Nursing 120 exam 1 Flashcards
A nurse educator is teaching a group of students about professionalism. The educator informs the students that a profession is distinguished from other kinds of occupations by a number of characteristics. Which of the following are among those characteristics? Select all that apply.
A) The members of a profession are financially liable for their actions.
B) The members of a profession participate in ongoing research.
C) The members of a profession must acquire specialized education.
D) The members of a profession possess autonomy.
E) The members of a profession regularly socialize with one another
Answer: B, C, D
Explanation: A) A profession is generally distinguished from other kinds of occupations by its requirement of prolonged, specialized training to acquire a specific body of knowledge; its emphasis on service to others; its support of ongoing research to expand the profession’s body of knowledge; its development of a code of ethics; the autonomy of its members; and the existence of a professional organization. Financial liability and socialization with other nurses are not among the criteria that distinguish nursing as a profession.
A nurse would like to implement an evidence-based practice change that will influence client care on the medical-surgical unit. The nurse works with the nurse manager and other members of the leadership team to write a new policy and produce educational materials for the unit's staff and clients. In carrying out these actions, the nurse is practicing which standard of professional performance? A) Leadership B) Collaboration C) Evaluation D) Collegiality
Answer: B
Explanation: A) The nurse is practicing collaboration by working with other staff members to implement a policy change. Collaboration involves working with clients, their families, and others in the conduct of nursing practice. Collegiality describes interaction with and contributions to the professional development of peers and colleagues, as would be the case in a mentoring relationship. Leadership involves providing direction in a professional practice setting. Evaluation involves a comparison between one’s own nursing practice and professional practice standards.
A nurse faculty member is speaking to prospective students of the Bachelor of Science in Nursing (BSN) program at their educational institution. Which of the following reasons should the nurse faculty member cite as a major incentive for students to select a BSN program over an Associate of Science in Nursing (ASN) program? Select all that apply.
A) Greater autonomy in the practice setting
B) Receipt of a fuller liberal arts education
C) Easier transition to graduate school
D) Ability to work in critical care areas
A nurse faculty member is speaking to prospective students of the Bachelor of Science in Nursing (BSN) program at their educational institution. Which of the following reasons should the nurse faculty member cite as a major incentive for students to select a BSN program over an Associate of Science in Nursing (ASN) program? Select all that apply.
A) Greater autonomy in the practice setting
B) Receipt of a fuller liberal arts education
C) Easier transition to graduate school
D) Ability to work in critical care areas
Answer: A, E
Explanation: A) Nurses who hold a BSN enjoy greater autonomy, responsibility, participation in institutional decision making, and career advancement than nurses who hold only an ASN. All RNs, regardless of their education level, can work in critical care areas. There are some institutions that offer RN-to-MSN educational programs, but the ease of transition is not the ultimate incentive, which is career advancement. Having a liberal arts education is also a plus, although not as major an incentive for career advancement
) \_\_\_\_\_\_\_\_ establishes and maintains the social, political, and economic arrangements that give professionals the means to control their professional affairs. A) Autonomy B) Governance C) Socialization D) Accountability
) \_\_\_\_\_\_\_\_ establishes and maintains the social, political, and economic arrangements that give professionals the means to control their professional affairs. A) Autonomy B) Governance C) Socialization D) Accountability
A nurse educator is conducting a continuing education in-service for the nurses in a pediatric intensive care unit. Why is it so important for the professional nurse to attend these in-services?
A) Most states require it to maintain licensure.
B) It is a good way to receive overtime pay.
C) Research and new technology demand that nurses stay current.
D) New diseases are discovered every day.
Answer: C
Explanation: A) Research and technology are constantly changing and improving client care. Professional nurses are accountable for staying abreast of new information by attending continuing education courses. Receiving overtime pay is not a reason to attend continuing education courses. Although new diseases are discovered regularly, nurses wouldn’t necessarily need ongoing training on the diseases themselves, but rather on new ways of treating diseases. Finally, although many states do have continuing education requirements for nurses, new technology and research are the most important reasons for staying current. In fact, these changes are the reasons why continuing education is required by most states.
A registered nurse (RN) who now works as a nursing supervisor at a local hospital is asked to talk about nursing during career day at a local high school. When explaining to the students why nursing is a profession rather than a job, which criteria should the RN include? Select all that apply.
A) Nurses engage in ongoing research.
B) Nurses receive high salaries.
C) More nurses are needed to meet current and predicted demand.
D) Nursing has a service orientation.
E) Nurses must have broad general knowledge of a variety of topics.
Answer: A, D
Explanation: A) Several characteristics make nursing a profession rather than a job. For instance, a service orientation differentiates nursing from occupations pursued primarily for profit. Also, as professionals, nurses engage in ongoing research to improve practice and expand the field’s body of knowledge. As with other professions, nursing’s knowledge base is well defined and specific rather than broad and general. Salary level is not a criterion for a profession, nor is the number of practitioners in the field.
Answer: A, D
Explanation: A) Several characteristics make nursing a profession rather than a job. For instance, a service orientation differentiates nursing from occupations pursued primarily for profit. Also, as professionals, nurses engage in ongoing research to improve practice and expand the field’s body of knowledge. As with other professions, nursing’s knowledge base is well defined and specific rather than broad and general. Salary level is not a criterion for a profession, nor is the number of practitioners in the field.
Explanation: A) Although an associate’s degree is usually sufficient for nursing licensure, the ANA recommends a bachelor’s degree to enter professional practice. Having a bachelor’s degree can also lead to more career opportunities, because many magnet hospitals and academic health centers require that their RNs have at least this level of education. A master’s degree is usually undertaken to provide specialized nursing education, such as that required to become a nurse practitioner. A doctorate involves advanced training, which may focus on clinical or organizational skills and usually involves research.
) What is the most powerful factor in encouraging adoption of the attitudes and behaviors that characterize professionalism in nursing? A) Employment opportunities B) Licensure requirements C) Interaction with peers D) Specialized training
Answer: C
Explanation: A) Employment opportunities and licensure requirements are not associated with adopting the attitudes and behaviors of professional nursing. Specialized training provides nurses with the knowledge and skills necessary to do their job, but it doesn’t necessarily lead a nurse to internalize the attitudes and behaviors that characterize professionalism in nursing. Rather, one of the most powerful mechanisms of professional socialization is interaction with fellow students and nurses.
How does accountability differ from responsibility?
A) Responsibility involves specific tasks that must be completed in order to fulfill a role, whereas accountability involves being answerable for the outcomes of those tasks.
B) Accountability involves specific tasks that must be completed in order to fulfill a role, whereas responsibility involves being answerable for the outcomes of those tasks.
C) Responsibility involves the professional standards used to determine what a nurse should or should not do, whereas accountability involves taking ownership of the actions of others.
D) Accountability involves the professional standards used to determine what a nurse should or should not do, whereas responsibility involves taking ownership of the actions of others.
How does accountability differ from responsibility?
A) Responsibility involves specific tasks that must be completed in order to fulfill a role, whereas accountability involves being answerable for the outcomes of those tasks.
B) Accountability involves specific tasks that must be completed in order to fulfill a role, whereas responsibility involves being answerable for the outcomes of those tasks.
C) Responsibility involves the professional standards used to determine what a nurse should or should not do, whereas accountability involves taking ownership of the actions of others.
D) Accountability involves the professional standards used to determine what a nurse should or should not do, whereas responsibility involves taking ownership of the actions of others.
A novice nurse on a medical-surgical unit is released from the orientation phase of training. The nurse is able to care for a four- to five-client assignment independently and is assigned a coach on the unit who will help with problem solving if needed. According to Benner's stages of nursing expertise, this nurse would belong in which stage? A) Stage II B) Stage V C) Stage III D) Stage IV
Explanation: A) The new graduate nurse who is fresh out of the orientation phase is considered to be in Stage II. A Stage II nurse is an advanced beginner, meaning he or she demonstrates marginally acceptable performance. Stage III is the competency stage; the nurse in this stage has 2 or 3 years of experience and demonstrates organizational and planning abilities. Stage IV is the proficiency stage. The Stage IV nurse has 3 to 5 years of experience, has a holistic understanding of the client that improves decision making, and focuses on long-term goals. The nurse at Stage V is considered an expert. His or her 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 individual has highly intuitive and analytic abilities in new situations.
One of the roles of the community health nurse is to educate individuals about health promotion and wellness. Which activity would the nurse dismiss as irrelevant to health promotion and wellness? A) Holding classes for teenagers regarding prevention of sexually transmitted infections B) Teaching a class about smoking cessation C) Initiating infant care classes for new parents D) Implementing an exercise class for clients who have had a heart attack
Answer: D
Explanation: A) Teaching clients about recovery activities, such as exercises that accelerate recovery after a heart attack, would fall under the category of health restoration, not health promotion. All of the other activities listed here promote health and wellness by teaching activities and behaviors that enhance clients’ quality of life and maximize their personal potential, including their physical fitness and emotional health.
A nurse educator is talking to a group of staff nurses about the importance of continued competence in nursing practice. One of the staff nurses asks about activities that can help professional nurses maintain competence. Which action should the nurse educator recommend?
A) Working overtime whenever hours are available
B) Designing a poster presentation on current research on care for the dying client
C) Volunteering to take blood pressures at a health and wellness fair
D) Organizing a seminar to educate new nurses about hospital policies
A nurse educator is talking to a group of staff nurses about the importance of continued competence in nursing practice. One of the staff nurses asks about activities that can help professional nurses maintain competence. Which action should the nurse educator recommend?
A) Working overtime whenever hours are available
B) Designing a poster presentation on current research on care for the dying client
C) Volunteering to take blood pressures at a health and wellness fair
D) Organizing a seminar to educate new nurses about hospital policies
A nurse, who has been working in a small rural hospital for 4 years since obtaining a nursing license, participates on an interdisciplinary task force to improve client care. Which skill level is this nurse demonstrating according to Benner's stages of nursing expertise? A) Advanced beginner B) Competent C) Proficient D) Expert
Answer: C
Explanation: A) According to Benner’s stages, this nurse would be considered proficient, because he or she has 3 to 5 years of experience and a holistic understanding of the client, which improves decision making. In comparison, an advanced beginner nurse has less than 2 years of experience and demonstrates marginally acceptable performance; a competent nurse has 2 or 3 years of experience and demonstrates organizational and planning abilities; and an expert nurse has more than 5 years of experience and demonstrates highly skilled intuitive and analytic ability in new situations.
A school nurse in a large urban high school regularly delivers presentations on nutrition, smoking cessation, and prevention of sexually transmitted infections (STIs). What area(s) of nursing competence is this nurse demonstrating? Select all that apply. A) Health restoration B) Health and wellness promotion C) Caring for the dying D) Illness prevention E) Care cost savings
A school nurse in a large urban high school regularly delivers presentations on nutrition, smoking cessation, and prevention of sexually transmitted infections (STIs). What area(s) of nursing competence is this nurse demonstrating? Select all that apply. A) Health restoration B) Health and wellness promotion C) Caring for the dying D) Illness prevention E) Care cost savings
An experienced nurse practitioner is always conscious of the need to maintain a high level of competence within professional nursing practice. Which activities support this nurse’s goal? Select all that apply.
A) Reading professional journals
B) Collaborating with peers
C) Counseling clients
D) Attending professional workshops and seminars
E) Administering medications appropriately
Answer: A, B, D
Explanation: A) Lifelong competence can be promoted by attending seminars offered by colleges and professional organizations, reading professional and peer-reviewed journals, and having formal and informal discussions with peers and other members of the healthcare team. Providing counseling to clients and administering medications are ways to implement nursing knowledge, not methods for increasing it.
) \_\_\_\_\_\_\_\_ is a state of being in which individuals engage in behaviors that enhance their quality of life and maximize their personal potential. A) Health promotion B) Wellness C) Prevention D) Health restoration
Answer: B
Explanation: A) Wellness can be described as a state of being in which individuals engage in activities and behaviors that enhance their quality of life and maximize their personal potential, including their physical fitness and emotional health. In comparison, health promotion is a process that enables individuals and communities to increase their control over the determinants of well-being, thereby improving their overall health; prevention focuses on maintaining health by working to stop illnesses and injuries from occurring; and health restoration involves efforts to return clients to their optimal state of health following illness or injury.
) Providing wound care, referring clients to post-trauma psychological counseling, and assisting clients with physical and occupational therapy are all activities associated with which area of nursing competence? A) Health promotion B) Illness prevention C) Health restoration D) Holistic care and support
Answer: C
Explanation: A) These activities all fall under the umbrella of health restoration, the area of nursing competency that involves efforts to return clients to their optimal state of physical, cognitive, psychological, and spiritual health following illness or injury. Health promotion is the area of nursing competency that involves enabling individuals and communities to increase their control over the determinants of well-being, thereby improving their overall health. Illness prevention is the area of nursing competency that involves helping individuals maintain optimal health by preventing disease and injury. Although holistic care and support are important aspects of nursing, they are not considered a core competency in the same sense as health promotion, illness prevention, health restoration, and caring for the dying.
Which of the following individuals is widely considered to be the founder of public health nursing? A) Lavinia Dock B) Lillian Wald C) Mary Mahoney D) Linda Richards
Which of the following individuals is widely considered to be the founder of public health nursing? A) Lavinia Dock B) Lillian Wald C) Mary Mahoney D) Linda Richards
) The nurse is administering a bed bath to a client in a long-term care facility. The nurse is careful to cover the client during the bath. Which nursing role does this action reflect? A) Communicator B) Caregiver C) Client advocate D) Teacher
Answer: B
Explanation: A) The caregiver role includes those activities that assist the client physically and psychologically while preserving the client’s dignity. In this scenario, the nurse is acting in the role of a caregiver. 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 healthcare procedures they need to perform to maintain or restore their health. As a client advocate, the nurse acts to protect clients and represents their needs and wishes to other health professionals.
Answer: B
Explanation: A) The caregiver role includes those activities that assist the client physically and psychologically while preserving the client’s dignity. In this scenario, the nurse is acting in the role of a caregiver. 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 healthcare procedures they need to perform to maintain or restore their health. As a client advocate, the nurse acts to protect clients and represents their needs and wishes to other health professionals.
Answer: C
Explanation: A) Discussing the situation with the nursing supervisor is the appropriate decision because the supervisor is the next highest link in the chain of command. As such, the supervisor is responsible for making the appropriate decision about how to deal with the potentially impaired charge nurse. Confronting the other nurse would not be appropriate given that the nurse seems impaired. Although the nurse manager will need to be notified, the charge nurse must first notify the nursing supervisor so he or she can determine how to proceed. Security may need to be notified eventually, but again, that decision would be made by the nursing supervisor.
A nurse is overseeing a group of students who are completing a clinical rotation on a medical-surgical unit. The students are providing direct client care with the assistance of the nurse. The nurse who is overseeing the students is functioning in which capacity? A) Clinical nurse specialist B) Nurse practitioner C) Nurse entrepreneur D) Nurse educator
Answer: D
Explanation: A) Nurse educators are responsible for classroom and often clinical teaching—as is happening in this scenario. A clinical nurse specialist has an advanced degree or expertise and is considered to be an expert in a specialized area of practice. He or she 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. A nurse entrepreneur usually has an advanced degree, manages a health-related business, and may be involved in education, consultation, or research.
A student nurse is trying to explain nursing to family members. Which contemporary aspects of nursing might the student nurse include in the explanation? Select all that apply. A) Nursing is a science. B) Nursing is easy. C) Nursing is a new profession. D) Nursing is focused on illness. E) Nursing is holistic.
Answer: A, E
Explanation: A) The American Nurses Association (ANA) recognizes the influence and contribution of the science of caring to nursing philosophy and practice. Nursing is complex and involves the interrelationship among nurses, nursing, the client, the environment, and the intended client outcome. Florence Nightingale defined nursing nearly 150 years ago. The nurse is concerned with both healthy and ill individuals and approaches care holistically, considering its physical, cognitive, psychological, and spiritual elements.
