Test Bank Fundamentals of Nursing 2nd Edition Yoost
Table of Contents Chapter 01: Nursing, Theory, and Professional Practice
... [Show More] ................................ ........... 2 Chapter 02: Values, Beliefs, and Caring ................................ ........................ 11 Chapter 03: Communication ................................ ................................ . 20 Chapter 04: Critical Thinking in Nursing ................................ ...................... 29 Chapter 05: Introduction to the Nursing Process ................................ ............... 39 Chapter 06: Assessment ................................ ................................ .... 48 Chapter 07: Nursing Diagnosis ................................ ............................... 58 Chapter 08: Planning ................................ ................................ ....... 68 Chapter 09: Implementation and Evaluation ................................ ................... 76 Chapter 10: Documentation, Electronic Health Records, and Reporting ............................. 85 Chapter 11: Ethical and Legal Considerations ................................ .................. 93 Chapter 12: Leadership and Management ................................ ................... 104 Chapter 13: Evidence-Based Practice and Nursing Research ................................ .... 112 Chapter 14: Health Literacy and Patient Education ................................ ............ 121 Chapter 15: Nursing Informatics ................................ ........................... 131 Chapter 16: Health and Wellness ................................ ........................... 139 Chapter 17: Human Development: Conception Through Adolescence ............................ 150 Chapter 18: Human Development: Young Adult Through Older Adult ............................ 158 Chapter 19: Vital Signs ................................ ................................ ... 165 Chapter 20: Health History and Physical Assessment ................................ .......... 173 Chapter 21: Ethnicity and Cultural Assessment ................................ ............... 180 Chapter 22: Spiritual Health ................................ ............................... 188 Chapter 23: Public Health, Community-Based, and Home Health Care ............................ 196 Chapter 24: Human Sexuality ................................ .............................. 203 Chapter 25: Safety ................................ ................................ ....... 211 Chapter 26: Asepsis and Infection Control ................................ ................... 219 Chapter 27: Hygiene and Personal Care ................................ ..................... 226 Chapter 28: Activity, Immobility, and Safe Movement ................................ ......... 233 Chapter 29: Skin Integrity and Wound Care ................................ .................. 241 Chapter 30: Nutrition ................................ ................................ .... 249 Chapter 31: Cognitive and Sensory Alterations ................................ ............... 257 Chapter 32: Stress and Coping ................................ ............................. 265 Chapter 33: Sleep ................................ ................................ ........ 272 Chapter 34: Diagnostic Testing ................................ ............................ 280 Chapter 35: Medication Administration ................................ ..................... 288 Chapter 36: Pain Management ................................ ............................. 296 Chapter 37: Perioperative Nursing Care ................................ ..................... 304 1 | P a g eChapter 38: Oxygenation and Tissue Perfusion ................................ ............... 312
Chapter 39: Fluid, Electrolytes, and Acid-Base Balance ................................ ........ 319
Chapter 40: Bowel Elimination ................................ ............................ 328
Chapter 41: Urinary Elimination ................................ ........................... 335
Chapter 42: Death and Loss ................................ ............................... 343
Chapter 01: Nursing, Theory, and Professional Practice
MULTIPLE CHOICE
1. A group of nursing students are discussing the impact of no nursing theories in clinical
practice. The students would be correct if they chose which theory to prioritize patient care?
a. Erikson’s Psychosocial Theory
b. Paul’s Critical-Thinking Theory
c. Maslow’s Hierarchy of Needs
d. Rosenstock’s Health Belief Model
ANS: C
Maslow’s hierarchy of needs specifies the psychological and physiologic factors that affect each person’s
physical and mental health. The nurse’s understanding of these factors helps with formulating Nursing
diagnoses that address the patient’s needs and values to prioritize care. Erikson’s Psychosocial Theory of
Development and Socialization is based on individuals’ interacting and learning about their world. Nurses
use concepts of developmental theory to critically think in providing care for their patients at various
stages of their lives.
Rosenstock (1974) developed the psychological Health Belief Model. The model addresses possible
reasons for why a patient may not comply with recommended health promotion behaviors. This model is
especially useful to nurses as they educate patients.
