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DeWit’s Fundamental Concepts and Skills for Nursing, 5th Edition By Patricia A. Williams –Test Bank

Chapter1
MULTIPLE CHOICE
1. Florence Nightingale’s contributions to nursing practice and education:
a. are historically important but have no validity for nursing today.
b. were neither recognized nor appreciated in her own time.
c. were a major factor in reducing the death rate in the Crimean War.
d. were limited only to the care of severe traumatic wounds.
ANS: C
By improving sanitation, nutrition ventilation, and handwashing techniques, Florence
Nightingale’s nurses dramatically reduced the death rate from injuries in the Crimean War.
DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: Theory #1
TOP: Nursing History KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. Early nursing education and care in the United States:
a. were directed at community health.
b. provided independence for women through education and employment.
c. were an educational model based in institutions of higher learning.
d. have continued to be entirely focused on hospital nursing.
ANS: B
Because of the influence of early nursing leaders, nursing education became more formalized
through apprenticeships in Nightingale schools that offered independence to women through
education and employment.
DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: Theory #4
TOP: Nursing History KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. In order to fulfill the common goals defined by nursing theorists (promote wellness, prevent
illness, facilitate coping, and restore health), the LPN must take on the roles of:
a. caregiver, educator, and collaborator.
b. nursing assistant, delegator, and environmental specialist.
c. medication dispenser, collaborator, and transporter.
d. dietitian, manager, and housekeeper.
ANS: A
In order for the LPN to apply the common goals of nursing, he or she must assume the roles of
caregiver, educator, collaborator, manager, and advocate.
DIF: Cognitive Level: Comprehension REF: p. 4 OBJ: Theory #2
TOP: Art and Science of Nursing KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
4. Although nursing theories differ in their attempts to define nursing, all of them base their
beliefs on common concepts concerning:
a. self-actualization, fundamental needs, and belonging.
b. stress reduction, self-care, and a systems model.
c. curative care, restorative care, and terminal care.
d. human relationships, the environment, and health.
ANS: D
Although nursing theories differ, they all base their beliefs on human relationships, the
environment, and health.
DIF: Cognitive Level: Comprehension REF: p. 4 OBJ: Theory #2
TOP: Nursing Theories KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
5. Standards of care for the nursing practice of the LPN are established by the:
a. Boards of Nursing Examiners in each state.
b. National Council of States Boards of Nursing (NCSBN).
c. American Nurses Association (ANA).
d. National Federation of Licensed Practical Nurses.
ANS: D
The National Federation of Licensed Practical Nurses modified the standards published by the
ANA in 2004 to better fit the role of the LPN.
DIF: Cognitive Level: Comprehension REF: p. 5 OBJ: Theory #2
TOP: Standards of Care KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
6. The LPN demonstrates an evidence-based practice by:
a. using a drug manual to check compatibility of drugs.
b. using scientific information to guide decision making.
c. using medical history of a patient to direct nursing interventions.
d. basing nursing care on advice from an experienced nurse.
ANS: B
The use of scientific information from high-quality research to guide nursing decisions is
reflective of the application of evidence-based practice.
DIF: Cognitive Level: Knowledge REF: p. 5 OBJ: Theory #3
TOP: Evidence Based Practice KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
7. Lillian Wald and Mary Brewster established the Henry Street Settlement Service in New York
in 1893 in order to:
a. offer a shelter to injured war veterans.
b. found a nursing apprenticeship.
c. provide health care to poor persons living in tenements.
d. offer better housing to low-income families.
ANS: C
Henry Street Settlement Service brought the provision of community health care to the poor
people living in tenements.
DIF: Cognitive Level: Comprehension REF: p. 2 OBJ: Theory #4
TOP: Growth of Nursing KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
8. An educational pathway for an LPN refers to an LPN:
a. learning on the job and being promoted to a higher level of responsibility.
b. moving from a maternity unit to a more complicated surgical unit.
c. obtaining additional education to move from one level of nursing to another.
d. learning that advancement requires consistent work and commitment.
ANS: C
By broadening the educational base, an LPN may advance and build a nursing career.
DIF: Cognitive Level: Knowledge REF: p. 6 OBJ: Theory #7
TOP: Nursing Education Pathways KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
9. When diagnosis-related groups (DRGs) were established by Medicare in 1983, the purpose
was to:
a. put patients with the same diagnosis on the same unit.
b. attempt to contain the costs of health care.
c. increase availability of medical care to the elderly.
d. identify a patient’s condition more quickly.
ANS: B
The purpose of instituting DRGs was to contain skyrocketing costs of health care.
DIF: Cognitive Level: Knowledge REF: p. 8 OBJ: Theory #10
TOP: Health Care Delivery KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
10. The advent of diagnosis-related groups (DRGs) required that nurses working in health care
agencies:
a.
record supportive documentation to confirm a patient’s need for care in order to qualify for
reimbursement.
b. use the DRG rather than their own observations for patient assessment.
c. be aware of the specific drugs related to the diagnosis.
d. acquire cross-training to make staffing more flexible.