A client who has been diagnosed with terminal pancreatic cancer states to the nurse, "I do not want any further treatment, but I am afraid my doctor will insist that I continue chemotherapy." Which role is the nurse performing when informing the healthcare provider of the client's choice to stop treatment? A) Change agent B) Case manager C) Advocate D) Teacher
Answer: C
Explanation: A) Here, the nurse is acting as client advocate, because this role involves representing the client’s needs and wishes to other health professionals. As change agents, nurses assist clients to make modifications in their behavior. Nurse case managers work with the multidisciplinary healthcare team to measure the effectiveness of the case management plan and monitor outcomes. As teachers, nurses help clients learn about their health and about healthcare procedures used to restore or maintain their health.
) A nurse working in the emergency department (ED) notes that a healthcare provider smells strongly of alcohol and appears confused. Which action by the nurse is appropriate?
A) Contact the charge nurse to report the problem.
B) Tell the healthcare provider to seek alcohol rehabilitation.
C) Report the healthcare provider to the hospital CEO.
D) Report the healthcare provider to the state licensing board.
Answer: A
Explanation: A) In a hospital, problems like this one are usually first reported to the charge nurse, then to the unit manager. If the problem is still not resolved, the nurse may approach someone in middle or upper management. Making suggestions to the healthcare provider about rehabilitation does not address the nurse’s responsibility to clients and the organization. The nurse should address the problem through the chain of command within the hospital.
A nurse obtains certification to provide direct client care, educate others, consult, conduct research, and manage oncology care. Which expanded nursing role best describes this nurse's career position? A) Nurse anesthetist B) Clinical nurse specialist C) Nurse educator D) Nurse researcher
A nurse obtains certification to provide direct client care, educate others, consult, conduct research, and manage oncology care. Which expanded nursing role best describes this nurse's career position? A) Nurse anesthetist B) Clinical nurse specialist C) Nurse educator D) Nurse researcher
) A staff nurse serves as a valuable source of expertise and advice to other nurses on the unit. However, the nurse does not have the authority to direct their work. Which characteristic does this nurse have? A) Staff authority B) Responsibility C) Line authority D) Organizational authority
Answer: A
Explanation: A) This nurse possesses staff authority, or the power to provide advice and support to employees or departments but not to assign tasks. In contrast, line authority is the power to direct the activities of subordinates within an organization. Responsibility means being accountable for meeting personal or organizational objectives and performing required tasks. Organizational authority is not a term used to describe this type of situation.
The nurse is caring for a terminally ill pediatric client. The parents have decided to remove their child from life support. Which action by the nurse displays the role of client advocate?
A) Respecting the parents’ decision
B) Telling the parents they are making the right decision
C) Asking to be assigned to a different client
D) Referring the parents to social services
Answer: A
Explanation: A) The nurse best advocates for the family by supporting the family’s right to make this decision. Telling the clients they are making the right decision is inappropriate and does not support advocacy. Referring the parents to another entity points to feelings of unease about the parents’ choice. Asking to be assigned to another client does not honor the right of clients and families to make decisions about healthcare.
By providing volunteer client care to an inadequately insured population, the nurse is demonstrating which value of client advocacy?
A) The client has the right to make choices and decisions.
B) The nurse has the responsibility to ensure the client has access to healthcare services.
C) The client has the right to expect a nurse-client relationship based on shared respect.
D) The nurse has the responsibility to make choices and decisions.
Answer: B
Explanation: A) The nurse has the responsibility to ensure the client has access to healthcare services that meet health needs. Although the client does have the right to make choices and decisions, the nurse volunteering at a free clinic to provide healthcare to the underinsured does not demonstrate this value. Although the client does have the right to expect a nurse-client relationship based on shared respect, the nurse volunteering at a free clinic to provide healthcare to the underinsured does not demonstrate this value. The nurse’s responsibility to make choices and decisions is not one of the values basic to client advocacy.
A charge nurse notices that a client has a black eye that was not present when admitted to the facility. Which action by the charge nurse is appropriate in this situation?
A) Ask a staff nurse to question the client about the situation.
B) Discuss the situation with the client in a private setting.
C) Ask the other staff members if abuse is involved.
D) Ignore the situation until the client shows a willingness to talk.
A charge nurse notices that a client has a black eye that was not present when admitted to the facility. Which action by the charge nurse is appropriate in this situation?
A) Ask a staff nurse to question the client about the situation.
B) Discuss the situation with the client in a private setting.
C) Ask the other staff members if abuse is involved.
D) Ignore the situation until the client shows a willingness to talk.
Which of the following is an advocacy intervention that a nurse may perform?
A) Ensuring that clients and their families understand their legal rights.
B) Deciding whether clients need to know information regarding their care.
C) Following organizational policies and procedures in all cases without question.
D) Leaving monitoring of clients’ care to the clients themselves.
Answer: A
Explanation: A) Educating clients and their families about their legal rights regarding informed decision-making is a specific advocacy intervention a nurse may make. Nurses should ensure that clients have all the information they need to give informed consent. They should review organizational policies and procedures to ensure protection of client rights, and they should monitor client care to ensure client rights.
The nurse notices that there is broken equipment on the playground in a neighborhood where care is provided to low-income residents. The nurse tries unsuccessfully to get the owner to address this safety issue. Which additional action is most consistent with the role of the nurse as a public advocate?
A) Write an article in the local newspaper to gain public attention.
B) No action is required; this is a civil problem beyond the realm of the nurse.
C) Call the police to report the owner’s neglect.
D) Tell the parents they should not pay their rent until the playground is fixed.
Answer: A
Explanation: A) Prevention of injury to clients is very much a part of nursing. The nurse should initially contact the owner. Because this was ineffective, it is appropriate for the nurse to write an article or talk to an individual on the town council. The police are a protection against crime and are not likely to do anything about the situation. Telling the parents not to pay their rent until the playground is fixed is not appropriate. Civil problem or not, the nurse has an obligation to protect the neighborhood children from injury and should act on it.
The nurse has been working in a long-term care facility for 1 week. The nurse notes that during the evening meal, an unlicensed assistive personnel (UAP) gives a tray to a client who is unable to cut up and eat the food independently, and then leaves. After the nurse assists the client with eating the meal, which action is appropriate to advocate for this client?
A) Report the UAP for neglect.
B) Notify the healthcare provider.
C) Call the client’s family to have them assist with evening meals.
D) Discuss the situation with the director of nursing.
Answer: D
Explanation: A) The nurse would advocate getting the client’s plan changed because the goal is to have someone available to help the client eat for every meal. Notifying the doctor will not help the client. The family might be able to help at times but cannot be expected to come for every meal. The nurse assesses that this happens at every meal and seeks to change how this client is cared for, not just changing one healthcare worker. The UAP is not neglecting the client. The UAP is assigned tasks by the nurse in charge of the client.
) The nurse is caring for a client on a mental health unit who is yelling at other clients and some of the staff. Which verbal intervention by the nurse is most consistent with the concept of advocacy?
A) “You should be ashamed of your behavior. No wonder you ended up on a mental health unit.”
B) “You seem upset. Can you tell me what you think might help to calm you down?”
C) “You need to behave. If this doesn’t stop you are going to be placed in restraints.”
D) “You are out of control. You have no choice but to take more medication.”
Answer: B
Explanation: A) The nurse’s role is to advocate for the rights of the individual with mental illness or disability. The nurse should validate the meaning of the behavior and encourage safe coping methods. Disparaging the client or threatening to restrain them or sedate them is inconsistent with client rights.
An older adult client with metastasized breast cancer informs the nurse that her doctor is insisting that she participate in a course of chemotherapy, even though the client does not want to have any further treatment. Which actions by the nurse exemplify advocacy for this client? Select all that apply.
A) Tell the client that it is in her best interest to follow the doctor’s advice.
B) Inform the doctor about the client’s clear wishes not to have further chemotherapy.
C) Ascertain whether or not the client has an advance care directive and, if not, assist her in creating one.
D) Discuss the implications of various choices with the client.
E) Avoid interfering in the doctor-client relationship
Answer: B, C, D
Explanation: A) Nurses acting as advocates should honor the moral principles and standards and respect clients’ right to make their own choices. The nurse should continuously advocate for the client in a professional manner. The nurse serves as both a teacher and an advocate by informing clients about their rights. When the client makes decisions about his or her treatment other than what is recommended, it is the nurse’s role to ensure that the client is making an informed decision and, if so, to advocate for the client’s right to make autonomous choices.
Which of the following advocacy interventions might nurses provide that are within their role and scope of practice? Select all that apply.
A) Educating clients and their families about their legal rights regarding informed decision-making
B) Ensuring that clients have the necessary information to make an informed decision or give informed consent
C) Evaluating organizational policies and procedures to ensure protection of client rights
D) Supporting medical authority even when this goes against the client’s wishes
E) Declaring clients incompetent so family members can make medical decisions for them
Answer: A, B, C
Explanation: A) Clients must understand their rights in order to be able to defend them. As an advocate, the nurse provides clients with the information they need to make informed decisions and supports the clients’ rights to make their own healthcare decisions. Nurses should evaluate organizational policies and procedures and monitor clients’ care to ensure protection of client rights. A nurse should understand that advocacy may require political action. Conflicts may arise over issues that require consultation, confrontation, or negotiation between the nurse and administrative personnel or between the nurse and primary care providers. Declaring clients incompetent is not the role of the nurse, and it should not be done just to please family members.
A nurse suspects another healthcare provider is under the influence of alcohol at work. Which actions by the nurse are correct? Select all that apply.
A) Assume that healthcare provider is handling any problem.
B) Immediately report it to a supervisor.
C) Respect the privacy of the healthcare provider.
D) Assist the provider while care is provided to clients.
E) Follow the state board guidelines.
Answer: B, E
Explanation: A) A nurse who suspects a colleague of engaging in illegal, immoral, or unethical conduct and fails to act is in direct violation of the ANA Code of Ethics for Nurses. Nurses have a legal responsibility to report any professional whom they suspect of engaging in illegal, immoral, or unethical activities. Although an impaired healthcare provider may view this intervention as an invasion of privacy, such prompt action will safeguard the client from harm, at the same time offering the impaired healthcare provider a chance at recovery. Impairment of a coworker or team member is the most common situation encountered by healthcare professionals. Nurses should follow guidelines set forth by the board of nursing for the state in which they work.
A school nurse who is concerned about an increase in sports injuries related to ineffective protective equipment decides to hold a community seminar related to the importance of proper protective equipment. Which advocacy activities is this nurse demonstrating? Select all that apply.
A) Advocating for vulnerable populations
B) Advocating for fair and equitable access to high-quality care for all clients
C) Ensuring that clients have the necessary information to make an informed decision or give informed consent
D) Informing the public about issues and concerns
E) Speaking publicly for the health, welfare, and safety of their clients
Answer: A, C, D, E
Explanation: A) Clients from vulnerable populations, such as children, particularly benefit from nursing advocacy. Through this seminar, the nurse is providing clients with information to make an informed decision and informing the public about issues and concerns that are important to them. The nurse is also speaking publicly to encourage safety practices for students. These are all important advocacy activities. Advocating for fair and equitable access to high-quality care is also an important advocacy activity, but it is not being demonstrated in this situation.
) The nurse is planning to carry out advocacy interventions when caring for a client with brain cancer. Which value should the nurse recognize as most basic to client advocacy?
A) The client is a holistic, autonomous being who has the right to make choices and decisions.
B) The nurse has the responsibility to ensure the client’s decisions guide care regardless of whether the client is mentally competent.
C) Clients should be advised that making their own care decisions is almost invariably detrimental to their well-being.
D) The client is a dependent being who has the right to expect the nurse to solve all healthcare needs.
Answer: A
Explanation: A) Safeguarding clients’ autonomy is the first core attribute of advocacy. It requires respecting and promoting each client’s right to self-determination, except in those situations when the client is incompetent to decide or does not wish to be involved in decision making. Clients should not be discouraged from making their own decisions or be treated as naturally dependent.
The home health nurse suspects that another nurse providing home care to a client has been taking the client’s narcotics. Which action should the nurse carry out?
A) Follow the reporting procedures for her agency.
B) Tell the client to confront the other nurse.
C) Confront the other nurse about the suspected theft.
D) Have the client file a police report.
Answer: A
Explanation: A) Nurses have a legal responsibility to report any professional whom they suspect of engaging in illegal, immoral, or unethical activities. Normally, the nurse making such a report will do so following established procedures at the facility at which the nurse is employed. Both state nurse practice acts and the ANA Code of Ethics require nurses to report unethical nurse behaviors, including boundary violations. The nurse should not leave the responsibility of addressing this problem to the client or directly confront the other nurse.
) A nurse involved in promoting client advocacy efforts in the community is assessing the vulnerability of populations in the area served by the healthcare facility where he works. This is a high-ozone area. Which of the following clients would have the lowest risk for ground-level ozone?
A) A 73-year-old female client with a high level of financial security
B) A 23-year-old male client with a regular salaried job able to pay his bills
C) A 33-year-old female client with COPD and without a job living at the poverty line
D) A 13-year-old male client whose parents both work at mid-level professional jobs
) A nurse involved in promoting client advocacy efforts in the community is assessing the vulnerability of populations in the area served by the healthcare facility where he works. This is a high-ozone area. Which of the following clients would have the lowest risk for ground-level ozone?
A) A 73-year-old female client with a high level of financial security
B) A 23-year-old male client with a regular salaried job able to pay his bills
C) A 33-year-old female client with COPD and without a job living at the poverty line
D) A 13-year-old male client whose parents both work at mid-level professional jobs
A nurse is organizing a client advocacy committee focused on improvements in water quality to protect the health of vulnerable populations. As she examines her own workplace, what is a likely area of improvement for her to focus on? A) Disposal of disinfectants B) Oil spills C) Pollution of water resources D) Use of arsenic
Answer: A
Explanation: A) Water supplies may be contaminated with either natural or human-made substances. Contaminants in the public drinking supply that can cause health hazards include disinfection by-products. The nurse’s facility is not likely to use arsenic, be involved in oil spills, or directly pollute water resources such as lakes, rivers, and streams, but the disposal of disinfectants could be a concern.
A nurse is organizing a community effort to reduce the rate of birth defects in the area. A nuclear power plant provides most of the electricity for the community. What aspect of this power plant’s operation should the nurse identify as problematic?
A) Production of particulate matter such as smoke
B) Production of ionizing radiation
C) Production of hazardous waste
D) Production of nuclear-generated electricity
A nurse is organizing a community effort to reduce the rate of birth defects in the area. A nuclear power plant provides most of the electricity for the community. What aspect of this power plant’s operation should the nurse identify as problematic?
A) Production of particulate matter such as smoke
B) Production of ionizing radiation
C) Production of hazardous waste
D) Production of nuclear-generated electricity
Which action by the nurse working in the emergency department best demonstrates advocacy for better environmental quality?
A) Improving prioritization skills for nurses in the ED
B) Adapting practices in the ED to cultural needs of clients
C) Revising policies for telephone triage to ensure better distribution of resources
D) Ensuring that bandages and dressings are properly disposed according to protocol
Answer: D
Explanation: A) A nurse working in an ED may advocate for better environmental quality for her clients by ensuring that bandages and dressings are properly disposed of according to protocol. Improved prioritization skills for nurses, more culturally aware practices, and telephone triage policies that make a better use of ED resources are all useful interventions but do not relate to environmental quality.
The nurse is working in a community health setting. Which of the following should the nurse identify as a threat to environmental quality?
A) Many residences appear to be vulnerable to intrusion, with open garage doors or ground-floor windows.
B) Children in many neighborhoods are playing in the street with no adult supervision.
C) Many people walking their pets do not clean up their pets’ waste.
D) On many residential streets, cars are parked in a way that blocks traffic and creates potential driving hazards.
Answer: C
Explanation: A) Improper disposal of pet waste is a danger to clean water that the National Resource Defense Council has identified as an area of concern. This would be an environmental quality concern. Vulnerability to intrusion, children playing in the street, or improperly parked cars are all areas of concern but do not relate to environmental quality.
