant or relevant observation.
Global Rationale:
Cognitive Level: Applying
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 1. Differentiate nursing diagnoses according to status.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 178
Question 6
Type: MCSA
The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family.
Which data cluster did the nurse use to support this diagnosis?
1. The family visits different congregations, the parents have been reflecting on their own spiritual
upbringings, and the children are questioning rituals of their friends and friends’ families.
2. The children attend Sunday school classes, one parent always attends services with the children,
and the parents attempt interaction with congregational activities.
3. The grandparents go to weekly services and have formal interaction with clergy.
4. The children have attended private, religious schools, and the parents are involved in the school’s
activities.
Correct Answer: 1
Rationale 1: A wellness diagnosis describes human responses to levels of wellness in an individual
family or community that has a readiness for enhancement or improvement. The data cluster that
describes the questioning, searching, and reflecting would support an attitude of readiness.
Rationale 2: A wellness diagnosis describes human responses to levels of wellness in an individual
family or community that has a readiness for enhancement or improvement. This option merely
shows activities but no real interest in improvement.
Rationale 3: A wellness diagnosis describes human responses to levels of wellness in an individual
family or community that has a readiness for enhancement or improvement. This option merely
shows activities but no real interest in improvement on the part of only specific family members.
Rationale 4: A wellness diagnosis describes human responses to levels of wellness in an individual
family or community that has a readiness for enhancement or improvement. This option merely
shows activities but no real interest in improvement.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1. Differentiate nursing diagnoses according to status.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 176
Question 7
Type: MCSA
The graduate nurse is struggling with identifying cues from clustered data. What should the nurse
use to recognize data patterns and cues?
1. Depend on knowledge gained from peers’ experiences.
2. Work with seasoned and experienced nurses and learn from them.
3. Take assessment notes and utilize information from textbooks for comparison.
4. Know that this will take time, and experience is the best teacher.
Correct Answer: 3
Rationale 1: Learning from peers is helpful, but does not take the place of didactic information.
Rationale 2: Learning from seasoned nurses is helpful, but does not take the place of didactic
information.
Rationale 3: The novice nurse must take careful assessment notes, search data for abnormal cues,
and use textbook resources for comparing the client’s cues with the defining characteristics and
etiologic factors of the accepted nursing diagnoses.
Rationale 4: Experience teaches much information, but it never takes the place of concrete, scientific
theory.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify the basic steps in the diagnostic process.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 179
Question 8
Type: MCSA
The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for
a client with chronic asthma. In looking at the client’s coping skills, the nurse realizes that the client
has a vast knowledge about the disease and what exacerbates symptoms in particular
situations. Why should the nurse utilize this information?
1. Strengths can be an aid to mobilizing health and the healing process.
2. The client will be more active in the plan.
3. It will be easier for the nurse to educate the client about other interventions.
4. The nurse won’t have to spend time going over the pathology of the client’s disease.
Correct Answer: 1
Rationale 1: Establishing strengths, resources, and ability to cope will help the client develop a more
well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and
regenerative processes.
Rationale 2: The client may be more active in the plan; however, this does not explain why the client
will be more active.
Rationale 3: Looking at what will be easier for the nurse is not the reason strengths are included in
the client’s plan.
Rationale 4: Looking at what will be time effective for only the nurse is not the reason strengths are
included in the client’s plan.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify the basic steps in the diagnostic process.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 181
Question 9
Type: MCSA
A client has been having pain without any clear pathology for cause. Which nursing diagnosis should
the nurse identify as being the most appropriate for this client?
1. Pain due to unknown factors
2. Pain related to unknown etiology
3. Pain caused by psychosomatic condition
4. Pain manifested by client’s report
Correct Answer: 2
Rationale 1: The second part of the nursing diagnosis statement is the etiology (E)—the factors
contributing to or probable causes—and should be joined to the first part, the problem (P), by the
words “related to” rather than “due to.”
Rationale 2: The second part of the nursing diagnosis statement is the etiology (E)—the factors
contributing to or probable causes—and should be joined to the first part, the problem (P), by the
words “related to” rather than “due to.” The phrase “related to” implies a relationship between the
problem and the cause. In this situation, the cause is unknown, but the problem is evident.
Rationale 3: Making an assumption that the cause is psychosomatic is not within the nurse’s scope
of practice.
Rationale 4: The third part of the nursing diagnosis statement is manifested by the (S) portion, which
includes the signs and symptoms, not a generalized statement.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 1. Differentiate nursing diagnoses according to status.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 182
Question 10
Type: MCSA
A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing
diagnosis should the nurse identify as a priority for this client?
1. Altered oral mucous membranes, related to dry mouth
2. Activity intolerance, related to oxygen supply imbalance
3. Knowledge deficit, related to medication regimen
4. Ineffective airway clearance, related to increased secretions
Correct Answer: 4
Rationale 1: Prioritizing care must begin with the basic needs. This option is appropriate but does
not match the primary need.
Rationale 2: Prioritizing care must begin with the basic needs. This option is appropriate but does
not match the primary need.
Rationale 3: Prioritizing care must begin with the basic needs. This option is appropriate but does
not match the primary need.
Rationale 4: Prioritizing care must begin with the basic needs, in this case, the airway.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 1. Differentiate nursing diagnoses according to status.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 185
Question 11
Type: MCSA
The nurse is caring for a client recovering from a long and difficult childbirth experience. Which
nursing diagnosis did the nurse write appropriately for this client?
1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days
2. Risk for infection, because of new incision, related to episiotomy
3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion
4. Altered urinary elimination, secondary to childbirth
Correct Answer: 3
Rationale 1: “Manifested” is not appropriate wording of the NANDA statement.
Rationale 2: “Because of” is not appropriate wording of the NANDA statement.
Rationale 3: The problem statement is listed first (NANDA label), followed by the etiology—factors
that contribute to or are the cause of the client’s response. The two parts are joined by the
words “related to,” implying a relationship between the two. Adding a second part to the etiology
statement makes it more descriptive and useful.
Rationale 4: The problem statement is listed first (NANDA label), followed by the etiology—factors
that contribute to or are the cause of the client’s response—which is lacking in this option.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 182
Question 12
Type: MCSA
The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric
problems, beginning in childhood, who is being placed in a long-term, structured institutional
environment. Which diagnosis indicates the client’s problem is adequately described?
1. Chronic low self-esteem, related to factors too numerous to mention
2. Risk for self-harm, related to many psychiatric problems
3. Impaired social interaction, due to long history of institutionalization
4. Alteration in thought processes, related to complex factors
Correct Answer: 4
Rationale 1: This option poorly describes the causing factors.
Rationale 2: This option poorly describes the causing factors.
Rationale 3: This option limits the description of causing factors.
Rationale 4: The phrase “complex factors” may be used when there are too many etiologic factors or
when they are too complex to state in a brief phrase. The actual cause of this client’s altered thought
process may be due to psychiatric diagnoses, medication tolerances and noncompliance, history of
institutionalization, and life history of mental disease. This is a variation of the basic two-part
statement, but is acceptable to use.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 182
Question 13
Type: MCSA
After communicating with the client and family, the nurse compares a client’s problem list with
identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors?
1. Understanding what is normal vs. what is not normal
2. Verifying
3. Consulting resources
4. Basing diagnoses on patterns
Correct Answer: 2
Rationale 1: Nurses must apply knowledge from various areas to recognize cues and patterns to
understand what is normal and not normal. This comes from principles of chemistry, anatomy, and
pharmacology—not the client or the family.
Rationale 2: The nurse, while taking the information and collecting data, begins to hypothesize
possible explanations of the data and then realizes all diagnoses are only tentative until they are
verified. The client and family should be included in the beginning and also at the end of the
diagnostic process to verify the nurse’s diagnoses.
Rationale 3: Both novices and experienced nurses should consult appropriate resources whenever
in doubt about a diagnosis; that is not what is described in the scenario.
Rationale 4: Diagnoses should be based on patterns and behavior over time, not an isolated
incident.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 184
Question 14
Type: MCSA
After formulating several diagnoses, the nurse does not understand the reason for some of the
discrepancies in the client’s lab values and diagnostic tests, when comparing to norms and
standards. Which action should the nurse take?
1. Verify the information with the client.
2. Compare all findings to the national norms and standards.
3. Consult other professionals and colleagues.
4. Improve critical thinking skills so answers come more easily.
Correct Answer: 3
Rationale 1: Verifying the information with the client would be inappropriate because the information
does not come from subjective data, but rather from testing and lab values.
Rationale 2: The nurse already has compared the findings to the norms and standards.
Rationale 3: Both novices and experienced nurses should consult appropriate resources whenever
in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are
all appropriate resources.
Rationale 4: Critical-thinking skills help the nurse be aware of and avoid errors. This comes with
experience and is a learned and practiced process.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify the basic steps in the diagnostic process.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 184
Question 15
Type: MCSA
The nurse has completed the initial assessment of a client and has analyzed and clustered the
data. What should the nurse complete next in the diagnostic process?
1. Formulate a diagnosis.
2. Verify the data.
3. Research collaborative and nursing-related interventions.
4. Identify the client’s problem, health risks, and strengths.
Correct Answer: 4
Rationale 1: There are steps in the process that precede the formulation of diagnostic statements.
Rationale 2: Verifying the data should be done at the end of the assessment/interview phase.
Rationale 3: Researching collaborative and nursing-related interventions comes after setting goals or
outcomes and is not part of the diagnostic process, but rather part of the implementation phase.
Rationale 4: The step that follows data analysis is identification of the client’s health problems, health
risks, and strengths.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 4. Identify the basic steps in the diagnostic process.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 179
Question 16
Type: MCSA
The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and
debilitation, manifested by reports of fatigue after any physical activity. What is the defining
characteristic of this label?
1. Activity intolerance
2. Weakness and debilitation
3. Reports of fatigue
4. Physical activity
Correct Answer: 3
Rationale 1: “Activity intolerance” is the NANDA label and identifies the problem, but “reports of
fatigue” is the defining characteristic.
Rationale 2: “Weakness and debilitation” are the etiology (underlying cause), but “reports of
fatigue” is the defining characteristic.
Rationale 3: The defining characteristics are those reports given by the client, or the signs and
symptoms.
Rationale 4: “Physical activity” is what brings on the reports of the defining
characteristic, but “reports of fatigue” is the defining characteristic.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 2. Identify the components of a nursing diagnosis.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 182
Question 17
Type: MCSA
A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse
has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process,
manifested by restlessness and tachycardia. What is the etiology of this diagnosis?
1. Unfamiliarity of disease process
2. Anxiety
3. Restlessness
4. Tachycardia
Correct Answer: 1
Rationale 1: The etiology is the underlying cause and a contributing factor of the client’s response. In
this case, the uncertainty of the diagnosis, fear of the unknown, and response to the diagnosis cause
the client to become anxious and upset.
Rationale 2: “Anxiety” is the NANDA label—the problem identified.
Rationale 3: “Restlessness” is a defining characteristic that the client exhibits.
Rationale 4: “Tachycardia” is a defining characteristic that the client exhibits.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 2. Identify the components of a nursing diagnosis.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 182
Question 18
Type: MCSA
The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to
infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing
an acute myocardial infarction. Which collaborative action would be appropriate for this client?
1. Provide a calm, quiet atmosphere in the client’s room.
2. Administer pain medication.
3. Educate the client and family regarding treatment and therapies.
4. Monitor for changes in the client’s condition.
Correct Answer: 2
Rationale 1: This option is not collaborative but rather nurse mediated, which the nurse can
implement independently.
Rationale 2: Collaboration occurs between the nurse, physician, and other health care professionals
to treat the client’s problem. In this case, the physician prescribes medications, and the nurse
administers them—a primarily dependent action that requires physician orders.
Rationale 3: This option is not collaborative but rather nurse mediated, which the nurse can
implement independently.
Rationale 4: This option is not collaborative but rather nurse mediated, which the nurse can
implement independently.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Differentiate nursing diagnoses according to status.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 183
Question 19
Type: MCMA
The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic
practice, secondary to current living conditions for a client. Which data did the nurse use to support
this diagnosis?
Standard Text: Select all that apply.
1. The client has dry, cracked skin.
2. The client has one large and several smaller open, ulcerated areas on his right leg.
3. The client does not drive.
4. The client states that he does not use alcohol or drugs.
5. The client’s clothes are soiled.
6. The client has obvious body odor.
Correct Answer: 1, 2, 5, 6
Rationale 1: Data that support this problem are clustered around the condition of the client’s skin.
Rationale 2: Data that support this problem are clustered around the condition of the client’s skin.
Rationale 3: The fact that the client does not drive does not play a part in this client’s skin condition.
Rationale 4: The fact that the client does not use alcohol or drugs does not play a part in this client’s
skin condition.
Rationale 5: Data that support this problem are clustered around the condition of the client’s clothes.
Rationale 6: Data that support this problem are clustered around the condition of the client’s general
appearance.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 4. Identify the basic steps in the diagnostic process.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 179
Question 20
Type: MCSA
The nurse is reviewing information about the formulation of nursing diagnoses. What should the
nurse identify as the area in which nursing diagnoses differ from medical diagnoses and
collaborative problems?
1. Mental status of the client
2. Chronic nature of the illness
3. Nursing care focus
4. Prognosis
Correct Answer: 3
Rationale 1: This is not considered and so is not an area of difference.
Rationale 2: This is not considered and so is not an area of difference.
Rationale 3: Nursing focus is an area that differs.
Rationale 4: This is not considered and so is not an area of difference.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 3. Compare nursing diagnoses, medical diagnoses, and collaborative problems.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 176
Question 21
Type: MCMA
The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize
are coded within this system?
Standard Text: Select all that apply.
1. Gordon’s health pattern groupings
2. Age
3. Time
4. Health status
5. Gender
6. Location
Correct Answer: 2, 3, 4, 6
Rationale 1: The diagnoses are no longer grouped by Gordon’s patterns.
Rationale 2: The Taxonomy II system codes diagnoses according to seven axes that include age.
Rationale 3: The Taxonomy II system codes diagnoses according to seven axes that include time.
Rationale 4: The Taxonomy II system codes diagnoses according to seven axes that include health
status.
Rationale 5: Gender is not an axis upon which diagnoses are coded.
Rationale 6: The Taxonomy II system codes diagnoses according to seven axes that
includes location.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 5. Describe various formats for writing nursing diagnoses.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 185
Question 22
Type: MCMA
The nurse is reviewing assessment data collected for a client’s care plan. What criteria should the
nurse use when formulating this client’s nursing diagnoses?
Standard Text: Select all that apply.
1. Nonjudgmental statements
2. Stated in terms of a need
3. Must be legally advisable
4. Cause/effect correctly stated
5. Medical terminology used to describe the cause
6. Diagnosis worded specifically and precisely
Correct Answer: 1,3,4,6
Rationale 1: This option reflects an accepted guideline for formulating nursing diagnoses.
Rationale 2: A nursing diagnosis statement must be stated in terms of a problem, not a need.
Rationale 3: This option reflects an accepted guideline for formulating nursing diagnoses.
Rationale 4: This option reflects an accepted guideline for formulating nursing diagnoses.
Rationale 5: Nursing terminology rather than medical terminology is used to describe the client’s
response and the probable cause of the client’s response.
Rationale 6: This option reflects an accepted guideline for formulating nursing diagnoses.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 6. List guidelines for writing a nursing diagnosis statement.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 184
Question 23
Type: MCSA
The nurse wants to propose a new nursing diagnosis. What action should the nurse take first?
1. Using the proposed nursing diagnosis when constructing client care plans
2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility
3. Submitting the diagnosis to NANDA’s Diagnostic Review Committee
4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association)
meeting.
Correct Answer: 3
Rationale 1: This option is inappropriate because only approved nursing diagnoses should be used
to direct nursing care.
Rationale 2: This is not the appropriate method for having a new nursing diagnosis included for use.
Rationale 3: This is the recognized procedure for initiating the approval of a new nursing diagnosis.
Rationale 4: This option is inappropriate because nursing diagnoses are not a part of medical care.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I1.B. 4. 1. Elicit patient values, preferences and expressed needs as part of
clinical interview, implementation of care plan and evaluation of care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 7. Describe the evolution of the nursing diagnosis movement, including work
currently in progress.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 185
Question 24
Type: MCMA
The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing
client care?
Standard Text: Select all that apply.
1. Ineffective Breathing Pattern
2. Risk of Infection
3. Readiness for Enhanced Nutrition
4. Readiness for Enhanced Family Coping
5. Anxiety
Chapter 13
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 13
Question 1
Type: MCSA
A client is admitted to a comprehensive rehabilitation center for continuing care following a motor
vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with
the ongoing planning of this client’s care?
1. The admitting nurse
2. All nurses who work with the client
3. Everybody involved in this client’s care
4. The client and the client’s support system
Correct Answer: 3
Rationale 1: The continuation of the client’s care plan is not the sole responsibility of the admitting
nurse.
Rationale 2: Although this is true, there is another option that better answers the item.
Rationale 3: Planning is basically the nurse’s responsibility, but input from the client and support
persons is essential if a plan is to be effective. In this case, therapies from other disciplines
(occupational, physical, speech, etc.) would be involved because the client is in a comprehensive
rehabilitation center. The client’s support people and caregivers are also going to be involved in the
plan of care, but not exclusively.
Rationale 4: Although it is important for the client and the client’s support people and
caregivers to be involved in the plan of care, there is an option that better answers this item.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Identify activities that occur in the planning process.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 189
Question 2
Type: MCSA
A client is admitted for complications following a routine diagnostic procedure of the
colon. Which type of care plan will most likely be implemented for this client?
1. Informal nursing care plan
2. Formal nursing care plan
3. Standardized care plan
4. Individualized care plan
Correct Answer: 4
Rationale 1: An informal nursing care plan is a strategy for action that exists only in the nurse’s
mind; this does not meet the needs expressed in the item.
Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information
about the client’s care; this does not meet the needs expressed in the item.
Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of
clients with common needs.
Rationale 4: An individualized care plan is tailored to meet a specific client need that is not
addressed by the standardized care plan. In this situation, the client had complications following a
relatively routine procedure—something that is unplanned and a rare occurrence.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be
individualized and used in creating a comprehensive nursing care plan.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 190
Question 3
Type: MCSA
A client is scheduled for elective hip replacement and will be admitted postoperatively to the
orthopedic unit for care. What should the nurses use to help plan this client’s care?
1. Informal nursing care plan
2. Formal nursing care plan
3. Standardized care plan
4. Individualized care plan
Correct Answer: 3
Rationale 1: An informal nursing care plan is a strategy for action that exists in the nurse’s mind.
Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information
about the client’s care.
Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of
clients with common needs. For example, all clients undergoing hip replacement surgery would have
basic, similar needs or problems such as pain, skin integrity disruption, risk for infection, decreased
mobility, or risk for fall or injury.
Rationale 4: An individualized care plan is tailored to meet the unique needs of a specific client—
needs not addressed by the standardized plan.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be
individualized and used in creating a comprehensive nursing care plan.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 190
Question 4
Type: MCMA
The nurse being oriented to a new position is reviewing the hospital’s standards of care,
standardized care plans, protocols, policies, and procedures. For which reasons should the nurse
realize that these documents are being used by the nursing staff?
1. Making sure all clients have the same types of care
2. Ensuring that minimally accepted standards are met
3. Promoting efficient use of the nurse’s time
4. Eliminating care disparities among clients
5. Ensuring medication errors do not occur
Correct Answer: 2, 3
Rationale 1: Ensuring that all clients receive the same type of care is not appropriate, as care must
be individualized to meet the client’s needs.
Rationale 2: Standards of care, standardized care plans, protocols, policies, and procedures are
developed and accepted by the nursing staff in order to ensure that minimally acceptable criteria are
met.
Rationale 3: Standards of care, standardized care plans, protocols, policies, and procedures are
developed and accepted by the nursing staff in order to promote efficient use of nurses’ time by
removing the need to author common activities that are done repeatedly for many of the clients on a
nursing unit.
Rationale 4: Standardized documents will not eliminate care disparities among clients.
Rationale 5: Standardized documents will not ensure that medication errors do not occur.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be
individualized and used in creating a comprehensive nursing care plan.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 191
Question 5
Type: MCSA
The neonatal intensive care nurse implements several actions to prevent further complications in a
newly admitted premature infant. Which type of document did the nurse use to find these actions?
1. Standardized care plan
2. Protocol
3. Standards of care
4. Policy and procedure manual
Correct Answer: 2
Rationale 1: Standardized care plans are preprinted guides for the nursing care of a client who has a
need that arises frequently in the agency—or all nursing diagnoses associated with a particular
medical condition. In this situation, the nurse is not working from the written care plan, as the baby
has just been admitted.
Rationale 2: Protocols are preprinted to indicate the actions commonly required for a particular group
of clients. Protocols may include both physicians’ orders and nursing interventions.
Rationale 3: Standards of care describe nursing actions for clients with similar medical conditions
rather than individuals, and they describe achievable rather than ideal nursing care.
Rationale 4: Policies and procedures are developed to govern the handling of frequently occurring
situations.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be
individualized and used in creating a comprehensive nursing care plan.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 191
Question 6
Type: MCSA
A nurse in the intensive care unit consults unit policy and administers a routinely used medication to
a client admitted to the unit with severe hypotension. What did the nurse implement in this situation?
1. A STAT order
2. A one-time order
3. A prn order
4. A standing order
Correct Answer: 4
Rationale 1: A STAT order is one that must be carried out immediately.
Rationale 2: A one-time order is for an action to be done only once.
Rationale 3: “prn” is pro re nata–Latin for “as needed.”
Rationale 4: Standing orders are a written document about policies, rules, regulations, or orders
regarding client 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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be
individualized and used in creating a comprehensive nursing care plan.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 191
Question 7
Type: MCSA
According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives
alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home
care nurse do when setting priorities for this client?
1. Make sure that he or she is able to get to the client’s home.
2. Assist the client in finding an alternative plan for the achieving the therapy’s outcomes.
3. Tell the client that this therapy will be impossible to receive.
4. Make arrangements to have the client moved to a long-term care facility.
Correct Answer: 2
Rationale 1: Driving 80 miles two times a day may not be feasible, but perhaps there are other
alternatives that could be considered.
Rationale 2: The nurse must consider a variety of factors when assigning priorities, including
resources available to the nurse and client. Factors in this case include the distance between the
client’s home and the hospital and the fact that therapy is ordered on a twice–daily basis. Driving 80
miles two times a day may not be feasible, but perhaps there are other alternatives that could be
considered (e.g., a neighbor who might be willing to drive the client, or someone in the area who
may be able to assist with the therapy).
Rationale 3: Telling the client that the therapy is impossible is premature at this point in time.
Rationale 4: Making arrangements for the client to move is premature at this point in time.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5. Identify factors that the nurse must consider when setting priorities.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 195
Question 8
Type: MCSA
A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse
write appropriately?
1. Client will ambulate without a walker by 6 weeks.
2. Client will ambulate freely in house.
3. Client will not fall.
4. Client will have freer movement in daily activities.
Correct Answer: 1
Rationale 1: Desired outcomes are the more specific, observable criteria used to evaluate whether
the goals have been met. Ambulating without a walker by a certain date is specific as well as
measurable.
Rationale 2: Desired outcomes are the more specific, observable criteria used to evaluate whether
the goals have been met. “Ambulate freely” does not give a time frame; therefore it is not as specific.
Rationale 3: Desired outcomes are the more specific, observable criteria used to evaluate whether
the goals have been met. Goals stated as “will not fall” are too vague, have no time limit, and do not
give the nurse a good set of criteria to evaluate the goal.
Rationale 4: Desired outcomes are the more specific, observable criteria used to evaluate whether
the goals have been met. Having freer movement in daily activities is too vague.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8. Identify guidelines for writing goals/desired outcomes.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 197
Question 9
Type: MCSA
The nurse identifies for a client the nursing diagnosis “Fluid volume deficit, related to active fluid
loss, secondary to diarrhea.” What would be and appropriate goal statement for this diagnosis?
1. Client will drink more fluids by tomorrow.
2. Client will have good skin turgor.
3. Client will have moist mucous membranes.
4. Client will have intake of at least 1000 mL within 24 hours.
Correct Answer: 4
Rationale 1: The goal statement must be specific with observable outcomes in order for the nurse to
evaluate client progress. Modifiers like “more” could be more specific.
Rationale 2: The goal statement must be specific with observable outcomes in order for the nurse to
evaluate client progress. Modifiers like “good” could be more specific, and all options must have a
time frame for evaluating the desired performance.
Rationale 3: The goal statement must be specific with observable outcomes in order for the nurse to
evaluate client progress, and all options must have a time frame for evaluating the desired
performance.
Rationale 4: The goal statement must be specific with observable outcomes in order for the nurse to
evaluate client progress, and all options must have a time frame for evaluating the desired
performance. This option includes all necessary components.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8. Identify guidelines for writing goals/desired outcomes.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 197
Question 10
Type: MCSA
The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can
the nurse compare this taxonomy?