DIF: Remembering
OBJ: 1.5
TOP: Planning
MSC: NCLEX Client Needs Category: Safe and effective Care Environment: Management of
Care NOT: Concepts: Care Coordination
2. A nursing student is preparing study notes from a recent lecture in nursing history.
The student would credit Florence Nightingale for which definition of nursing?
a. The imbalance between the patient and the environment decreases the capacity
for health.
b. The nurse needs to focus on interpersonal processes between nurse and patient.
c. The nurse assists the patient with essential functions toward independence.
d. Human beings are interacting in continuous motion as energy fields.
ANS: A
Florence Nightingale’s (1860) concept of the environment emphasized prevention and clean air, water,
and housing. This theory states that the imbalance between the patient and the environment decreases
the capacity for health and does not allow for conservation of energy. Hildegard Peplau (1952) focused on
the roles played by the nurse and the interpersonal process between a nurse and a patient. Virginia
Henderson described the nurse’s role as substitutive (doing for the person), supplementary (helping the
person), or complementary (working with the person), with the goal of independence for the patient.
Martha Rogers (1970) developed the Science of Unitary Human Beings. She stated that human beings and
their environments are interacting in continuous motion as infinite energy fields.
DIF: Understanding
OBJ: 1.4
TOP:
Planning MSC: NCLEX Client Needs Category: Health Promotion and
Maintenance NOT: Concepts: Health Promotion
2 | P a g e3. The nurse identifies which nurse established the American Red Cross during the Civil War?
a. Dorothea Dix
b. Linda Richards
c. Lena Higbee
d. Clara Barton
ANS: D
Clara Barton practiced nursing in the Civil War and established the American Red Cross. Dorothea Dix
was the head of the U.S. Sanitary Commission, which was a forerunner of the Army Nurse Corps. Linda
Richards was America’s first trained nurse, graduating from Boston’s Women’s Hospital in 1873, and
Lena Higbee, superintendent of the U.S. Navy Nurse Corps, was awarded the Navy Cross in 1918.
DIF: Remembering
OBJ: 1.3
TOP:
Assessment MSC: NCLEX Client Needs Category: Health Promotion and
Maintenance
NOT: Concepts: Professionalism
4. The nursing instructor is researching the five proficiencies regarded as essential for
students and professionals. The nursing instructor identifies which organization would be
found to have added safety as a sixth competency?
a. Quality and Safety Education for Nurses (QSEN)
b. Institute of Medicine (IOM)
c. American Association of Colleges of Nursing (AACN)
d. National League for Nursing (NLN)
ANS: A
The Institute of Medicine report, Health Professions Education: A Bridge to Quality (2003), outlines five
core competencies. These include patient-centered care, interdisciplinary teamwork, use of evidence-
based medicine, quality improvement, and use of information technology. QSEN added safety as a sixth
competency. The Essentials of Baccalaureate Education for Professional Nursing Practice are provided and
updated by the American Association of Colleges of Nursing (AACN) (2008). The document offers a
framework for the education of professional nurses with outcomes for students to meet. The National
League for Nursing (NLN) outlines and updates competencies for practical, associate, baccalaureate, and
graduate nursing education programs.
DIF: Remembering
OBJ: 1.1
TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Care Coordination
5. The nurse manager is interviewing graduate nurses to fill existing staffing vacancies. When
hiring graduate nurses, the nurse manager realizes that they will probably not be
considered “competent” until they complete which task?
a. They graduate and pass NCLEX.
b. They have worked 2 to 3 years.
c. Their last year of nursing school.
d. They are actually hired.
ANS: B
Benner’s model identifies five levels of proficiency: novice, advanced beginner, competent, proficient, and
expert. The student nurse progresses from novice to advanced beginner during nursing school and attains
the competent level after approximately 2 to 3 years of work experience after graduation. To obtain the
RN credential, a person must graduate from an approved school of nursing and pass a state licensing
examination called the National Council Licensure Examination for Registered Nurses (NCLEX-RN) usually
taken soon after completion of an approved nursing program.