The nurse in the clinic is assessing an adult client who has signs and symptoms of heart failure. Which of the following lifestyle habits would be useful for the nurse to assess before developing the client teaching plan? A) The client's occupation B) The client's diet C) The client's usual sleep schedule D) The client's marital status
Answer: B
Explanation: A) For clients who have heart failure, the nurse should ask questions aimed at obtaining information about lifestyle habits that may be contributing to the heart failure, such as smoking and diet. Although sleep schedule is a lifestyle habit about which the nurse should inquire, it is less likely than diet to be a contributing factor to heart failure. Gathering psychosocial information such as the client’s marital status and occupation is also important, but in this case, it is not directly related to the client’s current problem and teaching needs
) The nurse is preparing to assess a client who is experiencing difficulty breathing. Before palpating the client’s abdomen, which nursing action is appropriate?
A) Administering 10 L of oxygen to the client
B) Having the client remain upright
C) Placing the client in a modified Sims position
D) Asking the client to bend over a table
Answer: B
Explanation: A) Abdomen palpation is usually done in the supine position, but a client with difficulty breathing would not tolerate that position well. Instead, the nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in a modified Sims position could compromise the client’s ability to breathe effectively. A client who is experiencing dyspnea would not be asked to bend over a table. Depending on the client’s underlying condition, administering 10 L of oxygen may be excessive
The nurse is preparing to conduct a physical examination of a client’s head and neck area. The client is paralyzed from the neck down. Which action by the nurse is appropriate when conducting the physical assessment of this area?
A) Supporting the client during the examination
B) Placing the client in an armless regular chair
C) Placing the client in Sims position
D) Placing the client in supine position
Answer: A
Explanation: A) The client who is paralyzed from the neck down is not able to support his or her body. When considering positioning, the nurse should recognize that the client will require support during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. Sims position would not allow the nurse to observe the client adequately.
A client is complaining of pain in the lower-left quadrant of his abdomen. The nurse prepares to auscultate the lower abdomen and notes that the client has a great deal of hair there. Which action by the nurse is appropriate prior to auscultating the client’s abdomen?
A) Moistening the abdominal hair
B) Documenting that the client has hirsutism
C) Cutting the client’s hair over the entire abdomen
D) Discontinuing the use of auscultation and palpating the abdomen only
Answer: A
Explanation: A) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client’s hair for auscultation. The client complains of abdominal pain, so auscultation would be a necessary part of a thorough examination because the nurse would need to listen to bowel sounds. Hirsutism includes excess hair all over the entire body, not just the abdomen
An adult client and her spouse are seen in an urgent care clinic. The client presents with a temperature of 102°F, complains of nausea, and has experienced vomiting and diarrhea for 12 hours. The nurse notes that the client's mucous membranes are pale and dry and suspects that the client is dehydrated. Which action by the nurse is the most appropriate? A) Ask the spouse for more information. B) Assess for pedal edema. C) Assess skin turgor. D) Repeat the temperature measurement.
Answer: C
Explanation: A) A client who presents with hyperthermia, vomiting, diarrhea, and pale, dry mucous membranes is likely dehydrated and requires assessment to confirm this suspicion. An appropriate action by the nurse is to assess the client’s skin turgor, which can provide more support for a diagnosis of dehydration. Pedal edema would indicate fluid volume overload and not dehydration. Asking the spouse for more information will not provide adequate support for the treatment of dehydration. Only measurements that are extremely abnormal need to be repeated in stable clients.
The nurse is preparing to examine a toddler’s ear canals with an otoscope. Which actions by the nurse are appropriate? Select all that apply.
A) Having the child sit on the examination table
B) Having the child play with the equipment
C) Having the child sit on the parent’s lap
D) Telling the child the examination will not hurt
E) Asking the child to tilt the head
Answer: B, C
Explanation: A) The best way to get a child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, as well as to have the child sit on the parent’s lap. Asking the child to tilt the head does not encourage cooperation. Most children of this age need to see for themselves that a procedure will not hurt; simply telling the child that the procedure won’t be painful is not effective.
Answer: B, C
Explanation: A) The best way to get a child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, as well as to have the child sit on the parent’s lap. Asking the child to tilt the head does not encourage cooperation. Most children of this age need to see for themselves that a procedure will not hurt; simply telling the child that the procedure won’t be painful is not effective.
Answer: B
Explanation: A) To assess the range of motion of the knees, the client should be placed in a sitting position. The client should be instructed to alert the nurse at the first sign of discomfort when checking range of motion of the knees. The knee should not be forced beyond the pain limit. Placing the client prone and lifting the entire leg checks the range of motion of the hips. The client should not be asked to stand when assessing range of motion of the knees.
) The nurse is conducting a physical assessment of a middle-aged female client during an annual exam. What should the nurse assess that is particularly relevant to this age group? Select all that apply.
A) Speech and language
B) Body development and growth
C) Sleeping patterns
D) Ability to carry out activities of daily living (ADLs)
E) Body mass index (BMI) measurement
Answer: D, E
Explanation: A) Areas of assessment that are relevant to middle-aged adults include BMI measurement to assess for disease risk and the ability to carry out ADLs. Speech and language, body development and growth, and sleeping patterns are more appropriate to assess in pediatric clients.
The nurse is caring for a new older adult client who speaks a foreign language and who does not speak English. Which action by the nurse is appropriate when conducting the health history portion of the assessment?
A) Speaking in a loud tone when addressing the client
B) Providing the client with educational materials that are written in English
C) Asking the client’s adult son to translate during the assessment
D) Having a medical translator available during the health history
Answer: D
Explanation: A) Because the client speaks a foreign language, the nurse will need a medical translator to be available during the health history portion of the assessment. Although the nurse may need to increase the volume of speech because of age-related changes in the client’s hearing, this is not an appropriate action until the nurse determines that the client is hard of hearing. Educational material should be provided to the client in the client’s native language. Asking a family member to translate during an assessment can violate the client’s privacy.
The nurse is conducting a health history as part of a nursing assessment. The client says to the nurse, “I am allergic to penicillin.” Which assessment question would best help the nurse learn more about the client’s allergy?
A) “Where did you experience the reaction?”
B) “What type of reaction occurred?”
C) “How long did your symptoms last?”
D) “Do any other family members have this same allergy?”
Answer: B
Explanation: A) The nurse should ask the client to provide more information about the type of reaction that occurred when the penicillin was administered. The location of the reaction and how long the symptoms lasted are important, but the priority is determining the type of reaction the client experienced. Asking whether any other family members have the same allergy will not provide the nurse with useful information
Answer: B
Explanation: A) The nurse should ask the client to provide more information about the type of reaction that occurred when the penicillin was administered. The location of the reaction and how long the symptoms lasted are important, but the priority is determining the type of reaction the client experienced. Asking whether any other family members have the same allergy will not provide the nurse with useful information
Answer: C
Explanation: A) The dorsal recumbent position (back-lying with knees flexed and hips externally rotated) is usually contraindicated for clients with cardiopulmonary problems because of the increased physiologic stress that this position places on the body. The other positions listed here—sitting (with back supported or unsupported), supine (horizontal recumbent), and side-lying (Sims)—are typically better tolerated by clients with cardiopulmonary illness
The nurse is assessing an older adult client who is confused. The client is accompanied by his adult son. Who can the nurse employ as a primary source of data when assessing this client?
A) The client himself
B) The client’s adult son
C) A nurse who cares for the client at the retirement home
D) The client’s primary healthcare provider
Answer: A
Explanation: A) The client is the only person who is considered a primary source of data. Family members, other support people, health professionals, medical records, laboratory and diagnostic reports, and any other information sources beyond the client himself are considered secondary sources of data.
A nurse educator is providing information to a group of nursing students regarding appropriate assessment techniques that can be applied across the life span. Which statements should the educator include in the teaching session? Select all that apply.
A) “Auscultate the chest while the client is sleeping to obtain the most accurate assessment of the heart.”
B) “Use standard precautions during the history and physical examination process.”
C) “Perform invasive procedures like pharyngeal and otic exams at the end of the assessment.”
D) “Use age-appropriate terminology for explaining procedures and actions.”
E) “Use the assessment process to teach about exam procedures and findings.”
A nurse educator is providing information to a group of nursing students regarding appropriate assessment techniques that can be applied across the life span. Which statements should the educator include in the teaching session? Select all that apply.
A) “Auscultate the chest while the client is sleeping to obtain the most accurate assessment of the heart.”
B) “Use standard precautions during the history and physical examination process.”
C) “Perform invasive procedures like pharyngeal and otic exams at the end of the assessment.”
D) “Use age-appropriate terminology for explaining procedures and actions.”
E) “Use the assessment process to teach about exam procedures and findings.”
A nurse is reviewing the medical record for a school-age client prior to a scheduled health maintenance visit. Which data from the record indicates that the client is overweight?
A) Body mass index (BMI) >85th percentile
B) BMI >95th percentile
C) 25% increase in weight in a 6-month period
D) 35% increase in weight in a 6-month period
Answer: A
Explanation: A) A child with a BMI greater than the 85th percentile is considered overweight. A child with a BMI greater than the 95th percentile is considered obese. Percentage of weight gain in a 6-month period (regardless of baseline) does not determine whether a client is overweight or obese.
The nurse is assessing an older adult client who experienced a myocardial infarction (MI) a few months ago. The client states, “I don’t feel like doing much. I feel okay physically, but I just don’t want to be around anyone.” Based on this data, which tool should the nurse use to further assess the client?
A) Get-Up-and-Go Test
B) Barthel Index of Activities of Daily Living
C) Geriatric Depression Scale
D) Short Portable Mental Status tool
The nurse is assessing an older adult client who experienced a myocardial infarction (MI) a few months ago. The client states, “I don’t feel like doing much. I feel okay physically, but I just don’t want to be around anyone.” Based on this data, which tool should the nurse use to further assess the client?
A) Get-Up-and-Go Test
B) Barthel Index of Activities of Daily Living
C) Geriatric Depression Scale
D) Short Portable Mental Status tool
Data that are detectable by an observer or can be measured or tested against an accepted standard are known as A) subjective data or symptoms. B) objective data or symptoms. C) subjective data or signs. D) objective data or signs.
Data that are detectable by an observer or can be measured or tested against an accepted standard are known as A) subjective data or symptoms. B) objective data or symptoms. C) subjective data or signs. D) objective data or signs.
Which of the following sounds would not be detected during percussion of a healthy client? A) Tympany B) Hyperresonance C) Dullness D) Flatness
Answer: B
Explanation: A) Percussion elicits five types of sound: flatness, dullness, resonance, hyperresonance, and tympany. Flatness is an extremely dull sound produced by very dense tissue, such as muscle or bone. Dullness is a thudlike sound produced by dense tissue such as the liver, spleen, or heart. Resonance is a hollow sound, such as that produced by lungs filled with air. Hyperresonance is not produced in the healthy body. It is described as booming that can be heard over an emphysematous lung. Tympany is a musical or drumlike sound produced from an air-filled stomach
For which client would the Denver II tool not be an appropriate choice for the nurse to use during a well-child assessment? A) A male client B) A client aged 7 or older C) A female client D) A client aged 6 or younger
Answer: B
Explanation: A) The Denver II tool is a screening test administered to well children between birth and 6 years of age. It is designed to test 20 simple tasks and items in four sectors: personal-social, fine motor adaptive, language, and gross motor. This tool is used with both male and female clients, but it would not be used for clients aged 7 or older.
What is one possible conclusion the nurse could draw after assessing a client with the Braden Scale?
A) The client is at risk for falls.
B) The client is at risk for pressure ulcers.
C) The client is at risk for malnutrition.
D) The client may be unable to complete activities of daily living.
What is one possible conclusion the nurse could draw after assessing a client with the Braden Scale?
A) The client is at risk for falls.
B) The client is at risk for pressure ulcers.
C) The client is at risk for malnutrition.
D) The client may be unable to complete activities of daily living.
A nurse is providing care to a client who is scheduled for a colonoscopy. The client requires a bowel prep prior to the diagnostic test. Which approach should the nurse use to facilitate the client’s understanding of the procedure?
A) Use layman’s terms to explain the procedure, then ask the client to describe the procedure in her own words
B) Use medical terminology when explaining the procedure to the client to ensure maximum accuracy and clarity
C) Focus on intonation when describing the procedure to the client
D) Speak slowly and loudly when providing client teaching about the procedure
Answer: A
Explanation: A) Good verbal communication incorporates simplicity, brevity, and completeness. Simplicity involves the use of commonly understood words rather than medical terminology. For example, the term “bowel prep” may be completely meaningless to the client, so telling the client that she needs to drink a gallon of laxative-like medication will get the point across better. Asking the client to repeat the information back in her own words gives the nurse a chance to evaluate whether the teaching has been successful. While intonation can modify the feeling and impact of a message, focusing on intonation is less important than using easily understood terminology. Speaking too slowly or too loudly could be interpreted by the client as patronizing or aggressive.
) A nurse is teaching a client about a dressing change that should be done three times per day. The client is from a culture that is “present oriented.” Based on this data, at which times should the nurse tell the client to perform the dressing changes?
A) At whatever times the client selects, as long as they are 8 hours apart
B) At 9 a.m., 3 p.m., and 9 p.m.
C) At whatever times the client selects, as long as the dressing is changed three times each day
D) After breakfast, lunch, and dinner
Answer: D
Explanation: A) 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. Relating the dressing changes to regular daily activities would be a good approach for a client who is not focused on times of the day, such as 9 a.m., 3 p.m., and 9 p.m. It is not necessary for the dressing changes to be exactly 8 hours apart. Leaving it up to the client to change the dressing at any time as long as it is changed three times a day does not allow for any regularity in the dressing changes.
A nurse educator in a medical-surgical unit is demonstrating the use of new equipment to the rest of the nurses on the unit. After initial efforts at having the class gather closely around the models were met with discomfort and inattention, the nurse educator sets up the models in the front of the classroom. Which level of proxemics would be ideal for this situation? A) 4 to 12 feet B) 1 1/2 to 4 feet C) 12 to 15 feet D) Less than 1 1/2 feet
A nurse educator in a medical-surgical unit is demonstrating the use of new equipment to the rest of the nurses on the unit. After initial efforts at having the class gather closely around the models were met with discomfort and inattention, the nurse educator sets up the models in the front of the classroom. Which level of proxemics would be ideal for this situation? A) 4 to 12 feet B) 1 1/2 to 4 feet C) 12 to 15 feet D) Less than 1 1/2 feet
The nurse is admitting a client to an inpatient psychiatric unit. The client is speaking wildly and is obviously very agitated. Which action by the nurse would be appropriate to calm the client?
A) Placing the client in a private room, away from others
B) Speaking to the client in a soft, calm tone
C) Administering a prn medication to sedate the client
D) Using short sentences when talking to the client
The nurse is admitting a client to an inpatient psychiatric unit. The client is speaking wildly and is obviously very agitated. Which action by the nurse would be appropriate to calm the client?
A) Placing the client in a private room, away from others
B) Speaking to the client in a soft, calm tone
C) Administering a prn medication to sedate the client
D) Using short sentences when talking to the client
The nurse is starting preoperative teaching when the client receives a phone call. When the call ends and the nurse resumes teaching, the client is visibly upset and begins to cry. Which therapeutic initial response by the nurse is appropriate?
A) “You can deal with whatever is upsetting you once we have finished.”
B) “It’s very important to focus on this teaching so that you will recover quickly after surgery.”
C) “I can see that phone call has upset you. Let’s talk about why you are upset before we move on with teaching.”
D) “What can you do to solve the problem?”
The nurse is starting preoperative teaching when the client receives a phone call. When the call ends and the nurse resumes teaching, the client is visibly upset and begins to cry. Which therapeutic initial response by the nurse is appropriate?
A) “You can deal with whatever is upsetting you once we have finished.”
B) “It’s very important to focus on this teaching so that you will recover quickly after surgery.”
C) “I can see that phone call has upset you. Let’s talk about why you are upset before we move on with teaching.”
D) “What can you do to solve the problem?”
A female nurse is caring for a 21-year-old male client with a questionable gastrointestinal blockage. The healthcare provider prescribes an enema. Which reaction by the client would the nurse anticipate when planning care?
A) “May I have a visitor in the room with me for support during the procedure?”
B) “I would rather have my doctor perform this procedure.”
C) “I don’t know what an enema is.”
D) “I am afraid of having an enema.”