1. Nursing diagnosis statement
2. Planning portion of the care plan
3. Goal statement of the traditional care plan
4. Implementation phase of the care plan
Correct Answer: 3
Rationale 1: The nursing diagnosis statement must follow the NANDA format.
Rationale 2: Goal setting is part of the planning, but the NOC outcome is narrower in use than
general planning.
Rationale 3: The Nursing Outcomes Classification (NOC) describes client outcomes that respond to
nursing interventions seen in traditional care plans.
Rationale 4: Implementation is compared to the Nursing Interventions Classification (NIC) taxonomy.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 6. Discuss the Nursing Outcomes Classification, including an explanation of how
to use the outcomes and indicators in care planning.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 197
Question 11
Type: MCSA
The nurse is caring for a client with Parkinson’s disease who desires to improve fine motor
skills. Which statement should the nurse identify as an appropriate collaborative intervention for this
client?
1. Provide assistance as needed with dressing and grooming.
2. Provide assistive devices and educate client to use grab bar and large handled utensils.
3. Make sure lighting and space are adequate for client.
4. Administer medications to improve muscle tone.
Correct Answer: 2
Rationale 1: Providing assistance and attending to the client’s space would be independent
interventions.
Rationale 2: Collaborative interventions are actions the nurse carries out with other health team
members, such as physical therapists, social workers, dietitians, and physicians. Collaborative
nursing activities reflect the overlapping responsibilities of, and collegial relationships between,
health personnel. Providing assistive devices and educating on their proper use would fall into the
discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the
teaching and information.
Rationale 3: Collaborative interventions are actions the nurse carries out with other health team
members, such as physical therapists, social workers, dietitians, and physicians. Collaborative
nursing activities reflect the overlapping responsibilities of, and collegial relationships between,
health personnel. Attending to the client’s space would be an independent intervention.
Rationale 4: Administering medications would be a dependent intervention.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 201
Question 12
Type: MCSA
The nurse is reviewing interventions written for a client’s plan of care. Which intervention should the
nurse recognize as being dependent?
1. Repositioning the client every 2 hours
2. Assisting the client with transfers to the bathroom
3. Providing ongoing physical assessment, especially of the incisional sites
4. Administering medications for pain
Correct Answer: 4
Rationale 1: This is an example of an independent intervention: those activities that the nurse is
licensed to initiate on the basis of knowledge and skills.
Rationale 2: This is an example of an independent intervention: those activities that the nurse is
licensed to initiate on the basis of knowledge and skills.
Rationale 3: This is an example of an independent intervention: those activities that the nurse is
licensed to initiate on the basis of knowledge and skills.
Rationale 4: Dependent interventions are those activities carried out under the physician’s orders or
supervision or according to specified routines. The nurse is responsible for assessing the need for
and administering medications, but the physician prescribes them.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 201
Question 13
Type: MCSA
One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the
client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as
the modifier in this intervention?
1. 60 to 90 degrees during feeding times
2. Position in chair
3. Upright in a chair
4. Impaired swallowing
Correct Answer: 1
Rationale 1: Conditions or modifiers may be added to the verb to explain the circumstances under
which the behavior is to be performed. They explain what, where, when, or how. In this case,
defining “upright” as 60 to 90 degrees and “during feeding times” gives when this should be done.
Rationale 2: The word “position” is not descriptive enough for modifiers.
Rationale 3: The word “”upright” is not descriptive enough for modifiers.
Rationale 4: “Impaired swallowing” is the NANDA label.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered
care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 198
Question 14
Type: MCSA
A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility,
secondary to neurologic dysfunction. Which should the nurse identify as an observation
intervention?
1. Turn and reposition client every 2 hours.
2. Cushion bony prominences with soft foam while in bed.
3. Provide ongoing assessment for skin breakdown every shift.
4. Apply lotion to dry skin twice daily.
Correct Answer: 3
Rationale 1: Prevention interventions prescribe the care needed to avoid complications or reduce
risk factors. Turning and repositioning would help prevent any further skin breakdown.
Rationale 2: Prevention interventions prescribe the care needed to avoid complications or reduce
risk factors. Cushioning bony prominences would help prevent any further skin breakdown.
Rationale 3: Observations include assessments made to determine whether a complication is
developing as well as observations of the client’s responses to nursing and other therapies.
Assessment for skin breakdown would fall under this category.
Rationale 4: Application of lotion or other treatments to areas of skin impairment would be
considered a treatment intervention.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered
care
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 202
Question 15
Type: MCSA
The nurse wants to create an intervention to assist a client with ambulation. Which statement is the
most appropriate manner for the nurse to write this intervention?
1. Assist client with ambulation.
2. Ambulate with client, using a gait belt, twice daily for 15 minutes.
3. Make sure client understands the rationale for using the gait belt.
4. Client will ambulate in hallway twice daily.
Correct Answer: 2
Rationale 1: This option lacks some of the required components of a well–written intervention.
Rationale 2: A well-written intervention should include a verb, conditions, and modifiers, plus a time
element. Identifying what to do (ambulate), how to do it (with a gait belt), and how long (twice daily
for 15 minutes) is the most precise statement.
Rationale 3: This option lacks some of the required components of a well–written intervention.
Rationale 4: “Client will ambulate in the hallway” is a goal statement, not an intervention.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 201
Question 16
Type: MCSA
A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What
purpose will the implementation of this taxonomy serve?
1. Help the nurse with documentation of the care plan
2. Require that the nurse use sound judgment and knowledge of the client
3. Match nursing diagnoses to exact interventions
4. Help the nurse choose activities that are individualized to the client
Correct Answer: 2
Rationale 1: The NIC taxonomy may or may not help with documentation.
Rationale 2: The NIC taxonomy, like NOC, is similar to NANDA diagnoses—broadly stated
interventions that are standardized in language and generalized in nature. Each nursing diagnosis
contains suggestions for several interventions under the NIC taxonomy, and nurses must select the
appropriate interventions based on their judgment and knowledge of the client.
Rationale 3: Although it would utilize standard language for all nurses and offer suggestions of
interventions for each diagnosis, finding the most appropriate interventions still requires
individualization for each client.
Rationale 4: This taxonomy is general and standardized and must be tailored to fit the needs,
outcomes, and goals of the individual client.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10. Discuss the Nursing Interventions Classification, including an explanation of
how to use the interventions and activities in care planning.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 202
Question 17
Type: MCSA
The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a
client who experienced a cerebrovascular accident. Which intervention should the nurse identify as
including a rationale?
1. Have suction equipment available at all times.
2. Clear secretions from oral/nasal passageways as needed.
3. Keep client in low-Fowler’s position to prevent reflux.
4. Provide frequent assessment for presence of obstructive material in mouth and throat.
Correct Answer: 3
Rationale 1: A rationale is the scientific principle given as the reason for selecting a particular
nursing intervention. It helps explain “why” an intervention would be implemented. This intervention
does not explain “why” it is being done.
Rationale 2: A rationale is the scientific principle given as the reason for selecting a particular
nursing intervention. It helps explain “why” an intervention would be implemented. This intervention
does not explain “why” it is being done.
Rationale 3: A rationale is the scientific principle given as the reason for selecting a particular
nursing intervention. It helps explain “why” an intervention would be implemented. Keeping the client
in a position with the head elevated 30 to 45 degrees helps prevent the risk of reflux (food/liquids
returning up through the esophagus after having been swallowed).
Rationale 4: A rationale is the scientific principle given as the reason for selecting a particular
nursing intervention. It helps explain “why” an intervention would be implemented. This intervention
does not explain “why” it is being done.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 192
Question 18
Type: MCMA
The nurse manager is implementing computerized care plans for the care area. Which guidelines
should the manager emphasize when the staff is writing care plans?
Standard Text: Select all that apply.
1. Plans must be dated and signed.
2. Categories must have headings.
3. Plans must be specific.
4. Plans must include preventive care and health maintenance.
5. Plans must include interventions for ongoing assessment.
6. Plans are standardized and generalized for all clients.
Correct Answer: 1, 2, 3, 4, 5
Rationale 1: This is a recognized guideline when writing care plans.
Rationale 2: This is a recognized guideline when writing care plans.
Rationale 3: This is a recognized guideline when writing care plans.
Rationale 4: This is a recognized guideline when writing care plans.
Rationale 5: This is a recognized guideline when writing care plans.
Rationale 6: Care plans are not both standardized and generalized for all clients.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify essential guidelines for writing nursing care plans.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 194
Question 19
Type: MCMA
The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and
procedures for a multi-system health care facility. Why are these documents important to the nursing
staff when providing client care?
Standard Text: Select all that apply.
1. To make sure all clients have the same type of care
2. To ensure that minimally accepted standards of care are met
3. To promote efficient use of the nurse’s time
4. To eliminate care disparities among clients
5. To minimize health care costs
Correct Answer: 2, 3
Rationale 1: Although standardized approaches to care planning are common in many health care
agencies, ensuring that all clients receive the same type of care is not appropriate, as care must be
individualized to meet the client’s needs.
Rationale 2: Ensuring that minimally accepted standards of care are met is a reason for the actions
mentioned in the scenario.
Rationale 3: Ensuring that nurses’ time is used efficiently is a reason for the actions mentioned in
the scenario.
Rationale 4: Not all clients require the same care, and so disparities are not a concern.
Rationale 5: Although cost containment is important, it is not the focus of standardized approaches
to care planning.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be
individualized and used in creating a comprehensive nursing care plan.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 190
Question 20
Type: MCMA
The nurse is devising a care plan for a client with complex health issues and current acute health
problems. Which criteria should the nurse ensure is used when planning interventions for this client?
Standard Text: Select all that apply.
1. Congruent with the client’s values, beliefs, and culture
2. Are within established standards of care
3. Based on scientific and medical knowledge
4. Achievable with the resources available
5. Must be safe and appropriate for the client’s age
Correct Answer: 1, 2, 4, 5
Rationale 1: This is a recognized guideline.
Rationale 2: This is a recognized guideline.
Rationale 3: The plan must be based on nursing knowledge and experience or knowledge from
relevant sciences (based on rationale).
Rationale 4: This is a recognized guideline.
Rationale 5: This is a recognized guideline.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 201
Question 21
Type: MCMA
The nurse is reviewing a client’s plan of care. Which statements indicate that this care plan has been
completed accurately and appropriately?
Standard Text: Select all that apply.
1. Ineffective coping related to drug abuse as evidenced by drug overdose.
2. The client will identify two healthy coping mechanisms by time of discharge.
3. The client has identified two health coping mechanisms to replace inappropriate drug use.
4. The client will be provided with guidance in identifying healthy coping mechanisms.
5. The client has apologized to his family for drug abuse behaviors.
Correct Answer: 1, 2, 3, 4
Rationale 1: The care plan is often organized into sections that include nursing diagnoses.
Rationale 2: The care plan is often organized into sections that include goals/outcomes.
Rationale 3: The care plan is often organized into sections that include evaluations.
Rationale 4: The care plan is often organized into sections that include nursing interventions.
Rationale 5: Although this might be a desirable behavior, it is not written as a goal.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Identify essential guidelines for writing nursing care plans.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 198
Question 22
Type: MCMA
The nurse attends an educational program that provides information about the Nursing Intervention
Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been
effective?
Standard Text: Select all that apply.
1. “I can look up interventions according to the nursing diagnosis that I’ve selected.”
2. “The interventions connected to a diagnosis are appropriate for any client with that diagnosis.”
3. “If there is a NANDA diagnosis, I should be able to find some appropriate interventions.”
4. “Care plans are best written when the interventions are broad and flexible.”
5. “I find NIC interventions a really good place to start when I’m working on client interventions.”
Correct Answer: 1, 3, 5
Rationale 1: The nurse can look up a client’s nursing diagnosis to see which nursing interventions
are suggested.
Rationale 2: Each nursing diagnosis contains suggestions for several interventions, so nurses need
to select the appropriate interventions based on their judgment and knowledge of the client.
Rationale 3: All NIC interventions have been linked to NANDA nursing diagnostic labels.
Rationale 4: When writing individualized nursing interventions on a care plan, the nurse should
record customized activities rather than broad intervention labels.
Rationale 5: Not all activities suggested for the intervention would be needed for every client, so the
nurse chooses the activities appropriate for the client and individualizes them to fit the supplies,
equipment, and other resources available in the agency.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 10. Discuss the Nursing Interventions Classification, including an explanation of
how to use the interventions and activities in care planning.
MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing
process.
Page Number: 202
New Questions:
Question 23
Type: MCMA
The nurse is collecting information to plan care for a client with a heart problem. Which information
indicates that planning for this client’s discharge was started by the nurse?
Standard Text: Select all that apply.
1. The client is scheduled for cardiac catheterization and echocardiogram.
2. Recent laboratory data indicates the development of heart failure.
3. The client does not have a scale to perform daily weights at home.
4. The client’s spouse has care needs that the client will not be able to complete going forward.
5. The client is pleasant and eager to learn how to control newly diagnosed health problem.
Correct Answer: 3, 4
Rationale 1: The client’s current treatment plan is not a part of discharge planning.
Rationale 2: The client’s current health status is not a part of discharge planning.
Rationale 3: Effective discharge planning begins at first client contact and involves comprehensive
and ongoing assessment to obtain information about the client’s ongoing needs. The lack of a scale
at home for daily weights indicates that the nurse is planning ahead for the client’s needs once
discharged.
Rationale 4: Effective discharge planning begins at first client contact and involves comprehensive
and ongoing assessment to obtain information about the client’s ongoing needs. Concern about the
client’s activity level at home indicates planning ahead for the client’s needs once discharged.
Rationale 5: The client’s personality and desire to learn more about the health problem is not a part
of discharge planning.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Chapter 14
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 14
Question 1
Type: MCSA
The home health nurse uses creativity and critical thinking to devise a way for a client to receive
intravenous medication while sitting outside on the porch. Which skill did the nurse use for this
situation?
1. Technical
2. Interpersonal
3. Creativity
4. Cognitive
Correct Answer: 4
Rationale 1: Technical skills are “hands-on” skills such as manipulating equipment, giving injections,
bandaging, and moving, lifting, and repositioning clients.
Rationale 2: Interpersonal skills are all of the activities, verbal and nonverbal, people use when
interacting directly with one another.
Rationale 3: Creativity is part of cognitive skill.
Rationale 4: Cognitive skills include problem solving, decision making, critical thinking, and creativity.
Finding a unique way to provide the treatment while keeping the client’s wishes in mind is an
example of the nurse using cognitive abilities.
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. 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: 2. Describe three categories of skills used to implement nursing interventions.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 208
Question 2
Type: MCSA
A home care client must correctly self-administer insulin injections before being discharged from the
agency. On what skill is this client being evaluated?
1. Technical
2. Cognitive
3. Interpersonal
4. Academic
Correct Answer: 1
Rationale 1: Technical skills are “hands-on” skills such as manipulating equipment, giving injections,
bandaging, and moving, lifting, and repositioning clients. These skills can also be called tasks,
procedures, or psychomotor skills.
Rationale 2: Cognitive skills are intellectual skills that involve problem solving, decision making,
critical thinking, and creativity.
Rationale 3: Interpersonal skills are necessary for nursing activities: caring, comforting, advocating,
referring, counseling, and supporting, to name a few.
Rationale 4: Academic skills would fall under the category of cognitive skills.
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. 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: 2. Describe three categories of skills used to implement nursing interventions.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 209
Question 3
Type: MCSA
The nurse provides care to clients admitted to a mental health facility who exhibit paranoid behavior.
Which skill should the nurse use when caring for these clients?
1. Cognitive
2. Interpersonal
3. Technical
4. Therapeutic
Correct Answer: 2
Rationale 1: Cognitive skills are intellectual skills and include problem solving, decision making,
critical thinking, and creativity.
Rationale 2: Interpersonal skills are all of the activities, verbal and nonverbal, people use when
interacting directly with one another. The effectiveness of a nursing action often depends largely on
the nurse’s ability to communicate with others. Interpersonal skills are necessary for all nursing
activities, including comforting, counseling, and supporting—all of which are extremely important in
the acute psychiatric setting.
Rationale 3: Technical skills are “hands-on” skills such as manipulating equipment, giving injections,
bandaging, and repositioning clients.
Rationale 4: All nursing skills should be therapeutic.
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. 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: 2. Describe three categories of skills used to implement nursing interventions.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 209
Question 4
Type: MCMA
The nurse is preparing to provide care planned for a client. What actions should the nurse complete
during this phase of client care?
1. Evaluating the outcome of the interventions
2. Reassessing the client
3. Documenting the history and physical
4. Supervising delegated care
5. Implementing the nursing interventions
Correct Answer: 2, 4, 5
Rationale 1: Evaluating the outcome of the interventions is part of the evaluation phase.
Rationale 2: Other components of the implementation process include reassessing the client.
Rationale 3: Documentation of the history and physical is part of the initial assessment.
Rationale 4: Other components of the implementation process include supervising delegated care.
Rationale 5: Other components of the implementation process include implementing the nursing
interventions.
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. 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: 3. Discuss the five activities of the implementing phase.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 209
Question 5
Type: MCSA
Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of
them, offering presence and listening to their fears instead of providing the planned education. What
action did the nurse perform?
1. Implementing nursing intervention
2. Determining the nurse’s need for assistance
3. Supervising delegated care
4. Reassessing the client
Correct Answer: 4
Rationale 1: In this case, the client and the spouse are not in a good frame of mind to listen to or
retain any kind of teaching/learning experience and so the planned intervention should not be
initiated.
Rationale 2: In this situation, the nurse does not need assistance.
Rationale 3: This is not a situation where the nurse must supervise care that has been delegated.
Rationale 4: Just before implementing an intervention, the nurse must reassess the client to make
sure the intervention is still needed or to discover if there are new data that indicate a need to
change the priorities of care. In this case, the client and the spouse are not in a good frame of mind
to listen to or retain any kind of teaching/learning experience. Instead, the nurse reassesses the
situation and implements a more appropriate intervention.
Global Rationale:
Cognitive Level: Analyzing
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. 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: Assessment
Learning Outcome: 3. Discuss the five activities of the implementing phase.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 209
Question 6
Type: MCSA
The nurse is caring for a new mother and infant. Which action should the nurse take that
allows the new parents to feel in control when being taught how to bathe their infant?
1. Telling the parents everything the nurse is doing and why
2. Letting the parents watch a video after the bath
3. Letting the parents bathe the baby with direction and guidance from the nurse
4. Giving lots of advice and suggestions about different methods
Correct Answer: 3
Rationale 1: Explaining is helpful, but does not provide the clients with a sense of independence and
control in the situation.
Rationale 2: Active participation enhances a client’s sense of independence and control. In this
situation, the baby and parents will do best with future bathing times if they are allowed to complete
the bath themselves. Watching a video is helpful, but does not provide the clients with a sense of
independence and control in the situation.
Rationale 3: Active participation enhances a client’s sense of independence and control. In this
situation, the baby and parents will do best with future bathing times if they are allowed to complete
the bath themselves.
Rationale 4: Giving advice or suggestions is helpful, but does not provide the clients with a sense of
independence and control in the situation.
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. 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: 4. Identify guidelines for implementing nursing interventions.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 210
Question 7
Type: MCSA
During teaching, the nurse makes sure the client understands how to activate the safety mechanism
on the syringe to prevent needlestick injuries when self-administering insulin. Which guideline of
implementing interventions is the nurse using?
1. Adapt activities to the individual client.
2. Encourage clients to participate actively in implementing nursing interventions.
3. Base nursing interventions on scientific knowledge, research, and standards of care.
4. Implement safe care.
Correct Answer: 4
Rationale 1: Adapting activities would involve understanding the client’s beliefs, values, age, health
status, and environment as factors that can affect the success of a nursing action.
Rationale 2: Encouraging clients to participate enhances their sense of independence and control.
Rationale 3: The nurse must be aware of the scientific rationale for, as well as possible side effects
or complications of, all interventions so that implementation centers on specific knowledge and care
standards.
Rationale 4: Showing the client how to avoid injury with injections is part of implementing safe care.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the
diversity of human experience
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: 4. Identify guidelines for implementing nursing interventions.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 210
Question 8
Type: MCSA
On one of the first days working alone, the new nurse with limited patient teaching experience needs
to instruct tracheostomy care to a client and spouse. What action should the nurse take?
1. Ask the nurse mentor to assist with the teaching after reviewing the procedure.
2. Read the policy and procedure manual before the teaching session.
3. Do the best the nurse can by remembering what was taught in nursing school.
4. Ask for a different assignment until the nurse feels comfortable with this one.
Correct Answer: 1
Rationale 1: When implementing some nursing interventions, the nurse may require assistance. In
this case, the nurse lacks the knowledge or skills to implement a particular nursing activity
(teaching).
Rationale 2: Reading and reviewing the policy and procedure are important, but should be followed
up with asking for assistance.
Rationale 3: “Doing the best the nurse can” would not be acceptable.
Rationale 4: Asking for a different assignment would not be acceptable.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the
diversity of human experience
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: 4. Identify guidelines for implementing nursing interventions.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 210
Question 9
Type: MCSA
A client is prescribed a medication that the nurse has never administered and information about the
medication is not in the drug reference manual. What should the nurse do?
1. Follow the physician’s orders as written and give the medication.
2. Call the pharmacy and do further investigating before administering the medication.
3. Ask the client about this medication.
4. Call the physician and ask what the medication is and what it is for.
Correct Answer: 2
Rationale 1: Following the physician’s order is important, but the nurse is still responsible to know
and understand the medication, its action, and its adverse actions as well as its interactions with
other medications.
Rationale 2: The nurse should clearly understand all nursing interventions to be implemented and
question any that are not understood. The nurse is responsible for intelligent implementation of
medical and surgical plans of care. The pharmacist would be the most appropriate reference point
for this nurse to begin to research this problem.
Rationale 3: The client should be informed about the medications and treatments, but the nurse
does not utilize the client for scientific knowledge and professional standards of care.
Rationale 4: The pharmacist would be the most appropriate reference point for this nurse to begin to
research this problem.
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. 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: 4. Identify guidelines for implementing nursing interventions.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 210
Question 10
Type: MCSA
The nurse is providing care to an assigned client. Which action indicates that the nurse supports the
client’s respect for dignity?
1. Allowing the client to complete hygienic care when possible
2. Providing all care to the client whenever possible
3. Telling the other staff that the client is demanding, so they are able to meet the client’s needs
4. Presenting information to the client’s family about the client’s condition
Correct Answer: 1
Rationale 1: Respecting the dignity of each client enhances their self-esteem and is an important
aspect of implementing interventions. Providing privacy and allowing clients to make their own
decisions, or do their own care when possible, is a way of respecting dignity and increasing selfesteem.
Rationale 2: It is not necessary, nor appropriate, to provide all care at all times.
Rationale 3: Telling peers and other staff members that a client is demanding is the nurse’s opinion
and should not be part of the reporting process.
Rationale 4: Information should be presented to other family members only with the consent of the
client.
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. 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: 3. Discuss the five activities of the implementing phase.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 210
Question 11
Type: MCSA
The nurse provides routine morning care to a client, including all the medications and scheduled
treatments. What action should the nurse make next?
1. Move on to the next assignment to increase the nurse’s efficiency.
2. Report this to the charge nurse.
3. Document all care in the progress notes.
4. Get supplies organized for the next client’s medications and treatments.
Correct Answer: 3
Rationale 1: This option does not describe the appropriate nursing actions that come at the end of
client care activities.
Rationale 2: Reporting to the charge nurse would be done at the end of the shift, unless the client’s
condition is not stable.
Rationale 3: After carrying out the nursing activities, the nurse completes the implementing phase by
recording the interventions and client responses in the progress notes.
Rationale 4: This option does not describe the appropriate nursing actions that come at the end of
client care activities.
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. 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: 3. Discuss the five activities of the implementing phase.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 210
Question 12
Type: MCSA
The nurse is reviewing the difference between evaluation and assessment with a new graduate
nurse. What should the nurse emphasize as the major difference between these two steps in the
nursing process?
1. Assessment is done at the beginning of the process.
2. Evaluation is completed at the end of the process.
3. They are the same and there is no need to differentiate.
4. The difference is in how the data are used.
Correct Answer: 4
Rationale 1: Although assessment is the first phase of the nursing process, it is carried out during all
phases.
Rationale 2: Evaluation is carried out at the end of the process; however, this is not the major
difference between assessment and evaluation.
Rationale 3: Although the two processes overlap, there is a difference between the data collected.
Rationale 4: Although the two processes overlap, there is a difference between the data collected.
Assessment data are collected for the nurse to make a diagnosis and evaluate desired outcomes.
Evaluation data are collected for the purpose of comparing them to prescribed goals and judging the
effectiveness of the nursing care.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 5. Explain how evaluating relates to other 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: 211
Question 13
Type: MCSA
The nurse notes that a client has the outcome goal “Client will have a decrease in pain level (down
to a 3) within 45 minutes of receiving oral analgesic.” Which client statement should the nurse use to
evaluate this goal?