ANS: A
DRGs required that nurses provide more supportive documentation of their assessments and
identified patient needs to qualify the facility for Medicare reimbursement. Observant assessment
might also indicate another DRG classification and consequently more reimbursement for the
facility.
DIF: Cognitive Level: Comprehension REF: p. 8 OBJ: Theory #10
TOP: Managed Care KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
11. If a member of a health maintenance organization (HMO) is having respiratory problems such
as fever, cough, and fatigue for several days and wants to see a specialist, the person is required
to go:
a. directly to an emergency room for treatment.
b. to any general practitioner of choice.
c. directly to a respiratory specialist.
d. to a primary care physician for a referral.
ANS: D
Participants in an HMO must see their primary physician to receive a referral for a specialist in
order for the HMO to pay for the care.
DIF: Cognitive Level: Comprehension REF: p. 9 OBJ: Theory #11
TOP: Managed Care KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
12. An advantage of preferred provider organizations (PPOs) is that:
a. they make insurance coverage of employees less expensive to employers.
b. there are fewer physicians to choose from than in an HMO.
c. long-term relationships with physicians are more likely.
d. patients may go directly to a specialist for care.
ANS: A
The use of PPOs allows insurance companies to keep their premiums low and in turn makes
insurance coverage less expensive for the employers. There are usually more physicians from
which to choose than from a HMO, but long-term relationships between physician and patient
cannot be established easily. Patients still must see their primary physician before being referred
to other specialties.
DIF: Cognitive Level: Knowledge REF: p. 6 OBJ: Theory #11
TOP: Preferred Provider Organizations KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
13. After passing the National Council Licensure Examination for Practical Nurses (NCLEXPN),
the nurse is qualified to take an additional certification in the field of:
a. pharmacology.
b. care of infants and children.
c. operating room technology.
d. community health.
ANS: A
After becoming an LPN, the nurse may apply for additional certification in pharmacology or
long-term care.
DIF: Cognitive Level: Knowledge REF: p. 6 OBJ: Theory #6
TOP: Educational Opportunities KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
14. Nursing interventions are best defined as activities that:
a. are taken to improve the patient’s health.
b. involve researching methods to maintain asepsis.
c. include the family in nursing care.
d. review guidelines for handling infectious wastes.
ANS: A
Interventions are actions taken to improve, maintain, or restore health.
DIF: Cognitive Level: Comprehension REF: p. 4 OBJ: Theory #2
TOP: Art and Science of Nursing KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease
15. Nurse Practice Acts define the legal scope of an LPN’s practice, which are written and
enforced by:
a. the American Nurses Association.
b. the National Council Licensure Examiners.
c. each state.
d. each health care agency.
ANS: C
Each state writes and enforces the Nurse Practice Act, which defines the legal scope of nursing
practice.
DIF: Cognitive Level: Comprehension REF: p. 5 OBJ: Theory #3
TOP: Nurse Practice Act KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
16. Women volunteers were organized to give nursing care to the wounded soldiers during the
Civil War by:
a. Florence Nightingale.
b. Dorothea Dix.
c. Clara Barton.
d. Lillian Wald.
ANS: B
The Union government appointed Dorothea Dix, a social worker, to organize women volunteers
to provide nursing care for the soldiers during the Civil War.
DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: Theory #4
TOP: Nursing History KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
17. The nursing theory presented by Sister Calista Roy is based on:
a. reduction of stress.
b. achievement of maximum level of wellness.
c. relief of self-care deficit.
d. adaptation modes.
ANS: D
Adaptation modes (physiologic, psychological, sociologic, and independence) are the basis of the
nursing theory of Sister Calista Roy.
DIF: Cognitive Level: Knowledge REF: p. 4, Table 1-1
OBJ: Theory #2 TOP: Nursing Theories KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
18. The founding of the Red Cross is attributed to:
a. Lillian Wald.
b. Dorothea Dix.
c. Florence Nightingale.
d. Clara Barton.
ANS: D
Clara Barton founded the Red Cross.
DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: Theory #4
TOP: Nursing History KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
19. The nursing theorist whose practice framework is based on 14 fundamental needs is:
a. Dorothy Johnson.
b. Jean Watson.
c. Virginia Henderson.
d. Martha Rogers.
ANS: C
Virginia Henderson’s nursing theory framework is based on 14 fundamental needs.
DIF: Cognitive Level: Knowledge REF: p. 4, Table 1-1
OBJ: Theory #2 TOP: Nursing Theorists KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
20. The nursing theory that uses seven behavioral subsystems in an adaptation model is:
a. Betty Neumann.
b. Sister Calista Roy.
c. Dorothy Johnson.
d. Patricia Benner.
ANS: C
Dorothy Johnson’s practice framework is based on seven behavioral subsystems in an adaptation
model.