DIF: Remembering
OBJ: 1.7
TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
3 | P a g eCare NOT: Concepts: Care Coordination
6. The prospective student is considering options for beginning a career in nursing. Which
degree would best match the student’s desire to conduct research at the university
level?
a. Associate Degree in Nursing (ADN)
b. Bachelor of Science in Nursing (BSN)
c. Doctor of Nursing Practice (DNP)
d. Doctor of Philosophy in Nursing (PhD)
ANS: D
Doctoral nursing education can result in a Doctor of Philosophy (PhD) degree. This degree prepares
nurses for leadership roles in research, teaching, and administration that are essential to advancing
nursing as a profession. Associate Degree in Nursing (ADN) programs usually are conducted in a
community college setting. The nursing curriculum focuses on adult acute and chronic disease;
maternal/child health; pediatrics; and psychiatric/mental health nursing. ADN RNs may return to school
to earn a bachelor’s degree or higher in an RN-to-BSN or RN-to-MSN program. Bachelor’s degree
programs include community health and management courses beyond those provided in an associate
degree program. A newer
practice-focused doctoral degree is the Doctor of Nursing practice (DNP), which concentrates on the
clinical aspects of nursing. DNP specialties include the four advanced practice roles of
NP, CNS, CNM, and CRNA.
DIF: Remembering
OBJ: 1.9
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Care Coordination
7. During a staff meeting, the nurse manager announces that the hospital will be seeking Magnet
status. To explain the requirements for this award, the nurse manager will contact which
organization?
a. American Nurses Association (ANA)
b. American Nurses Credentialing Center (ANCC)
c. National League for Nursing (NLN)
d. Joint Commission
ANS: B
The American Nurses Credentialing Center (ANCC) awards Magnet Recognition to hospitals that have
shown excellence and innovation in nursing. The ANA is a professional organization that provides
standards of nursing practice. The National League for Nursing (NLN) outlines and updates competencies
for practical, associate, baccalaureate, and graduate nursing education programs. The Joint Commission is
the accrediting organization for health care facilities in the United States.
DIF: Remembering
OBJ: 1.1
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Care Coordination
8. The nurse is caring for a patient who refuses two units of packed red blood cells. When the
nurse notifies the health care provider of the patient’s decision, the nurse is acting in
which role?
a. Manager
b. Change agent
c. Advocate
d. Educator
ANS: C
As the patient’s advocate, the nurse interprets information and provides the necessary education. The
nurse then accepts and respects the patient’s decisions even if they are different from the nurse’s own
4 | P a g ebeliefs. The nurse supports the patient’s wishes and communicates them to other health care providers. A
nurse manages all of the activities and treatments for patients. In the role of change agent, the nurse
works with patients to address their health concerns and with staff members to address change in an
organization or within a community. The nurse ensures that the patient receives sufficient information on
which to base consent for care and related treatment. Education becomes a major focus of discharge
planning so that patients will be prepared to handle their own needs at home.
DIF: Applying
OBJ: 1.2
TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Care Coordination
9. The nursing student develops a plan of care based on a recently published article describing
the effects of bed rest on a patient’s calcium blood levels. When creating the plan of care, the nursing
student has the obligation to consider which action?
a. Critically appraise the evidence and determine validity.
b. Ensure that the plan of care does not alter current practice.
c. Change the process even when there is no problem identified.
d. Maintain the plan of care regardless of initial outcome.
ANS: A
Evidence-based practice (EBP) is an integration of the best-available research evidence with clinical
judgment about a specific patient situation. The nurse assesses current and past research, clinical
guidelines, and other resources to identify relevant literature. The application of EBP includes critically
appraising the evidence to assess its validity, designing a change for practice, assessing the need for
change and identifying a problem, and integrating and maintaining change while monitoring process and
outcomes by reevaluating the application of evidence and assessing areas for improvement.
DIF: Applying
OBJ: 1.2
TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Care Coordination
10. The nurse is delegating frequent blood pressure (BP) measurements for a patient
admitted with a gunshot wound to a licensed practical nurse (LPN). When delegating, the
nurse understands which fact?
a. He/she may assume that the LPN is able to perform this task appropriately.
b. The LPN is ultimately responsible for the patient findings and assessment.
c. The LPN may perform the tasks assigned without further supervision.
d. He/she retains ultimate responsibility for patient care and supervision is needed.
ANS: D
The RN retains ultimate responsibility for patient care, which requires supervision of those to whom
patient care is delegated. In the process of collaboration, the nurse delegates certain activities to other
health care personnel. The RN needs to know the scope of practice or capabilities of each health care
member for delegation to be effective and safe.