1. “I’m getting really sleepy from that medication. I think I’ll take a nap.”
2. “My pain is a 4.”
3. “I still have some pain.”
4. “Will the pain ever go away?”
Correct Answer: 2
Rationale 1: This option does not address the client’s pain level.
Rationale 2: The nurse collects data so that conclusions can be drawn about whether goals have
been met. If the goal is clearly stated, precise, and measurable, it will be easy to evaluate. If the goal
was a pain level of 3, the client should be able to give a numerical rating to the pain in order for the
nurse to evaluate it.
Rationale 3: This option does not clearly define the level of the client’s pain, so evaluating
the effectiveness of the treatment is not possible.
Rationale 4: This option does not address the client’s pain level.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6. Describe five components of the evaluation process.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 211
Question 14
Type: MCSA
A client has the goal statement “Client will be able to state two positive aspects of rehab therapy by
the end of the week.” What statement demonstrates that the nurse appropriately evaluated this
goal?
1. Goal not met, client able to state one positive aspect by the end of the week.
2. Goal met, client able to state one positive aspect by the end of the week.
3. Goal met, client able to state two positive aspects of therapy by week’s end.
4. Goal incomplete, client not able to positively state anything about rehab.
Correct Answer: 3
Rationale 1: If the client can only state one aspect or it takes longer than a week, then the goal could
be partially met.
Rationale 2: If the client can only state one aspect or it takes longer than a week, then the goal could
be partially met.
Rationale 3: An evaluation statement consists of two parts: a conclusion and supporting data. The
conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The
supporting data are the list of the client responses that support the conclusion. In this situation, the
goal was met if the client was able to state two positive aspects of rehab by the end of the week, and
the evaluation statement should reveal that.
Rationale 4: Using the word “incomplete” is not appropriate for the evaluation statement.
Global Rationale:
Cognitive Level: Analyzing
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and
outcomes.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 211
Question 15
Type: MCSA
A client has the goal statement “Client will have clear lung sounds bilaterally within 3 days.” One
intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have
the client do this several times every 2 hours. At the end of the third day, the client’s lungs are
indeed clear. What should the nurse do to relate the intervention to the outcome?
1. Ask how many times per day the client practiced the coughing and deep breathing exercises.
2. Tell the client that the lungs are clear.
3. Document the assessment findings to show the effectiveness of the intervention.
4. Write this evaluation statement: Goal met, lung sounds clear by third day.
Correct Answer: 1
Rationale 1: Part of the evaluating process is determining whether the nursing activities had any
relation to the outcomes. Did the lungs clear because the client actually did the coughing and deep
breathing? In order to know for sure, the nurse must collect more data and not assume that this
particular nursing intervention had any relation to the outcome.
Rationale 2: Telling the client that his or her lungs are clear is not relating the intervention
to the outcome because no mention of the intervention is made.
Rationale 3: Documenting does not show the effectiveness of the intervention.
Rationale 4: Writing an evaluation statement does not show the effectiveness of the intervention.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 5. Explain how evaluating relates to other 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: 211
Question 16
Type: MCSA
A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to
diarrhea and vomiting was implemented for a home health client who began with these symptoms 5
days ago. A goal was that the client’s symptoms would be eliminated within 48 hours. The client is
being seen after a week, and has had no diarrhea or vomiting for the past 5 days. What should the
nurse do?
1. Keep the problem on the care plan, in case the symptoms return.
2. Document that the problem has been resolved and discontinue the care for the problem.
3. Assume that whatever the cause was, the symptoms may return, but document that the goal was
met.
4. Document that the potential problem is being prevented because the symptoms have stopped.
Correct Answer: 2
Rationale 1: In this case, the risk factors no longer exist because the causative factors have
stopped. The nurse should document that the goal has been met and discontinue the care for the
problem. If the problem returns, it can be implemented again and addressed at that time.
Rationale 2: In this case, the risk factors no longer exist because the causative factors have
stopped. The nurse should document that the goal has been met and discontinue the care for the
problem. If the problem returns, it can be implemented again and addressed at that time.
Rationale 3: In this case, the risk factors no longer exist because the causative factors have
stopped. The nurse should document that the goal has been met and discontinue the care for the
problem. If the problem returns, it can be implemented again and addressed at that time.
Rationale 4: In this case, the risk factors no longer exist because the causative factors have
stopped. The nurse should document that the goal has been met and discontinue the care for the
problem. If the problem returns, it can be implemented again and addressed at that time.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
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 steps involved in reviewing and modifying the client’s care plan.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 212
Question 17
Type: MCSA
A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement
of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As
an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What
is the flaw in this plan?
1. The goal statement is written inaccurately.
2. The interventions are dependent of nursing.
3. The goal is unrealistic.
4. The interventions are not clear enough.
Correct Answer: 3
Rationale 1: The goal statement is written accurately and is inclusive of all required components.
Rationale 2: Dependent interventions would be appropriate in this situation.
Rationale 3: When a care plan needs to be modified, discontinued, or changed in some manner,
several decisions need to be made. If the nursing diagnosis is accurate, as it is in this case, the
nurse should check to see if the goals are attainable and realistic—the flaw in this plan. A client with
terminal cancer is not going to be pain-free, regardless of the amount of medication delivered. To
think otherwise is inappropriate.
Rationale 4: The interventions are clearly written.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Identify guidelines for implementing nursing interventions.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 213
Question 18
Type: MCSA
A teenage client has been having problems with peer support, school performance, and parental
expectations, all of which contributed to an eating disorder. After gathering this assessment data,
the nurse formulates the diagnosis Activity Intolerance related to weakness. What should the nurse
realize after evaluating this diagnosis?
1. The data collected would support the diagnosis.
2. The diagnosis is directly related to the data presented.
3. The nursing diagnosis is not relevant to the data.
4. The data are not sufficient enough to support this diagnosis.
Correct Answer: 4
Rationale 1: Perhaps this diagnosis is appropriate for this client, but there are not enough data
presented to know that for sure.
Rationale 2: Once data are complete, the diagnosis and information need to be directly related to
each other.
Rationale 3: Once data are complete, the diagnosis and information need to be relevant to each
other.
Rationale 4: An incomplete database influences all steps of the nursing process and care plan. The
nurse must complete the assessment before formulating a diagnosis about weakness and fatigue.
Perhaps this diagnosis is appropriate for this client, but there are not enough data presented to know
that for sure.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Identify guidelines for implementing nursing interventions.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 213
Question 19
Type: MCSA
A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An
appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction
has been formulated. A goal for this client is not to sustain any injuries for the next
month; however, the client has fallen several times. In this situation, what should the nurse do?
1. Review the data and make sure that the diagnosis is relevant.
2. Investigate whether the best nursing interventions were selected.
3. Modify the whole nursing plan.
4. Discard the nursing plan and start over from the assessment phase.
Correct Answer: 2
Rationale 1: The data presented are relevant for the diagnosis selected in this case.
Rationale 2: Even if all sections of the care plan appear to be satisfactory, the manner in which the
plan was implemented may have interfered with goal achievement. The nurse needs to check and
see if the interventions were appropriate for the client. If the interventions selected did not help the
client achieve the goal, then rearranging or implementing new ones may be necessary.
Rationale 3: The data presented are relevant for the diagnosis selected in this case, and it is not
necessary to modify the whole plan.
Rationale 4: The data presented are relevant for the diagnosis selected in this case, and it is not
necessary to discard the whole plan and start over. Modifications may be the key to a successful
outcome for the client.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the
diversity of human experience
AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
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 steps involved in reviewing and modifying the client’s care plan.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 213
Question 20
Type: MCSA
The nurse manager has been appointed to implement a quality assurance program at the
hospital. Which components should the manager prepare to evaluate for this program?
1. Methods
2. Structure
3. Finances
4. Process
5. Outcome
Correct Answer: 2, 4, 5
Rationale 1: Quality assurance is an ongoing, systematic process designed to evaluate and promote
excellence in the health care provided to clients. It requires evaluation of three consistent
components of care. Each type of evaluation requires different criteria and methods.
Rationale 2: Quality assurance is an ongoing, systematic process designed to evaluate and promote
excellence in the health care provided to clients. It requires evaluation of three components of
care, with structure being one of them.
Rationale 3: Quality assurance is an ongoing, systematic process designed to evaluate and promote
excellence in the health care provided to clients. It requires evaluation of three components of care;
finance is not one of them.
Rationale 4: Quality assurance is an ongoing, systematic process designed to evaluate and promote
excellence in the health care provided to clients. It requires evaluation of three components of
care, with process being one of them.
Rationale 5: Quality assurance is an ongoing, systematic process designed to evaluate and promote
excellence in the health care provided to clients. It requires evaluation of three components of
care, with outcome being one of them.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the
setting in which one is engaged in clinical practice
AACN Essentials Competencies: II. 10. Use improvement methods, based on data from the
outcomes of care processes, to design and test changes to continuously improve the quality and
safety of health care
NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome
achievement
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and
outcomes.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 214
Question 21
Type: MCSA
A care area has been short staffed for the past month with a heavy client load and high acuity. The
nurses have been working extra as well as double shifts and often do not have time to make sure
that properly working equipment is cleaned, returned, and stored in the appropriate areas. At what
level should this care area be evaluated?
1. Management
2. Structure
3. Process
4. Outcome
Correct Answer: 2
Rationale 1: Management is not one of the three components of quality assurance evaluation.
Rationale 2: Structure evaluation focuses on the setting in which care is given. Structural standards
describe desirable environmental and organizational characteristics that influence care, such as
equipment and staffing. Process evaluation focuses on how the care was given.
Rationale 3: Process evaluation focuses on how the care was given.
Rationale 4: Outcome evaluation focuses on demonstrable changes in the client’s health status as a
result of nursing care.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the
setting in which one is engaged in clinical practice
AACN Essentials Competencies: II. 10. Use improvement methods, based on data from the
outcomes of care processes, to design and test changes to continuously improve the quality and
safety of health care
NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome
achievement
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and
outcomes.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 214
Question 22
Type: MCSA
A nursing unit has had a large number of negative client responses about various aspects of their
care in the previous quarter. When evaluating this care area, on which care component should the
quality assurance officer focus?
1. Competency
2. Structure
3. Process
4. Outcome
Correct Answer: 3
Rationale 1: Competency is not one of the components of quality assurance evaluation.
Rationale 2: Structure evaluation focuses on the setting in which the care is given.
Rationale 3: Process evaluation focuses on how the care was given. Is the care relevant to the
clients’ needs? Is it appropriate, complete, and timely? Process standards focus on the manner in
which the nurse uses the nursing process.
Rationale 4: Outcome evaluation focuses on demonstrable changes in the client’s health status as a
result of nursing care.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. A. 1. Describe strategies for learning about the outcomes of care in the
setting in which one is engaged in clinical practice
AACN Essentials Competencies: II. 10. Use improvement methods, based on data from the
outcomes of care processes, to design and test changes to continuously improve the quality and
safety of health care
NLN Competencies: Quality and Safety; Practice; Contribute to assessment of outcome
achievement
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8. Describe three components of quality evaluation: structure, process, and
outcomes.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 214
Question 23
Type: MCSA
A nursing unit’s records of client care have been reviewed for accuracy in documentation. Which
type of review is being completed on these records?
1. Nursing audit
2. Peer review
3. Individual audit
4. Concurrent audit
Correct Answer: 1
Rationale 1: An audit is an examination or review of records. A nursing audit is a type of peer review
that focuses on evaluating nursing care through the review of records. The success of these audits
depends on accurate documentation.
Rationale 2: Peer review is a type of evaluation where nurses functioning in the same capacity
perform the audit. Peer review is based on pre–established standards or criteria.
Rationale 3: An individual audit focuses on the performance of an individual nurse.
Rationale 4: Concurrent audits are reviews of a client’s health care and occur while the client is still
receiving the care.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
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 steps involved in reviewing and modifying the client’s care plan.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 215
Question 24
Type: MCSA
The nurse reviews clients’ records and the care they received while in the hospital for an insurance
company. Part of the job description requires the nurse to make sure that the client and insurance
company were billed for services and treatment/therapies rendered and that there were no errors in
billing. Which type of audit is the nurse completing?
1. Concurrent
2. Peer review
3. Nursing audit
4. Retrospective
Correct Answer: 4
Rationale 1: A concurrent audit is the evaluation of a client’s health care while the client is still
receiving the care from an agency.
Rationale 2: A nursing audit is a type of peer review, in which the audit focuses on evaluating a
specific nurse’s nursing care through the review of records.
Rationale 3: A nursing audit is a type of peer review, in which the audit focuses on evaluating a
specific nurse’s nursing care through the review of records.
Rationale 4: A retrospective audit is the evaluation of a client’s record after discharge from an
agency. The word retrospective means “relating to the past.” If the nurse is reviewing records after
the client has been discharged, the information being examined is in the past.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 9. Differentiate quality improvement from quality assurance.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 216
Question 25
Type: MCSA
The nurse assigns unlicensed assistive personnel to measure vital signs for several clients. The task
is completed and documented correctly; however, one of the clients had a blood pressure reading of
180/110. The nurse learns this information at the end of the shift. Which responsibility of delegation
did the nurse fail to carry out?
1. Delegating to the appropriate staff
2. Delegating the appropriate task
3. Selecting the appropriate client
4. Appropriately supervising care
Correct Answer: 4
Rationale 1: The nurse did delegate to the appropriate staff, as securing vital signs is within the
scope of practice for unlicensed assistive personnel.
Rationale 2: The nurse did delegate an appropriate task, as securing vital signs is within the scope
of practice for unlicensed assistive personnel.
Rationale 3: There was no indication given that the clients were not appropriately selected for this
task.
Rationale 4: The nurse has two responsibilities in delegating and assigning duties: (1) appropriate
delegation of duties (that is, giving people duties within their scope of practice) and (2) adequate
supervision of personnel to whom work is delegated or assigned. In this situation, the nurse gave an
unlicensed person a duty that was appropriate. Unlicensed assistive personnel completed the duty
and documented the findings. The nurse is still responsible for analyzing data, planning care, and
evaluating outcomes. In this case, the nurse failed to follow up (supervise) after the duty was
performed and analyze the findings.
Global Rationale:
Cognitive Level: Analyzing
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify guidelines for implementing nursing interventions.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 210
Question 26
Type: MCMA
The nurse is implementing care and treatments for assigned clients. What actions should the nurse
prepare to complete during this phase of the nursing process?
Standard Text: Select all that apply.
1. Evaluating the outcome of the interventions
2. Reassessing the client
3. Documenting the history and physical
4. Supervising delegated care
5. Implementing the nursing intervention
Correct Answer: 2, 4, 5
Rationale 1: Evaluating the outcome of the interventions is part of the evaluation phase.
Rationale 2: This is a component of the implementation process.
Rationale 3: Documentation of the history and physical is part of the initial assessment.
Rationale 4: This is a component of the implementation process.
Rationale 5: This is a component of the implementation process.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Discuss the five activities of the implementing phase.
MNL Learning Outcome: 1.4.3. Distinguish the nurse’s role in the implementation phase of the
nursing process.
Page Number: 209
Question 27
Type: MCMA
After implementing interventions and reassessing the client’s response, the nurse completes the
process by evaluating. What attributes of evaluation should the nurse include when completing this
step of the nursing process?
Standard Text: Select all that apply.
1. Purposeful activity
2. Nursing accountability
3. Continuous
4. Judgments
5. Opinion
Correct Answer: 1, 2, 3, 4
Rationale 1: Evaluating is a planned, ongoing, purposeful activity in which clients and health care
professionals determine the client’s progress toward achievement of goals/outcomes and the
effectiveness of the nursing care plan.
Rationale 2: Through evaluating, nurses demonstrate responsibility and accountability for their
actions.
Rationale 3: Evaluation is continuous and done while or immediately after implementing a nursing
order.
Rationale 4: To evaluate is to judge or appraise. Through evaluation, the nurse is able to establish
whether nursing interventions should be terminated, continued, or changed.
Rationale 5: Evaluation does not rest on opinion.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6. Describe five components of the evaluation process.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 210
Question 28
Type: MCMA
The nurse is preparing to evaluate care provided to a client. What behaviors should the nurse
demonstrate that show an understanding of the relationship of evaluation to the other phases of the
nursing process?
Standard Text: Select all that apply.
1. Effectively assessing the client’s needs
2. Selecting the appropriate nursing diagnosis related to the client’s needs
3. Collecting client-focused data with a specific need in mind
4. Evaluating by using assessment data to determine effective achievement of goals and outcomes
5. Basing evaluation on assessment data collected during the admission phase
Correct Answer: 1, 2, 3, 4
Rationale 1: Successful evaluation depends on the effectiveness of the steps that precede it.
Assessment data must be accurate and complete so that the nurse can proceed with the nursing
process.
Rationale 2: Successful evaluation depends on the effectiveness of the steps that precede it so that
the nurse can formulate appropriate nursing diagnoses.
Rationale 3: Data are collected for different purposes at different points in the nursing process.
Rationale 4: During the evaluation step, the nurse collects data for the purpose of comparing it with
preselected goals/outcomes and judging the effectiveness of the nursing care.
Rationale 5: During the assessment phase, the nurse collects data for the purpose of making
diagnoses.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Explain how implementing relates to other 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: 211
Question 29
Type: MCMA
The nurse notes that assessment data indicate a change in a client’s condition. What should the
nurse ask before changing this client’s plan of care?
Standard Text: Select all that apply.
1. How difficult will it be to change the care plan?
2. Are the new data complete?
3. Are the new data accurate?
4. Do the new data require a change in the care plan?
5. Will the primary medical provider agree with the need to alter the care plan?
Correct Answer: 2, 3, 4
Rationale 1: The degree of difficulty in changing the care plan is not a consideration for its change.
Rationale 2: This condition must be met before consideration is given to altering a client’s care plan.
Rationale 3: This condition must be met before consideration is given to altering a client’s care plan.
Rationale 4: This condition must be met before consideration is given to altering a client’s care plan.
Rationale 5: The medical provider is generally not involved in the formation or alteration of a nursing
care plan.
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 7. Describe the steps involved in reviewing and modifying the client’s care plan.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 212
New Questions:
Question 30
Type: MCMA
The nurse is evaluating care provided to a client. Which nursing actions indicate that the phases of
evaluation were completed by the nurse appropriately?
Standard Text: Select all that apply.
1. Client problems updated
2. Data linked to NOC indicators
3. Data compared to desired outcomes
4. Interventions changed on the care plan
5. Physician notified of changes in the care plan
Correct Answer: 1, 2, 3, 4
Rationale 1: The evaluation phase has five components. Updating the client problems indicates that
the plan of care was modified.
Rationale 2: The evaluation phase has five components. One phase is ensuring that the collected
data are related to the NOC indicators.
Rationale 3: The evaluation phase has five components. One phase is comparing the data with
desired outcomes.
Rationale 4: The evaluation phase has five components. One phase is changing the interventions on
the care plan to meet the client’s needs or changes in health status.
Rationale 5: The evaluation phase has five components. Notifying the physician of changes in the
care plan is not a phase of the evaluation process.
Global Rationale:
Cognitive Level: Analyzing
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: III. 6. Integrate evidence, clinical judgment, interprofessional
perspectives and patient preferences in planning, implementing, and evaluating outcomes of care
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6. Describe five components of the evaluation process.
MNL Learning Outcome: 1.4.4. Integrate the evaluation phase of the nursing process in the care of
the client.
Page Number: 211
Question 31
Type: MCMA
A client recovering from total knee replacement surgery falls out of bed on the night shift and dies.
Which quality improvement actions should the nurse manager expect to complete for this client
occurrence?
Standard Text: Select all that apply.
1. A root cause analysis
2. Paperwork about a sentinel event
3. Analysis of the nurse assigned to the client
4. Number of times the client was observed on the night shift
5. Number of hours since the client last received pain medication
Correct Answer: 1, 2
Rationale 1: Root cause analysis is a process for identifying the factors that bring about deviations in
practices that lead to the event. It focuses primarily on systems and processes, not individual
performance.
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 15
Question 1
Type: MCSA
A client who is being transferred to a rehabilitation center asks the nurse if he can take his chart
with him, as it’s his record. How should the nurse respond to this client’s request?
1. “You’ll have to ask your doctor for permission to do that.”
2. “Actually, the original record is the property of the hospital, but you are welcome to copies of your
records.”
3. “We’ll make sure that all of your records are sent ahead to the rehab hospital, so you don’t really
have to worry about those details.”
4. “There’s a new law that protects your records, so you’re not going to be able to have access to
them.”
Correct Answer: 2
Rationale 1: The doctor’s permission is not a requirement for the release of a client’s medical record.
Rationale 2: Although the client’s record is protected legally as private, access to the record is
restricted to health professionals involved in the client’s care. The institution or agency is the rightful
owner of the client’s record, but the client has the right to access all information contained within his
own record and to have a copy of the original record. The hospital has the right to charge a fee for
the copying costs. The Health Insurance Portability and Accountability Act (HIPAA) is a law enacted
to protect health information and maintain confidentiality of client records.
Rationale 3: The client does have a legal right concerning his medical record, so this option doesn’t
adequately address the question.
Rationale 4: This option is not correct; the client does have a legal right to access his medical
records.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. C. 3. Protect confidentiality of protected health information in electronic
health records
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; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. List the measures used to maintain confidentiality and security of
computerized client records.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 221
Question 2
Type: MCSA
After classroom discussion regarding confidentiality policies and laws protecting client records, a
student asks why it’s permissible for them to review and have access to client records in the clinical
area. How should the nursing instructor respond?
1. “Confidentiality and privacy laws don’t apply to students.”
2. “Most students review so many records and charts that they could not possibly remember details
from any one of them.”
3. “Records are used in educational settings and for learning purposes, but the student is bound to
hold all information in strict confidence.”
4. “As long as the clinical instructor is in the area, accessing client records is part of the education
process.”
Correct Answer: 3
Rationale 1: This option is not correct; the laws do apply to students.
Rationale 2: Although this may or may not be a true statement, it is not an appropriate response to
the student’s question.
Rationale 3: For purposes of education and research, most agencies allow students and graduate
health professionals access to client records. The student or graduate is bound by a strict ethical
code and legal responsibility to hold all information in confidence. It is the responsibility of the
student or health professional to protect the client’s privacy by not using a name or any statements
in the notations that would identify the client.
Rationale 4: Although this is true, the nursing instructor should not imply that the laws of
confidentiality don’t apply to students.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. C. 3. Protect confidentiality of protected health information in electronic
health records
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; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. List the measures used to maintain confidentiality and security of
computerized client records.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 222
Question 3
Type: MCSA
The nurse works at an organization that is installing a new computerized record system. What
should the nurse learn that has been implemented to help ensure the security of client records?
1. A firewall to protect the server from unauthorized access
2. One unit password to protect the unit’s information
3. Expectation to log off a terminal after using it
4. Expectation to turn the monitor away from view when unattended
5. Requirement to shred all computer-generated worksheets
Correct Answer: 1, 3, 5
Rationale 1: The Security Rule of HIPAA became mandatory in 2005 and governs the security of
electronic protected health information. Guidelines for confidentiality and security of computerized
records include the installation of a firewall to protect from unauthorized access.
Rationale 2: Guidelines for confidentiality and security of computerized records include assignment
of a personal password to enter and log off computer files. The password should not be shared with
anyone, including other team members.
Rationale 3: The Security Rule of HIPAA became mandatory in 2005 and governs the security of
electronic protected health information. The nurse should learn to never leaving a monitor
unattended after logging on.
Rationale 4: The Security Rule of HIPAA became mandatory in 2005 and governs the security of
electronic protected health information. Turning the monitor away from view is not a sufficient
safeguard.
Rationale 5: The Security Rule of HIPAA became mandatory in 2005 and governs the security of
electronic protected health information. Guidelines for confidentiality and security of computerized
records include shredding all confidential information.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. C. 3. Protect confidentiality of protected health information in electronic
health records
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; Ethical Comportment; Act in accordance with legal
and regulatory requirements, including HIPAA, for faculty, students, patients, and families
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. List the measures used to maintain confidentiality and security of
computerized client records.
MNL Learning Outcome: 1.1.2. Examine the impact the legal aspects of nursing have on practice.
Page Number: 222
Question 4
Type: MCSA
A hospital is not able to be reimbursed for care a particular client received while in the emergency
department. The client came in with chest pain, which was later diagnosed as gastric reflux. Which
problem with documentation might have caused the lack of reimbursement?
1. The client’s record contained an incorrect DRG.
2. The client was charged for an ECG.
3. A code cart was opened and the client was charged for medications opened but not used.
4. The physician made a diagnostic mistake.
Correct Answer: 1
Rationale 1: Documentation helps a facility receive reimbursement from the federal government. The
client’s clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that
the appropriate care has been given. Coded diagnoses, such as DRGs, are supported by accurate,
thorough recording by nurses.