Answer: B
Explanation: A) The nurse would anticipate that most young adult clients will be embarrassed by this procedure when the nurse and client are of different genders. When the client states that he would rather have his doctor perform the enema, he is probably motivated by embarrassment and acting on the assumption that the doctor is male. The nurse should approach the client beforehand to address the issue. Most clients would only experience annoyance, not fear, in relation to this procedure. Most clients in this age group would also be familiar with what an enema is, even if they have not had an enema themselves. The nurse would definitely not expect the client to request the presence of another individual in the room for this procedure
The nurse is caring for a young adult client after a cervical biopsy. The client has expressed anxiety about the results. The healthcare provider peeks into the client’s room and says, “The biopsy is negative.” The nurse later finds the client sobbing. Which response by the nurse is most appropriate?
A) “What did the healthcare provider tell you about the biopsy?”
B) “You seem upset. Do you want to talk to me about the test results?”
C) “Why are you crying after getting such good news?”
D) “In this case, the term ‘negative’ is good!”
Answer: B
Explanation: A) The nurse does not know specifically what the client is upset about and should ask the client an open-ended question so she can talk. The healthcare provider, in delivering important news to the client, should have taken time to sit with her and discuss the test results. In telling the client that the test was negative, the provider did not clarify what “negative” actually meant. Using medical jargon without explanation can lead to misinterpretation by the client. Asking the client why she is crying about good news does not allow the client to express concern regarding the results. Asking the client what the provider told her assumes that she is crying because of what the provider said and does not allow her to express her concern in an open-ended manner. Saying that the test results are good in this case assumes that the client has misunderstood the results, which may be true but does not allow the client to express her concerns.
) A home health nurse is precepting a new nurse during a routine wound care visit. The new nurse is assessing the client's wound and notes that it is showing signs and symptoms of infection. The client's spouse asks the new nurse how the wound looks. The new nurse responds by stating, "It looks fine," but the new nurse's face indicates a different story. When evaluating the new nurse, the preceptor should note a need to work on which aspect of communication? A) Credibility B) Congruence C) Timing D) Clarity and brevity
) A home health nurse is precepting a new nurse during a routine wound care visit. The new nurse is assessing the client's wound and notes that it is showing signs and symptoms of infection. The client's spouse asks the new nurse how the wound looks. The new nurse responds by stating, "It looks fine," but the new nurse's face indicates a different story. When evaluating the new nurse, the preceptor should note a need to work on which aspect of communication? A) Credibility B) Congruence C) Timing D) Clarity and brevity
A nurse is providing care for a client who has vocal cord damage and wants to implement strategies that will promote communication with this client. Which interventions would be appropriate? Select all that apply.
A) Facing the client when speaking
B) Having pen and paper on hand for the client
C) Making sure that the language spoken is the client’s dominant language
D) Using a picture board to facilitate communication
E) Employing an interpreter
Answer: B, D
Explanation: A) The client who is nonverbal would respond best to use of a picture board or pen and paper. Because the client cannot communicate verbally, facing the client when talking, using an interpreter, or using the client’s dominant language would not address the client’s inability to communicate.
The nurse is caring for a client who was admitted to the emergency department with abdominal pain. The client speaks very little English and requires an emergency appendectomy. The nurse has enlisted the hospital interpreter to explain the procedure and help with informed consent. When the interpreter arrives, which action by the nurse is appropriate?
A) Ask the interpreter to translate as closely as possible.
B) Ask the client’s family to be included in the interpreting process and exchange of information.
C) Direct questions to the interpreter and not the client.
D) Request that the interpreter use the same dialect as the client to promote understanding
Answer: A
Explanation: A) An interpreter is an individual who mediates spoken or signed communication between people who use different languages without adding, omitting, distorting meaning, or editorializing. It is not the interpreter’s responsibility to determine the dialect with which the client is most familiar. The nurse should direct all questions to the client, not the interpreter. The nurse should also avoid asking the client’s family, especially a child or spouse, to help interpret
The nurse is providing care for a client who is about to be discharged. The nurse is discussing the discharge orders with the client’s primary healthcare provider. Which statement by the nurse is an appropriate example of using assertive communication?
A) “Can we talk about this client prior to discharge?”
B) “That new medication you prescribed for the client is ineffective.”
C) “I am worried about the client’s blood pressure. It remains high even with the new medication.”
D) “Excuse me, Doctor, I think you need to do something about the client’s blood pressure.”
Answer: C
Explanation: A) The nurse who expresses concern because the client’s blood pressure remains high even with new medication is being assertive, clear, and concise. Stating that the new medication is ineffective could be interpreted as an inflammatory remark by the provider. Asking whether the provider can talk about a client does not give the provider enough information. Saying the provider must do something about the client’s blood pressure may cause the provider to become defensive.
A young adolescent client is in the hospital preparing for major surgery for the removal of a tumor on the kidney. The client’s mother tells the nurse that she doesn’t want her child to receive narcotics for postoperative pain. What is the nurse’s best response?
A) “Okay, I’ll tell the healthcare provider not to order any. Are you sure you want to do this?”
B) “The pain will be severe. Why don’t we ask your child about this?”
C) “Your child’s pain will be severe after the surgery. Can you tell me why you feel this way?”
D) “You do not have a choice of medication. Decisions involving pain relief are up to the healthcare providers.”
Answer: C
Explanation: A) As a client advocate, the nurse should defend the need for effective pain medication by using assertive communication. Thus, the best response is for the nurse to tell the mother the truth about the client’s pain and then explore the mother’s objection to the drugs. Acceding to the mother’s request is submissive communication and would not be in the best interests of the child. Telling the mother she does not have a choice is aggressive and untrue. Putting the child in the middle of the discussion is a divisive maneuver.
The nurse is caring for a client who is having difficulty understanding the dressing changes that need to be completed in the home as part of postdischarge wound care. The client asks the nurse to demonstrate the procedure again and allow the client’s spouse to perform the procedure while the nurse watches. What is the most likely outcome of this assertive request by the client?
A) A slightly increased chance that the wound will become infected due to exposure during dressing changes
B) Less compassionate care for the client due to the nurse’s irritation by the request
C) A greater likelihood that the wound will heal appropriately
D) A guarantee that the spouse will change the dressings correctly
Answer: C
Explanation: A) The client used assertive communication to ensure that the dressing changes would be performed correctly, which will likely result in appropriate healing of the client’s wound. No information is provided about the nurse’s response to the request, and even if the nurse is irritated, these feelings should not affect the quality of care. There is no guarantee that the client’s spouse will always perform the task correctly, because humans make mistakes. Infection of a wound that is dressed correctly is not the likely result of this request.
The nurse is caring for a client with a new colostomy. The client has been taught how to perform colostomy care and has been successful with return demonstration to the staff. Although the client is able to perform care independently and has asked to do so, the charge nurse has instructed the nursing staff to continue performing colostomy care for this client. When addressing this issue directly with the charge nurse, which statement by a staff nurse is the most appropriate?
A) “The client will change the apparatus whether you like it or not.”
B) “The client has been trained to change the apparatus and has expressed interest in performing this procedure independently.”
C) “You have no right to continue delegating this task to nurses when the client has been trained to change the apparatus.”
D) “I am going to tell the nurse manager that you won’t allow the client to change the apparatus independently.”
Answer: B
Explanation: A) The nurse should make a clear, assertive statement saying that the client learned the procedure and wishes to execute it. Saying “You have no right . . .” is a challenge to the charge nurse and will only result in escalation of the argument. Telling the charge nurse that the nurse manager will be notified is a threat and inflames the situation. Insisting that the client will continue to change the apparatus will likely result in the charge nurse taking further action to prevent the client from performing self-care.
) Which of the following barriers to communication involves asking a client for information chiefly out of curiosity rather than with the intent to assist the client? A) Challenging B) Probing C) Testing D) Rejecting
Answer: B
Explanation: A) Probing involves asking a client for information chiefly out of curiosity rather than out of a desire to assist the client. Probing often places clients in a defensive position and violates their privacy. Challenging refers to giving a response that makes clients prove their statement or point of view. Testing involves asking questions that make a client admit to something. Rejecting is refusing to discuss certain topics with a client. All four of these behaviors are barriers to effective nurse-client communication.
Answer: B
Explanation: A) Probing involves asking a client for information chiefly out of curiosity rather than out of a desire to assist the client. Probing often places clients in a defensive position and violates their privacy. Challenging refers to giving a response that makes clients prove their statement or point of view. Testing involves asking questions that make a client admit to something. Rejecting is refusing to discuss certain topics with a client. All four of these behaviors are barriers to effective nurse-client communication.
Answer: C
Explanation: A) Testing involves asking questions that make the patient admit to something. These responses permit the patient only limited answers and often meet the nurse’s need rather than the patient’s. Of the options listed here, “Do you think you’re the only client on the unit right now?” best meets this definition. Telling the client that most people have little or no pain after a procedure is an example of stereotyping. Asking about why a client started using marijuana may be an example of probing. Questioning how the client is still in pain after medication administration is an example of challenging, or making clients prove their statements or point of view.
A nurse case manager spends the morning in a peer discussion and the afternoon in an ad hoc quality management committee meeting that is led by the hospital administrator. Which two types of groups has the nurse case manager participated in?
A) Camaraderie group and information group
B) Work group and administrative group
C) Primary group and secondary group
D) Support group and governance group
Answer: C
Explanation: A) Primary groups are typically informal groups that communicate regularly in face-to-face interactions. The case manager’s peer group would be considered a primary group. Secondary groups are larger, more impersonal, and goal-oriented. The quality management committee would be classified as a secondary group. All of the other options–camaraderie, information, work, administrative, support, and governance–are functions of groups, not group types.
Which of the following terms encompasses the way a group functions, communicates, sets goals, and achieves objectives? A) Cohesiveness B) Group dynamics C) Commitment D) Member behavior
Answer: B
Explanation: A) Group dynamics, or group processes, are related to how a group functions, communicates, sets goals, and achieves objectives. Cohesiveness, commitment, and member behavior are all aspects of group dynamics.
Answer: B
Explanation: A) Group dynamics, or group processes, are related to how a group functions, communicates, sets goals, and achieves objectives. Cohesiveness, commitment, and member behavior are all aspects of group dynamics.
Answer: B
Explanation: A) Group dynamics, or group processes, are related to how a group functions, communicates, sets goals, and achieves objectives. Cohesiveness, commitment, and member behavior are all aspects of group dynamics.
A nurse is developing objectives for a charter group of nurses from a national association. Which characteristics should the nurse expect to encounter when working with this semiformal group?
A) The group has a formal structure, with voluntary, selective membership and structured activities during meeting times.
B) The group has a formal structure, with structured activities, leadership selection from above, and easily recognized basic objectives.
C) The group has an informal structure, with voluntary, selective membership and negotiable day-to-day operating standards.
D) The group has an informal structure, with superimposed rules and managers who are symbols of authority.
Answer: A
Explanation: A) There are three levels of group formality: formal, semiformal, and informal. Most groups move in and out of all three levels, but traditionally, a charter group of an association is a semiformal group with a formal structure, carefully delineated hierarchy, and selective, voluntary membership with attached prestige and status. Semiformal groups also have structured deliberate activities during meetings, objectives and goals that are not easily changed, negotiable day-to-day operating standards and methods, and a leader who has direct control over the choice of a successor
Answer: A
Explanation: A) There are three levels of group formality: formal, semiformal, and informal. Most groups move in and out of all three levels, but traditionally, a charter group of an association is a semiformal group with a formal structure, carefully delineated hierarchy, and selective, voluntary membership with attached prestige and status. Semiformal groups also have structured deliberate activities during meetings, objectives and goals that are not easily changed, negotiable day-to-day operating standards and methods, and a leader who has direct control over the choice of a successor
Answer: A, B, C
Explanation: A) Groups function most effectively when they listen to the ideas of all members, use group members’ expertise, and have a positive atmosphere. In an effective group, members feel satisfied with their participation and time is well used—that is, the discussion focuses on the major decisions to be made, and members feel committed to these decisions and responsible for their implementation.
A nurse is providing teaching for an inpatient support group meeting. Which group behavior indicates that the teaching was effective?
A) The group members appear relaxed and interested in the topic.
B) The group members are tentative in expressing their feelings.
C) The group avoids discussion about their signs and symptoms.
D) The group members appear self-conscious when asked questions about their condition.
Answer: A
Explanation: A) To be effective, a group must accomplish its goals, maintain cohesion, and develop/modify its structure to improve effectiveness. The features of an effective group include an informal, comfortable, and relaxed atmosphere; goals, tasks, and objectives that are clear and understood; leader and member participation; an emphasis on goals; open, two-way communication; appropriate decision-making procedures; cohesion; conflict tolerance; and shared power
Four groups of nurses are attempting to determine which methods are most effective for teaching patients about proper self-care. Which of these groups is least likely to arrive at a successful decision in a timely manner?
A) The group that launches a pilot project to determine which teaching methods are most effective
B) The group that uses scenario planning to evaluate the potential results of various teaching methods
C) The group that uses trial and error to gauge the effectiveness of various teaching methods
D) The group that uses a decision tree to visualize the potential results of various teaching methods
Answer: C
Explanation: A) Trial-and-error techniques are the most haphazard method for decision making. Managers and groups who use these techniques are typically seen as poor problem solvers, especially in a healthcare context. Use of pilot projects, scenario planning, or decision trees is more likely to result in successful decision making because these methods all involve proposal and analysis of various alternatives prior to taking action.
Which of the following situations is an example of countertransference in the group setting?
A) After failing at an assigned task, the members of a group place all blame for this failure on a single group member.
B) A group member reveres the group’s leader, largely because the leader possesses many similarities to the member’s mother, whom he adores.
C) The members of a group become so caught up in the group’s current beliefs and actions that they fail to recognize simple changes that would greatly improve the group’s efficiency.
D) The leader of a group distrusts one of the group members solely because the member reminds him of his ex-wife.
Answer: D
Explanation: A) Countertransference occurs when leaders respond to group members because of reactions from earlier relationships. The leader who distrusts the group member because of similarities to his ex-wife is exhibiting countertransference. The scenario in which the members of a group place all blame on one person is an example of scapegoating. The scenario in which a group member reveres the leader because she reminds him of his mother is an example of transference. The scenario in which the group members become excessively caught up in group processes is an example of groupthink.
Which of the following statements is true with regard to monopolizing in the group setting?
A) Group members who engage in monopolizing behavior do so intentionally.
B) When one member of a group engages in monopolizing behavior, the other group members may become angry or frustrated with the group’s leader.
C) Monopolizing behavior may be motivated by anxiety or a need for attention, recognition, and approval.
D) One useful strategy for dealing with monopolizing is to simply and directly interrupt the individual who is engaging in this behavior.
Answer: B
Explanation: A) Monopolizing is the domination of a discussion by one member of a group. When this behavior occurs, a sense of resentment may develop within the group, and some members may direct their frustration and anger toward the group leader, whom they expect to do something to stop the monopolizer’s behavior. Monopolizing behavior may be motivated by anxiety or a need for attention, recognition, and approval, although many compulsive talkers are unaware of their behavior and its effect on others. One useful strategy for dealing with monopolizing is to interrupt the monopolizer simply, directly, and supportively
The nurse is caring for an older adult client in a long-term care facility. Which behavior by the nurse conveys physical attending when communicating with this client?
A) Facilitating and taking action when needed
B) Maintaining a proper social distance when speaking with the client
C) Leaning toward the client during conversation
D) Being concrete about actions that need to be taken during client care
Answer: C
Explanation: A) The nurse best conveys physical attending by leaning toward the client, which communicates involvement. Facilitating and taking action and maintaining social distance do not convey physical attending. Being concrete is a method of communicating information to the client, not a method of conveying physical attending
A nurse educator is teaching a group of students about therapeutic touch. In which situation is it appropriate to use therapeutic touch as a means of communication?
A) When a client’s family member is making inappropriate comments to the nurse
B) When an upset spouse is alone and the client has just expired
C) When speaking to a client with a history of physical abuse
D) When a young male client asks a young student nurse for a hug
A nurse educator is teaching a group of students about therapeutic touch. In which situation is it appropriate to use therapeutic touch as a means of communication?