DIF: Understanding
OBJ: 1.2
TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Care Coordination
11. The nurse is preparing to discharge a patient admitted with fever of unknown origin. The
patient states, “I never got past the fifth grade in school. Don’t read much. Never saw much
sense in it. But I do OK. I can read most stuff. But my doctor explains things good and
doesn’t think that my sickness is serious.” Considering this patient response, what action
should the nurse carry out?
a. Provide discharge medication information from a professional source to provide
the most information.
b. Expect that the patient may return to the hospital if the discharge process is
poorly done.
c. Assume that the physician and the patient have a good rapport and that the
5 | P a g ephysician will clarify everything.
d. Defer offering the patient the opportunity to sign up for wellness classes due to the
low literacy rate.
ANS: B
Low health literacy is associated with increased hospitalization, greater emergency care use, lower use of
mammography, and lower receipt of influenza vaccine. A goal of patient education by the nurse is to
inform patients and deliver information that is understandable by examining their level of health literacy.
The more understandable health information is for patients, the closer the care is coordinated with need.
DIF: Applying
OBJ: 1.2
TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Health Promotion
12. A nurse is caring for a patient who lost a large amount of blood during childbirth. The nurse
provides the opportunity for the patient to maintain her activity level while providing
adequate periods of rest and encouragement. Which nursing theory would the nurse most
likely choose as a framework for addressing the fatigue associated with the low blood count?
a. Watson Human Caring Theory
b. Parse’s Theory of Human Becoming
c. Roy’s Adaptation Model
d. Rogers’ Science of Unitary Human Beings
ANS: C
Roy’s Adaptation Model is based on the human being as an adaptive open system. The person adapts by
meeting physiologic-physical needs, developing a positive self-concept–group identity, performing social
role functions, and balancing dependence and independence.
Stressors result in illness by disrupting the equilibrium. Nursing care is directed at altering stimuli that
are stressors to the patient. The nurse helps patients strengthen their abilities to adapt to their illnesses
or helps them to develop adaptive behaviors. Watson’s theory is based on caring, with nurses dedicated to
health and healing. The nurse functions to preserve the dignity and wholeness of humans in health or
while peacefully dying. Parse’s theory is called the Human Becoming School of Thought. Parse formulated
the Theory of Human Becoming by combining concepts from Martha Rogers’ Science of Unitary Human
Beings with existential-phenomenologic thought. This theory looks at the person as a constantly changing
being, and at nursing as a human science. Martha Rogers (1970) developed the Science of Unitary Human
Beings. She stated that human beings and their environments are interacting in continuous motion as
infinite energy fields.
DIF: Applying
OBJ: 1.4
TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Care Coordination
13. The nurse recognizes which nursing theorist who described the relationship between the
nurse and the patient as an interpersonal and therapeutic process?
a. Virginia Henderson
b. Betty Neuman
c. Imogene King
d. Hildegard Peplau
ANS: D
Hildegard Peplau focused on the roles played by the nurse and the interpersonal process between a
nurse and a patient. The interpersonal process occurs in overlapping phases: (1) orientation, (2) working,
consisting of two subphases: identification and exploitation, and (3) resolution. Betty Neuman’s Systems
Model includes a holistic concept and an open-system approach. The model identifies energy resources
that provide for basic survival, with lines of resistance that are activated when a stressor invades the
system. Virginia Henderson described the nurse’s role as substitutive (doing for the person),
supplementary (helping the person), or complementary (working with the person), with the ultimate goal
of independence for the patient. Imogene King developed a general systems framework that incorporates
6 | P a g ethree levels of systems: (1) individual or personal, (2) group or interpersonal, and (3) society or social.
The theory of goal attainment discusses the importance of interaction, perception, communication,
transaction, self, role, stress, growth and development, time, and personal space. In this theory, both the
nurse and the patient work together to achieve the goals in the continuous adjustment to stressors.
DIF: Remembering
OBJ: 1.4
TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological
Adaptation NOT: Concepts: Health Promotion
14. When a nursing class volunteers to serve hot meals at a local homeless shelter on a Saturday
afternoon, which term identifies this focus on serving the community?
a. Altruism
b. Accountability
c. Autonomy
d. Advocate
ANS: A
A profession provides services needed by society. Additionally, practitioners’ motivation is public service
over personal gain (altruism). Service to the public requires intellectual activities, which include
responsibility. This accountability has legal, ethical, and professional implications. Members of a profession
have autonomy in decision making and practice and are self-regulating in that they develop their own
policies in collaboration with one another.