Rationale 2: This would not necessarily result in the problem related to reimbursement because it is
a reasonable diagnostic test to perform in this situation.
Rationale 3: This would not necessarily result in the problem related to reimbursement.
Rationale 4: This would not necessarily result in the problem related to reimbursement.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. A. 1. Explain why information and technology skills are essential for safe
patient care
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Discuss purposes for client records.
MNL Learning Outcome: 1.2.3. Examine the factors affecting health care delivery.
Page Number: 222
Question 5
Type: MCSA
When attempting to locate recent lab results, the new nurse employee notices that each department
has a separate section in the client’s chart. Which type of documentation system is the nurse using?
1. Source-oriented record
2. Problem-oriented record
3. Case management
4. Focus charting
Correct Answer: 1
Rationale 1: The traditional client record is a source-oriented record in which each person or
department makes notations in a separate section or sections of the client’s chart.
Rationale 2: In the problem-oriented medical record, the data are arranged according to the
problems the client has rather than the source of the information.
Rationale 3: Case management uses a multidisciplinary approach to documenting client care, called
critical pathways.
Rationale 4: Focus charting is intended to make the client and client concerns the focus of care,
utilizing a three-column format.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 3. Navigate the electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception, computerized records,
and the case management model.
MNL Learning Outcome: 1.5.3. Distinguish the legal and ethical considerations related to the
different types of documentation.
Page Number: 223
Question 6
Type: MCSA
The nurse makes chronological entries in a client’s chart that include documentation about the
routine care provided, assessment findings, and client problems during a 12–hour shift. Which type
of charting is this nurse completing?
1. Problem-oriented recording
2. Source-oriented recording
3. Narrative charting
4. Plan of care
Correct Answer: 3
Rationale 1: Problem-oriented recording is arranging the data according to the problem the client
has.
Rationale 2: Source-oriented recording is arranged in separate sections for each department that
contributes to the client’s care. The plan of care is part of the problem-oriented medical record.
Rationale 3: Narrative charting is a traditional part of the source-oriented record. It consists of written
notes that include routine care, normal findings, and client problems. There is no right or wrong order
to the information, although chronological order is frequently used.
Rationale 4: The plan of care is part of the problem-oriented medical record.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception, computerized records,
and the case management model.
MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge
planning and for long-term care.
Page Number: 223
Question 7
Type: MCSA
The nurse is reviewing a client’s chart in a facility that utilizes problem-oriented recording. In which
section would the nurse find the most recent physician orders?
1. Database
2. Problem list
3. Plan of care
4. Progress notes
Correct Answer: 3
Rationale 1: The database consists of all known information about the client upon admission.
Rationale 2: The problem list includes all identified problems, listed in the order in which they are
identified.
Rationale 3: The initial list of orders or plan of care is made with reference to the client’s active
problems in this type of charting. Physicians write physician orders or the medical care plan.
Rationale 4: Progress notes are chart entries made by all health professionals involved in the client’s
care.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception, computerized records,
and the case management model.
MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge
planning and for long-term care.
Page Number: 225
Question 8
Type: MCSA
A client has specific cultural needs that affect the plan of care. In which part of the client’s problemoriented medical record should the nurse document this information?
1. Database
2. Problem list
3. Plan of care
4. Progress notes
Correct Answer: 2
Rationale 1: The database includes information about the client when admitted to the facility.
Rationale 2: The problem list is derived from the database and is usually kept at the front of the
chart. The problem list serves as an index to the numbered entries in the progress notes. All
caregivers contribute to the problem list, which includes the client’s physiologic, psychologic, social,
cultural, spiritual, developmental, and environmental needs.
Rationale 3: The plan of care is made with reference to the active problems.
Rationale 4: Progress notes are chart entries made by all health professionals involved in a client’s
care.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception, computerized records,
and the case management model.
MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge
planning and for long-term care.
Page Number: 224
Question 9
Type: MCSA
The client states: “I really don’t want anyone to visit me who has not been cleared by me first.” If
utilizing SOAP format, in which category should the nurse document this statement?
1. Subjective data
2. Objective data
3. Assessment
4. Planning
Correct Answer: 1
Rationale 1: Subjective data consist of information obtained from what the client says. When
possible, the nurse quotes the client’s words; otherwise, they are summarized.
Rationale 2: Objective data consist of information that is measured or observed.
Rationale 3: Assessment is the interpretation or conclusion drawn about the subjective and objective
data. This is the area where the problems are documented initially. Then the client’s condition and
level of progress are subsequently described.
Rationale 4: Planning is the care designed to resolve the problem.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception, computerized records,
and the case management model.
MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge
planning and for long-term care.
Page Number: 225
Question 10
Type: MCSA
The nurse administered analgesic medications to an assigned client via central line. In which section
of PIE charting should the nurse document this information?
1. Plan
2. Intervention
3. Evaluation
4. Progress notes
Correct Answer: 2
Rationale 1: The problem statement is labeled “P” and referred to by number.
Rationale 2: The interventions employed to manage the problem are labeled “I” and numbered
according to the problem.
Rationale 3: The “E” is the evaluation of the effectiveness of the intervention and is labeled and
numbered according to the problem.
Rationale 4: Progress notes are not part of the identified labels of PIE charting.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception, computerized records,
and the case management model.
MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge
planning and for long-term care.
Page Number: 226
Question 11
Type: MCSA
The nurse is documenting client care on flow sheets that identify abnormal assessment findings.
Which type of documentation system is the nurse using?
1. Computerized documentation
2. Focus charting
3. SOAP charting
4. Charting by exception
Correct Answer: 4
Rationale 1: Computerized documentation is a way to manage the volume of information required in
a client’s chart, and different systems may include a variety of setups and programs.
Rationale 2: Focus charting is organized into data, action, and response sections, referred to as
DAR.
Rationale 3: SOAP charting is a way to organize data and information in the client’s record: S =
subjective data; O = objective data; A = assessment; P = plan.
Rationale 4: Charting by exception (CBE) is a documentation system in which only abnormal or
significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and
bedside access to chart forms are all incorporated into CBE.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception, computerized records,
and the case management model.
MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge
planning and for long-term care.
Page Number: 227
Question 12
Type: MCSA
The nurse working in a hospital that utilizes a charting by exception (CBE) documentation
system notes that a client did not require care in all of the areas identified on a flow sheet. What
action should the nurse take?
1. Leave the areas blank.
2. Leave the areas blank, but then add an extensive explanation in the progress notes section of the
chart.
3. Write N/A on the flow sheet in the areas that are not applicable to that client.
4. Make sure this information gets passed along in the shift report.
Correct Answer: 3
Rationale 1: It is never a good idea to leave blanks in any charting area because it implies that the
area was ignored.
Rationale 2: It is never a good idea to leave blanks in any charting area. Adding the information in
the progress notes is not an appropriate use of that section.
Rationale 3: Many nurses are uncomfortable with the CBE system and believe that if something was
not charted, it was not done. A suggestion to address this would be to write N/A on the flow sheets
where the items are not applicable to the client, and not leave the spaces blank. This would avoid
the possible assumption that the assessment or intervention was not done by the nurse.
Rationale 4: Passing information along in the report is a good way to ensure continuity of care for
clients, but this would only be an oral report, not written documentation.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare and contrast different documentation methods: source-oriented and
problem-oriented medical records, PIE, focus charting, charting by exception, computerized records,
and the case management model.
MNL Learning Outcome: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a
client’s record.
Page Number: 227
Question 13
Type: MCSA
A client did not meet the goal of walking unassisted, without assistive devices, by discharge from
rehabilitation. The case manager using a critical pathway should identify this outcome as
being which of the following?
1. An unattainable goal
2. A variance
3. An error in care planning
4. An error in intervention implementation
Correct Answer: 2
Rationale 1: Critical pathways are a multidisciplinary approach to planning and documenting client
care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways.
When a goal is not reached, it is not referred to as an unattainable goal because a change in the
client’s care plan may result in success.
Rationale 2: Critical pathways are a multidisciplinary approach to planning and documenting client
care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways.
When a goal is not reached, it is called a variance. Variances are deviations to what is planned in
the critical pathway—unexpected occurrences that affect the planned care or the client’s response to
care.
Rationale 3: Critical pathways are a multidisciplinary approach to planning and documenting client
care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways.
When a goal is not reached, it is not referred to as an error in care planning because the success of
a goal is dependent on specific interventions and individual client response.
Rationale 4: Critical pathways are a multidisciplinary approach to planning and documenting client
care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways.
When a goal is not reached, it is not referred to as an error in implementation because the success
of a goal is not solely dependent on the implementation of a single intervention.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Explain how various forms in the client record (e.g., critical pathways care
plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps
of the nursing process (assessing, diagnosing, planning, implementing, and evaluating).
MNL Learning Outcome: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a
client’s record.
Page Number: 230
Question 14
Type: MCSA
A cardiac specialty hospital has several written plans in place for clients who are admitted, according
to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as
standard nursing interventions are included in these plans. Which type of form is this hospital
utilizing?
1. Standardized care plans
2. Traditional care plans
3. Critical pathways
4. Kardex
Correct Answer: 1
Rationale 1: Standardized care plans were developed to save documentation time. These plans may
be based on an institution’s standards of practice, thereby helping to provide a high quality of
nursing care. Standardized care plans are usually individualized to address each client’s specific
needs.
Rationale 2: Traditional care plans are written for each client, are specific, and are individualized for
that client.
Rationale 3: Critical pathways are used in case management, involving a multidisciplinary approach
to planning and documenting client care.
Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making
information quickly accessible for all health professionals.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Explain how various forms in the client record (e.g., critical pathways care
plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps
of the nursing process (assessing, diagnosing, planning, implementing, and evaluating).
MNL Learning Outcome: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a
client’s record.
Page Number: 231
Question 15
Type: MCSA
Before providing care, the nurse reviews the client’s pertinent history, daily treatments, diagnostic
procedures, allergies, problems, and other information. Which form should the nurse review to learn
all of this information?
1. The client’s medical record
2. The MAR (medication administration record)
3. The written care plan
4. The Kardex
Correct Answer: 4
Rationale 1: The medical record contains this type of information, but the complete chart is lengthy
and would take the student more time to review.
Rationale 2: The MAR includes only those medications that are prescribed or scheduled to be
administered during the client’s stay. It would not include other information like diagnostic tests, daily
care, and so on.
Rationale 3: The written care plan may be utilized, but there is another more effective option
available.
Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making
information quickly accessible to all health professionals. The system is on either an index-type file
or a computer-generated form. Information is usually organized into sections: client
history/information, list of medications, IV fluids, daily treatments and procedures, diagnostic
procedures, allergies, how the client’s physical needs are met (type of diet, bathing needs, etc.), and
a problem list with stated goals.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Explain how various forms in the client record (e.g., critical pathways care
plans, Kardexes, flow sheets, progress notes, discharge/transfer forms) are used to document steps
of the nursing process (assessing, diagnosing, planning, implementing, and evaluating).
MNL Learning Outcome: 1.5.1. Demonstrate how to ensure the accuracy of documentation in a
client’s record.
Page Number: 231
Question 16
Type: MCSA
The nurse is teaching medication administration to a client being discharged. Which instruction
should the nurse rewrite for this client?
1. Lasix, 20 mg, po bid
2. Lasix, 20 mg tablet, twice daily
3. Lasix, 20 mg by mouth, two times a day a day
4. Lasix, 20 mg by mouth 8 AM and 2 PM
Correct Answer: 1
Rationale 1: If the discharge plan is given directly to the client and family, it is imperative that
instructions be written in terms that can be readily understood. For example, medications,
treatments, and activities should be written in layperson‘s terms, and use of medical abbreviations
should be avoided. “Twice a day” should be written out, not abbreviated as “bid.”
Rationale 2: If the discharge plan is given directly to the client and family, it is imperative that
instructions be written in terms that can be readily understood. For example, medications,
treatments, and activities should be written in layperson’s terms, and use of medical abbreviations
should be avoided. “Twice a day” should be written out, not abbreviated as “bid.”
Rationale 3: If the discharge plan is given directly to the client and family, it is imperative that
instructions be written in terms that can be readily understood. For example, medications,
treatments, and activities should be written in layperson’s terms, and use of medical abbreviations
should be avoided. “Twice a day” should be written out, not abbreviated as “bid.”
Rationale 4: If the discharge plan is given directly to the client and family, it is imperative that
instructions be written in terms that can be readily understood. For example, medications,
treatments, and activities should be written in layperson’s terms, and use of medical abbreviations
should be avoided. “Twice a day” should be written out, not abbreviated as “bid.”
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Compare and contrast the documentation needed for clients in acute care,
long-term care, and home health care settings.
MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge
planning and for long-term care.
Page Number: 232
Question 17
Type: MCSA
A client in long-term care is scheduled for a review of the assessment and care screening
process. Where should the nurse document this information?
1. MDS
2. OBRA
3. CBE
4. Kardex
Correct Answer: 1
Rationale 1: The Minimum Data Set (MDS) for assessment and care screening must be performed
within 4 days of a client’s admission to a long-term care facility and reviewed every 3 months. Laws
influencing the kind and frequency of documentation required are the Health Care Financing
Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987.
Rationale 2: Laws influencing the kind and frequency of documentation required are the Health Care
Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987.
Rationale 3: CBE stands for charting by exception and is not the form of documentation used for this
type of assessment.
Rationale 4: Kardex is a system of organizing client information so it can be accessed quickly. It is
usually used in the acute care area.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Compare and contrast the documentation needed for clients in acute care,
long-term care, and home health care settings.
MNL Learning Outcome: 1.5.2. Differentiate general documentation activities, including discharge
planning and for long-term care.
Page Number: 232
Question 18
Type: MCSA
When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around
the legs. Which chart entry should the nurse document for this finding?
1. Client fell out of bed, but did push the call button for assistance.
2. Client became tangled in the bed linens, then called for assistance after falling out of bed.
3. Recorder responded to client’s call light, upon entering the room, found client on floor.
4. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed
linens.
Correct Answer: 3
Rationale 1: It should never be assumed that the client fell out of bed.
Rationale 2: It should never be assumed that the client fell out of bed, became tangled in bedding, or
anything else.
Rationale 3: Accurate notations consist of facts or observations rather than opinions or
interpretations. The client was found on the floor, and the call light was activated. Those are the only
things known until the nurse learns further information from questioning the client.
Rationale 4: It should never be assumed that the client became tangled in bedding, or anything else.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Discuss guidelines for effective recording that meet legal and ethical
standards.
MNL Learning Outcome: 1.5.3. Distinguish the legal and ethical considerations related to the
different types of documentation.
Page Number: 235
Question 19
Type: MCSA
After completing the client care and documenting it in the progress notes, the nurse realizes that
documentation was placed on the wrong medical record. What should the nurse do?
1. Use white-out over the mistake.
2. Take a wide permanent marker and blacken out all the documentation.
3. Put an “X” through the entire page, identify it as an “error,” initial, and move on to the correct
chart.
4. Draw a single line through the documentation, write “mistaken entry” next to the original entry, and
initial it.
Correct Answer: 4
Rationale 1: Erasure, blotting out, or correction fluid should not be used.
Rationale 2: Erasure, blotting out, or correction fluid should not be used.
Rationale 3: When a mistake is recorded, the correction applies to only the erroneous
information, not the entire page.
Rationale 4: When a mistake is recorded, a line should be drawn through it and the words “mistaken
entry” written above or next to the original entry, then initial or signature—whichever is agency
policy. The original entry must remain visible.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: IV. B. 4. Document and plan patient care in an electronic health record
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies,
information systems, and communication devices that support safe nursing practice
NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative,
education, and/or research purposes; document via electronic health records; use software
applications related to nursing practice
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Discuss guidelines for effective recording that meet legal and ethical
standards.
MNL Learning Outcome: 1.5.3. Distinguish the legal and ethical considerations related to the
different types of documentation.
Page Number: 235
Question 20
Type: MCMA
The nurse manager is conducting a survey of personnel to see what the general feeling is before
implementing computerized charting in an acute care hospital. What should the nurse select as
positive aspects of implementing this type of system?
Standard Text: Select all that apply.
1. The system is relatively inexpensive to maintain.
2. Bedside terminals eliminate worksheets and note taking.
3. The system links to various sources of client information.
4. The system better protects client privacy.
5. Information is legible.
6. Results, requests, and client information can be sent and received quickly.
Correct Answer: 2, 3, 5, 6
Rationale 1: This system is not inexpensive to maintain.
Rationale 2: This is considered a positive aspect of this type of charting.
Rationale 3: This is considered a positive aspect of this type of charting.
Rationale 4: The effectiveness of this system to protect a client’s privacy is dependent upon the
personnel using it.
Rationale 5: This is considered a positive aspect of this type of charting.
Rationale 6: This is considered a positive aspect of this type of charting.
Global Rationale:
Cognitive Level: Applying
Chapter 16
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 16
Question 1
Type: MCSA
The nurse is providing care within the total care context. What should the nurse consider when using
this care approach?
1. The individualism of the client
2. Principles applicable to the client at this moment
3. Principles general to all clients of the same age and condition
4. The person’s self-identity
Correct Answer: 3
Rationale 1: In the individualized care context, the nurse becomes acquainted with the client as an
individual, referring to the total care principles and using those principles that apply to this person at
this time.
Rationale 2: In the individualized care context, the nurse becomes acquainted with the client as an
individual, referring to the total care principles and using those principles that apply to this person at
this time.
Rationale 3: In the total care context, the nurse considers all the principles and areas that apply
when taking care of any client of that age and condition.
Rationale 4: The person’s self-identity is part of the individual health dimension of any one 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. 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: 1. Explain the relationship of individuality and holism to nursing practice.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 244
Question 2
Type: MCSA
The nurse is practicing the concept of holism with a client. Which action is the nurse most likely
making?
1. Considering how the loss of a client’s job will affect the regulation of the client’s diabetes
2. Making sure to do complete teaching regarding pharmacological interventions
3. Following physician treatments on schedule
4. Prioritizing the needs of the client assigned according to Maslow’s hierarchy
Correct Answer: 1
Rationale 1: The concept of holism emphasizes that nurses must keep the whole person in mind and
strives to understand how one area of concern relates to the whole person. In this situation, the
stress from a job loss will affect the person’s chronic condition. The nurse must also consider the
relationship of the individual to the external environment and to others.
Rationale 2: This option is only focused on the physiology of the person’s condition.
Rationale 3: This option is only focused on the physiology of the person’s condition.
Rationale 4: This option is only focused on the physiology of the person’s condition.
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. 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: 1. Explain the relationship of individuality and holism to nursing practice.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 244
Question 3
Type: MCSA
Psychologic homeostasis is maintained by a variety of mechanisms. Which client should the nurse
identify as being the most likely candidate to obtain psychologic homeostasis?
1. A child who is used to getting ready for school alone
2. A teenager whose circle of friends includes single parents of the same age
3. An elderly person who has just moved to a long-term care facility
4. A young adult who is in a long-term relationship
Correct Answer: 4
Rationale 1: Psychologic homeostasis is acquired or learned through the experience of living and
interacting with others. Individuals can develop psychologic homeostasis if they are in a stable
physical environment where they feel safe and secure. A child who is alone while getting ready for
school may not feel safe and secure.
Rationale 2: Individuals also need a stable psychologic environment from infancy onward so that
feelings of love and trust develop, a social environment that includes adults who are healthy role
models, and a life experience that provides satisfaction. Having friends of the same age who are
parents may eliminate healthy adult role models for the teenager.
Rationale 3: Individuals also need a stable psychologic environment from infancy onward so that
feelings of love and trust develop, a social environment that includes adults who are healthy role
models, and a life experience that provides satisfaction. Moving into a long-term care facility can be
a huge adjustment for some people, which may affect feelings of safety and security.
Rationale 4: Individuals also need a stable psychologic environment from infancy onward so that
feelings of love and trust develop, a social environment that includes adults who are healthy role
models, and a life experience that provides satisfaction. A young adult who has a relationship that
lasts is the one option that would fit most of these mechanisms.
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. 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: Assessment
Learning Outcome: 2. List four main characteristics of homeostatic mechanisms.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 246
Question 4
Type: MCSA
A client is having difficulty with feelings of self-loathing and disgust after being attacked and raped.
According to Maslow’s human needs theory, at which level should the nurse recognize that
the client is struggling?
1. Physiological
2. Safety and security
3. Love and belonging
4. Self-esteem
Correct Answer: 4
Rationale 1: Physiological needs include air, food, water, rest, and sleep.
Rationale 2: Safety and security needs are those things, both psychological and physiological, that
help the person feel safe.
Rationale 3: Love and belonging needs include giving and receiving affection, attaining a place in a
group, and maintaining the feeling of belonging.
Rationale 4: Self-esteem and esteem from others includes feelings of independence, competence,
self-respect, recognition, respect, and appreciation. Self-hatred and disgust is opposite of what one
would expect in the self-esteem level of Maslow’s model.
Global Rationale:
Cognitive Level: Analyzing
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: 4. Identify Maslow’s characteristics of the self-actualized person.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 247
Question 5
Type: MCSA
A client is hospitalized with numerous acute health problems. According to Maslow’s basic needs
model, which nursing diagnosis should the nurse identify as being the highest priority for this client?
1. Risk for Injury related to unsteady gait
2. Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients
3. Self-Care Deficit related to weakness and debilitation
4. Powerlessness related to chronic disease state
Correct Answer: 2
Rationale 1: Risk for Injury would be the lower–priority need.
Rationale 2: In needs theories, human needs are ranked on an ascending scale according to how
essential the needs are for survival. Physiologic needs are those such as air, food, water, shelter,
rest, sleep, activity, and temperature maintenance, which are all crucial for survival. Nutritional
deficits would fall into this level and take priority over the others listed.
Rationale 3: Self-Care Deficit would fall in the fourth level—self-esteem needs.
Rationale 4: Powerlessness is part of the need to develop one’s maximum potential. It falls into the
fifth and highest level of self-actualization.
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: Assessment
Learning Outcome: 4. Identify Maslow’s characteristics of the self-actualized person.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 247
Question 6
Type: MCSA
The nurse is using Kalish’s adaptation of Maslow’s hierarchy of needs when planning client
care. Which client should the nurse identify as exhibiting a level of Kalish’s adaptation?
1. Has a homosexual encounter for the first time
2. Has a need to participate in school sports and be “on the team”
3. Strives to become the CEO of a company
4. Is sleep deprived because of musculoskeletal discomfort
Correct Answer: 1
Rationale 1: Richard Kalish added a sixth level to Maslow’s five levels and referred to it as
stimulation needs. This level includes sexual activity, exploration, manipulation, and novelty.
Rationale 2: A client who “wants to be on the team” is exhibiting characteristics of love and
belonging needs; mentioned in Maslow’s original five-level hierarchy.
Rationale 3: Striving to be in charge of a company is part of self-actualization, mentioned in
Maslow’s original five-level hierarchy.
Rationale 4: Sleep is one of the basic physiological needs mentioned in Maslow’s original five-level
hierarchy.
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: Assessment
Learning Outcome: 4. Identify Maslow’s characteristics of the self-actualized person.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 247
Question 7
Type: MCSA
A nurse is delivering a workshop regarding health promotion to a group of elderly clients. In
describing Healthy People 2010, which goal should the nurse emphasize for this group?
1. Eliminating health disparities
2. Believing that individual health is closely related to community health
3. Increasing quality and years of life
4. Developing partnerships between individual and community health
Correct Answer: 3
Rationale 1: The second goal of Healthy People 2010 is to eliminate health disparities, which reflects
the diversity of the entire population, not just the elderly.
Rationale 2: The foundation for this document is the belief that individual health is closely linked to
community health, and the reverse, but this applies to the entire population, not just the elderly.
Rationale 3: Healthy People 2010 has four main goals. The first is to increase quality and years of
healthy life, which applies to the clients who will be the focus of this workshop.
Rationale 4: The foundation for this document is the belief that individual health is closely linked to
community health, and the reverse. In order to bring this about, partnerships are important to
improve the health of individuals and communities, but this applies to the entire population, not just
the elderly.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease
prevention strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Describe the vision, mission, and goals of Healthy People 2020 to help
improve the health of a community.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 248
Question 8
Type: MCSA
A client comes to the clinic seeking information regarding smoking cessation classes and ways to
improve respiratory function. This client is modeling which behavior?
1. Health promotion
2. Health protection
3. Tertiary prevention
4. Primary prevention
Correct Answer: 2
Rationale 1: Health promotion is behavior motivated by the desire to increase well-being and
actualize human health potential.
Rationale 2: Health protection or illness prevention is “behavior motivated by a desire to actively
avoid illness, detect it early, or maintain functioning within the constraints of illness.” Expressing a
desire to quit smoking would be modeling this behavior. The information we are given does not tell
us if the client has pathology or not, but the client certainly has been exposed to a health hazard.