A) When a client’s family member is making inappropriate comments to the nurse
B) When an upset spouse is alone and the client has just expired
C) When speaking to a client with a history of physical abuse
D) When a young male client asks a young student nurse for a hug
The nurse completes a teaching session on wound care for a client who will require dressing changes after discharge. The nurse then evaluates the effectiveness of the teaching session and determines that more education is required. Which statement by the nurse is appropriate in this situation?
A) “Let me clarify again some of the steps that are required during wound care.”
B) “You didn’t pay attention, did you?”
C) “Here, let me do it for you.”
D) “I don’t think you understood me correctly the first time.”
Answer: A
Explanation: A) Responding with some clarifications indicates that the client understood some of the teaching and preserves the client’s dignity and trust in the nurse. Saying that the client did not understand the information is belittling. Beginning a negative phrase with “you” is assigning blame, which impedes the therapeutic relationship. Telling the client that the nurse can take care of the task defeats the goal of feedback; the nurse would want to instill self-confidence in the client, and this type of action will hurt that goal.
A nurse is caring for a client with cancer who is struggling with chronic pain. The nurse tells the client, "It is normal to feel frustrated about the discomfort." Which skill associated with the working phase of the nurse-client relationship does the nurse's statement best reflect? A) Confronting B) Respect C) Concreteness D) Genuineness
Answer: B
Explanation: A) Respect is correct because the nurse is validating the client’s feelings. This situation is not an example of genuineness because the nurse is giving information versus making a personal statement. Rather than being confrontational by pointing out discrepancies between thoughts, feelings, and actions that inhibit the client’s self-understanding or exploration of specific areas, the nurse is being supportive by respecting the client’s feelings. Concreteness involves assisting the client by giving specific examples rather than speaking in generalities.
A novice nurse is working with a client who is admitted to a medical-surgical unit. The nurse is establishing a therapeutic relationship with the client by conveying empathy. Which statement by the nurse best exemplifies empathy?
A) “I wouldn’t be afraid if I were you.”
B) “You shouldn’t have done it that way.”
C) “You seem to be frightened by the procedure. Tell me how you are feeling.”
D) “I know just how you feel, because my mother has the same illness.”
Answer: C
Explanation: A) To be able to empathize with patients, the nurse must be able to understand and acknowledge the ideas that the patient is expressing or that the patient feels are important to the situation. By stating that the client seems frightened and asking the client to describe his or her feelings, the nurse is demonstrating empathy. The nurse should not say he or she knows how the client feels; such a statement will likely be met with disbelief, because one individual never knows how another individual is feeling unless that individual tells them. Telling the client not to be afraid is demeaning; instead, the nurse should ascertain the source of the client’s fear and provide appropriate teaching. Saying the client should not have done something is passing judgment and inappropriate.
) The nurse is caring for a school-age client who is scheduled to have major heart surgery the next morning. The nurse enters the room to administer a medication and finds the client crying. Which response by the nurse is most therapeutic?
A) “Would you like some toys from the playroom?”
B) “I’m going to go get the doctor.”
C) “You shouldn’t cry. You are not in pain.”
D) “It is okay to cry. I know this is scary.”
Answer: D
Explanation: A) Assertive communication is appropriate in the group setting, but for this client, the nurse should be accepting of the client’s feelings of fear. Telling the client not to cry invalidates the client’s feelings. Leaving to get the doctor could be seen by the child as abandonment and would signal that the nurse is uncomfortable with the child. Distraction is not appropriate when the client is clearly upset, so the nurse should not ask whether the client wants toys. Instead, the nurse should attempt to seek more information about what the child is feeling.
) The nurse is providing care for a client who is newly diagnosed with chronic obstructive pulmonary disease (COPD). In this scenario, which action by the nurse would be considered an example of therapeutic communication?
A) The nurse asks appropriate questions about the client’s medical history.
B) The nurse closes the conversation with an anecdote about breathing.
C) The nurse plans to tell the client about a COPD support group.
D) The nurse bonds with the client by describing her own experiences living with COPD.
Answer: A
Explanation: A) Attentive or “mindful” listening is a therapeutic communication technique that involves listening and absorbing the content and feeling of what an individual is conveying, without selectivity. This technique requires paying attention to the client’s total message, both verbal and nonverbal, and noting whether these communications are congruent. During attentive listening, the nurse focuses not on the nurse’s own needs but rather on the client’s needs. By asking appropriate questions about the client’s medical history and carefully noting the client’s responses, the nurse is engaging in attentive listening and thus in therapeutic communication
The nurse is providing care to a client who is newly diagnosed with human immunodeficiency virus (HIV). Which statements by the nurse could inhibit the development of therapeutic communication with this client? Select all that apply.
A) “I am so happy today! I just found out that I got accepted into nurse practitioner school!”
B) “Well, I guess your lifestyle finally caught up to you.”
C) “One of my cousins has AIDS. It is hard to watch him die.”
D) “Tell me your feelings about the diagnosis.”
E) “Would you like to talk about the new medications you’ve been prescribed?”
Answer: A, B, C
Explanation: A) Various obstacles to attentive listening can inhibit the development of therapeutic communication. Being concerned with oneself, assuming, and identifying are all common obstacles to attentive listening. In contrast, using open-ended questions and providing general leads-in are actions that enhance therapeutic communication
The nurse is providing care to a client who is diagnosed with hypertension. Which response by the nurse is an appropriate example of informational confrontation with the client?
A) “I noticed you rubbing your head and your eyes. Are you hurting? Let’s take your blood pressure.”
B) “I heard raised voices when I was coming down the hall to your room. Are you upset?”
C) “It is 3 p.m. and time to take your blood pressure before I give you your medication.”
D) “Is the blood pressure medication making your head hurt?”
Answer: A
Explanation: A) An informational confrontation describes the visible behavior of another individual, whereas an interpretive confirmation expresses thoughts and feelings about behavior and draws inferences. Of the options provided, only the one that begins with “I noticed you rubbing your head and your eyes” is an example of an informational confrontation
What is the first phase in the therapeutic nurse-client relationship? A) Introductory phase B) Working phase C) Preinteraction phase D) Anticipatory phase
Answer: C
Explanation: A) The therapeutic nurse-client relationship can be described in terms of four sequential phases: the preinteraction phase, introductory phase, working (maintaining) phase, and termination phase. During the preinteraction phase, the nurse plans for the initial face-to-face meeting with the client.
Which of the following statements by the nurse is an example of the therapeutic communication technique of offering self?
A) “Would you like to talk with me about your emotions right now?”
B) “I’m not sure I understand. Please tell me more about the situation.”
C) “I don’t know the answer to your question, but I will check with the physician.”
D) “I’ll stay here with you until your family arrives.”
Answer: D
Explanation: A) Offering self involves suggesting one’s presence, interest, or wish to understand the client without making any demands or attaching conditions that the client must comply with to receive the nurse’s attention. The nurse’s offer to stay with the client until the family arrives is an example of offering self. In comparison, asking whether the client wants to talk about his or her emotions is an example of providing general leads; asking the client to provide more details about a situation is an example of using open-ended questions; and offering to get answers from the physician is an example of giving information.
A nurse has just been hired as a medical information system (MIS) trainer at a hospital where an electronic medical record system is being installed. The nurse has been asked to assess the security of clients’ medical records. According to HIPAA’s Security Rule, which recommendations by the nurse will enhance security? Select all that apply.
A) Assign each staff member a unique username and password.
B) Install a firewall.
C) Store computer-generated worksheets in a locked vault.
D) Turn monitors away from view when unattended.
E) Assign each unit unique passwords.
Answer: A, B
Explanation: A) To comply with HIPAA’s Security Rule, institutions should assign individual passwords to each staff member for logging on and off computer files. Firewalls should be installed to enhance the security of client records. Client information should not be displayed on unattended terminals, regardless of which direction the monitor faces, and computer-generated worksheets should be shredded when no longer needed.
The nurse is conducting a health history on a client who is being admitted to a medical-surgical unit for the treatment of chronic pain. The client is concerned about privacy and asks why it is necessary for the nurse to ask for private information and then document it in the medical record. Which response by the nurse is most appropriate?
A) “You will be able to read the record and review your care.”
B) “Documentation decreases the likelihood that you will have to repeat this information to others who will care for you.”
C) “Your family can review the record and ensure that your care is appropriate.”
D) “A record ensures there are no breaches of confidentiality.”
Answer: B
Explanation: A) A client’s record serves as a vehicle by which different health professionals who interact with the client communicate with one another. This prevents fragmentation, repetition, and delays in client care, and it relieves the client from having to repeat information to each provider offering care. The client can read the record, but that is not a reason to keep one. The client’s family does not have access to the record. Recordkeeping does not prevent breaches of confidentiality.
The nurse is caring for a client who received analgesic medication via central line to treat pain associated with cancer. After reassessing the client's response, which section of the PIE record will the nurse use when documenting the client's care? A) Evaluation B) Progress notes C) Problem D) Intervention
Answer: A
Explanation: A) The PIE documentation model groups information into three categories: problems (P), interventions (I), and evaluation (E) of nursing care. Reassessing the client’s pain level after medication administration is considered evaluation and would be documented under “E.” Interventions such as medication administration would labeled “I,” whereas the problem statement would be labeled “P.” Progress notes are not part of the identified labels of PIE charting.
Use of flow sheets would be most appropriate during which phase of the nursing process? A) Evaluation B) Diagnosis C) Implementation D) Planning
Answer: C
Explanation: A) Flow sheets use specific assessment criteria in a particular format. They are frequently used on a client’s chart to record routine nursing tasks and assessment data. Examples of flow sheets include a graphic record, fluid balance record, daily nursing assessments record, patient teaching record, patient discharge record, and skin assessment record. Typically, flow sheets are used during the assessment and implementation portions of the nursing process.
A nurse manager is educating staff nurses about the types and frequency of documentation required for clients being cared for in long-term care facilities. These requirements originate from which of the following laws and regulatory bodies? Select all that apply.
A) Problem-Oriented Medical Record (POMR) Act
B) Omnibus Budget Reconciliation Act (OBRA)
C) Health Care Financing Administration (HCFA)
D) Minimum Data Set (MDS) Act
E) American Recovery and Reinvestment Act (ARRA)
Answer: B, C, E
Explanation: A) Long-term care facilities must comply with documentation requirements set forth in the Omnibus Budget Reconciliation Act (OBRA) of 1987 and the American Recovery and Reinvestment Act (ARRA) of 2009, as well as with regulations established by the Health Care Financing Administration (HCFA). The POMR is a system of medical recordkeeping, not a law or regulatory body. The Minimum Data Set (MDS) is an effort to establish standards for collecting standardized, essential nursing data for inclusion in computer databases. Although established under OBRA, the MDS is not a specific law or regulatory body.
)The nurse is documenting care in a client's medical record. The nurse provides narrative documentation only for abnormal assessment findings. Based on this information, which type of charting is the nurse using? A) Computerized documentation B) Charting by exception (CBE) C) SOAP charting D) Focus charting
Answer: B
Explanation: A) 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. 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. Focus charting is organized into data, action, and response sections, referred to as DAR. SOAP charting is a way to organize data and information in the client’s record: S indicates subjective data, O indicates objective data, A indicates assessment, and P indicates plan of care.
The healthcare provider prescribes digoxin for a client who will be discharged in the morning. When documenting the order in the medical record, which action by the nurse is most appropriate?
A) Entering “digoxin, .0125 mg QD”
B) Entering “digoxin, 0.0125 mg QD PO”
C) Entering “digoxin, 0.0125 mg, once daily by mouth”
D) Entering “digoxin, 1 pill each day”
Answer: C
Explanation: A) Although many healthcare facilities supply an approved list of abbreviations and symbols, the nurse can best prevent confusion by writing out the order in full. This means the nurse should place a zero before the decimal when recording the dosage. The nurse should also write out “once daily” instead of using the abbreviation “QD,” which may be interpreted incorrectly. Similarly, writing “by mouth” is preferable to using the abbreviation “PO.” Simply recording “1 pill each day” is not appropriate because it does not specify a dosage amount.
The nurse educator is teaching a group of nursing students about the purposes of documentation and medical records. Which of the following purposes is not appropriate for the educator to include in the teaching session with the students? A) Communication B) Planning C) Employee discipline D) Research
Answer: C
Explanation: A) Client records are kept for a number of purposes. These include communication among healthcare professionals who are treating the same client, planning client care to evaluate care plan effectiveness, tracking services provided for reimbursement purposes, research to help all clients, education for students in health disciplines, healthcare analysis to determine agency needs, and quality assurance purposes. Although recordkeeping provides necessary legal evidence of the care provided and can thus be referenced during the employee discipline process, employee discipline is not a primary purpose of the medical record.
) Traditional client records employ which of the following documentation systems? A) Source-oriented record B) Problem-oriented medical record C) PIE model D) Focus charting
Answer: A
Explanation: A) The traditional client record is a source-oriented record, in which each individual or department makes notations in a separate section or sections of the client’s chart. In many healthcare environments, this traditional system has been replaced by newer methods of documentation, such as the problem-oriented medical record (POMR), the PIE model, and focus charting.
The nurse is assigned to provide care to a client with chronic obstructive pulmonary disease (COPD). Overnight, the client's oxygen saturation levels decreased and the client has been placed on oxygen by the respiratory therapist. To review specific information about the care received from the respiratory therapist, which portion of the medical record should the nurse review? A) The consultation report B) The nurses' notes C) The medication record D) The diagnostic report
The nurse is assigned to provide care to a client with chronic obstructive pulmonary disease (COPD). Overnight, the client's oxygen saturation levels decreased and the client has been placed on oxygen by the respiratory therapist. To review specific information about the care received from the respiratory therapist, which portion of the medical record should the nurse review? A) The consultation report B) The nurses' notes C) The medication record D) The diagnostic report
A novice nurse asks the preceptor why the staff spends time talking about clients between shifts when the oncoming nurses can read the clients’ charts instead. Which is the best response by the preceptor?
A) “Maybe we should suggest primary nursing as an alternative.”
B) “Change-of-shift reporting ensures that oncoming staff know the most critical information about the clients they’ll be caring for.”
C) “Shift changes have always been done this way.”
D) “You’re right. Talking about clients during shift changes is a waste of time.”
Answer: B
Explanation: A) Nurses often do not have time to read clients’ charts prior to assuming care, which could result in errors and assumptions. By participating in change-of-shift reports, outgoing nurses can ensure that oncoming staff are aware of critical information. The preceptor should not tell the new nurse that change-of-shift reports are a waste of time because these reports allow for communication of valuable client data. Stating that shift changes have always been done a certain way does not help the novice nurse understand why a change-of-shift report is necessary. Primary nursing promotes continuity of care, but even the primary nurse would need to be informed of client changes that occurred during his or her absence.
The nurse is caring for a client who is reporting a pain level of 8 on a 0-to-10 numeric pain scale. The nurse administers the prescribed pain medication. When the nurse re-evaluates the client 1 hour later, the client is still reporting a pain level of 8. Which action by the nurse is appropriate at this time?
A) Wait for the healthcare provider to make rounds to report the problem.
B) Report to the healthcare provider by telephone.
C) Increase the dosage of the medication.
D) Include an entry in the nursing report indicating that the medication is ineffective.
Answer: B
Explanation: A) In this case, reporting to the healthcare provider by telephone is appropriate. The nurse would address the client’s distress immediately and later include the event in the end-of-shift report to the oncoming nurse. The nurse cannot alter the dose of medication. Waiting for the provider to arrive could cause the client to experience a great deal of pain in the interim.
A new nurse on a unit asks to speak to the nurse manager because several clients have complained that family members were able to hear the verbal report outside their loved one’s room during nursing rounds. The nurse manager asks the nurse for suggestions that could enhance client privacy. Which suggestion by the new nurse is appropriate?
A) Nursing rounds should take place in each client’s room.
B) The unit should be closed to family and visitors during rounds.
C) Nurses should tape-record their reports outside the room.
D) Clients should be allowed to choose whether a written or oral report is used.