As the patient’s advocate, the nurse interprets information and provides the necessary education. The
nurse then accepts and respects the patient’s decisions even if they are different from the nurse’s own
beliefs.
DIF: Understanding
OBJ: 1.6
TOP:
Assessment MSC: NCLEX Client Needs Category: Health Promotion and
Maintenance
NOT: Concepts: Health Promotion
15. A patient is being discharged from the hospital with wound care dressing changes. The nurse
recommends a referral for home health nursing care. The nurse is using which standard of
practice?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
ANS: C
As a care provider, the nurse follows the nursing process to assess patient data, prioritize Nursing
diagnoses, plan the care of the patient, implement the appropriate interventions, and
evaluate care in an ongoing cycle. In recommending a referral, the nurse is, in effect, planning care.
DIF: Applying
OBJ: 1.2
TOP: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity: Basic Care and
Comfort NOT: Concepts: Care Coordination
16. The nurse administers a medication to the patient and then realizes that the medication had
been discontinued. The error is immediately reported to the physician. The nurse recognizes
which term that identifies complying with the standards of professional performance?
a. Ethics
b. Socialization
c. Altruism
d. Autonomy
ANS: A
7 | P a g eGuiding the nurse’s professional practice are ethical behaviors. Ethics is the standards of right and wrong
behavior. The main concepts in nursing ethics are accountability, advocacy, autonomy (be independent
and self-motivated), beneficence (act in the best interest of the patient), confidentiality, fidelity (keep
promises), justice (relate to others with fairness and equality), nonmaleficence (do no harm),
responsibility, and veracity (be truthful). Ethical guidelines direct the nurse’s decision making in routine
situations and in ethical dilemmas.
Socialization to professional nursing is a process that involves learning the theory and skills necessary for
the role of nurse. A profession provides services needed by society.
Additionally, practitioners’ motivation is public service over personal gain (altruism).
Members of a profession have autonomy in decision making and practice and are
self-regulating in that they develop their own policies in collaboration with one another.
DIF: Applying
OBJ: 1.6
TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control NOT: Concepts: Ethics
17. A newly licensed registered nurse is curious about the scope of care that he or she has in
caring for patients undergoing conscious sedation. Which would be the best source of
information for this nurse?
a. National Student Nurses Association
b. Nurse Practice Act
c. ANA Standards of Professional Performance
d. National League for Nursing
ANS: B
Nurse practice acts provide the scope of practice defined by each state or jurisdiction and set forth the
legal limits of nursing practice. Nursing organizations enable the nurse to have access to current
Information and resources as well as a voice in the profession. Nursing
organizations include the ANA, the NLN, the ICN, Sigma Theta Tau International Honor
Society of Nursing, and the National Student Nurses Association (NSNA).
DIF: Remembering
OBJ: 1.7
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Health Care Law
18. The nursing student is writing a paper about the direct patient care role of advanced
practice nurses. Which advanced practice role would the student include in the report?
a. Nurse Administrator
b. Clinical Nurse Leader
c. Clinical Nurse Specialist
d. Nurse Educator
ANS: C
There are four specialties in which nurses provide direct patient care in advanced practice roles: certified
nurse midwife (CNM), nurse practitioner (NP), clinical nurse specialist (CNS), and certified registered
nurse anesthetist (CRNA). Four additional advanced practice roles that do not always involve direct
patient care are clinical nurse leader (CNL), nurse educator, nurse researcher, and nurse administrator.
DIF: Remembering
OBJ: 1.9
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Health Care Law
19. The nurse is determining the patient care assignments for a nursing unit. The nurse
knows which responsibility may be delegated to the licensed practical nurse?
a. Initiating the nursing care plans
b. Formulating Nursing diagnoses
8 | P a g ec. Assessing a newly admitted patient
d. Administering oral medications
ANS: D
LPNs, or LVNs in California and Texas, are not RNs. They complete an educational program consisting of
12 to 18 months of training, and then they must pass the National Council Licensure Examination for
Practical Nurses (NCLEX-PN) to practice as an LPN/LVN. They are under the supervision of an RN in
most institutions and are able to collect data but cannot perform an assessment requiring decision
making, cannot formulate a Nursing diagnosis, and cannot initiate a care plan. They may update care plans
and administer medications except for certain IV medications.