Rationale 3: Tertiary prevention focuses on restoration and rehabilitation—it is not a behavior.
Rationale 4: Primary prevention focuses on health promotion—it is not a behavior.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6. Differentiate health promotion from health protection or illness prevention.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 249
Question 9
Type: MCMA
A community health nurse wants to provide health promotion classes through the local hospital.
Which topics should the nurse include in this endeavor?
Standard Text: Select all that apply.
1. Time management
2. Healthy eating habits
3. Exercise after stroke
4. Bicycle safety for children
5. Performing self-examination of the breasts
Correct Answer: 1, 2, 4
Rationale 1: Health promotion activities include those items that increase well-being and overall
health.
Rationale 2: Health promotion activities include those items that increase well-being and overall
health.
Rationale 3: Teaching about exercise following a stroke focuses on rehabilitation, not health
promotion.
Rationale 4: Health promotion activities include those items that increase well-being and overall
health.
Rationale 5: Performing self-examination of the breasts is a health protection activity.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 7. Identify various types and sites of health promotion programs.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 248
Question 10
Type: MCSA
A client has joined a fitness club and is working with the nurse to design a program for weight
reduction and increased muscle tone. The client has tried exercise in the past with success, but has
not been participating in a program for some time. In order to assess the potential for success with
this client, the nurse should evaluate which of the behavior-specific cognitions?
1. Interpersonal influences
2. Perceived benefits of action
3. Situational influences
4. Perceived self-efficacy
Correct Answer: 2
Rationale 1: Interpersonal influences are a person’s perceptions concerning the behaviors, beliefs,
or attitudes of others—including family, peers, and health professionals—who can influence their
success.
Rationale 2: Behavior-specific cognitions and affect are considered to be of major motivational
significance for acquiring and maintaining health-promoting behaviors. Perceived benefits of action
affect the person’s plan to participate in health-promoting behaviors and may facilitate continued
practice. If this client has prior positive experience with the behavior or observations of others
engaged in the behavior, he or she may be motivated to success.
Rationale 3: Situational influences are direct and indirect influences on health-promoting behaviors
and include perceptions of options, demand characteristics, and the aesthetic features of the
environment.
Rationale 4: Perceived self-efficacy refers to the conviction that a person can successfully carry out
the behavior necessary to achieve a desired outcome.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7. Identify various types and sites of health promotion programs.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 251
Question 11
Type: MCSA
A client has been working hard in rehabilitation following a traumatic brain injury. She has a weak
support system in that her family lives a far distance away and her coworkers are not involved. On
which behavior-specific cognitions should the nurse focus to assist this client with success in
the rehabilitation program?
1. Situational influences
2. Perceived benefits of action
3. Perceived barriers to action
4. Interpersonal influences
Correct Answer: 4
Rationale 1: Situational influences are direct and indirect influences on health-promoting behaviors
and include perceptions of available options, demand characteristics, and the aesthetic features of
the environment.
Rationale 2: Perceived benefits of action affect the person’s plan to participate in health-promoting
behaviors and may facilitate continued practice.
Rationale 3: Perceived barriers to action may be real or imagined and may affect health-promoting
behaviors by decreasing the individual’s commitment to a plan of action.
Rationale 4: Interpersonal influences are a person’s perceptions concerning the behaviors, beliefs,
or attitudes of others. Family, peers, and health professionals are sources of interpersonal influences
that can affect a person’s health-promoting behaviors. Because this particular client does not have a
close support system, the nurse will look to other possibilities (i.e., the other health professionals
involved in the client’s care such as other nurses, therapists, and physicians).
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 7. Identify various types and sites of health promotion programs.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 252
Question 12
Type: MCSA
A client is learning how to manage his asthma. In providing teaching, the nurse stresses the
importance of using the peak flow meter every morning to help determine changes in respiratory
status. The nurse is stressing which health promotion behavior?
1. Competing preferences
2. Competing demands
3. Situational influences
4. Interpersonal influences
Correct Answer: 1
Rationale 1: Competing preferences are behaviors over which an individual has a high level of
control and depend on the individual’s ability to be self-regulating. In this case, the individual must
make a choice to use his peak flow meter every day. It’s really his choice—either he uses it or he
doesn’t.
Rationale 2: Competing demands are behaviors over which an individual has a low level of control;
something unexpected competes with a planned activity.
Rationale 3: Situational influences are direct and indirect influences on health-promoting behaviors
and include perceptions of available options, demand characteristics, and the aesthetic features of
the environment.
Rationale 4: Interpersonal influences are a person’s perceptions concerning the behaviors, beliefs,
or attitudes of others.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8. Discuss the Health Promotion Model.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 252
Question 13
Type: SEQ
Before helping a client with smoking cessation, the nurse reviews the steps of the change process.
In which order should the nurse expect the client to progress through the stages of health change
behavior? Arrange the following stages in the correct order:
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Preparation stage
Choice 2. Contemplation stage
Choice 3. Maintenance stage
Choice 4. Precontemplation stage
Choice 5. Termination stage
Choice 6. Action Stage
Correct Answer: 4, 2, 1, 6, 3, 5
Rationale 1: This is the third stage, where the client intends to take action in the immediate future
(e.g., within the next month). Some people in this stage may have already started making small
behavioral changes, such as buying a self-help book. At this stage, the person makes the final
specific plans to accomplish the change.
Rationale 2: This is the second stage, where the client acknowledges having a problem, seriously
considers changing a specific behavior, actively gathers information, and verbalizes plans to change
the behavior in the near future (e.g., next 6 months).
Rationale 3: This is the fifth stage, where the client strives to prevent relapse by integrating newly
adopted behaviors into his or her lifestyle. This stage lasts until the person no longer experiences
temptation to return to previous unhealthy behaviors. It is estimated that maintenance lasts
from 6 months to 5 years.
Rationale 4: This is the first stage, where the client is not contemplating change for at least 6
months.
Rationale 5: This is the sixth and last stage (the ultimate goal), where the individual has complete
confidence that the problem is no longer a temptation or threat. It is as if the individual never
acquired the habit in the first place or the new behavior has become automatic.
Rationale 6: This is the fourth stage, where the client actively implements behavioral and cognitive
strategies of the action plan to interrupt previous health risk behaviors and adopt new ones. This
stage requires the greatest commitment of time and energy.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 9. Explain the stages of health behavior change.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 252
Question 14
Type: MCSA
Several nursing students have been discussing the benefits of joining a study group. They realize
the importance of applying nursing knowledge to the clinical area and determine that together they
may be more effective in retaining this information than if they continued in their individual settings.
Which stage of behavior change are they exemplifying?
1. Termination stage
2. Preparation stage
3. Contemplation stage
4. Action stage
Correct Answer: 3
Rationale 1: The termination stage is the ultimate goal, where the individual has complete
confidence that the problem is no longer a temptation or threat.
Rationale 2: The preparation stage occurs when the person undertakes cognitive and behavioral
activities that prepare the person for change.
Rationale 3: During the contemplation stage, the person acknowledges the problem, considers
changing a specific behavior, actively gathers information, and verbalizes plans to change the
behavior in the near future. Discussing benefits of a study group would fall into this stage. They
haven’t started a group nor have they made any preparation toward it; they have merely been talking
about it.
Rationale 4: The action stage occurs when the person actively implements behavioral and cognitive
strategies to interrupt previous behavior patterns and adopt new ones.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9. Explain the stages of health behavior change.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 252
Question 15
Type: MCSA
A client with diabetes wants to have better control over her blood sugar levels. She has set a goal
that she will have laboratory values that reflect this, and she has been monitoring her blood sugar
twice a day for the past month. Along with regular checks, she has kept all appointments with her
nutritionist. This client is modeling which stage of health behavior change?
1. Termination stage
2. Maintenance stage
3. Contemplation stage
4. Action stage
Correct Answer: 4
Rationale 1: The termination stage occurs when the individual has complete confidence that the
problem is no longer a temptation or a threat.
Rationale 2: The maintenance stage is where the person integrates adopted behavior patterns into
his or her lifestyle. This stage lasts until the person no longer has temptation to return to previous
unhealthy behaviors.
Rationale 3: In the contemplation stage, the person acknowledges having a problem, seriously
considers changing a specific behavior, actively gathers information, and verbalizes plans to change
the behavior in the near future.
Rationale 4: The action stage occurs when the person actively implements behavioral and cognitive
strategies to interrupt previous behavior patterns and adopt new ones. This stage requires the
greatest commitment of time and energy and is where the person is actually doing something to
change the behavior.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 9. Explain the stages of health behavior change.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 252
Question 16
Type: MCSA
The health nurse of a busy university campus is implementing a health promotion activity by placing
posters about proper hand washing in all of the public restrooms on campus. Which type of health
promotion program is the nurse implementing?
1. Environmental control
2. Information dissemination
3. Health risk appraisal and wellness assessment
4. Lifestyle and behavior change
Correct Answer: 2
Rationale 1: Environmental control programs have been developed as a result of the continuing
increase of contaminants of human origin that have been introduced into the environment.
Rationale 2: Information dissemination is the most basic type of health promotion program. This
method makes use of a variety of media to offer information to the public about the risk of a
particular lifestyle choice and personal behavior as well as the benefits of changing that behavior.
Rationale 3: Health risk appraisal and wellness assessment programs are used to describe risk
factors to people and motivate them to reduce specific risks and develop positive health habits.
Rationale 4: Lifestyle and behavior change programs require participation of the individual and are
geared toward enhancing the quality of life and extending the life span.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7. Identify various types and sites of health promotion programs.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 253
Question 17
Type: MCSA
The nurse is preparing information packets for incoming college students regarding sexually
transmitted disease, drug and alcohol abuse, and the use of stimulants among this age group. In this
situation, the nurse has assumed which role?
1. Facilitator
2. Advocate
3. Teacher
4. Coordinator of services
Correct Answer: 3
Rationale 1: A facilitator is involved in the assessment, implementation, and evaluation of health
goals.
Rationale 2: The advocate helps implement changes that promote a healthy environment.
Rationale 3: The teaching role focuses on self-care strategies such as enhancing fitness, improving
nutrition, managing stress, and enhancing relationships.
Rationale 4: A coordinator helps to guide and reinforce the client’s development in effective problem
solving and decision making as well as reinforces personal and family health-promoting behaviors.
Global Rationale:
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10. Discuss the nurse’s role in health promotion.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10. Discuss the nurse’s role in health promotion.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 253
Question 18
Type: MCSA
The nurse suggests that a client make a list of past experiences that have brought joy, peace, and
hope into the client’s life. What action is the nurse assisting the client to complete?
1. Lifestyle assessment
2. Social support systems review
3. Health beliefs review
4. Spiritual health assessment
Correct Answer: 4
Rationale 1: Lifestyle assessment focuses on the personal lifestyle and habits of the client as they
affect health.
Rationale 2: A social support systems review takes into account the social context in which a person
lives and works and is important in health promotion. This includes individuals, groups, and
interpersonal relationships that provide comfort, assistance, encouragement, and information.
Rationale 3: A health beliefs review is a clarification of those beliefs that determine how a person
maintains control of his or her own health status.
Rationale 4: Spiritual health is the ability to develop one’s spiritual nature to its fullest potential,
including the discovery of how to experience love, joy, peace, and fulfillment. An assessment of
spiritual well-being is a part of evaluating the person’s overall health.
Global Rationale:
Cognitive Level: Analyzing
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. 18. Develop an awareness of patients as well as healthcare
professionals’ spiritual beliefs and values and how those beliefs and values impact health care
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11. Describe components of health assessment that pertain to health promotion.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 255
Question 19
Type: MCSA
A client has received a high score on the Life-Change Index. For which part of the client’s
assessment should the nurse use this information?
1. Life stress review
2. Social support systems review
3. Lifestyle assessment
4. Health beliefs review
Correct Answer: 1
Rationale 1: The Life-Change Index is a tool that assigns numerical values to life events and is a
way to identify clients in stress. Studies have shown that high levels of stress are associated with an
increased possibility of illness in an individual.
Rationale 2: A social support systems review takes into account the social context in which a person
lives and works.
Rationale 3: A lifestyle assessment focuses on the personal lifestyle habits of the client as they
affect health.
Rationale 4: A health beliefs review provides information about how much clients believe they can
influence or control health through personal behaviors.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11. Describe components of health assessment that pertain to health promotion.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 256
Question 20
Type: MCSA
The client is a high school student who is also a single parent. She is attending parenting classes
while studying full time and living in an apartment with her child. The student also meets twice a
week with a teen peer group and participates in a nutrition program through the county. Which is the
most appropriate diagnosis for this client?
1. Risk for Situational Low Self-Esteem
2. High Risk for Caregiver Role Strain
3. Readiness for Enhanced Coping
4. Readiness for Enhanced Nutrition
Correct Answer: 3
Rationale 1: The information given in the scenario does not indicate that the client is experiencing
problems with low self-esteem.
Rationale 2: The information given in the scenario does not indicate that the client is experiencing
problems with caregiver role strain.
Rationale 3: Wellness diagnoses describe the human responses to levels of wellness in an
individual. In this situation, even though the client is young and single, she is making every effort to
be well in her situation. Attending parenting classes, meeting with peers, and learning about nutrition
all point to a person who has a positive outlook but requires teaching.
Rationale 4: The client is doing much more than just learning about nutrition. She is learning how to
cope and be well in her life and the life of her child.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 12. Discuss nursing diagnosing, planning, implementing, and evaluating as they
relate to health promotion.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 256
Question 21
Type: MCSA
The nurse educator provides developmental testing for kindergarten through third–
grade students. Which level of prevention is the nurse performing?
1. Primary
2. Secondary
3. Tertiary
4. Community
Correct Answer: 2
Rationale 1: Primary prevention is true health promotion and precedes disease or dysfunction.
Rationale 2: Secondary prevention emphasizes early detection of disease and health maintenance
for individuals experiencing health problems. This would include providing assessment of the growth
and development of children.
Rationale 3: Tertiary prevention begins after an illness, when a defect or disability is fixed, stabilized,
or determined to be irreversible.
Rationale 4: Community health is a broad category that includes many facets. It is not a level of
prevention.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8. Discuss the Health Promotion Model.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 249
Question 22
Type: MCSA
A client has had a severe brain injury and has been in a rehabilitation hospital for several months.
Recently, the client developed pneumonia and is currently on intravenous antibiotic therapy. Which
level of prevention should the nurse use to address the health problem of pneumonia?
1. Primary
2. Secondary
3. Tertiary
4. Acute
Correct Answer: 2
Rationale 1: Primary prevention is true health promotion and provides specific interventions against
disease.
Rationale 2: Secondary prevention emphasizes early detection of disease, prompt intervention, and
health maintenance for individuals experiencing health problems. Because the pneumonia is a
current health problem, interventions focused on that would be considered secondary prevention.
Rationale 3: All cares related to rehabilitation following the brain injury would be tertiary prevention.
Tertiary prevention focuses on rehabilitating individuals to an optimum level of functioning.
Rationale 4: Acute care is a part of health care, but not one of the levels of prevention.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8. Discuss the Health Promotion Model.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 249
Question 23
Type: MCSA
A nurse in charge of an assisted living complex that includes independent living apartments
understands the unique needs of individuals of this age group. When planning health promotion
strategies, what factor should the nurse take into consideration?
1. Rest and exercise
2. Adjusting to physiologic changes and limitations
3. High obesity percentages
4. Safety promotion and injury prevention
Correct Answer: 2
Rationale 1: Rest and exercise are life span considerations of children.
Rationale 2: In the elderly population, health promotion and illness prevention are important, but the
focus is often on learning to adapt to and live with increasing changes and limitations. Maximizing
strengths continues to be of prime importance in maintaining optimal function and quality of life.
Rationale 3: In the elderly population, health promotion and illness prevention are important, but the
focus is often on learning to adapt to and live with increasing changes and limitations. Maximizing
strengths continues to be of prime importance in maintaining optimal function and quality of life. Rest
and exercise and high obesity percentages are life span considerations of children.
Rationale 4: Safety promotion and injury prevention are life span considerations for adolescents.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8. Discuss the Health Promotion Model.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 250
Question 24
Type: MCSA
A nurse is working with various cultures while implementing health promotion activities for the
community center. Bringing the minister of the church into the planning stage of these activities
would be sensitive to which cultural groups?
1. Latino American
2. Asian American
3. Native American
4. African American
Correct Answer: 4
Rationale 1: Latino Americans view the family as being a major social support system.
Rationale 2: Asian Americans view the family as being a major social support system.
Rationale 3: Native American people live in social networks that foster mutual assistance and
support.
Rationale 4: In the African American community, the family and church have been major providers of
social support.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 12. Discuss nursing diagnosing, planning, implementing, and evaluating as they
relate to health promotion.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 253
Question 25
Type: MCMA
The nurse is reviewing the characteristics of homeostatic mechanisms prior to assessing a client.
Which characteristics should the nurse keep in mind during this assessment?
Standard Text: Select all that apply.
1. They are self-regulating.
2. They are compensatory.
3. They are regulated by negative feedback systems.
4. They can require several feedback mechanisms to correct only one physiologic imbalance.
5. They are related to a closed system.
Correct Answer: 1, 2, 3, 4
Rationale 1: Homeostatic mechanisms are self-regulating.
Rationale 2: Homeostatic mechanisms are compensatory.
Rationale 3: Homeostatic mechanisms are regulated by negative feedback systems.
Rationale 4: Homeostatic mechanisms can require several feedback mechanisms to correct a
physiologic imbalance.
Rationale 5: Homeostatic mechanisms are not related to a closed system.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. List four main characteristics of homeostatic mechanisms.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 245
Question 26
Type: MCMA
The nurse is an advocate for health promotion activities. Which nursing actions demonstrate this
nurse’s advocacy?
Standard Text: Select all that apply.
1. Participating in a community-focused 5-mile run.
2. Attending the local high school’s football games.
3. Providing an educational program to senior citizens on blood pressure–control strategies.
4. Attending a community meeting that is promoting the creating of a walking path in the city park.
5. Encouraging an anxious client to practice relaxation techniques.
Correct Answer: 1, 3, 4, 5
Rationale 1: The nurse’s role in health promotion includes modeling healthy lifestyle behaviors and
attitudes.
Rationale 2: This is not an example of active role modeling.
Rationale 3: The nurse’s role in health promotion includes assisting clients, families, and
communities to develop and choose health-promoting options.
Rationale 4: The nurse’s role in health promotion includes advocating in the community for changes
that promote a healthy environment.
Rationale 5: The nurse’s role in health promotion includes teaching clients self-care strategies to
enhance fitness, improve nutrition, manage stress, and enhance relationships.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10. Discuss the nurse’s role in health promotion.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 249
Question 27
Type: MCMA
The nurse is reviewing information collected while providing client care. Which findings should the
nurse identify as being a homeostatic mechanism?
Standard Text: Select all that apply.
1. The client’s heart rate increases when walking up a flight of stairs.
2. The client shivers when core body temperature drops.
3. A child’s bone growth occurs in spurts.
4. Decreased secretion of insulin occurs when food is not ingested.
5. Lactation occurs in a pregnant woman.
Correct Answer: 1, 2, 4
Rationale 1: Homeostatic mechanisms have characteristics that include self-regulation, such as
automatically increased respiratory rates.
Rationale 2: Homeostatic mechanisms have characteristics that include compensatory actions, such
as shivering to create body heat.
Rationale 3: This is not an example of a homeostatic mechanism; they are self-regulation,
compensation, negative feedback, and utilization of multiple mechanisms to correct a physiological
imbalance.
Rationale 4: Homeostatic mechanisms have characteristics that include regulation by negative
feedback systems.
Rationale 5: This is not an example of a homeostatic mechanism; they are self-regulation,
compensation, negative feedback, and utilization of multiple mechanisms to correct a physiological
imbalance.
Global Rationale:
Page Reference:
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. List four main characteristics of homeostatic mechanisms.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 245
Chapter 17
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 17
Question 1
Type: MCSA
A client is attending classes on building positive relationships with significant others as well as
learning skills to be open-minded and respectful to those whose opinions are different. The nurse
realizes that this client is focusing on which component of wellness?
1. Physical
2. Social
3. Emotional
4. Environment
Correct Answer: 2
Rationale 1: The physical component of wellness is the ability to carry out daily tasks, achieve
fitness of all body systems, and practice positive lifestyle habits.
Rationale 2: The social component of wellness focuses on the ability to interact successfully with
people and within the environment of which each person is a part, to develop and maintain intimacy
with significant others, and to develop respect and tolerance for those with different opinions and
beliefs.
Rationale 3: The emotional component deals with the ability to manage stress and express emotions
appropriately.
Rationale 4: The environmental component focuses on the health measures that improve the
standard of living and quality of life in the community.
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: VII. 1. Assess protective and predictive factors, including genetics,
which influence the health of individuals, families, groups, communities and populations
NLN Competencies: Context and Environment; Practice; apply health promotion/disease
prevention strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Describe five components of wellness.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 263
Question 2
Type: MCSA
The nurse is assisting a client and his family after the client had a stroke and is no longer able to
return to his previous employment. The nurse has made a referral to vocational rehabilitation for
assistance in retraining the client in a different occupation. With which component of wellness is the
nurse assisting this client?
1. Intellectual
2. Environmental
3. Occupational
4. Emotional
Correct Answer: 3
Rationale 1: The intellectual component focuses on learning and using information effectively for
personal, family, and career development. It also involves striving for continued growth and learning
to deal with new challenges effectively.
Rationale 2: Environmental components focus on standards of living and quality of life in the
community and include basic human needs such as water, air, and food.
Rationale 3: Occupational components deal with a balance between work and leisure time. A
person’s beliefs about education, employment, and home influence personal satisfaction and
relationships with others. Assisting a client in retraining to find gainful employment and to attain
satisfaction in his work is part of the occupational component of wellness. Because the client
requires retraining, he must learn anew those aspects of a job that allow for growth, which would
better fit under the occupational component of wellness.
Rationale 4: Emotional components of wellness involve the ability to manage stress and express
emotions appropriately.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Describe five components of wellness.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 264
Question 3
Type: MCSA
A nurse educator is explaining the concept of health and parallels this with interruption of body
systems and symptoms of disease or injury. This educator is interpreting health according to which
model?
1. Health–illness continua
2. Eudemonistic
3. Adaptive
4. Clinical
Correct Answer: 4
Rationale 1: The health–illness continua is often used to measure a person’s perceived level of
wellness in which health and illness are at opposite ends of a health continuum.
Rationale 2: The eudemonistic model incorporates a comprehensive view of health, where health is
seen as a condition of actualization or realization of a person’s potential.
Rationale 3: In the adaptive model, health is seen as a creative process and disease is seen as a
failure in adaptation or maladaptation.
Rationale 4: The narrowest interpretation of health occurs in the clinical model, where people are
viewed as physiologic systems with related functions and health is defined by the absence of signs
and symptoms of disease or injury.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare the various models of health outlined in this chapter.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 264
Question 4
Type: MCSA
A nurse is working in a rehabilitation center with a client who had a serious injury. Part of the client’s
care plan includes working on coping with her current limitations since the injury. This nurse is
working within which model of health?
1. Role performance
2. Adaptive
3. Eudemonistic
4. Clinical
Correct Answer: 2
Rationale 1: The role performance model defines health in terms of the individual’s ability to fulfill
societal roles or to perform work. According to this model, people who fulfill their roles are healthy,
even though they may have an illness.
Rationale 2: In the adaptive model, health is a creative process; disease is a failure in adaptation or
maladaptation. The aim of treatment is to restore the ability of the person to adapt and cope, as in a
rehabilitation setting.
Rationale 3: The eudemonistic model incorporates a comprehensive view of health, which is seen as
a condition of actualization or realization of a person’s potential.
Rationale 4: The clinical model is a narrow interpretation of health, which is defined by the absence
of disease.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare the various models of health outlined in this chapter.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 264
Question 5
Type: MCSA
A nurse is conducting a community assessment to determine which diseases are prevalent and most
likely to occur. The nurse is basing the assessment on which model of health?
1. Role performance
2. Eudemonistic
3. Ecological
4. Adaptive
Correct Answer: 3
Rationale 1: The role performance model defines health according to how individuals are able to
fulfill their roles or perform their work.
Rationale 2: The eudemonistic model incorporates a comprehensive view of health, which is seen as
a condition of actualization or realization of a person’s potential.
Rationale 3: The ecological model—also called the agent-host-environment model of health and
illness—is used primarily in predicting illness rather than promoting wellness. Identification of risk
factors results from interactions between agent, host, and environment, and is helpful in promoting
and maintaining health.
Rationale 4: The adaptive model defines health as a creative process and disease as a
maladaptation. The aim of treatment is restoration of the person’s ability to cope.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Compare the various models of health outlined in this chapter.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 264
Question 6
Type: MCSA
A nurse is assessing a client who practices yoga for relaxation, is following a nutritionally sound diet,
and has supportive, sound relationships with her spouse and children. According to Dunn’s highlevel wellness grid, this client would exemplify which health characteristic?