Answer: B
Explanation: A) Closing the unit during nursing rounds permits nurses to talk freely and relate important information regarding clients and their care while minimizing the risk of violating client privacy. Rounds could take place in each client’s room, but if a client’s family is present, confidentiality is compromised. The nursing staff and manager should determine what form of report is used, keeping in mind the confidentiality of the client. Taped reports are acceptable if conducted in private but not appropriate if conducted out on the unit.
) The nurse is preparing to document care provided to a client during the day shift. The nurse notes that the client experienced an increased pain level while ambulating and thus required an extra dose of pain medication; took a shower; visited with family; and ate a small lunch. Which information is important to include during the oral end-of-shift reporting? Select all that apply. A) The extra dose of pain medication B) The client's visit with family C) The client's response to ambulation D) The last antibiotics given E) The client's taking a shower
Answer: A, C
Explanation: A) To best provide for the client’s safety, the nurse should pass on information about the client’s response to ambulation so that the oncoming staff can take fall precautions. The nurse should also report any as-needed medications that were given and when they were last administered. The client’s visit with family need not be mentioned at change of shift but should be documented. Likewise, taking a shower does not need to be reported, only documented. Antibiotic administration would be reflected on the medication administration record (MAR).
Handoff communication, or the transfer of data during transitions in care, includes an opportunity to ask questions, clarify, and confirm the information being passed between sender and receiver. What is the main objective for ensuring effective communication during a client handoff?
A) To avoid lawsuits
B) To make sure all documentation is complete
C) To facilitate quality improvement
D) To ensure client safety
Answer: D
Explanation: A) Ineffective communication is the primary cause of sentinel events, making client safety the primary objective of the handoff communication process. Handoff communication may be scrutinized during a lawsuit, but avoiding litigation is not a primary objective. Similarly, engaging in handoff communication can help a nurse determine whether all documentation related to a particular client’s care is complete, but this is not a primary objective. Finally, analysis of handoff communication may be a quality improvement criterion, but it is not a primary objective.
The nurse on third shift is handing off clients to the nurse on first shift. Which of the following statements is most important for the third shift nurse to report during this handoff?
A) “The client in room 312 is complaining about a headache unrelieved by pain medication. I am awaiting a call from the physician for orders.”
B) “The client in room 313 ate a full meal several hours ago and is currently sleeping peacefully.”
C) “The client in room 315 received an enema at 2100.”
D) “The client in room 311 was transferred from room 212.”
The nurse on third shift is handing off clients to the nurse on first shift. Which of the following statements is most important for the third shift nurse to report during this handoff?
A) “The client in room 312 is complaining about a headache unrelieved by pain medication. I am awaiting a call from the physician for orders.”
B) “The client in room 313 ate a full meal several hours ago and is currently sleeping peacefully.”
C) “The client in room 315 received an enema at 2100.”
D) “The client in room 311 was transferred from room 212.”
) When the nurse receives a telephone order from the healthcare provider’s office, which guidelines should the nurse use to ensure the order is correct? Select all that apply.
A) Ask the provider to repeat or spell out medication.
B) Read the order back to the provider.
C) Ask the provider to speak slowly.
D) Know agency policy for telephone orders.
E) Sign the provider’s name and credentials.
Answer: A, B, C, D
Explanation: A) When receiving a telephone order from a provider, the nurse should ask the provider to repeat or spell out any medications and speak slowly. The nurse should also read the order back to the provider once the order is complete. In addition, the nurse should know the agency’s policy regarding telephone orders. The nurse should not sign the provider’s name and credentials; the nurse only transcribed the prescription, so the provider will need to countersign it within a time period prescribed by organizational policy.
The nurse is providing care to a client diagnosed with end-stage renal disease. When organizing a care plan conference for this client, whom should the nurse invite to participate? A) The client's family members B) A psychiatrist C) An oncologist D) The hospital CEO
Answer: A
Explanation: A) Care plan conferences allow for collaborative reporting among the healthcare professionals who provide care to a client. They are most often used for clients who have complex care needs. During the conference, the client’s healthcare providers discuss possible solutions to client problems. The choice of healthcare professionals who are invited to attend the conference is based on the needs of the client; given this client’s diagnosis, it is unlikely that an oncologist or psychiatrist would be part of the healthcare team. However, family members are an important part of the care plan conference, especially for clients who are unable to advocate for themselves.
What are the four steps of the SBAR communication technique?
A) Scenario, Basics, Analysis, and Reaction
B) Situation, Background, Assessment, and Recommendation
C) Scenario, Background, Analysis, and Recommendation
D) Situation, Basics, Assessment, and Reaction
Answer: B
Explanation: A) The SBAR technique provides a framework for safe, efficient communication between members of the healthcare team. In the first or “Situation” step, the nurse provides a concise statement of the problem. In the second or “Background” step, the nurse relates information relevant to the situation. In the third or “Assessment” step, the nurse provides an analysis and consideration of options. Finally, in the fourth or “Recommendation” step, the nurse provides a recommendation based on the relevant evidence.
The nurse is caring for a client in the intensive care unit (ICU) who was in a motor vehicle crash. The healthcare provider asks the nurse to extubate the client because there is no communication between the brain and body due to a cervical fracture. The family agrees with the decision of the healthcare provider, but the nurse is uncomfortable pulling the tube. Which is the reason the nurse is experiencing difficulty with this task? A) An ethical conflict B) Personal values C) Legal issues D) Cultural values
Answer: B
Explanation: A) The nurse is distressed because of personal values, which are in conflict with causing the client’s death. The decision is within ethical principles. Cultural values are not in evidence in this instance. Extubating this client would not be a legal decision.
A nurse is caring for an older adult client with terminal cancer. The client's family wants to continue treatment, but the client would like to discontinue treatment and go home. The nurse agrees to be present while the client tells the family. Which principle is the nurse supporting? A) Beneficence for the client B) Autonomy for the client C) Nonmaleficence for the client D) Justice for the client
Answer: B
Explanation: A) Autonomy refers to the right to make one’s own decisions. The nurse is supporting this principle by supporting the client in his decision. Nonmaleficence is the duty to “do no harm.” Justice is often referred to as fairness. Beneficence means “doing good.”
Which statement accurately describes the purpose of the American Nurse’s Association’s Code of Ethics for Nurses?
A) It serves as a statement of nurses’ personal values and standards.
B) It serves as the profession’s nonnegotiable ethical standard.
C) It serves as an announcement of nurses’ commitment to the profession.
D) It serves as a standard protocol for performing nursing procedures
Answer: B
Explanation: A) The ANA Code of Ethics for Nurses serves as a statement of nurses’ ethical obligations and duties (not their personal values and standards), as the profession’s nonnegotiable ethical standard, and as the nursing profession’s statement of commitment to society (not the nurse’s commitment to the profession). Nurses should refer to the ANA Code of Ethics for Nurses to direct how they perform their duties in daily practice, but it does not provide standard protocols for performing nursing procedures
A nurse is volunteering time in a local free clinic that provides care to the underinsured population. By volunteering time to work in the clinic, this nurse is demonstrating which professional value? A) Human dignity B) Social justice C) Integrity D) Autonomy
Answer: B
Explanation: A) Social justice is upholding fairness on a social scale. This value is demonstrated in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality healthcare. Human dignity is respect for the worth and uniqueness of individuals and populations. Autonomy is respecting the client’s right to make decisions about their healthcare. Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice.
A nurse educator is talking to a student about how to deal with an ethical dilemma in practice. Which does the nurse educator explain to the student as important regarding actions during an ethical dilemma?
A) Examining all conflicts in the situation
B) Investigating all aspects of the situation
C) Relying on nursing judgment
D) Making a decision based on the policy of the agency
Answer: B
Explanation: A) To avoid making a premature decision, the nurse plans to investigate all aspects of the dilemma before deciding. Overconfidence can lead to poor decision making. Reading the agency policy regarding the matter addresses only one aspect of the situation. Examining the conflicts surrounding the issue is only one aspect of the situation to consider
Answer: B
Explanation: A) To avoid making a premature decision, the nurse plans to investigate all aspects of the dilemma before deciding. Overconfidence can lead to poor decision making. Reading the agency policy regarding the matter addresses only one aspect of the situation. Examining the conflicts surrounding the issue is only one aspect of the situation to consider
The nurse is caring for a client on a medical-surgical unit. The client tells the nurse that the healthcare provider has refused to treat the client further if the client continues to be noncompliant with the healthcare provider’s recommendations. Which is the priority nursing action in this situation?
A) Take the issue to the hospital ethics committee.
B) Advise the client to sue the healthcare provider.
C) Have the client contact a consumer agency.
D) Notify the healthcare provider of the client’s complaints.
Answer: A
Explanation: A) Acting as a client advocate and protecting the client’s rights, the nurse should enlist the help of the hospital ethics committee. The nurse never advises a client to sue but assists the client to find help resolving the issue. A consumer agency is not appropriate because this is an ethical matter. The nurse should act on behalf of the client, and the best way to do that is by taking the issue to the hospital ethics committee, not to the healthcare provider
The nurse is caring for a 22-year-old client with Down syndrome. Because the client has an intellectual disability, he is under the legal care of his parents. The client needs medical treatment for aspiration pneumonia, but the parents are declining care because they have heard that aspiration pneumonia is often fatal in clients with chronic health conditions. In addition to ethics and advocacy, what other nursing concept must the nurse factor into care decisions made in this case? A) Informatics B) Development C) Mood and Affect D) Spirituality
Answer: B
Explanation: A) Down syndrome causes intellectual disability, so the client’s developmental stage needs to be taken into consideration when providing care, especially related to client teaching and advocating for the client whose rights appear to be in jeopardy. Informatics, mood and affect, and spirituality do not appear to play a role in this case.
The nurse administers morphine to a client after surgery to help manage pain even though morphine has a risk of creating dependence and addiction. What ethical principle does the nurse apply in this situation when planning care? A) Veracity B) Justice C) Autonomy D) Beneficence
Answer: D
Explanation: A) Beneficence requires that the actions one takes should promote good. This includes giving treatments that have some risks when the nurse and others involved in client care have determined that the benefits outweigh the risks. Autonomy is the right to self-determination. Justice means treating all clients fairly. Veracity is the principle of always telling the truth.
Every year, the nurse attends a nursing conference and takes several continuing education courses to help maintain licensure. Which section of the ICN Code of Ethics does this uphold? A) Nurses and people B) Nurses and practice C) Nurses and the profession D) Nurses and co-workers
Answer: B
Explanation: A) The nurses and practice section of the ICN Code of Ethics states that nurses carry the professional responsibility and accountability for nursing practice and for maintaining competence by continual learning. The other sections of the ICN Code of Ethics do not address continuing education for nurses.
Answer: B
Explanation: A) The nurses and practice section of the ICN Code of Ethics states that nurses carry the professional responsibility and accountability for nursing practice and for maintaining competence by continual learning. The other sections of the ICN Code of Ethics do not address continuing education for nurses.
Answer: B
Explanation: A) Religion and morals can at times be interrelated within healthcare. The client wants to maintain the baby until natural delivery occurs because having an abortion would be against her religion. The client is demonstrating her morals. The client may or may not be demonstrating sound judgment or a healthy decision. The nurse has no way of knowing if the client is in fear of retribution.
Which situation indicates a conflict in morality?
A) The nurse provides a terminally ill client a meal that includes foods that should be avoided but were requested.
B) The nurse provides the mother of a dying neonate a cup of coffee in the intensive care unit.
C) The nurse provides over-the-counter pain relievers to the daughter of a client because of a headache.
D) The nurse purchases the daily newspaper for a client who does not have any money but will when his wife comes to visit.
Answer: A
Explanation: A) Morality refers to issues that are either right or wrong. In the situations provided, the nurse who provides a terminally ill client a meal with food that he should avoid but requested would demonstrate a conflict with morality. The nurse is going against the “right” decision, which would be to not provide the client with the foods; however, the client is terminally ill and is requesting foods that he enjoys. The other situations would not involve the same question of morality
The family of a terminally ill client requests that the client not be informed of the diagnosis. Which moral principle does the request violate? A) Justice B) Veracity C) Beneficence D) Nonmaleficence
Answer: B
Explanation: A) Veracity is the duty to tell the truth. The family of a terminally ill client is requesting that the diagnosis be withheld from the client, which would violate the principle of veracity. Beneficence is the duty to “do good.” Nonmaleficence is the duty to do no harm. Justice refers to fairness.
Answer: B
Explanation: A) Veracity is the duty to tell the truth. The family of a terminally ill client is requesting that the diagnosis be withheld from the client, which would violate the principle of veracity. Beneficence is the duty to “do good.” Nonmaleficence is the duty to do no harm. Justice refers to fairness.
Answer: B
Explanation: A) The client’s decision is to have an abortion even though it is against her religion. The best thing for the nurse to do is to ask the client what she needs to support her decision. The nurse should not provide information about adoption because the client is not planning on carrying the child to term. The nurse should not suggest she talk with clergy because the client did not ask to do so. The nurse should not remind the client that abortion is killing because this would not support the client’s resolution of her moral dilemma.
A nursing instructor is discussing moral principles with a group of students. Which comment made by a student nurse indicates the need for further instruction?
A) “A client choosing not to have a needed blood transfusion is an example of autonomy.”
B) “An example of veracity would be if a client asks her nurse if she is going to die and the nurse feels obligated to explain to the client that she is dying.”
C) “If a client asks the nurse to please come right back, and the nurse tells the client he will be back in just a couple of minutes, then that would be an example of fidelity.”
D) “A home health nurse carefully planning his or her day to assure each client gets an adequate amount of time is an example of beneficence
Answer: D
Explanation: A) Justice is often referred to as fairness, which would be demonstrated by the nurse assuring that each client gets an adequate amount of time with the nurse. Beneficence refers to the fact that nurses are obligated to do good. Autonomy refers to the right to make one’s own decisions. Veracity refers to telling the truth. Fidelity means to be faithful to agreements and promises.
Answer: D
Explanation: A) Justice is often referred to as fairness, which would be demonstrated by the nurse assuring that each client gets an adequate amount of time with the nurse. Beneficence refers to the fact that nurses are obligated to do good. Autonomy refers to the right to make one’s own decisions. Veracity refers to telling the truth. Fidelity means to be faithful to agreements and promises.
Answer: A
Explanation: A) Social isolation led to the client’s current medical manifestations. The priority nursing diagnosis based on the data is Social Isolation. Noncompliance and Interrupted Family Processes are not supported by the scenario presented. Impaired Gas Exchange is not a psychosocial nursing diagnosis; it is a physiologic nursing diagnosis.
The nurse is caring for a client who has chosen to discontinue hemodialysis. The client’s family, however, is not supportive of the decision. The nurse who uses the theory of principles-based reasoning would make which statement regarding the current situation?
A) “The client understands the decision and the advanced stage of the disease. If the client quits treatment, the client will die.”
B) “I need to try to help the family understand the client’s decision so they can work through this situation together.”
C) “This client is of sound mind and is capable of making independent decisions regarding healthcare. It really is the client’s decision to make.”
D) “This client’s health is so deteriorated that the treatment is not saving the client’s life. It is prolonging the ultimate outcome, which is death.”
The nurse is caring for a client who has chosen to discontinue hemodialysis. The client’s family, however, is not supportive of the decision. The nurse who uses the theory of principles-based reasoning would make which statement regarding the current situation?
A) “The client understands the decision and the advanced stage of the disease. If the client quits treatment, the client will die.”
B) “I need to try to help the family understand the client’s decision so they can work through this situation together.”
C) “This client is of sound mind and is capable of making independent decisions regarding healthcare. It really is the client’s decision to make.”
D) “This client’s health is so deteriorated that the treatment is not saving the client’s life. It is prolonging the ultimate outcome, which is death.”
) The nurse on a committee to determine the funding that each part of the hospital receives would be most concerned with which moral theory? A) Consequence-based theory B) Principles-based theory C) Relationship-based theory D) Legal-based theory
Answer: A
Explanation: A) Consequence-based theories tend to view a moral act as one that brings about the most good and the least harm to the greatest number of people. This moral theory would be a driving force when allocating funding in a hospital. Principles-based theory determines morality based on an impartial, objective principle and is more concerned with the individual than the group. Relationship-based theories judge actions according to a perspective of caring and responsibility, which is less likely to be needed when determining funding. Legal-based theory is not a moral theory
A hospice nurse is working closely with a client who, on several occasions, has asked about guidance and support in ending life. The nurse recognizes which in regard to making ethical and moral decisions in this circumstance?