DIF: Applying
OBJ: 1.9
TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Health Care Law
20. The nursing student is taking a class in Nursing Research. In class the student has learned
which term that identifies the most abstract level of knowledge?
a. Metaparadigm
b. Philosophy
c. Conceptual framework
d. Nursing theory
ANS: A
A metaparadigm, as the most abstract level of knowledge, is defined as a global set of concepts that
identify and describe the central phenomena of the discipline and explain the relationship between those
concepts. For example, the metaparadigm for nursing focuses on the concepts of person, environment,
health, and nursing. The next level of knowledge is a philosophy, which is a statement about the beliefs
and values of nursing in relation to a specific phenomenon such as health. The third level of knowledge is
a nursing conceptual framework, or model, which is a collection of interrelated concepts that provides
direction for nursing practice, research, and education. The fourth level of nursing knowledge is a nursing
theory, which represents a group of concepts that can be tested in practice and can be derived from a
conceptual model.
DIF: Remembering
OBJ: 1.4
TOP:
Assessment MSC: NCLEX Client Needs Category: Health Promotion and
Maintenance
NOT: Concepts: Professionalism
MULTIPLE RESPONSE
1. The nurse recognizes which statements contribute to the understanding that nursing
is considered a profession? (Select all that apply.)
a. Nursing requires specialized training.
b. Nursing has a specialized body of knowledge.
c. The ANA regulates nursing practice.
d. Nurses make independent decisions within their scope of practice.
e. Once licensure is complete, no further education is required.
ANS: A, B, D
A profession is an occupation that requires at a minimum specialized training and a specialized body of
knowledge. Nursing meets these minimum requirements. Thus nursing is considered to be a profession.
Members of a profession have autonomy in decision making and practice and are self-regulating in that
they develop their own policies in collaboration with one another. Nursing professionals make
independent decisions within their scope of practice and are responsible for the results and
consequences of those decisions. A profession is committed to competence and has a legally recognized
license. Members are accountable for continuing their education. The ANA is a professional organization
9 | P a g ethat provides standards (not regulation) of nursing practice.
DIF: Remembering
OBJ: 1.6
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Professionalism
2. The Institute of Medicine (IOM) Report identified several goals for nursing in the United
States. The nurse identifies that the IOM offered which suggestions? (Select all that apply.)
a. Nurses should practice to the full extent of their education.
b. Nursing education should demonstrate seamless progression.
c. Nurses should continue to be subservient to physicians in the hospital setting.
d. Policy making requires better data collection and information infrastructure.
e. Higher levels of education will not be needed by practicing nurses.
ANS: A, B, D
The Future of Nursing: Leading Change, Advancing Health (IOM, 2011) identified several
goals for nursing in the United States: nurses should practice to the full extent of their education and
training; Nurses should achieve higher levels of education and training through an improved education
system that promotes seamless academic progression; Nurses should be full partners with physicians and
other health care professionals in redesigning health care in the United States; and Effective workforce
planning and policy making require better data collection and an improved information infrastructure.
DIF: Remembering
OBJ: 1.1
TOP:
Assessment MSC: NCLEX Client Needs Category: Health Promotion and
Maintenance
NOT: Concepts: Professionalism
3. The nurse is caring for a patient admitted for the removal of an infected appendix. Which
actions by the nurse would indicate an understanding of the 2018 hospital safety goals?
(Select all that apply.)
a. Places an identification band on the right arm.
b. Marks the surgical site with a black-felt pen.
c. Checks medications three times before administration.
d. Washes hands between patients and/or when soiled.
e. Removes allergy bands prior to transfer to surgery.
ANS: A, B, C, D
The Joint Commission identifies each category and has specific elements of performance that are required
for the health care worker to meet the goals. As new problems in patient care emerge, the safety goals
are reassessed and revised. The 2018 hospital goals include the following broad categories: improve the
accuracy of patient identification, improve the effectiveness of communication among caregivers, improve
the safety of using medications, reduce the harm associated with clinical alarm systems, reduce the risk
of health care– associated infections. The organization identifies safety risks inherent in its patient
population. Improve the accuracy of patient identification. (Placing an ID band on the right are), improve
the safety of using medications (check medications three times before administration), reduce the risk of
health care–associated infections. (Washing hands), and the organization identifies safety risks inherent in
its patient population. (Mark the surgical site with a black-felt pen) are all examples of actions that
comply with the 2018 safety goals.