1. Emergent high-level wellness in a favorable environment
2. Emergent high-level wellness in an unfavorable environment
3. Protected health in a favorable environment
4. High-level wellness in a favorable environment
Correct Answer: 4
Rationale 1: Dunn describes a health grid in which a health axis and an environmental axis intersect.
The intersection of the two axes forms four quadrants of health and wellness. Emergent high-level
wellness in a favorable environment is not part of Dunn’s four quadrants of health and wellness.
Rationale 2: Dunn describes a health grid in which a health axis and an environmental axis intersect.
The intersection of the two axes forms four quadrants of health and wellness. Emergent high-level
wellness in an unfavorable environment would be exemplified by a client who has the knowledge to
implement healthy lifestyles, but does not implement them because of family responsibilities, job
demands, or other factors.
Rationale 3: Dunn describes a health grid in which a health axis and an environmental axis intersect.
The intersection of the two axes forms four quadrants of health and wellness. Protected health in a
favorable environment is not part of Dunn’s four quadrants of health and wellness.
Rationale 4: Dunn describes a health grid in which a health axis and an environmental axis intersect.
The intersection of the two axes forms four quadrants of health and wellness. High-level wellness in
a favorable environment involves biopsychosocial, spiritual, and economic resources that support
healthy lifestyles.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 265
Question 7
Type: MCSA
A nurse has volunteered to go on a health mission to rural Haiti, where the majority of the people do
not have access to health care and live in poverty. According to Dunn’s high-level wellness grid, the
nurse will be working with clients in which quadrant?
1. Emergent high-level wellness in an unfavorable environment
2. Protected poor health in a favorable environment
3. Poor health in an unfavorable environment
4. Protected poor health in an unfavorable environment
Correct Answer: 3
Rationale 1: According to Dunn’s grid, the health axis extends from peak wellness to death, and the
environmental axis extends from very favorable to very unfavorable. Emergent high-level wellness in
an unfavorable environment would include clients who have the knowledge to implement healthy
lifestyle practices, but cannot implement them because of other factors or demands.
Rationale 2: According to Dunn’s grid, the health axis extends from peak wellness to death, and the
environmental axis extends from very favorable to very unfavorable. Protected poor health in a
favorable environment is where clients have an illness but their needs are met by the health care
system. These clients have adequate access to appropriate medications, diet, and health care
instruction.
Rationale 3: According to Dunn’s grid, the health axis extends from peak wellness to death, and the
environmental axis extends from very favorable to very unfavorable. A health mission to an
environment such as rural Haiti would involve clients who are not being treated for problems
because of poor access and who also live in poor environmental conditions such as poverty and
below–standard sanitation.
Rationale 4: According to Dunn’s grid, the health axis extends from peak wellness to death, and the
environmental axis extends from very favorable to very unfavorable. Protected poor health in an
unfavorable environment is not one of Dunn’s quadrants.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 265
Question 8
Type: MCSA
The nurse educator is reviewing internal variables that affect people’s health status. On which
variables is this nurse focusing?
Standard Text: Select all that aply.
1. Genetic makeup
2. Age
3. Developmental level
4. Environment
5. Spiritual and religious beliefs
Correct Answer: 1, 2, 3, 5
Rationale 1: Internal variables that affect people’s health include biologic, psychologic, and cognitive
dimensions. Biologic dimensions include genetic makeup.
Rationale 2: Internal variables that affect people’s health include biologic, psychologic, and cognitive
dimensions. Biologic dimensions include age.
Rationale 3: Internal variables that affect people’s health include biologic, psychologic, and cognitive
dimensions. Biologic dimensions include developmental level.
Rationale 4: Internal variables that affect people’s health include biologic, psychologic, and cognitive
dimensions. Environment is an example of an external variable that affects a person’s health.
Rationale 5: Internal variables that affect people’s health include biologic, psychologic, and cognitive
dimensions. Cognitive dimensions include spiritual and religious beliefs.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 267
Question 9
Type: MCSA
An occupational health nurse is surveying employees. Which employee should the nurse identify as
being predisposed to an illness?
1. An employee who is in a middle-management position and takes stress from administration as
well as the employees
2. An employee who works in the janitorial department
3. An employee who works 12-hour days, 3 days a week
4. An employee who works 4 days on and 3 days off
Correct Answer: 1
Rationale 1: People who hold management positions are in stressful occupational roles that
predispose them to stress-related diseases.
Rationale 2: Working as a custodian would not pose the same type of stress as the management
position.
Rationale 3: Working longer shifts would not pose the same type of stress as the management
position.
Rationale 4: Working longer shifts would not pose the same type of stress as the management
position.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 267
Question 10
Type: MCSA
A community health nurse is testing the theory of locus of control (LOC). Which client demonstrates
the internal control concept of this theory?
1. A client who takes an active role in all health decisions
2. A client who allows the primary care provider to make all the decisions
3. A client who does not make any decisions without his or her spouse’s input
4. A client who relies on information from the local hospital for his or her health needs
Correct Answer: 1
Rationale 1: Locus of control (LOC) is a concept from social learning theory. People who exercise
internal control are more likely than others to take the initiative on their own health care and to be
more knowledgeable about their health. They are also more likely to adhere to prescribed health
care regimens such as taking medication, making and keeping appointments with physicians,
maintaining diets, and giving up smoking.
Rationale 2: People who believe their health is largely controlled by outside forces (chance or
others) are referred to as externals.
Rationale 3: People who believe their health is largely controlled by outside forces (chance or
others) are referred to as externals.
Rationale 4: People who believe their health is largely controlled by outside forces (chance or
others) are referred to as externals.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4. Identify variables affecting health status, beliefs, and practices.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 269
Question 11
Type: MCSA
The nurse case manager is concerned about a particular client being discharged from the hospital.
Which factors should alert the nurse to possible problems with this client’s adherence to treatment?
1. The prescribed therapy is costly and of unknown duration.
2. The therapy will require no lifestyle changes of the client.
3. The client has not had difficulty understanding the regimen.
4. The client’s culture is supportive of Western medicine.
Correct Answer: 1
Rationale 1: Adherence to a particular therapy can be compromised if the therapy is expensive or if
the duration of the proposed therapy is long.
Rationale 2: Adherence is the extent to which an individual’s behavior coincides with medical or
health advice. If no lifestyle changes are expected, then adherence should not be an issue.
Rationale 3: Adherence is the extent to which an individual’s behavior coincides with medical or
health advice. If the client understands the regimen, adherence is not an issue.
Rationale 4: Adherence is the extent to which an individual’s behavior coincides with medical or
health advice. Following Western medicine is not an adherence issue.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Describe factors affecting health care adherence.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 270
New Questions:
Question 12
Type: MCMA
During a home visit with a new community member, the nurse suspects that a client has a chronic
illness. What did the nurse assess to make this clinical decision?
Standard Text: Select all that apply.
1. Experienced symptoms for 8 months
2. Has periods where the symptoms disappear
3. Altered activities of daily living because of the illness
4. Problem disappeared with over-the-counter medication
5. Symptoms appeared abruptly and disappeared after treatment
Correct Answer: 1, 2, 3
Rationale 1: A chronic illness is one that lasts for an extended period, usually 6 months or longer,
and often for the person’s life.
Rationale 2: Chronic illnesses usually have a slow onset and often have periods of remission, when
the symptoms disappear.
Rationale 3: With chronic illnesses clients often need to modify activities of daily living.
Rationale 4: An acute illness may subside with the help of over-the-counter medication.
Rationale 5: Symptoms of an acute illness appear abruptly and subside quickly after intervention.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6. Differentiate illness from disease and acute illness from chronic illness.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 271
Question 13
Type: MCMA
The nurse determines that an older client is in the medical care contact stage of an illness. What did
the client demonstrate to cause the nurse to make this decision?
Standard Text: Select all that apply.
1. The client asked if the illness can be treated or recovery is possible.
2. The client asked if the symptoms experienced are a part of an illness.
3. The client asked if the symptoms can be explained in plain language.
4. The client stated that the illness is not acceptable and wants a second opinion.
5. The client stated that treatment is accepted and will be completed as identified.
Correct Answer: 1, 2, 3, 4
Rationale 1: In the medical care contact stage the client seeks reassurance that the illness can be
treated and the outcome predicted.
Rationale 2: In the medical care contact stage the client wants validation of a real illness.
Rationale 3: In the medical care contact stage the client wants the symptoms explained in
understandable terms.
Rationale 4: In the medical care contact stage the client may deny the diagnosis and seek the other
of other health care professionals.
Rationale 5: In the dependent client role the client becomes dependent on the professional for help.
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: VII. 5. Use evidence-based practices to guide health teaching,
health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up
throughout the lifespan
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8. Explain Suchman’s stages of illness.
MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.
Page Number: 272
Chapter 18
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 18
Question 1
Type: MCMA
A community health nurse is learning about the REACH initiative and has decided to implement
community education on this approach. What topics should the nurse include in this education?
Standard Text: Select all that apply.
1. Child and adult immunizations
2. Cardiovascular disease
3. Chronic lower respiratory disease
4. Stroke
5. Infant mortality
Correct Answer: 1, 2, 5
Rationale 1: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the
Centers for Disease Control and Prevention. Topics within the REACH initiative include child and
adult immunizations.
Rationale 2: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the
Centers for Disease Control and Prevention. Topics within the REACH initiative
include cardiovascular diseases.
Rationale 3: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the
Centers for Disease Control and Prevention. Chronic lower respiratory disease is not a topic within
the REACH initiative.
Rationale 4: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the
Centers for Disease Control and Prevention. Stroke is not a topic within the REACH initiative.
Rationale 5: REACH: Racial and Ethnic Approaches to Community Health is an initiative of the
Centers for Disease Control and Prevention. Topics within the REACH initiative include infant
mortality.
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. 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: 3. Describe the role of federal agencies and initiatives regarding the provision of
culturally responsive health care.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 279
Question 2
Type: MCSA
A new graduate nurse is working in a busy emergency department of a hospital, situated in a
culturally diverse area of the city. In striving to be culturally sensitive, what should the nurse do?
1. Try to learn about the attitudes toward health care and traditions of the different cultures in that
area.
2. Understand and attend to the total context of the client’s situation, using knowledge, attitudes, and
skills.
3. Possess the underlying background knowledge that will provide these clients with the best
possible health care.
4. Continuously strive to be culturally competent.
Correct Answer: 1
Rationale 1: Cultural sensitivity implies that nurses possess some basic knowledge of and
constructive attitudes toward the health traditions observed among the diverse cultural groups found
in the setting in which they are practicing.
Rationale 2: To understand and attend to the total context of the client’s situation, using knowledge,
attitudes, and skills, is a general nursing expectation and does not address cultural sensitivity
directly.
Rationale 3: To possess the underlying background knowledge that will provide these clients with
the best possible health care is a general nursing expectation and does not address cultural
sensitivity directly.
Rationale 4: Becoming culturally competent is an ongoing process in which an individual develops
along a continuum until diversity is accepted as a norm and the nurse has acquired greater
understanding and capacity in a diverse environment.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 6. Differentiate culturally influenced approaches to healing and treatment..
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 288
Question 3
Type: MCSA
A client is the child of an African American father and Asian American mother. The client has been
exposed to cultural foods, traditions, and customs from both parents throughout life. What term
should the nurse use to describe this client’s cultural development?
1. Diversity
2. Subculture
3. Multicultural
4. Cultural sensitivity
Correct Answer: 3
Rationale 1: Diversity refers to the fact or state of being different.
Rationale 2: A subculture is usually composed of people who have a distinct identity yet are related
to a larger cultural group.
Rationale 3: Multicultural is used to describe a person who has multiple patterns of identification or
crosses several cultures, lifestyles, and sets of values.
Rationale 4: Nurses demonstrate cultural sensitivity when they possess some basic knowledge of
and constructive attitudes toward the health traditions observed among the diverse cultural groups
found in a setting in which they are practicing.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 277
Question 4
Type: MCSA
A nurse is working with a home health client whose spouse was not born in the United States.
During the home visit, the nurse realizes that the client has acquired the identity of her spouse’s
culture and has adopted some of the health practices of that culture. Which process should the
nurse identify as occurring with the spouse?
1. Acculturation
2. Assimilation
3. Diversity
4. Heritage consistency
Correct Answer: 2
Rationale 1: Acculturation occurs when people adapt to or borrow traits from another culture.
Acculturation can also be defined as the changes of one’s cultural patterns to those of the host
society.
Rationale 2: Assimilation is the process by which an individual develops a new cultural identity. It
encompasses various aspects such as behavior, marital roles, identification, and civic duties. The
underlying assumption is that the person from a given cultural group loses his or her original cultural
identity to acquire the new one.
Rationale 3: Diversity is the fact or state of being different.
Rationale 4: Heritage consistency relates to the observance of beliefs and practices of a person’s
traditional cultural system.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 279
Question 5
Type: MCSA
The nurse manager is concerned that a staff nurse provides client care with a cultural
prejudice. Which situation did the manager observe to come to this conclusion?
1. Making an assumption that all members of each culture are alike
2. Believing that all culture members will have the same beliefs
3. Bringing previous negative information and experiences into this situation
4. Taking general knowledge from literature and applying it to the situation
Correct Answer: 3
Rationale 1: Making an assumption that all members of each culture are
alike describes stereotypical behavior.
Rationale 2: Believing that all culture members have the same beliefs describes stereotypical
behavior.
Rationale 3: Prejudice is a negative belief or preference that is generalized about a group, which
leads to “prejudgment.” Prejudice occurs when the person making the judgment generalizes an
experience of one individual from a culture to all members of that group.
Rationale 4: Taking general knowledge from literature and applying it to the situation is a form of
stereotyping.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8. Create self-awareness of your own culture, beliefs, biases, and assumptions.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 278
Question 6
Type: MCSA
A new graduate nurse is moving from a small rural college town to a metropolitan area to begin work
in a county hospital. The nurse has had limited prior experience with the various cultural groups that
are served by the hospital. What might be this nurse’s greatest challenge?
1. Prejudice
2. Stereotyping
3. Discrimination
4. Assimilation
Correct Answer: 4
Rationale 1: Prejudice is a negative belief or preference that is generalized about a group and leads
to “prejudging.”
Rationale 2: Stereotyping is assuming that all members of a culture or ethnic group are alike.
Rationale 3: Discrimination occurs when a person acts on prejudice and denies another person one
or more of the fundamental rights.
Rationale 4: Assimilation is the process by which an individual develops a new cultural identity.
Assimilation means becoming like the members of the dominant culture. Because this is a conscious
effort, it is not always possible, and the process may cause severe stress and anxiety.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8. Create self-awareness of your own culture, beliefs, biases, and assumptions.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 279
Question 7
Type: MCSA
A client has requested that she have a special item present in her room and explains that it gives her
a feeling of comfort and a sense of organization. On which psychosocial component is this client
focusing?
1. Culture
2. Religion
3. Ethnicity
4. Socialization
Correct Answer: 2
Rationale 1: Culture is a learned behavior and depends on underlying societal traits, including
knowledge, beliefs, art, law, morals, and customs.
Rationale 2: Religion may be defined by a system of beliefs, practices, and ethical values about
divine or superhuman power and is closely related to ethnicity. Religion gives a person a frame of
reference and a perspective with which to organize information.
Rationale 3: Ethnicity describes the traits and common religious customs and language of a group
within the social system.
Rationale 4: Socialization is the process of being raised within a culture and acquiring the
characteristics of that group.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 277
Question 8
Type: MCSA
Before a client goes to surgery, he requests to have his spiritual leader present and pray over him.
According to the HEALTH traditions model, which traditional method is the client invoking?
1. Maintaining HEALTH
2. Protecting HEALTH
3. Restoring HEALTH
4. Changing HEALTH
Correct Answer: 3
Rationale 1: Methods of maintaining HEALTH include following a proper diet, wearing proper
clothing, concentrating and using the mind, and practicing one’s religion.
Rationale 2: Traditional methods of protecting HEALTH include wearing protective objects such as
amulets, avoiding people who may cause trouble, and placing religious objects in the home.
Rationale 3: Traditional methods of restoring HEALTH—physical, mental, and spiritual—include the
use of herbal remedies, exorcism, and health rituals. This situation describes a healing ritual.
Rationale 4: Changing HEALTH is not one of the traditional methods in the HEALTH traditions
model.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention
strategies; apply health policy
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Describe health views from culturally diverse perspectives.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 281
Question 9
Type: MCSA
A client makes the following statement: “I must be paying for all the wrongs I did in my life, to have
such a diagnosis as this.” The nurse suspects that this client views health from which type of belief?
1. Magico-religious belief
2. Holistic health belief
3. Biomedical health belief
4. Folk medicine
Correct Answer: 1
Rationale 1: In the magico-religious health belief view, health and illness are controlled by
supernatural forces. The client may believe that illness is the result of “being bad” or opposing God’s
will.
Rationale 2: The holistic health belief holds that the forces of nature must be maintained in balance
or harmony. Human life is one aspect of nature that must be in harmony with the rest of nature.
Rationale 3: Biomedical health belief, also termed scientific belief, is based on the belief that life and
life processes are controlled by physical and biochemical processes that can be manipulated by
humans.
Rationale 4: Folk medicine is defined as those beliefs and practices related to illness prevention and
healing that derive from cultural traditions rather than from modern medicine’s scientific base.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5. Describe health views from culturally diverse perspectives.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 282
Question 10
Type: MCSA
A Chinese client is hospitalized with a fever of unknown origin and follows a very traditional, cultural
view of illness. Which food should the nurse offer the client?
1. Hot tea
2. Warm soup
3. Spicy meat
4. Cold liquids
Correct Answer: 4
Rationale 1: In this case, the fever would be considered a “hot” illness and the client is not likely to
select this treatment.
Rationale 2: In this case, the fever would be considered a “hot” illness and the client is not likely to
select this treatment.
Rationale 3: In this case, the fever would be considered a “hot” illness and the client is not likely to
select this treatment.
Rationale 4: The concept of yin and yang in the Chinese culture is an example of a holistic health
belief. A Chinese client who has a yang illness, or a “hot” illness, may prefer a yin or “cold”
treatment. In this case, the fever would be considered a “hot” illness and the client may prefer the
opposite or yin treatment.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 282
Question 11
Type: MCSA
A community health nurse works with a variety of cultures providing health care services that include
preventive care, acute treatment, and education. Of the following clients, which is most likely to use
folk medicine?
1. The client who speaks little English and does not have a job
2. A family who has numerous relatives in a Spanish-American sector of the city
3. A female client whose culture is one of male dominance
4. A Chinese client who has a small, family–run business in the area
Correct Answer: 1
Rationale 1: Folk medicine is defined as beliefs and practices that relate illness prevention and
healing to cultural traditions rather than modern medicine’s scientific base. People who have limited
access to scientific health care may turn to folk medicine or folk healing. Because folk healing is
more culturally based, it may be more comfortable and less frightening for the client who is not fluent
in the English language and has limited access to scientific health care.
Rationale 2: There is no evidence to suggest that this family would prefer to use folk medicine.
Rationale 3: There is no evidence to suggest that this client would prefer to use folk medicine.
Rationale 4: There is no evidence to suggest that this client would prefer to use folk medicine.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6. Differentiate culturally influenced approaches to healing and treatment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 282
Question 12
Type: MCSA
A female client is being discharged after a lengthy hospitalization. The family is from a maledominated culture. Before discharge instructions are given, which action should the nurse take?
1. Make sure instructions are understood by the client.
2. Arrange for teaching when the spouse is available.
3. Make sure that the physician gives the instructions.
4. Ask the client when the best time for teaching would be.
Correct Answer: 2
Rationale 1: Regardless of cultural considerations, it’s always necessary to make sure that the
instructions are understood.
Rationale 2: The nurse needs to identify who has the “authority” to make decisions in a client’s
family. If the decision maker is someone other than the client, as in this situation, the nurse needs to
include that person in health care discussions. In this situation, we do not know if the nurse is male
or female, so the best answer given with the information that is known is to arrange for teaching
when the spouse is available.
Rationale 3: This will not address the cultural issue of male dominance.
Rationale 4: This will not address the issue of male dominance.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 6. Differentiate culturally influenced approaches to healing and treatment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 283
Question 13
Type: MCSA
A newly immigrated client is constantly attended to by family members. This has presented a
problem to the nursing staff and the delivery of nursing care. In order to address this issue in a
culturally sensitive manner, the nurse should take which action?
1. Explain to the client that he has to limit visitors.
2. Evaluate the benefits of family participation in the client’s care.
3. Question the family members as to how they see their interaction with the client.
4. Have the physician limit the number of visitors the client can have.
Correct Answer: 2
Rationale 1: Telling the client he has to limit visitors or having the physician do this may be in conflict
with cultural values and is not helpful to the client.
Rationale 2: Cultural family values may dictate the extent of the family’s involvement in the
hospitalized client’s care. In some cultures, the entire community may want to visit and participate in
the client’s care. The nurse should evaluate the positive benefits of family participation in the client’s
care and modify visiting policies as appropriate.
Rationale 3: It would be more appropriate to question the client, not the family members, about the
positive benefits of the family interactions because the family members are obviously supportive of
their presence.
Rationale 4: This is a nursing issue and should be managed by the nurse.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 6. Differentiate culturally influenced approaches to healing and treatment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 283
Question 14
Type: MCSA
The nurse is planning to conduct a physical assessment with a client from a different culture. What is
the best way for the nurse to show cultural sensitivity when addressing the personal questions
required of the nursing history?
1. Break the assessment into shorter intervals and discuss general topics first.
2. Thoroughly explain the reason for asking many questions before beginning the assessment.
3. Pick a time when the family is present and can help with the admission assessment questions.
4. Wait until the nurse–client relationship has been established.
Correct Answer: 1
Rationale 1: Clients may be offended when the nurse immediately asks personal questions. In some
cultures, courtesies should be established before business or personal topics are discussed.
Discussing general topics can convey that the nurse is interested and has time for the client. This
enables the nurse to develop a rapport with the client before progressing to discussion that is more
personal.
Rationale 2: Even if the explanation is given, clients from some cultures may still find questions of a
personal nature offensive so early in the nurse–client association.
Rationale 3: The sensitive issue is not necessarily one of language or communication barriers.
Rationale 4: Waiting to complete the assessment is not a good idea as there is certain, initial
information that needs to be collected from the client.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 9. Identify methods of cultural assessment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 284
Question 15
Type: MCSA
A non-English–speaking client is needs to have an emergency surgical procedure. The hospital has
an interpreter available. When the interpreter arrives to explain the procedure and help with the
consent form, the nurse provides the best support when
1. asking the interpreter to use words the client is familiar with for the best understanding.
2. requesting that the interpreter translate, as closely as possible, the same words used by the
professional staff.
3. suggesting that the questions be directed to the interpreter, so nothing is omitted.
4. addressing the questions to the client’s family.
Correct Answer: 2
Rationale 1: The objective of the professional interpreter is for the complete transfer of the thought
behind the utterance in one language into an utterance in a second language.
Rationale 2: An interpreter is an individual who mediates spoken or signed communication between
people using different languages without adding, omitting, or distorting meaning or editorializing. The
objective of the professional interpreter is for the complete transfer of the thought behind the
utterance in one language into an utterance in a second language.
Rationale 3: The questions should be addressed to the client, not the interpreter.
Rationale 4: The questions should be addressed to the client, not the family, unless the client is
incapable of answering.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 7. Describe ways culture influences communication patterns and how to provide
linguistically appropriate care.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 284
Question 16
Type: MCSA
During the admission interview, the culturally diverse client averts her eyes and refrains from
answering questions for long periods of time. The culturally sensitive nurse should take which
action?
1. Come back at a different time, when the client is feeling more communicative.
2. Have another nurse finish the interview, as there is something uncomfortable the client senses.
3. Understand that this may be completely appropriate and take cues accordingly.
4. Leave the room and come back after having learned more about this particular culture.
Correct Answer: 3
Rationale 1: The nursing interview is the nurse’s responsibility and should not be postponed for what
the nurse perceives as the client’s reluctance to communicate.
Rationale 2: The nurse is responsible for the admission interview and it should not be avoided for
reasons of discomfort.
Rationale 3: Nonverbal communication includes silence, touch, eye movement, facial expressions,
and body posture. Some cultures are quite comfortable with long periods of silence. Many people
value silence and view it as essential to understanding a person’s needs or use silence to preserve
privacy. Before assigning meaning to nonverbal behavior, the nurse must consider the possibility
that the behavior may have a different meaning for the client and family.
Rationale 4: The admission history can not be postponed in order for the nurse to improve his or her
cultural awareness.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 7. Describe ways culture influences communication patterns and how to provide
linguistically appropriate care.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 285
Question 17
Type: MCSA
The school nurse is conducting head lice screenings. Before checking the head of an Asian child,
the nurse should first take which action?