A) Euthanasia has legal implications along with moral and ethical ones.
B) Passive euthanasia is an easy decision to arrive at.
C) Active euthanasia is supported in the Code for Nurses.
D) Assisted suicide is illegal in all states.
Answer: A
Explanation: A) 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. Passive euthanasia involves the withdrawal of extraordinary means of life support and is never an easy decision. Active euthanasia and assisted suicide are in violation of the Code for Nurses, according to the position statement by the ANA (2013). Some states and countries have laws permitting assisted suicide for clients who are severely ill, are near death, and wish to commit suicide.
) The nurse is talking with a parent who decides to decline treatment for a 3-year-old client whose cancer has metastasized. There is a conflict between the parents and the rest of the family regarding the withdrawal of care from the child. Which should the nurse consider when determining the appropriate action for this client? A) The beliefs of the child B) The values of the parents C) The age of the child D) The values of the rest of the family
Answer: B
Explanation: A) When confronted with a conflict regarding care, one of the first actions by the nurse is to consider the values and beliefs of the parents who are making the decision. The age of the child is not a relevant factor in the decision making if the child is under 18 years. The child is too young to have values and beliefs. The nurse is respectful with the rest of the family but should consider the parents’ decision only.
A client comes to the clinic and is found to have a sexually transmitted infection (STI). The client states to the nurse, “Promise you won’t tell anyone about my condition.” According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which action must the nurse take?
A) Honor the client’s wishes.
B) Respect the client’s privacy and confidentiality.
C) Communicate only necessary information.
D) Not disclose any information to anyone.
A client comes to the clinic and is found to have a sexually transmitted infection (STI). The client states to the nurse, “Promise you won’t tell anyone about my condition.” According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which action must the nurse take?
A) Honor the client’s wishes.
B) Respect the client’s privacy and confidentiality.
C) Communicate only necessary information.
D) Not disclose any information to anyone.
When faced with ethical dilemmas, which are some of the elements of risk management that can assist nurses in decision making? Select all that apply. A) Education B) Peer support and consultation C) Resource accumulation D) Righteousness E) Financial support
Answer: A, B, C
Explanation: A) In addition to the ANA code of conduct in ethical situations, education and didactic training represent another source for developing primary risk-management skills. A practitioner’s professional network, consisting of peers, supervisors, and colleagues, can be a significant resource for primary prevention of ethical challenges. Resource accumulation involves acquiring the requisite resources and skills prior to the occurrence of a dilemma. Righteousness and financial support are not elements of risk management.
Answer: A, B, C
Explanation: A) In addition to the ANA code of conduct in ethical situations, education and didactic training represent another source for developing primary risk-management skills. A practitioner’s professional network, consisting of peers, supervisors, and colleagues, can be a significant resource for primary prevention of ethical challenges. Resource accumulation involves acquiring the requisite resources and skills prior to the occurrence of a dilemma. Righteousness and financial support are not elements of risk management.
Answer: A, B, D
Explanation: A) Strikers may be concerned about client care as it is related to adequate staffing. Strikes may adversely affect client care and outcomes. Nurses may feel allegiance to a hospital where they have worked for years. The desire to take time off and the need for higher pay are not ethical issues.
Answer: A, B, D
Explanation: A) Strikers may be concerned about client care as it is related to adequate staffing. Strikes may adversely affect client care and outcomes. Nurses may feel allegiance to a hospital where they have worked for years. The desire to take time off and the need for higher pay are not ethical issues.
Answer: C, D, E
Explanation: A) Refusing HIV testing is legal and is not mandatory for obtaining care. However, if the mother-to-be is HIV-positive, the test will help her protect her health and the health of her child by obtaining appropriate treatment. The nurse should emphasize the importance of HIV testing and encourage her to receive the test. Offering counseling would also be appropriate. Refusing to treat the client is against the ANA position statement on risk and responsibility in nursing. Doing the test anyway goes against the client’s right to autonomy.
Answer: C, D, E
Explanation: A) Refusing HIV testing is legal and is not mandatory for obtaining care. However, if the mother-to-be is HIV-positive, the test will help her protect her health and the health of her child by obtaining appropriate treatment. The nurse should emphasize the importance of HIV testing and encourage her to receive the test. Offering counseling would also be appropriate. Refusing to treat the client is against the ANA position statement on risk and responsibility in nursing. Doing the test anyway goes against the client’s right to autonomy.
Answer: A, C, D
Explanation: A) A nurse’s role as educator is crucial to ethical practice. Inaccurate reassurance or avoidance does not respect client rights. Providing appropriate alternatives and options for the client and the family are correct responses to the client’s concerns.
What are some reasons the nurse might withhold food and fluids from a client? Select all that apply.
A) A competent and informed client refuses them.
B) A son decides that it is his father’s time to die.
C) It is determined to be more harmful to administer them than to withhold them.
D) A schizophrenic client believes that they are being poisoned.
E) The nurse thinks that the client is in too much pain.
Answer: A, C
Explanation: A) The autonomy of a competent and informed client must be respected. Family members cannot overrule client choices. Forcing an individual with terminal illness to eat, or starting artificial nutrition, will often make the client feel bloated, feel nauseated, and/or develop diarrhea. Clients must be capable of making informed choices. The nurse’s opinion about the client’s pain status is not a justification for withholding nourishment.
A client with acquired immune deficiency syndrome (AIDS) is admitted to the acute care floor. According to a 2015 American Nurses Association (ANA) position statement, which stance addressing this bioethical issue is appropriate?
A) The nurse is morally obligated to care for the client unless the risk exceeds responsibility.
B) The nurse has the responsibility to ensure the client gets adequate medical care.
C) The client has the right to choose not to disclose his or her condition to staff.
D) The client is morally bound to disclose every aspect of his or her condition to staff.
A client with acquired immune deficiency syndrome (AIDS) is admitted to the acute care floor. According to a 2015 American Nurses Association (ANA) position statement, which stance addressing this bioethical issue is appropriate?
A) The nurse is morally obligated to care for the client unless the risk exceeds responsibility.
B) The nurse has the responsibility to ensure the client gets adequate medical care.
C) The client has the right to choose not to disclose his or her condition to staff.
D) The client is morally bound to disclose every aspect of his or her condition to staff.
An adolescent client diagnosed with leukemia decides to stop chemotherapy treatments. The parents of the client, however, want the healthcare team to continue all treatments as necessary. Which action by the nurse is appropriate when providing care to this client and family?
A) Helping the family by providing information and allowing them to voice concerns
B) Confronting the parents and telling them not to be “selfish” in their child’s time of need
C) Calling the authorities immediately
D) Obtaining a court order to determine the client legally able to make his or her own decisions
Answer: A
Explanation: A) Parents have the authority to make healthcare decisions for their children. Dilemmas arise when parents and children do not agree on whether or not to go forward with a recommended treatment. In most cases, the nurse and other members of the healthcare team who have developed a therapeutic alliance with the child and family may be able to help the family come to a joint decision by providing additional information and opportunity to discuss their concerns with each other calmly and openly. In some cases, however, the healthcare team may need to seek guidance from the agency’s ethics committee.
) What are some of the rights clients have when receiving care within a healthcare system? Select all that apply.
A) Clients have the right to be given information only in English.
B) Clients have the right to refuse care.
C) Clients have the right to know when something goes wrong with their care.
D) Clients have the right to care that is free from discrimination.
E) Clients have the right to know the titles, but not necessarily the names, of their caregivers.
Answer: B, C, D
Explanation: A) Clients have the right to get important information about their care in their preferred language. Clients may reject as well as accept care. Clients should be informed of problems with their care. Clients should be treated without discrimination. Clients have the right to know the names of the caregivers who treat them.
A nurse is providing hospice care for an older adult client. The nurse is approached by the client’s adult child. The adult child believes that her other parent, who is in a nursing home, is being neglected. What suggestions can the nurse offer in this situation? Select all that apply.
A) Contact the client advocate at the nursing facility.
B) Contact the local newspaper.
C) Encourage the daughter to immediately place her other parent in a different facility.
D) Contact the consumer protection agency.
E) Report suspicions to the licensing agency.
A nurse is providing hospice care for an older adult client. The nurse is approached by the client’s adult child. The adult child believes that her other parent, who is in a nursing home, is being neglected. What suggestions can the nurse offer in this situation? Select all that apply.
A) Contact the client advocate at the nursing facility.
B) Contact the local newspaper.
C) Encourage the daughter to immediately place her other parent in a different facility.
D) Contact the consumer protection agency.
E) Report suspicions to the licensing agency.
A nurse educator is explaining the idea of healthcare as a partnership between provider and client. Which are client responsibilities that some hospitals have included in their client bill of rights? Select all that apply.
A) Involving your family in your healthcare decisions
B) Reporting accurate and complete information about your health to your healthcare team
C) Answering questions asked by your healthcare team
D) Immediately paying all expenses not covered by insurance
E) Accepting the consequences if you fail to comply with instructions given to you
Answer: B, C, E
Explanation: A) It is not essential for clients to involve their family members in healthcare decisions. Clients have the responsibility to provide complete and accurate information about their symptoms, history, and status to their healthcare team. Accepting financial responsibility for treatment does not require immediate payment. Clients must understand that noncompliance with treatment recommendations may result in poor outcomes.
A client tells his nurse, “I really don’t like the nurse on first shift. I was treated badly.” Which action should the nurse take as an advocate for this client?
A) Call the agency client advocacy department.
B) Confront the nurse when she comes to work.
C) Tell the client he has the right to switch nurses.
D) Call the local authorities.
Answer: A
Explanation: A) Individual clients who feel their rights have been violated or are endangered have a number of options. Many hospitals and large provider agencies have client advocates who can help clients navigate the system and intervene to ensure that their rights are maintained. Many states have an office designated by the governor or secretary of health to assist clients with issues related to patient rights in long-term care. The state’s department of health may also be able to help.
The nurse performing an admission assessment on a client must inform the client of client rights and responsibilities. Which client rights are considered standard by many healthcare agencies? Select all that apply.
A) You have a right to be informed about the care you receive.
B) You have the right to safe care.
C) You have the right to be treated with courtesy and respect.
D) You have the right to be listened to.
E) You have the right to be appointed a personal advocate by the healthcare provider.
Answer: A, B, C, D
Explanation: A) The Joint Commission’s Speak Up program is dedicated to patient rights and begins as follows: You have the right to be informed about the care you will receive; get important information about your care in your preferred language; get information in a manner that meets your needs; make decisions about your care; refuse care; know the names of the caregivers who treat you; safe care; have your pain addressed; care that is free from discrimination; know when something goes wrong with your care; get a list of all your current medications; be listened to; be treated with courtesy and respect; have a personal representative of your choice, not to have one appointed to you by the healthcare provider.
Answer: A, B, C, D
Explanation: A) The Joint Commission’s Speak Up program is dedicated to patient rights and begins as follows: You have the right to be informed about the care you will receive; get important information about your care in your preferred language; get information in a manner that meets your needs; make decisions about your care; refuse care; know the names of the caregivers who treat you; safe care; have your pain addressed; care that is free from discrimination; know when something goes wrong with your care; get a list of all your current medications; be listened to; be treated with courtesy and respect; have a personal representative of your choice, not to have one appointed to you by the healthcare provider.
Answer: A
Explanation: A) Most hospitals now publish lists of client responsibilities, emphasizing that healthcare is a partnership between the client and caregivers, that other clients have a right to be comfortable too, and that there are consequences if clients don’t comply with treatment plans, cooperate with the healthcare team, or be considerate of the staff and other clients.
Answer: A
Explanation: A) Most hospitals now publish lists of client responsibilities, emphasizing that healthcare is a partnership between the client and caregivers, that other clients have a right to be comfortable too, and that there are consequences if clients don’t comply with treatment plans, cooperate with the healthcare team, or be considerate of the staff and other clients.
Answer: D
Explanation: A) Sometimes older adults forget and get confused. However, the nurse should notify the surgeon because the client has the right to informed consent. The client’s age is not the reason for the nurse taking action. The family does not make the decision regarding surgery unless the client has been declared incompetent by the court. The nurse would want to have the surgery explained for the client’s sake, not because the nurse signed the form.
A pregnant woman has been rushed to the operating room for an emergency cesarean section. The physician explained the procedure to the parents, and he asked the father to wait in the waiting room until the procedure is complete. The mother asked if the father could be in the room to see the baby delivered and to help make decisions about the baby’s care, but the physician explained that because of the emergency situation, that wouldn’t be allowed. In this situation, which client right was violated?
A) The right to know when something goes wrong with care.
B) The right to be treated with courtesy and respect.
C) The right to have a personal representative.
D) The right to be listened to.
A pregnant woman has been rushed to the operating room for an emergency cesarean section. The physician explained the procedure to the parents, and he asked the father to wait in the waiting room until the procedure is complete. The mother asked if the father could be in the room to see the baby delivered and to help make decisions about the baby’s care, but the physician explained that because of the emergency situation, that wouldn’t be allowed. In this situation, which client right was violated?
A) The right to know when something goes wrong with care.
B) The right to be treated with courtesy and respect.
C) The right to have a personal representative.
D) The right to be listened to.
A student nurse administers a medication to the wrong client while the instructor is with another student. Which statement by the instructor is most appropriate in this situation?
A) “You have placed the nursing student program in danger.”
B) “You may be sued by the hospital for the extra care cost to the client.”
C) “You are expected to practice like a licensed nurse.”
D) “You have set a bad example for the other students.”
Answer: C
Explanation: A) A nursing student is held to the standard of conduct of an experienced, licensed professional nurse. Students are required to know the standards and to follow them. Hospitals do not generally sue nurses to recover money for extended care due to an error. It is not likely that the teaching program is in danger, as people do make mistakes and hospitals do rely on nursing schools to help provide care to clients. It is not likely that the other students are apt to follow the example of a student who fails to follow policy.
The nurse is concerned about being sued for negligence when providing care. Which nursing actions may be grounds for negligence? Select all that apply.
A) Client fell getting out of bed because the call light was not used.
B) Client name band was checked prior to providing all medications.
C) Client’s morning medications were administered in the early afternoon.
D) Client states not understanding activity restrictions and wound eviscerated.
E) Client documentation did not include appearance of infiltrated IV site.
Answer: A, C, D, E
Explanation: A) Checking the client name band before providing medications is not an action that is negligent. However, providing medications beyond the prescribed time can be viewed as negligent care. One strategy to prevent instances of professional negligence is to ensure client safety. The client fell when getting out of bed because the call light was not used. Because there is no way of knowing if the client knew how to use the call light, the nurse should be concerned with this situation. Clear communication of directions, explanations, and providing effective client education regarding the client’s healthcare requirements can help decrease the risk of bad outcomes, so the wound evisceration could be viewed as negligent care. Poor documentation about care, wounds, and intravenous sites could be viewed as negligent care.
A nurse working on a medical-surgical unit wants to ensure care is provided within the standard of nursing care. Which actions by the nurse are appropriate? Select all that apply.
A) Analyze the position description.
B) Review and become familiar with the policy and procedure manual.
C) Question the value of collaborating with other disciplines.
D) Review applicable state nurse practice act and administrative rules.
E) Adhere to national standards of practice and care.
Answer: A, B, D, E
Explanation: A) Nurses are expected to demonstrate competence within multiple areas of their professional role, including collaboration with the entire care team. The nurse’s specific job description will contribute to defining the standard of care. Employers can limit but not expand the scope of practice, and the nurse will be held to functioning within the scope of employment. Agency policies and procedures serve in defining the standard of care. The applicable state nurse practice act and administrative rules form the basis of the standard of care to which each nurse is held. A primary source for defining the standard of care is the prevailing national nursing standards. Nurses who follow national standards of practice and standards of care will provide their clients with the best care possible and be far less likely to commit any unintentional act that may rise to the level of malpractice.
The nurse observes a healthcare provider discussing an operative procedure with a client and determines that informed consent was achieved. Which information was included in the informed consent process? Select all that apply.