Removing allergy bands would prevent identification of that patient’s safety risk.
DIF: Applying
OBJ: 1.1
TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control NOT: Concepts: Care Coordination
4. The nurse is conducting a health assessment on a patient from a foreign country. Which
concepts should be addressed by the nurse during the interview? (Select all that apply.)
a. Food preferences
b. Religious practices
10 | P a g ec. Health beliefs
d. Family orientation
e. Politics
ANS: A, B, C, D
Culture is the integrated patterns of human behavior that include the language, thoughts,
communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social
groups.
DIF: Applying
OBJ: 1.7
TOP: Implementation
MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Care Coordination
5. The nurse documents that patient laboratory results often take 4 hours to populate into
the electronic medical record. The lengthy time frame has contributed to delayed
antibiotic administration. From this point, what should the nurse do to produce change
using Evidence-Based practice? (Select all that apply.)
a. Identify a problem affecting patient care.
b. Realize the facility resources may influence the decision.
c. Review pertinent journal articles from the literature search.
d. Apply the findings to clinical practice considering patient preferences.
e. Using the process recommended by the best clinical article.
ANS: A, B, C, D
The process of using evidence-based practice (EBP) starts with the identification of a problem. The nurse
then conducts a literature search to find the best evidence pertaining to the problem. Facility resources
may impact the ability to implement the chosen decision. Patient preferences need to be incorporated
into the use of evidence from the literature combined with clinical expertise. The nurse would not use just
one clinical article to determine a solution to the issue.
DIF: Applying
OBJ: 1.2
TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Evidence
Chapter 02: Values, Beliefs, and Caring
11 | P a g eMULTIPLE CHOICE
1. The nurse identifies the concept of enduring ideas about what a person considers desirable
or has worth in life is known by which term?
a. Values
b. First-order belief
c. Higher-order belief
d. Stereotype
ANS: A
Values are enduring ideas about what a person considers is the good, the best, and the “right” thing to do
and their opposites—the bad, worst, and wrong things to do—and about what is desirable or has worth
in life. First-order beliefs serve as the foundation or the basis of an individual’s belief system. Higher-
order beliefs are ideas derived from a person’s first-order beliefs through inductive or deductive
reasoning. A stereotype is a belief about a person, a group, or an event that is thought to be typical of all
others in that category.
DIF: Remembering
OBJ: 2.1
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Professionalism
2. A group of nursing students are discussing the history of nursing to a staff nurse. When a
student states, “Yeah, nurses used to be called doctors’ handmaidens.” the staff nurse
recognizes that this comment is identified by which term?
a. Prejudice
b. Generalization
c. Stereotype
d. Belief
ANS: C
A stereotype is a belief about a person, a group, or an event that is thought to be typical of all others in
that category. A prejudice is a preformed opinion, usually an unfavorable one, about an entire group of
people that is based on insufficient knowledge, irrational feelings, or inaccurate stereotypes. In the
process of learning, people form generalizations (general statements or ideas about people or things) to
relate new information to what is already known and to categorize the new information, making it easier
to remember or understand. A belief is a mental representation of reality or a person’s perceptions about
what is right (correct), true, or real, or what the person expects to happen in a given situation.
DIF: Understanding
OBJ: 2.1
TOP: Evaluation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of
Care NOT: Concepts: Professionalism
3. A values system is a set of somewhat consistent values and measures that are organized
hierarchically into a belief system on a continuum of relative importance. The nurse knows
that a value system is also identified by which concept?
a. It is culturally based.
b. It is unique to each individual.
c. It is a poor basis for making decisions.
d. It is rigid and uniform within a culture.
ANS: A
Anthropologists and social scientists have noted that in every culture, a particular value system prevails
and consists of culturally defined moral and ethical principles and rules that are learned in childhood.
Everyone possesses a relatively small number of values and may share the same values with others, but
to different degrees. A value system helps the person choose between alternatives, resolve values
conflicts, and make decisions. Within every culture, however, values vary widely among subcultural
groups and even between individuals on the basis of the person’s gender, personal experiences,
personality, education, and many other variables.