1. Ask permission.
2. Make sure the child understands the reason for the contact.
3. Put gloves on.
4. Ask the child to wait until last, to avoid embarrassing the child.
Correct Answer: 1
Rationale 1: In some Asian cultures, only certain elders are permitted to touch the head of others,
and children are never patted on the head. Nurses should, therefore, touch a client’s head only with
permission.
Rationale 2: The nurse should explain the reason for the touching to all children.
Rationale 3: Nurses should always wear gloves for this type of screening process.
Rationale 4: Asking the child to wait until last to avoid embarrassment is not appropriate and does
not address the cultural issue.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 6. Differentiate culturally influenced approaches to healing and treatment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 286
Question 18
Type: MCSA
The nurse needs to determine the apical pulse of a client from a different culture. In order to show
appropriate sensitivity to the client, the nurse should take which action?
1. Explain the procedure, then wait for permission to continue.
2. Explain to the client what will occur during the assessment.
3. Ask the client to stay quiet because the nurse will be listening to the heart.
4. Take the baseline vital signs, then determine if cardiac auscultation is necessary.
Correct Answer: 1
Rationale 1: Cardiac assessment requires that the nurse move into the client’s intimate space.
Before beginning this, the nurse should explain the procedure and then await permission to
continue.
Rationale 2: Explaining the assessment only while performing the procedure and not before is likely
to cause the client anxiety and thus negatively affect the assessment values.
Rationale 3: This option is not addressing the sensitivity issues appropriate for this scenario.
Rationale 4: This option is not addressing the sensitivity issues appropriate for this scenario.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 6. Differentiate culturally influenced approaches to healing and treatment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 286
Question 19
Type: MCSA
The nurse is teaching a client from a culture that is “present oriented” about a dressing change that
should be performed twice a day. How should the nurse address the cultural issue?
1. Allow the client to select the times the dressing will be changed.
2. Instruct the client to change the dressing after breakfast and before going to bed.
3. Explain that the client should complete the dressing change at 10 AM and 4 PM.
4. Suggest that the dressing change can be performed whenever the client chooses, as long as it
gets done twice daily.
Correct Answer: 2
Rationale 1: This option does not assure the dressing changes will occur as prescribed.
Rationale 2: For clients who are “present oriented,” it is important to avoid fixed schedules. The
nurse can offer a time range for activities and treatments, such as in the morning or after breakfast,
and in the evening or before going to bed. This would fit better with the client who isn’t focused on
times of the day, such as 10 AM and 4 PM, but will provide for a dressing change twice daily.
Rationale 3: This option is not likely to be followed by a client who is “present oriented.”
Rationale 4: This option does not comply with the intended order for the dressing changes.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 6. Differentiate culturally influenced approaches to healing and treatment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 286
Question 20
Type: MCSA
The nurse is preparing a menu for a Jewish client who observes kosher customs. Which food items
would be appropriate to serve this client, assuming all have been properly inspected and prepared?
1. Hamburger, fruit, and milk
2. Fish, vegetables, and hot tea
3. Ham, baked potato, and fresh fruit
4. Cream soup, sausage, and toast
Correct Answer: 2
Rationale 1: The eating of milk products and meat products at the same meal is prohibited.
Rationale 2: This menu is in accordance with the kosher tradition because there is no pork being
served and dairy and meat are not served together.
Rationale 3: Orthodox Judaism and Islam prohibit the ingestion of pork or pork products (ham and
sausage).
Rationale 4: The eating of milk products and meat products at the same meal is prohibited.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 6. Differentiate culturally influenced approaches to healing and treatment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 287
.
Question 21
Type: MCSA
The nurse is working in a clinic setting and is meeting a new client for the first time. In order to
convey cultural sensitivity, how should the nurse introduce herself?
1. “I’m Jane, and I’ll be your nurse today.”
2. “I’m Dr. Smith’s nurse, Jane.”
3. “I’m Jane Brown, and I’m a nurse here at the clinic.”
4. “I’m glad to meet you. You can call me Jane.”
Correct Answer: 3
Rationale 1: The appropriate introduction should include introducing themselves by full name, then
explaining their role. This helps establish a relationship and provides an opportunity for clients,
others, and nurses to learn the pronunciation of one another’s names and their roles. This option
does not fulfill these requirements.
Rationale 2: The appropriate introduction should include introducing themselves by full name, then
explaining their role. This helps establish a relationship and provides an opportunity for clients,
others, and nurses to learn the pronunciation of one another’s names and their roles. This option
does not fulfill these requirements.
Rationale 3: Ways for nurses to be culturally sensitive and to convey sensitivity to clients include
introducing themselves by full name, then explaining their role. This helps establish a relationship
and provides an opportunity for clients, others, and nurses to learn the pronunciation of one
another’s names and their roles.
Rationale 4: The appropriate introduction should include introducing themselves by full name, then
explaining their role. This helps establish a relationship and provides an opportunity for clients,
others, and nurses to learn the pronunciation of one another’s names and their roles. This option
does not fulfill these requirements.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 7. Describe ways culture influences communication patterns and how to provide
linguistically appropriate care.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 288
Question 22
Type: MCSA
A home health client participates in cultural health practices that the nurse feels may be detrimental
to his health. In order to remain attentive to cultural sensitivity and provide appropriate cultural
nursing care, the nurse should take which action?
1. Explain the right and wrong of the client’s treatment and try to persuade him to follow the scientific
perspective.
2. Have the client’s physician explain the care to the client in a firm but gentle manner.
3. Validate the client’s practices and understand that for this client, it may be beneficial to continue
with his preferences.
4. Try to negotiate with the client by exploring his views and then provide relevant scientific
information.
Correct Answer: 4
Rationale 1: “Right” and “wrong” terms should be avoided in culturally sensitive areas and where
differing views are present.
Rationale 2: The nurse, not the physician, is the caregiver in this situation, so it is the nurse’s
responsibility to teach and see that the plan of care is carried out.
Rationale 3: If the client’s views can lead to harmful behavior or outcomes, then an attempt is made
to shift the client’s perspectives to the scientific view.
Rationale 4: Negotiation acknowledges that the nurse–client relationship is reciprocal and that
different views exist of health, illness, and treatment. During the negotiation process, the client’s
views are explored and acknowledged, then relevant scientific information is provided.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
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: 10. Create a culturally responsive nursing care plan.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 290
Question 23
Type: MCSA
A client who is from a different culture than the nurse has not been able to achieve this goal: Client
will select low-fat foods from a list by the end of the month. What should the nurse do?
1. Consider whether the client’s belief system has been an influencing factor.
2. Extend the time frame and give the client a longer period to achieve the goal.
3. Make sure that the client understands the importance of the goal.
4. Select a different goal.
Correct Answer: 1
Rationale 1: If the outcomes are not achieved for a client from a different culture, the nurse should
be especially careful to consider whether the client’s belief system has been adequately included as
an influencing factor.
Rationale 2: Extending the time frame may not be as helpful as looking at the cultural practices—
including dietary ones—of the client.
Rationale 3: Checking how the client understands the importance of the goal may not be as helpful
as looking at the cultural practices—including dietary ones—of the client.
Rationale 4: Selecting a different goal may not be as helpful as looking at the cultural practices—
including dietary ones—of the client.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 10. Create a culturally responsive nursing care plan.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 291
Question 24
Type: MCSA
A nurse educator uses Madeleine Leininger’s model and describes a formal area of study and
practice focused on comparative human-care differences and similarities of the beliefs, values, and
patterned lifeways of cultures to provide culturally congruent, meaningful, and beneficial health care
to people. What type of nursing is the educator practicing?
1. Transcultural nursing
2. Cultural competence
3. Cultural knowledge
4. Competent nursing
Correct Answer: 1
Rationale 1: Transcultural nursing focuses on providing care within the differences and similarities of
the beliefs, values, and patterns of cultures.
Rationale 2: Cultural competence is a life-long process in which the nurse continuously strives to
achieve the ability and availability to effectively work within the cultural context of a client (individual,
family, community).
Rationale 3: Cultural knowledge reflects the presences of a sound educational foundation
concerning the various worldviews of different cultures.
Rationale 4: Transcultural nursing is a component of competent nursing.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4. Describe cultural models of care, such as cultural competency.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 280
Question 25
Type: MCMA
The community health nurse is using the Heritage Assessment Interview tool with a group of
community members. Which data indicate heritage consistent?
Standard Text: Select all that apply.
1. A client frequently visits the “old country neighborhood” he grew up in.
2. A client is raised by a single parent.
3. The client’s education occurred at a religious school.
4. The client participates in religious festivals and cultural events.
5. The client has been the first of his family to earn a college degree.
Correct Answer: 1, 3, 4
Rationale 1: The tool is designed to enhance the process of determining whether clients are
identifying with their traditional cultural heritage (heritage consistent), such as by visiting an ethic
neighborhood.
Rationale 2: The tool is not designed to assess such nonculturally oriented events.
Rationale 3: The tool is designed to enhance the process of determining whether clients are
identifying with their traditional cultural heritage (heritage consistent), such as by attending a
religiously affiliated school.
Rationale 4: The tool is designed to enhance the process of determining whether clients are
identifying with their traditional cultural heritage (heritage consistent), such as by attending and
participating in religious and cultural events.
Rationale 5: The tool is not designed to assess such nonculturally oriented events.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9. Identify methods of cultural assessment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 288
Question 26
Type: MCMA
The nurse is planning to provide culturally responsive care to a minority client and family. What
actions should the nurse perform when providing this care?
Standard Text: Select all that apply.
1. Personally reflecting on feelings related to the client’s nationality
2. Making an effort to direct all assessment questions initially to the client
3. Involving the family with the client’s permission
4. Assessing the client’s interest in alternative healing methods
5. Educating the client and family when appropriate
Correct Answer: 1, 3, 4, 5
Rationale 1: Culturally responsive care that involves family appropriately includes self–reflection to
identify your personal assumptions, biases, attitudes, prejudices, and stereotypes.
Rationale 2: Determine the cultural expectations related to the hierarchy of the family.
Rationale 3: Culturally responsive care that involves family appropriately includes explaining in detail
the client’s condition and the treatment plan with the family if the client is willing for the nurse to do
so.
Rationale 4: Culturally responsive care that involves family appropriately includes asking about the
client’s use of cultural or alternative approaches to healing.
Rationale 5: Culturally responsive care that involves family appropriately includes explaining in detail
the client’s condition and treatment plan with the family if the client is willing for the nurse to do so.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 9. Identify methods of cultural assessment.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 288
Question 27
Type: MCMA
The nurse is planning to explain the importance of culturally appropriate care to a new nursing
assistant. What should the nurse include when explaining the term “culture” to this staff person?
Standard Text: Select all that apply.
1. “Culture involves groups who share biological markers.”
2. “Cultures seldom have diversity within them.”
3. “Male nurses are an example of a culture.”
4. “A culture is primarily exhibited through shared thoughts, actions, and beliefs.”
5. “A culture shapes its members’ view of the world.”
Correct Answer: 4, 5
Rationale 1: Race has been a term used to refer to groupings of people according to common origin
or background and associated with perceived biological markers.
Rationale 2: Diversity occurs not only between cultural groups but also within cultural groups.
Rationale 3: A subculture is usually composed of people who have a distinct identity and yet are
related to a larger cultural group.
Rationale 4: Culture is the thoughts, communications, actions, customs, beliefs, values, and
institutions of racial, ethnic, religious, or social groups.
Rationale 5: Macro- and micro-cultures combine to shape the individual’s worldview and influence
interaction with the others.
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. 5. Deliver compassionate, patient-centered, evidence-based
care that respects patient and family preferences
NLN Competencies: Relationship Centered Care; Knowledge; The role of family, culture, and
community in a person’s development
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Describe concepts related to culture such as race, ethnicity, and acculturation.
MNL Learning Outcome: 1.3.3. Consider cultural and spiritual aspects that influence nursing care.
Page Number: 276
New Questions:
Question 28
Type: MCMA
After an assessment, the nurse determines that a client of African American descent is experiencing
disparities that are a part of behavioral health determinants. What assessment data did the nurse
use to come to this conclusion?
Standard Text: Select all that apply.
Chapter 19
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-thecounter (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 selfsufficient. 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
Chapter 20
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 20
Question 1
Type: MCSA
The nurse is plotting the height and weight of children during a school assessment clinic. Which
aspect of the children’s health is the nurse assessing?
1. Development
2. Health
3. Growth
4. Bone size
Correct Answer: 3
Rationale 1: Development is an increase in the complexity of function and skill progression. It is the
capacity and skill of a person to adapt to the environment.
Rationale 2: Health is a dynamic process with varying definitions, all of which point to well-being.
Rationale 3: Growth refers to physical change and increase in size. Indicators include height, weight,
bone size, and dentition.
Rationale 4: Bone size is one of the indicators of growth.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. Differentiate between the terms growth and development.
MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and
psychosocial development.
Page Number: 312
Question 2
Type: MCSA
A parent brings a 16-month-old child to the clinic for a well-child checkup. During the assessment,
the nurse finds that the child cannot stand next to furniture and does not try to pull himself up from a
sitting position. In which process should the nurse identify that this child is lagging?
1. Growth
2. Development
3. Height
4. Behavior
Correct Answer: 2
Rationale 1: Growth is physical change and increase in size.
Rationale 2: Development is an increase in the complexity of function and skill progression. It is the
behavioral aspect of growth—the person’s ability to walk, talk, and run, for example.
Rationale 3: Height is one of the indicators of growth.
Rationale 4: Behavior is a component of the developmental stage.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. Differentiate between the terms growth and development.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 312
Question 3
Type: MCSA
A child is starting school and is being screened for certain developmental milestones. What is the
nurse assessing when determining how the child interacts with other children?
1. Temperament
2. Physical characteristics
3. Environment
4. Culture
Correct Answer: 1
Rationale 1: Temperament is the way individuals respond to their external and internal environment
and sets the stage for the interactive dynamics of growth and development.
Rationale 2: Physical characteristics include eye color and potential height and do not affect how
children interact, for the most part.
Rationale 3: Environment includes family, religion, climate, culture, school, community, and nutrition
and would not play as big of a role in how the child responds to peers as temperament does.
Rationale 4: Culture is part of environmental factors.
Global Rationale:
Page Reference: 355
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. Explain the concept of temperament.
MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and
psychosocial development.
Page Number: 312
Question 4
Type: MCSA
A parent is concerned that her child is unable to sit alone. The nurse explains that development is
based on in-born timetables and the child will be most likely able to meet this milestone at a specific
time. Upon which theory did the nurse base the response to the client?
1. Havighurst’s theory
2. Task theory
3. Psychosocial theory
4. Maturational theory
Correct Answer: 4
Rationale 1: Havighurst, in his developmental task theory, described growth and development
occurring during six stages, each associated with 6 to 10 tasks to be learned.
Rationale 2: Havighurst, in his developmental task theory, described growth and development
occurring during six stages, each associated with 6 to 10 tasks to be learned.
Rationale 3: Psychosocial theory is focused on the development of personality, not physical
development.
Rationale 4: The maturational theory (Arnold Gesell) postulates that child development is a
maturational process based on an in-born timetable. Although children benefit from experience, they
will achieve maturational milestones such as rolling over, sitting, and walking at specific times.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 5. Describe the stages of growth and development according to various
theorists.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 313
Question 5
Type: MCSA
A toddler shows fear and begins to cry when her parent leaves her at day care. According to
Havighurst, which developmental task should the nurse recognize this child is exhibiting?
1. Building wholesome attitudes toward oneself
2. Learning to get along with age-mates
3. Learning to relate emotionally
4. Achieving personal independence
Correct Answer: 3
Rationale 1: This task is part of the middle childhood age period and would not be appropriate for
this child.
Rationale 2: This task is part of the middle childhood age period and would not be appropriate for
this child.
Rationale 3: A toddler would be in the infancy and early childhood age period, in which learning to
relate emotionally to parents, siblings, and other people is a developmental task.
Rationale 4: This task is part of the middle childhood age period and would not be appropriate for
this child.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. Identify developmental tasks associated with Havighurst’s six age periods.
MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 316
Question 6
Type: MCSA
A parent is concerned that her 5-year-old is beginning to masturbate. How should the nurse, familiar
with Freud’s stages of development, respond?
1. “All children are curious, but make sure the child knows that this behavior might be offensive to
others.”
2. “You should probably consult a child psychologist if you’re this concerned.”
3. “Let’s make sure to ask your physician at the next appointment.”
4. “This behavior is a normal part of your child’s development.”
Correct Answer: 4
Rationale 1: Assuring the parent that this is a normal part of development is the best response.
Rationale 2: Assuring the parent that this is a normal part of development is the best response. This
response would lead the parent to believe that the child’s behavior is abnormal.
Rationale 3: Assuring the parent that this is a normal part of development is the best response. This
response would lead the parent to believe that the child’s behavior is abnormal.
Rationale 4: In the phallic stage, as described by Freud, which occurs from age 4 to 6 years, the
child’s genitals are the center of pleasure. Masturbation offers pleasure, and questions about sexual
topics from parents are normal. Assuring the parent that this is a normal part of development is the
best response.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. Describe characteristics and implications of Freud’s five stages of
development.
MNL Learning Outcome: 2.1.2 Analyze the school-age child and adolescent’s physiologic and
psychosocial development.
Page Number: 315
Question 7
Type: MCSA
A young adult has never lived away from his parents and feels unable to make decisions on his own.
According to Freud’s theory of development, the nurse should suspect that this person would be
fixated at which stage of development?
1. Phallic
2. Latency
3. Genital
4. Anal
Correct Answer: 3
Rationale 1: The phallic stage is from 4 to 6 years of age, and fixation would be related to the
individual’s genital organs and the pleasure sensations they create.
Rationale 2: The latency stage is 6 years to puberty. Energy is directed to physical and intellectual
activities. Sexual impulses tend to be repressed.
Rationale 3: Freud’s genital stage is characterized by energy that is directed toward full sexual
maturity and function and development of skills needed to cope with the environment. It occurs
during puberty and extends beyond. Implications of this stage include separation from parents,
achievement of independence, and decision making. Fixation occurs at any stage and is the
immobilization or the inability of the personality to proceed to the next stage because of anxiety.
Rationale 4: The anal stage is from 11/2 to 3 years. The anus and bladder are the sources of
pleasure (sensual satisfaction, self-control).
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. Describe characteristics and implications of Freud’s five stages of
development.
MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 315
Question 8
Type: MCSA
A client is being seen in the mental health clinic for antisocial behavior. According to Erikson’s
stages of development, the nurse realizes that this client is dealing with which task of development?
1. Initiative versus guilt
2. Industry versus inferiority
3. Intimacy versus isolation
4. Identity versus role confusion
Correct Answer: 4
Rationale 1: Initiative versus guilt is the late childhood stage and occurs from age 3 to 5 years.
Industry versus inferiority occurs from 6 to 12 years, during the school-age stage.
Rationale 2: Industry versus inferiority occurs from 6 to 12 years, during the school-age stage.
Rationale 3: Intimacy versus isolation is the task during young adulthood and occurs from 18 to 25
years.
Rationale 4: According to Erik Erikson, the adolescent stage is from 12 to 20 years and the central
task is identity versus role confusion. Positive resolution indicates sense of self with plans to
actualize one’s abilities. Negative resolution indicates feelings of confusion, indecisiveness, and
possible antisocial behavior.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 7. Identify Erikson’s eight stages of development.
MNL Learning Outcome: 2.1.2 Analyze the school-age child and adolescent’s physiologic and
psychosocial development.
Page Number: 316
Question 9
Type: MCSA
A client who has a terminal diagnosis has been using her time to help family members deal with her
impending death. Among her activities, she collected pictures for a scrapbook and wrote a journal of
favorite memories for family members to read after the client dies. According to Peck, the nurse
realizes that this client is working through which developmental task?
1. Body transcendence versus body preoccupation
2. Ego transcendence versus ego preoccupation
3. Ego differentiation versus work-role preoccupation
4. Integrity versus despair
Correct Answer: 2
Rationale 1: Body transcendence versus body preoccupation calls for the individual to adjust to
decreasing physical capacities and at the same time maintain feelings of well-being.
Rationale 2: Ego transcendence is the acceptance without fear of one’s death as inevitable. This
acceptance includes being actively involved in one’s own future beyond death. Peck proposes that
there are three developmental tasks during old age, in contrast to Erikson’s one—integrity versus
despair.
Rationale 3: Ego differentiation versus work-role preoccupation maintains that an adult’s identity and
feelings of worth are highly dependent on that person’s work role.
Rationale 4: Erikson proposed integrity versus despair, not Peck.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. Compare Peck’s and Gould’s stages of adult development.
MNL Learning Outcome: 2.1.4 Analyze the older adult’s physiologic and psychosocial development.
Page Number: 316
Question 10
Type: MCSA
A college-age client shares that he is struggling with feelings of both independence and dependence
regarding his family. The nurse recognizes this as which stage of development, according to Roger
Gould?
1. Stage 2
2. Stage 3
3. Stage 4
4. Stage 5
Correct Answer: 1
Rationale 1: Roger Gould studied adult development and described seven stages. Stage 2 (ages
18–22) is where individuals have established autonomy, feel it is in jeopardy, and feel they could be
pulled back into their families.
Rationale 2: Roger Gould studied adult development and described seven stages. Stage 3 (ages
22–28) is when individuals feel established as adults and autonomous from their families. They see
themselves as well defined, but still feel the need to prove themselves to their parents.
Rationale 3: Roger Gould studied adult development and described seven stages. Stage 4 (ages
29–34) is when marriage and careers are well established. Individuals question what life is all about
and wish to be accepted as they are, no longer finding it necessary to prove themselves.
Rationale 4: Roger Gould studied adult development and described seven stages. Stage 5 (ages
35–43) is a period of self-reflection. Individuals question values and life itself. They see time as finite,
with little time left to shape the lives of adolescent children.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. Compare Peck’s and Gould’s stages of adult development.
MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 317
Question 11
Type: MCSA
A parent reports to the nurse that his child is learning new words faster than he can write them in the
baby book. According to Piaget, the nurse realizes that this child is in which phase?
1. Intuitive thought phase
2. Preconceptual phase
3. Concrete operations phase
4. Formal operations phase
Correct Answer: 2
Rationale 1: The intuitive thought phase is from age 4 to 7 years and is where egocentric thinking
diminishes. The child thinks of one idea at a time and includes others in the environment.
Rationale 2: Ages 2 to 4 years, according to Piaget, is the preconceptual phase where the child uses
an egocentric approach to accommodate the demands of an environment. Language development is
rapid and the child associates words with objects.
Rationale 3: The concrete operations phase, ages 7 to 11, is where the child solves concrete
problems. The child also begins to understand relationships such as size and right and left, and is
cognizant of viewpoints.
Rationale 4: During the formal operations phase (ages 11 to 15), the child uses rational thinking, and
reasoning is deductive and futuristic.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 11. Explain Piaget’s theory of cognitive development.
MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 319
Question 12
Type: MCSA
The nurse notes that a 20-month-old child is lagging in stage 6 of Piaget’s phases of cognitive
development. Which activity did the nurse observe that indicates that this child is struggling at this
stage?
1. The child wants the same toy to sleep with during naptime and bedtime.
2. The child merely watches as the other children pretend-play.
3. The child cries when the parents leave the unit.
4. The child does not cooperate with some of the treatments.
Correct Answer: 2
Rationale 1: Ritual is important for the child of the tertiary circular reaction stage, age 12 to 18
months.
Rationale 2: In this stage of development, inventions of new means, children interpret the
environment by mental images. They use make-believe and pretend-play. A child who is unable to
do this would not be demonstrating the behavior that is significant at this stage.
Rationale 3: Crying when parents leave the unit and not cooperating with certain medical treatments
is normal behavior for children of various ages, especially when hospitalized, and would not indicate
lags in development.
Rationale 4: Not cooperating with certain medical treatments is normal behavior for children of
various ages, especially when hospitalized, and would not indicate lags in development.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 11. Explain Piaget’s theory of cognitive development.
MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 319
Question 13
Type: MCSA
The nurse is exploring the behavior of children and how they interpret right from wrong or bad from
good. Which theorist should the nurse study to learn this information?
1. Vygotsky
2. Skinner
3. Kohlberg
4. Piaget
Correct Answer: 3
Rationale 1: Vygotsky explored the concept of cognitive development within a social, historical, and
cultural context, arguing that adults guide children to learn and that development depends on the
use of language, play, and extensive social interaction.
Rationale 2: Skinner’s research led to the term “operant conditioning,” and most of his work was with
laboratory animals.
Rationale 3: Lawrence Kohlberg’s theory specifically addresses the moral development of children
and adults.
Rationale 4: Piaget developed the cognitive theory of development.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 12. Compare Kohlberg’s and Gilligan’s theories of moral development.
MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 321
Question 14
Type: MCSA
A nurse educator believes that teaching students without caring about them is an exercise in futility.