A) The provider’s disapproval if the surgery is not performed
B) The health problem that requires surgery
C) The purpose of the surgery
D) The expectations of the surgery
E) Outcome if surgery is not performed
The nurse observes a healthcare provider discussing an operative procedure with a client and determines that informed consent was achieved. Which information was included in the informed consent process? Select all that apply.
A) The provider’s disapproval if the surgery is not performed
B) The health problem that requires surgery
C) The purpose of the surgery
D) The expectations of the surgery
E) Outcome if surgery is not performed
) A client is receiving care in the hospital for life-threatening injuries sustained in a motor vehicle crash and is taken immediately to surgery. There is no family available to provide consent; however, the client’s medical record is available and reviewed by the nurse. Which treatments are inappropriate in this situation? Select all that apply.
A) Emergency surgery
B) Treatment that was previously refused
C) Treatment that violates religious beliefs
D) Medications to treat the injury
E) Experimental medications for a research study
Answer: B, C, E
Explanation: A) In most states, the law assumes an individual’s consent to medical treatment when the person is in imminent danger of loss of life or limb and unable to give informed consent. In other words, the emergency doctrine assumes that the individual would reasonably consent to treatment if able to do so. This doctrine serves as a guiding principle that permits healthcare providers to perform potentially life-saving procedures under circumstances that make it impossible or impractical to obtain consent. Treatment that was previously refused or violates the client’s documented religious beliefs is not appropriate. Experimental medications that are being initiated in conjunction with a research study are also not appropriate
A 16-year-old client has requested that she be examined and receive counseling without her parents being present. Which response demonstrates a correct response to this request?
A) The nurse asks the client’s parents if this is okay with them.
B) The nurse agrees but still informs the parents immediately of everything they did not witness.
C) The nurse strongly urges the client to reconsider this request to receive the best possible care.
D) The nurse agrees that the client has the right to make this request but suggests that the parents still be present and involved.
Answer: D
Explanation: A) Adolescent clients may wish to be examined or receive counseling separate from their parents. The nurse should make every effort to honor this request, though doing so may lead to confrontation with the parents. Understanding state statutes and organizational policy related to adolescent confidentially is essential when situations such as this arise. When providing confidential care to adolescents, the nurse should encourage adolescents to consider involving parents or guardians in their decision making. The nurse should make it clear that this is a suggestion and not a requirement for receiving care. The nurse should not clear this request with the parents, involve the parents anyway, or make it sound as though competent care depends on the adolescent reconsidering her request.
Which action demonstrates correct reporting of suspected child abuse?
A) The nurse includes the entirety of the client’s medical record.
B) The nurse compiles a report with all pertinent information that is factually true.
C) The nurse recommends that the organization report the abuse to state authorities.
D) The nurse reports only information the client has authorized for release
Answer: B
Explanation: A) Reports should be complete and accurate and should be made according to the policy of the organization for which the nurse works. In addition to reporting the abuse within the organizational framework, the nurse should personally report the abuse to the proper authorities. When abuse is reported, all pertinent information in the client’s medical record (not simply the entire record) is required by law to be disclosed to the reporting agency. As such, reporting abuse or suspected abuse represents an exception to client confidentiality rules.
A client newly diagnosed with diabetes mellitus tells the nurse that the prescribed diet does not provide enough variation of choice. It is against the state’s nurse practice act for a nurse to order a diet for the client. Which response by the nurse is most appropriate?
A) “I will bring you a different menu.”
B) “I will ask my manager to talk with the dietitian.”
C) “Let’s look at your diet and see what type of variety we can find.”
D) “I will notify the dietary department to change your diet.”
Answer: C
Explanation: A) A nurse practice act (NPA) is a series of state statutes that define the scope of practice, standards for education programs, licensure requirements, and grounds for disciplinary actions. The law provides a framework for establishing nursing actions in the care of clients. It is against most states’ nurse practice acts for the nurse to order a diet for the client. The nurse is allowed to assist the client to choose appropriate foods as ordered by the physician. The nurse cannot notify the dietary department or enlist the assistance of a manager to change the diet with a healthcare provider prescription. Providing the client with another menu will not help the client choose foods within the prescribed diet.
) A nurse educator is teaching a group of nursing students about the function of the state board of nursing. Which information will the educator include in the teaching session? Select all that apply.
A) Creating the NCLEX-RN examination
B) Defining professional standards
C) Investigating violations of the nurse practice act
D) Suspending or revoking licenses
E) Finding drug treatment centers for impaired nurses
Answer: B, C, D
Explanation: A) Boards of nursing oversee nursing licensure by defining professional standards, investigating violations of the nurse practice act, sanctioning those who violate the nurse practice act, and suspending or revoking licenses. The National Council for the State Boards of Nursing creates the NCLEX-RN examinations. The state board of nursing is not responsible for finding treatment programs for drug-impaired nurses.
The nurse receives a notice that the state board of nursing has become a member of the Nurse Licensure Compact. How would this change in the state board of nursing structure influence the nurse’s ability to practice nursing? Select all that apply.
A) The nurse can only practice nursing in the residing state.
B) The nurse can practice nursing in other states within the compact.
C) The nurse is accountable to the state in which the nurse and clients reside.
D) The nursing license will become similar to having a driver’s license.
E) The nurse has to obtain an additional license.
Answer: B, C, D
Explanation: A) The mutual recognition model of nurse licensure allows a nurse to have a single license that confers the privilege to practice in other states that are part of the Nurse Licensure Compact. The nurse is held accountable for following the laws and rules of the state in which the nurse practices or where the client is located. It is similar to the driver’s license model: A single license to drive is issued in the state of primary residency, but this license also allows the privilege to drive in other compact states. Multistate licensure privilege means the authority to practice nursing in another state that has signed an interstate compact. It is not an additional license.
The nursing instructor asks a student to explain why the American Board of Managed Care Nursing (ABMCN) is an example of a certification program. How should the student respond?
A) It formally recognizes nurses who have achieved a high standard of practice in managed care.
B) It provides a process for recognizing the professional competence of individuals who pass the program.
C) It investigates and adjudicates cases of professional negligence.
D) It lists the state requirements for a nursing professional to achieve licensure.
The nursing instructor asks a student to explain why the American Board of Managed Care Nursing (ABMCN) is an example of a certification program. How should the student respond?
A) It formally recognizes nurses who have achieved a high standard of practice in managed care.
B) It provides a process for recognizing the professional competence of individuals who pass the program.
C) It investigates and adjudicates cases of professional negligence.
D) It lists the state requirements for a nursing professional to achieve licensure.
Which of the following is a licensure examination developed by the National Council of State Boards of Nursing (NCSBN) for state and territory boards of nursing (BONs) to implement as part of their requirements for licensure?
A) National Council Licensure Examination for Registered Nurses (NCLEX-RN)
B) National Nurse Aide Assessment Program (NNAAP)
C) Medication Aide Certification Examination (MACE)
D) Nursing Workforce Diversity (NWD) program
Answer: A
Explanation: A) The National Council of State Boards of Nursing (NCSBN) has developed two licensure examinations, the National Council Licensure Examination for Registered Nurses (NCLEX-RN) and the National Council Licensure Examination for Practical Nurses (NCLEX-PN), for state and territory BONs to implement as part of their requirements for licensure. The NCSBN also offers two additional examinations: the National Nurse Aide Assessment Program (NNAAP) and the Medication Aide Certification Examination (MACE). The Nursing Workforce Diversity (NWD) program is not a licensure examination.
Which statement exemplifies the ultimate accountability of nursing students for their actions?
A) “State regulatory bodies have the ultimate responsibility for my actions.”
B) “The client’s perception of the care I give determines the correctness of my actions.”
C) “I am responsible for my own actions, correct or incorrect.”
D) “No one may judge my actions as correct or incorrect other than me.”
Answer: C
Explanation: A) Each nurse practice act (NPA) addresses the duties and responsibilities of nursing students in that state. Typically, this includes language that allows nursing students the privilege to practice nursing without a license while engaged in the clinical practicum of an approved nursing education program under the supervision of qualified faculty. Nursing students have the ultimate responsibility (accountability for their actions that includes the obligation to answer for an act done and to repair any injury one may have caused) for their own actions. This responsibility does not rest ultimately with the state and does not depend solely on client perceptions. Responsibility does not mean that no one else but the nursing student may judge the student’s actions.
A client with terminal cancer has signed an advance directive indicating that no parenteral nutrition or hydration will be implemented. For several days the client has refused food and fluids, pushing 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.” Which actions by the nurse are appropriate? Select all that apply.
A) Take the case to the hospital’s ethics committee.
B) Honor the client’s refusal of parenteral nutrition and hydration.
C) Talk to the healthcare provider so the family’s wishes can be acted upon.
D) Help the family come to terms with the situation.
E) Honor the family’s wishes and have them sign a consent form.
Answer: B, D
Explanation: A) A nurse is morally obligated to honor the refusal of food and fluids by a competent client who has signed an advance directive. 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 healthcare and treatment. The physician may or may not be involved, but would not disregard the client’s refusal. An ethics committee is usually considered when there is an ethical dilemma, and more input is needed to make a decision.
Answer: B, D
Explanation: A) A nurse is morally obligated to honor the refusal of food and fluids by a competent client who has signed an advance directive. 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 healthcare and treatment. The physician may or may not be involved, but would not disregard the client’s refusal. An ethics committee is usually considered when there is an ethical dilemma, and more input is needed to make a decision.
Answer: D
Explanation: A) The nurse, recognizing that the client is no longer competent, should follow whatever hospital policy is in place for contacting the agent named in a durable power of attorney for healthcare. The physician is not the appropriate individual to make decisions for the client. Social services may be the department that would contact the agent of a durable power of attorney, but social services would not be that power. In the case of an incompetent client, the spouse would be the agent of the durable power of attorney only if the court appointed the spouse.
After discussing advance directives during a home visit, an older adult client decides to prepare documents for future care needs. Which actions by the nurse are appropriate in this situation? Select all that apply.
A) Telling the client that changes to the advance directive can be made at any time
B) Telling the client that it is not necessary to make decisions about healthcare needs in the future
C) Giving a copy of the advance directives to the client’s adult children
D) Educating the client about the purpose and types of life-sustaining measures
E) Having the client name an individual to be responsible for care decisions
Answer: A, C, D
Explanation: A) The nurse should explain that if a decision is made on an advance directive, the decision can be changed. Clients should be instructed to provide a copy of their advance directives to their next of kin. The nurse needs to assess whether the client has an accurate understanding of life-sustaining measures and provide teaching on these measures if necessary. An advance directive does not mean that the client does not need to make any future decisions about healthcare. An individual to be responsible for care decisions is a durable power of attorney for healthcare and may or may not be included when creating an advance directive.
A nurse educator on an oncology unit is teaching staff nurses about advance directives. Which elements will the nurse include in the teaching session? Select all that apply.
A) The surrogate decision maker has the authority to consent to any medical treatment or diagnostic procedure.
B) The surrogate decision maker has the authority to consent to only lifesaving medical treatments.
C) The surrogate decision maker has the authority to authorize admission only to medical facilities and not long-term care facilities.
D) The surrogate decision maker has the authority to have access to all medical records.
E) The surrogate decision maker has the authority to refuse any medical treatment or diagnostic procedure.
A nurse educator on an oncology unit is teaching staff nurses about advance directives. Which elements will the nurse include in the teaching session? Select all that apply.
A) The surrogate decision maker has the authority to consent to any medical treatment or diagnostic procedure.
B) The surrogate decision maker has the authority to consent to only lifesaving medical treatments.
C) The surrogate decision maker has the authority to authorize admission only to medical facilities and not long-term care facilities.
D) The surrogate decision maker has the authority to have access to all medical records.
E) The surrogate decision maker has the authority to refuse any medical treatment or diagnostic procedure.
The nurse on the medical unit is admitting a client. When the nurse asks the client about advance directives, the client states, “I have a living will.” Which is the purpose of a living will?
A) Provides specific instructions about type of medications the client requires to sustain life
B) Provides specific instructions about what medical treatment the client does not want in the event they can no longer make decisions for themselves
C) Provides specific instructions about who will make healthcare decisions if the client cannot
D) Provides specific instructions about how decisions are to be made if the client is unable to make the decisions
Answer: B
Explanation: A) There are two types of advanced directives, the living will and the durable power of attorney for healthcare. The living will provides specific instructions about what medical treatment the client chooses to omit or refuse. The durable power of attorney for healthcare identifies who will be making healthcare decisions if the client cannot. Living wills do not dictate medication requirements or how decisions are to be made if the client cannot make them.
The nurse working on a medical unit is admitting a client diagnosed with heart failure. During the admission process, the client states, “I do not want to be put on a ventilator because I had to watch my mother die on a ventilator. I want information on making out a living will.” When planning care for this client, which intervention is the most appropriate?
A) Educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so.
B) Encourage the client to allow for mechanical ventilation.
C) Educate the client on the purpose of mechanical ventilation.
D) Refer the client to a therapist to deal with the death of her mother.
Answer: A
Explanation: A) Although it is appropriate to educate the client on mechanical ventilation, the client asked for information on making out a living will. It would be most appropriate at this time for the nurse to educate the client on the process and purpose of a living will and arrange for one to be created should the client choose to do so. The nurse should not attempt to convince the client to allow for medical treatment. The nurse may educate the client on a medical treatment, but that does not address the client’s desire for a living will. There is no indication that this client needs therapy.
A client on a medical-surgical unit experiences a code blue situation unexpectedly. The emergency situation has ended and the client survived. The nurses are breaking for lunch and plan to process their feelings about the emergency. Which action by the nurses will facilitate this?
A) Discussing the event outside the hospital
B) Asking management for the use of a private room to debrief
C) Talking while riding in the staff elevator
D) Debriefing about the situation at home
Answer: B
Explanation: A) To comply with HIPAA, nurses cannot discuss events involving clients in any setting where the conversation can be heard by others, so a private room would be the best place to debrief. The nurses must also guard against other health professionals not directly involved with the client overhearing their discussion; consequently, a staff elevator is not acceptable. Discussing the event outside the hospital is inappropriate because anyone could overhear the conversation. This would also preclude nurses from discussing client care in the home.
Answer: B
Explanation: A) To comply with HIPAA, nurses cannot discuss events involving clients in any setting where the conversation can be heard by others, so a private room would be the best place to debrief. The nurses must also guard against other health professionals not directly involved with the client overhearing their discussion; consequently, a staff elevator is not acceptable. Discussing the event outside the hospital is inappropriate because anyone could overhear the conversation. This would also preclude nurses from discussing client care in the home.
Answer: C
Explanation: A) The Privacy Rule protects all “individually identifiable health information” held or transmitted in any form or media, whether electronic, paper, or oral. The rule calls this information protected health information and delineates it further to include information that identifies the individual (e.g., name, address, birth date, and Social Security number) or for which a reasonable basis exists to believe the information can be used to identify the individual. Information in a computer data system may not always be safe, and it would be inappropriate for the nurse to say this. Nurses need to be involved with the design, implementation, and evaluation of electronic medical records to maximize their use and effectiveness, but this does not ensure security. Reminding the client that there is indeed cause for privacy concerns is not as therapeutic as explaining that the system requires a password.
) Which action protects the client’s confidentiality?
A) The nurse discusses details of a client’s case with family members she expects will tell no one else.
B) The nurse doesn’t reveal outside the healthcare team that he was involved with the treatment of a famous client.
C) The nurse thinks HIPAA procedures for her facility are too restrictive to enable necessary sharing of information.
D) The nurse discusses clients only with other employees of the healthcare facility where he works.
Answer: B
Explanation: A) Confidentiality refers to the assurance the client has that private information will not be disclosed without his or her consent. Confidentiality applies both to the nature of the information the nurse obtains from the client and to how the nurse treats client information once it has been disclosed to the nurse. The nurse who does not reveal he participated in the treatment of a famous client is protecting that client’s confidentiality. The nurse discussing the details of a client’s case with family members and the nurse discussing clients with any other employees of his facility are violating client confidentiality. The nurse who thinks her facility’s HIPAA procedures are too restrictive is neither protecting nor violating confidentiality.