12 | P a g eDIF: Remembering
OBJ: 2.1
TOP: Assessment
MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Professionalism
4. The nurse is caring for a patient who is under arrest for murder and is attempting to
perform nursing care duties while, at the same time, feeling a sense of repugnance toward
the patient. The nurse recognizes this situation is identified by which term?
a. Value clarification
b. Value conflict
c. First-order beliefs
d. Higher-order beliefs
ANS: B
A values conflict occurs when a person’s values are inconsistent with his or her behaviors or when the
person’s values are not consistent with the choices that are available. Providing care
for a convicted murderer may elicit troubling feelings for a nurse, resulting in a values conflict between
the nurse’s commitment to care for all people and a personal repugnance for the act of murder. First-
order beliefs serve as the foundation or the basis of an individual’s belief system. Higher-order beliefs are
ideas derived from a person’s first-order beliefs, inductive, or syllogistic reasoning.
DIF: Understanding
OBJ: 2.1
TOP: Diagnosis
MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Professionalism
5. While helping patients with values clarification and care decisions, the nurse should complete
which action?
a. Convince the patient to do what the nurse believes is best.
b. Give advice about what the nurse would do.
c. Tell the patient what the right thing to do is.
d. Provide information so the patient can make informed decisions.
ANS: D
While helping patients with values clarification and care decisions, nurses must be aware of the potential
influence of their professional nursing role on patient decision making. Nurses should be careful to assist
patients to clarify their own values in reaching informed decisions. Providing information to patients so
that they can make informed decisions is a critical nursing role. Giving advice or telling patients what to
do in difficult circumstances is both unethical and ill-advised.
DIF: Applying
OBJ: 2.2
TOP: Implementation
MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Professionalism
6. A patient with terminal cancer says to the nurse, “I just don’t know if I should allow CPR in
the event I quit breathing. What do you think?” Which statement by the nurse would be most
beneficial to the patient?
a. “If it were me, I would want to live no matter what.”
b. “Don’t worry. You have plenty of time to decide that later on.”
c. “It’s totally up to you. Have you discussed this with your family?”
d. “Let’s talk about what CPR means to you.”
ANS: D
The use of the value clarification process is helpful when assisting patients in making health care
decisions regarding end-of-life care. Giving advice or telling patients what to do is unethical and not
recommended. Ignoring a patient concern or changing the subject is inappropriate. Patients should be
given factual information in order for them to make their own decisions.
DIF: Applying
OBJ: 2.2
TOP: Implementation
MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Professionalism
7. The nurse is observed sitting at the bedside of a patient discussing the nursing care plan for
the shift. The nurse identifies which theory or model most accurately reflects this nurse–patient
13 | P a g erelationship? a. Swanson’s Theory of Caring b. Travelbee’s human-to-human relationship model c. Watson’s Theory of Caring d. Leininger Cultural Care Theory
ANS: A
Swanson’s five caring processes include being with and enabling. Sitting at the bedside and sharing information are activities that exemplify these behaviors. Travelbee’s model describes steps toward compassionate and empathetic care. Watson’s Theory of Caring impacts both the person and the universe and is built upon 10 caritas processes. Leininger describes patient care and its relationship to cultural diversity.
DIF: Understanding OBJ: 2.4 TOP: Diagnosis MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Professionalism
8. The student nurse is planning care for a patient who believes that Western medicine is effective but not always accurate and recognizes which nursing theory would best explain the patient’s health practices? a. Nursing: Human Science and Human Care b. Theory of Cultural Care Diversity and Universality
c. Theory of Nursing as Caring d. Five caring processes
ANS: B
Leininger describes patient care and its relationship to cultural diversity. Swanson’s five caring processes include maintaining belief, knowing, being with, doing for, and enabling. In the Theory of Nursing as Caring, Boykin & Schoenhofer, note that caring is defined as “the intentional and authentic presence of the nurse with another who is recognized as person living caring and growing in caring.” Watson’s Theory of Human Science and Human Care impacts both the person and the universe and is built upon 10 caritas processes.
DIF: Understanding OBJ: 2.4 TOP: Diagnosis MSC: NCLEX Client Needs Category: Psychosocial Integrity NOT: Concepts: Professionalism
9. The nurse identifies which nursing theorist/theorists who describes/describe the nurse– patient relationship as a situation in which the nurse and patient share the lived experience of caring? a. Kristen Swanson [Show Less]