This educator also believes that in meeting the students’ needs, educators must also work to take
care of themselves and care for their own needs. From which stage of Gilligan’s theory is the
educator approaching the teaching of students?
1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
Correct Answer: 3
Rationale 1: Stage 1 is caring for oneself.
Rationale 2: Stage 2 is caring for others.
Rationale 3: Gilligan’s stage 3—caring for self and others—is the last stage of development, where a
person sees the need for a balance between caring for others and caring for the self.
Rationale 4: Gilligan does not describe more than three stages in her theory.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: 1.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: 12. Compare Kohlberg’s and Gilligan’s theories of moral development.
MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 22
Question 15
Type: MCSA
A nurse educator is working with students and assisting them in addressing their clients’ spiritual
needs. The educator understands that most traditional, second-year college students are aware of
their own spiritual development or working to develop their own system of spirituality. The educator
realizes that the students are in which stage of Fowler’s developmental theory?
1. Mythic-lyrical
2. Intuitive-projective
3. Universalizing
4. Individuating-reflexive
Correct Answer: 4
Rationale 1: Mythical-lyrical describes the person between ages 7 and 12, in a private world of
fantasy and wonder.
Rationale 2: The intuitive-projective stage, ages 4 to 6 years, is a combination of images and beliefs
given by trusted others, mixed with the child’s own experience and imagination.
Rationale 3: Universalizing, which may never be reached by an individual, is a stage of becoming
incarnate of the principles of love and justice.
Rationale 4: Fowler describes this as a stage in which the person is constructing his or her own
explicit system with a high degree of self-consciousness.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: 1.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: 13. Compare Fowler’s and Westerhoff’s stages of spiritual development.
MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 323
Question 16
Type: MCSA
A client with an acute, serious illness has been hospitalized. Upon entering the room, the nurse
observes the client praying. The client states to the nurse: “I don’t know how people manage to get
through difficult times without their faith. It’s where I get my strength.” With which theorist should the
nurse associate this client’s belief?
1. Fowler
2. Westerhoff
3. Gilligan
4. Kohlberg
Correct Answer: 2
Rationale 1: Fowler’s theory describes the development of faith as a force that gives meaning to a
person’s life.
Rationale 2: Westerhoff describes faith as a way of being and behaving that evolves from an
experienced faith guided by parents and others during a person’s infancy and childhood to an owned
faith that is internalized in adulthood. For the client who is ill, faith provides strength and trust.
Rationale 3: Gilligan is not a spiritual theorist.
Rationale 4: Kohlberg is not a spiritual theorist.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: 1.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: 13. Compare Fowler’s and Westerhoff’s stages of spiritual development.
MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 323
Question 17
Type: SEQ
The nurse is reviewing the four stages of development in Westerhoff’s spiritual theory. In which order
should the nurse review these stages to match the life cycle?
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Owned faith
Choice 2. Affiliative faith
Choice 3. Experienced faith
Choice 4. Searching faith
Correct Answer: 4, 2, 1, 3
Rationale 1: Puts faith into personal and social action and is willing to stand up for what the
individual believes even against the nurturing community is Stage 4.
Rationale 2: Actively participates in activities that characterize a particular faith tradition; experiences
awe and wonderment; feels a sense of belonging is Stage 2.
Rationale 3: Experiences faith through interaction with others who are living a particular faith
tradition is Stage 1.
Rationale 4: Through a process of questioning and doubting own faith, acquires a cognitive as well
as an affective faith is Stage 3.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: 1.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: 13. Compare Fowler’s and Westerhoff’s stages of spiritual development.
MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 323
Question 18
Type: MCSA
A nurse is working with a school-age client who is learning how to use a peak flow meter to monitor
his asthma. The child has been frustrated at first, but now is able to give the reason to use the meter
on a daily basis. Remembering the growth and development characteristics of the adolescent, how
should the nurse respond to this client?
1. “You should feel very proud for understanding and using your meter.”
2. “Think of using the meter as one of your daily chores.”
3. “Maybe you could make a game out of the daily use of your meter.”
4. “It’s too bad if you don’t want to use the meter, it’s just something you’ll have to do.”
Correct Answer: 1
Rationale 1: School-age children (6–12 years) are in the preadolescent period, where the peer group
begins to increasingly influence behavior. The nurse must allow time and energy for the school-age
child to pursue hobbies and school activities and should recognize and support the child’s
achievement. Play and social activity are more important in the preschool-age child as new
experiences and social roles are tried during play.
Rationale 2: This phrase does not support the child’s growth and development.
Rationale 3: This phrase does not support the child’s growth and development.
Rationale 4: This phrase does not support the child’s growth and development.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 2. Describe essential principles related to growth and development.
MNL Learning Outcome: 2.1.2 Analyze the school-age child and adolescent’s physiologic and
psychosocial development.
Page Number: 314
Question 19
Type: MCSA
A nurse is working with the residents of an assisted living complex. When planning care for the oldold stage, the nurse realizes that what action will be important?
1. Provide as much care to the residents as possible.
2. Allow as much independence for the residents as possible.
3. Make sure to provide safety measures as needed.
4. Make sure the residents maintain peer interactions and social groups.
Correct Answer: 2
Rationale 1: Providing as much care as possible does not meet the independence need required in
this age group.
Rationale 2: The old-old stage, age 85 and older, is characterized by increasing physical problems.
The nursing implication for this age group is to assist with self-care as required, but maintain as
much independence as possible.
Rationale 3: Safety measures should be applied in the middle-old age group, age 75 to 84 years.
Rationale 4: Peer interactions become important in the young-old stage, age 65 to 74 years.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 2. Describe essential principles related to growth and development.
MNL Learning Outcome: 2.1.4 Analyze the older adult’s physiologic and psychosocial development.
Page Number: 314
Question 20
Type: MCSA
A community health nurse is planning adult health education classes. According to Erikson’s stages
of development, the nurse should address which task with this age group?
1. Industry versus inferiority
2. Identity versus role confusion
3. Intimacy versus isolation
4. Generativity versus stagnation
Correct Answer: 4
Rationale 1: This task is appropriate for the 6– to 12–year-old school–age child.
Rationale 2: This task is appropriate for the adolescent 12 to 20 years old.
Rationale 3: This task is appropriate for the 18- to 24–year–old young adult.
Rationale 4: Adulthood, age 25 to 65 years, is characterized by the central task of generativity
versus stagnation. Positive resolution is indicated by creativity, productivity, and concern for others.
Negative resolution is characterized by self-indulgence, self-concern, and lack of interests and
communication.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 7. Identify Erikson’s eight stages of development.
MNL Learning Outcome: 2.1.3 Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 316
Question 21
Type: MCSA
A parent brings her baby in for a well-child checkup. Which action of the child should the nurse
identify as an indicator of positive resolution of the central task of this age?
1. The child does not cry when the parent allows the nurse to hold the child.
2. The child shows mistrust when strangers approach.
3. The child becomes willful when disciplined.
4. The child does not play with other children.
Correct Answer: 1
Rationale 1: In the infancy years (birth to 18 months), the child’s central task is to form trust or
mistrust with people. Positive resolution would indicate a safe feeling when the parents leave the
child with someone they are familiar with and can trust.
Rationale 2: Positive resolution would indicate a safe feeling when the parents leave the child with
someone they are familiar with and can trust. Negative resolution would indicate mistrust,
withdrawal, and estrangement.
Rationale 3: Willfulness and defiance are negative indicators of the early childhood stage.
Rationale 4: Playing with other children is part of the self-esteem and self-expression of the early
childhood years.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 2. Describe essential principles related to growth and development.
MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 315
Question 22
Type: MCSA
A parent tells the nurse that his child is quite creative and learning how to pretend with “almost
anything in the house.” According to Piaget, the nurse realizes this child is demonstrating
which stage/phase?
1. Tertiary circular reaction: stage 5
2. Inventions of new means: stage 6
3. Preconceptual phase
4. Concrete operations phase
Correct Answer: 2
Rationale 1: Stage 5, 12 to 18 months, is characterized by discovery of new goals and ways to attain
goals. Rituals are important in this stage.
Rationale 2: Stage 6, inventions of new means, is from 18 to 24 months. The significant behavior is
identified by interpretation of the environment by mental image. Make-believe and pretend-play are
in use during this stage.
Rationale 3: The preconceptual phase, 2 to 4 years, is when the child uses an egocentric approach
to accommodate the demands of an environment.
Rationale 4: The concrete operations phase, 7 to 11 years, is where the child is able to solve
concrete problems and begins to understand relationships such as size and right and left, and is
cognizant of viewpoints.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 11. Explain Piaget’s theory of cognitive development.
MNL Learning Outcome: 2.1.1 Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 319
Question 23
Type: MCMA
The nurse concludes that a young adult client is completing developmental tasks within Havighurst’s
early adulthood age period. What did the nurse assess to come to this conclusion?
Standard Text: Select all that apply.
1. Taking on civic responsibility
2. Developing adult leisure-time activities
3. Getting started in an occupation
4. Relating oneself to one’s spouse as a person
5. Managing a home
Correct Answer: 1, 3
Rationale 1: Taking on civic responsibilities is one of Havighurst’s early adulthood tasks.
Rationale 2: Developing adult leisure-time activities is not a part of the middle–age period.
Rationale 3: Getting started in an occupation is one of Havighurst’s early adulthood tasks.
Rationale 4: Relating oneself to one’s spouse as a person is not a part of the middle–age period.
Rationale 5: Managing a home is one of Havighurst’s early adulthood tasks.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. Identify developmental tasks associated with Havighurst’s six age periods.
MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 316
Question 24
Type: MCMA
The nurse is discussing human growth and development with the parents of a newborn. What should
the nurse include in this discussion?
Standard Text: Select all that apply.
1. Growth involves physical change and increase in size.
2. Skills and function increase with growth.
3. Most humans experience a similar pattern of growth.
4. Being able to adapt to one’s environment is an indicator of growth.
5. Children’s growth is monitored by height, weight, bone size, and dentition.
Correct Answer: 1, 3, 5
Rationale 1: Growth is physical change and increase in size.
Rationale 2: Development is an increase in the complexity of function and skill progression.
Rationale 3: The pattern of physiologic growth is similar for all people.
Rationale 4: Development skills include the ability to adapt to one’s environment.
Rationale 5: Growth can be measured quantitatively. Indicators of growth include height, weight,
bone size, and dentition.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 2. Describe essential principles related to growth and development..
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 313
Question 25
Type: MCMA
The nurse is assessing a child’s growth and development. What questions should the nurse ask the
parents that demonstrate an understanding of the factors that affect growth and
development processes?
Standard Text: Select all that apply.
1. How tall the parents are
2. Whether noises seem to bother their child
3. How many ounces of formula their child drinks daily
4. What their yearly income is
5. Whether their child will receive day–care services
Correct Answer: 1, 2, 3
Rationale 1: The genetic inheritance of an individual is established at conception. It remains
unchanged throughout life, and determines such characteristics as gender and physical
characteristics (e.g., eye color, potential height).
Rationale 2: Temperament sets the stage for the interactive dynamics of growth and development.
Rationale 3: Adequate nutrition is an essential component of growth and development.
Rationale 4: Although adequate family income allows for sufficient nutrition, housing, and other
needs, it is not generally considered a factor affecting growth and development.
Rationale 5: Being cared for by individuals other than one’s parents is not generally considered as a
factor unless care is neglected by whoever is responsible.
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: 03 List factors that influence growth and development.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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: 3. List factors that influence growth and development.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 312
New Questions:
Question 26
Type: MCMA
The nurse is preparing a teaching session for a group of parents with newborn children. What should
the nurse include about Bowlby’s attachment theory during this presentation?
Standard Text: Select all that apply.
1. Use the attachment figure as security
2. Desire to be near the attachment figure
3. Plan to separate from the attachment figure
4. Return to the attachment figure when threatened
5. Express anxiety when the attachment figure is absent
Correct Answer: 1, 2, 4, 5
Rationale 1: Bowlby believed that attachment served as a protective or survival mechanism for the
infant. Characteristics of Bowlby’s attachment theory include using the attachment figure as a
security base.
Rationale 2: Bowlby believed that attachment served as a protective or survival mechanism for the
infant. Characteristics of Bowlby’s attachment theory include the desire to be near the attachment
figure.
Rationale 3: Bowlby believed that attachment served as a protective or survival mechanism for the
infant. Characteristics of Bowlby’s attachment theory do not include a plan to separate from the
attachment figure.
Rationale 4: Bowlby believed that attachment served as a protective or survival mechanism for the
infant. Characteristics of Bowlby’s attachment theory include returning to the attachment figure when
threatened.
Rationale 5: Bowlby believed that attachment served as a protective or survival mechanism for the
infant. Characteristics of Bowlby’s attachment theory include expressing anxiety (separation anxiety)
when the attachment figure is absent.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: 1.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. State the four characteristics of Bowlby’s attachment theory.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 319
Question 27
Type: MCMA
After analyzing behavior, the nurse determines that a client is demonstrating defense mechanisms.
According to Freud, what should the nurse realize as being the cause of this behavior?
Standard Text: Select all that apply.
1. Anxiety created by conflicts
2. Activation of the conscience
3. Conflict between the id’s impulses
4. Immediate pleasure and gratification
5. Underlying motivation for development
Correct Answer: 1, 3
Rationale 1: Defense mechanisms or adaptive mechanisms are the result of anxiety created by the
conflicts due to social and environmental restrictions.
Rationale 2: Activation of the conscience is a function of the superego.
Rationale 3: Defense mechanisms or adaptive mechanisms are the result of conflicts between the
id’s impulses.
Rationale 4: Immediate pleasure and gratification is a function of the id.
Rationale 5: The underlying motivation for development is the libido.
Global Rationale: Defense mechanisms or adaptive mechanisms are the result of conflicts between
the id’s impulses and the anxiety created by the conflicts due to social and environmental restrictions
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: 1.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: 6. Describe characteristics and implications of Freud’s five stages of
development.
MNL Learning Outcome: 2.1.3. Analyze the young and middle adult’s physiologic and psychosocial
development.
Page Number: 315
Chapter 21
Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 21
Question 1
Type: MCSA
A client comes to the women’s clinic, stating she has had a positive home pregnancy test. The client
states that her last menstrual cycle was 2 months ago. According to this time frame, the nurse
determines that the client is in which stage of pregnancy?
1. Fetal phase
2. Second trimester
3. Third trimester
4. Embryonic phase
Correct Answer: 4
Rationale 1: The fetal phase of development is characterized by a period of rapid growth in the size
of the fetus and corresponds to the second trimester of pregnancy.
Rationale 2: The fetal phase of development is characterized by a period of rapid growth in the size
of the fetus and corresponds to the second trimester of pregnancy.
Rationale 3: The third trimester is the last 3 months of the pregnancy period.
Rationale 4: Traditionally, pregnancy has been divided into three periods called trimesters, each of
which lasts 3 months. The embryonic phase is the period during which the fertilized ovum develops
into an organism with most of the features of the human. This period is considered to encompass the
first 8 weeks of pregnancy.
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: Assessment
Learning Outcome: 1. Describe usual physical development from infancy through adolescence.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 328
Question 2
Type: MCSA
The parents of a baby born prematurely during the sixth month of pregnancy question the nurse
about the hair all over their baby. What is the nurse’s best response?
1. “All babies are hairy. It is more noticeable on preemies.”
2. “Fine downy hair helps keep the baby insulated in utero.”
3. “You should be more concerned with the baby’s respiratory function.”
4. “Don’t worry about how the baby looks. All preemies look funny.”
Correct Answer: 2
Rationale 1: This option, although not incorrect, doesn’t adequately address the parents’ question.
Rationale 2: Lanugo, a fine downy hair, covers the body of the baby and usually disappears by the
time gestation is full term. Because this baby was born early, the lanugo is more noticeable and will
disappear as the baby nears full term.
Rationale 3: This option dismisses the parents’ question.
Rationale 4: This option is insensitive and does not answer the parents’ question.
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. 4. Communicate effectively with all members of the healthcare
team, including the patient and the patient’s support network
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe usual physical development from infancy through adolescence.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 329
Question 3
Type: MCSA
The nurse is preparing to instruct a client about nutritional needs before and during pregnancy. What
should the nurse encourage the patient to consume in order to meet the requirements for folic acid?
1. Meats, fish, and poultry
2. A mix of vegetables and fiber
3. Oranges and green leafy vegetables
4. Low–fat and high–protein foods
Correct Answer: 3
Rationale 1: Protein sources are important for overall health but do not increase intake of folic acid.
Rationale 2: Folic acid is important to prevent neural tube defects in the fetus. Neural tube
defects occur in the first few weeks of fetal development. Folic acid–rich foods include green leafy
vegetables, oranges, and dried beans.
Rationale 3: Folic acid is important to prevent neural tube defects in the fetus. Neural tube
defects occur in the first few weeks of fetal development. Folic acid–rich foods include green leafy
vegetables, oranges, and dried beans.
Rationale 4: Protein sources and low-fat foods are important for overall health but do not increase
intake of folic acid.
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. 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. Identify essential activities of health promotion and protection to meet the
needs of infants, toddlers, preschoolers, school-age children, and adolescents.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 329
Question 4
Type: MCSA
The nurse is completing a health history with a client who is 10 weeks pregnant. Which factor should
the nurse identify as increasing this client’s risk for a spontaneous abortion?
1. Having taken a medication that is a known teratogen
2. Smoking
3. Having low levels of folic acid
4. Genetic history
Correct Answer: 2
Rationale 1: Teratogens are medications known to adversely affect normal cellular development in
the embryo or fetus.
Rationale 2: Exposure to environmental tobacco smoke has been associated with preterm births,
stillbirth, miscarriage, and low-birth-weight infants.
Rationale 3: Folic acid is necessary for normal neural tube development.
Rationale 4: Genetic history does not affect the risk for spontaneous abortion.
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: Assessment
Learning Outcome: 1. Describe usual physical development from infancy through adolescence.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 329
Question 5
TYPE: MCMA
The school nurse determines that a 14–year–old student has reached an expected level of cognitive
development. What did the nurse assess to come to this conclusion?
Standard Text: Select all that apply.
1. Thinks logically
2. Thinks about the future
3. Makes rational statements
4. Uses a trial–and–error process
5. States things as they could be
Correct Answer: 1, 2, 3, 5
Rationale 1: Adolescents between the ages of 11 and 15 begin the formal operations stage of
cognitive development. They are able to think logically.
Rationale 2: Adolescents between the ages of 11 and 15 begin the formal operations stage of
cognitive development. They are able to think futuristically.
Rationale 3: Adolescents between the ages of 11 and 15 begin the formal operations stage of
cognitive development. They are able to think rationally.
Rationale 4: A trial–and–error process is a cognitive approach used by toddlers.
Rationale 5: Adolescents between the ages of 11 and 15 begin the formal operations stage of
cognitive development. They can conceptualize things as they could be rather than as they are.
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: Assessment
Learning Outcome: 4. Explain cognitive development according to Piaget from infancy through
adolescence.
MNL Learning Outcome: 2.1.2. Analyze the school-age child and adolescent’s physiologic and
psychosocial development.
Page Number: 347
Question 6
Type: MCSA
At birth a baby weighed 8 lb. What should the nurse expect this baby to weight at the age of 1?
1. 32 lb
2. 16 lb
3. 20 lb
4. 24 lb
Correct Answer: 4
Rationale 1: This weight is above the expected weight for this infant at 1 year of age..
Rationale 2: This weight is well below the expected weight for this infant at 1 year of age.
Rationale 3: This weight is below the expected weight for this infant at 1 year of age.
Rationale 4: Normal growth patterns dictate that infants usually reach three times their birth weight
by 12 months, and twice their birth weight at 6 months. They typically gain weight at a rate of 5 to 7
ounces weekly for 6 months.
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: Assessment
Learning Outcome: 1. Describe usual physical development from infancy through adolescence.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 330
Question 7
Type: MCSA
Parents of a newborn ask the nurse why their newborn’s head seems lopsided and not round, as
they thought it should be. How should the nurse respond to these parents?
1. “I don’t think it looks unusual; actually the head is beautifully shaped.”
2. “Your baby’s head had to shape itself to the birth canal. It will look round in a few days.”
3. “You’re right. We’ll make sure your doctor checks this out.”
4. “Babies’ heads always look funny. Once his hair grows out, you’ll hardly notice it.”
Correct Answer: 2
Rationale 1: This option dismisses the parents’ concerns.
Rationale 2: Molding of the head is made possible by the fontanels and occurs during vaginal
deliveries as the head comes through the birth canal. Within a week, the newborn’s head usually
regains its symmetry. It is normal with vaginal deliveries. Babies born via cesarean section do not
experience molding. Molding is not permanent—a fact that makes parents feel more reassured.
Rationale 3: This condition is not abnormal and does not need to be referred to the
doctor; rather, the nurse needs to reassure the parents that nothing is wrong.
Rationale 4: This option is not necessarily true, nor does it adequately address the
parents’ concerns.
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. 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: 1. Describe usual physical development from infancy through adolescence.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 331
Question 8
Type: MCSA
The parents of a newborn ask what their baby can see. What should the nurse respond to these
parents?
1. “Babies aren’t able to see until they are around 4 months old.”
2. “Babies won’t track moving objects until about 5 months.”
3. “Newborns blink in response to bright lights and sound and will follow large objects.”
4. “Newborns aren’t able to focus, so everything looks blurry to them.”
Correct Answer: 3
Rationale 1: This is not necessarily correct information because we don’t know what they “see” or
how it looks to them.
Rationale 2: At 5 months, the infant reaches for objects, but starts tracking them much sooner.
Rationale 3: Newborns can follow large, moving objects and blink in response to bright lights and
sound. Their pupils respond slowly, and the eyes cannot focus on close objects. We don’t know what
they “see” or how it looks to them.
Rationale 4: We don’t know what newborns “see” or how it looks to them.
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. 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: 1. Describe usual physical development from infancy through adolescence.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 331
Question 9
Type: MCSA
The parents of a newborn male ask the nurse about pain during circumcision. What should the nurse
respond to these parents?
1. “Newborns can’t feel pain, so don’t worry about it.”
2. “We’ll make sure to bring your baby to you right after the procedure, so you can comfort him.”
3. “I’ll have the pediatrician speak to you about it.”
4. “Newborns’ pain experience is real. We’ll use some medication to help your baby feel more
comfortable.”
Correct Answer: 4
Rationale 1: Newborns certainly do feel pain.
Rationale 2: Newborns certainly do feel pain and it is important to comfort the child, but this option
does not answer the parents’ question. Nurses who care for newborns should be able to explain
expected reactions to the parents.
Rationale 3: Nurses who care for newborns should be able to explain expected reactions to the
parents.
Rationale 4: Young babies react diffusely to pain and cannot isolate the discomfort. The pain of
circumcision is not isolated in the genital region, but may be felt more diffusely, throughout the body.
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. 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: 1. Describe usual physical development from infancy through adolescence.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 332
Question 10
Type: MCMA
An expectant parent asks the nurse about health problems of newborns. On what should the nurse
provide information to this client?
Standard Text: Select all that apply.
1. Infant colic
2. Respiratory tract infections
3. Failure to thrive
4. Injuries
5. SIDS
Correct Answer: 1, 3, 5
Rationale 1: Health problems of newborns include infant colic.
Rationale 2: Respiratory tract infections are more common for toddlers and school-age children.
Rationale 3: Health problems of newborns include failure to thrive.
Rationale 4: Injuries are more problematic as the child grows, especially in the school-age child.
Rationale 5: Health problems of newborns include SIDS.
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. 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: 1. Describe usual physical development from infancy through adolescence.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 333
Question 11
Type: MCSA
New parents ask if their 8–month–old baby is performing activities that are expected at this age.
What should the nurse suggest to screen this baby’s developmental level?
1. The Denver Developmental Screening Test (DDST-II)
2. Growth and development charts from the Centers for Disease Control and Prevention (CDC)
3. Assessment tools utilized by the state education department
4. The Apgar scoring system
Correct Answer: 1
Rationale 1: The Denver Developmental Screening Test (DDST-II) can be used to assess the
infant’s behavior and can be used from birth to 6 years. It is intended to estimate the abilities of a
child compared to those of an average group of children of the same age.
Rationale 2: The CDC utilizes growth charts for physical assessment, but these do not address
developmental issues.
Rationale 3: The school system assessment tools would be focused on the school-age child.
Rationale 4: The Apgar scoring system is used to provide information about the baby’s physiologic
adaptation within minutes after birth.
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: 2. Identify tasks characteristic of different stages of development from infancy
through adolescence.
MNL Learning Outcome: 2.1.1. Analyze the infant, toddler, and preschooler’s physiologic and
psychosocial development.
Page Number: 335
Question 12
Type: MCSA
The parents of a toddler are concerned that their child is so messy during eating, so they feed
him instead of allowing him to feed himself. What should the nurse respond to the parents?
1. “That’s probably best. I’m sure it makes your mealtime more pleasant.”
2. “At least you’re sharing meals as a f