DIF: Cognitive Level: Knowledge REF: p. 4, Table 1-1
OBJ: Theory #2 TOP: Nursing Theorists KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
21. The Standards of Clinical Nursing Practice are designed to direct LPNs to:
a. advance their nursing career.
b. seek a scientific basis for their interventions.
c. deliver safe, knowledgeable care.
d. a leadership role.
ANS: C
The Standards of Clinical Nursing Practice are designed to guide the LPN to deliver safe,
knowledgeable care.
DIF: Cognitive Level: Knowledge REF: p. 5 OBJ: Theory #2
TOP: Nursing Standards KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe Effective Care Environment
22. A state’s Nurse Practice Act is designed to protect the:
a. physician.
b. nurse.
c. public.
d. hospital.
ANS: C
Nurse Practice Acts are designed to protect the public.
DIF: Cognitive Level: Knowledge REF: p. 6 OBJ: Theory #5
TOP: Nurse Practice Act KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
23. It is appropriate for practical nurses to provide direct patient care to persons in a hospital
under the supervision of a:
a. physician’s assistant.
b. registered nurse on the unit.
c. supervising nurse who is responsible for care on several units.
d. more experienced LPN on the unit.
ANS: B
Practical nurses provide direct patient care under the direct supervision of a registered nurse,
physician, or dentist.
DIF: Cognitive Level: Knowledge REF: p. 6 OBJ: Theory #9
TOP: Scope of Practice KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
24. An example of tertiary health care is _____ care.
a. hospice
b. restorative
c. emergency
d. home health
ANS: A
Tertiary health care includes extended care, chronic disease management, medical homes, inhome
personal care, and hospice care.
DIF: Cognitive Level: Comprehension REF: p. 9, Box 1-2
OBJ: Theory #8 TOP: Health Care Services KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
COMPLETION
25. Preferred provider organizations (PPOs) use __________ to finance their services and pay the
physical cost of the service.
ANS:
capitated cost
The capitated cost is the set fee that is paid to the network for each patient enrolled to finance its
services.
DIF: Cognitive Level: Knowledge REF: p. 9 OBJ: Theory #8
TOP: Capitated Cost KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
26. In the United States, the Young Women’s Christian Association (YMCA) in New York opened
The __________ School, the first practical nursing school.
ANS:
Ballard
In 1892, the YMCA opened The Ballard School, a 3-month course in practical nursing that was
the first school of practical nursing.
DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: Theory #4
TOP: Ballard School KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
27. Such health services as surgical procedures, restorative care, and home health care would be
classified as __________ care.
ANS:
secondary
Surgical procedures, restorative care, and home health are part of the many services classified as
secondary care.
DIF: Cognitive Level: Comprehension REF: p. 9, Box 1-2
OBJ: Theory #10 TOP: Health Care Services KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
MULTIPLE RESPONSE
28. Characteristics of primary nursing include which of the following? (Select all that apply.)
a. Elimination of fragmentation of care between shifts
b. Evolved in the mid-1950s
c. Planning and direction performed by one nurse
d. Ancillary workers used to increase productivity
e. The care plan covering the entire day
f. Associate nurses taking over care and planning when the primary nurse is off duty
ANS: A, C, D, E, F
Primary care reduces fragmentation of care between shifts. Care is planned by one nurse to cover
a 24-hour period using ancillary workers to increase productivity. An associate nurse may take
on direction of care in the absence of the primary nurse.
DIF: Cognitive Level: Knowledge REF: p. 8 OBJ: Theory #8
TOP: Nursing Care Delivery KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
29. In 1991, the American Nurses Association (ANA) published the Standards of Clinical
Nursing Practice. These standards are designed to: (Select all that apply.)
a. set standards for safe nursing care delivery.
b. define the legal scope of practice.
c. establish state legal requirements for clinical practice.
d. protect the nurse, patient, and health care agency.
e. regulate the nursing profession.
f. define activities in which nurses may engage.
ANS: A, D, F
The Standards of Clinical Nursing Practice generally define activities in which nurses may
engage, set standards for nursing care and delivery, and thereby protect the nurse, patient, and
health care agency.
DIF: Cognitive Level: Knowledge REF: p. 5 OBJ: Theory #2
TOP: Nursing Practice KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
30. An example of the role of an LPN as a delegator is: (Select all that apply.)
a. changing a patient’s wound dressing.
b. assisting a patient to complete his or her bath.
c. assigning patient care tasks to certified nursing assistants.
d. requesting the housecleaning staff to mop the floor of a patient’s room.
e. instructing the unit secretary to page a physician to the floor.
ANS: C, D, E
Delegation under the scope of the practice of an LPN is the assignment of a certified nursing
assistant to certain nursing care or other non-medical staff to aspects of patient care.
DIF: Cognitive Level: Comprehension REF: p. 4 OBJ: Theory #5
TOP: Art and Science of Nursing KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
31. During the Civil War, nursing schools offered education to women both in England and in the
United States. The schools in the United States differed from those in Europe because in U.S.
schools: (Select all that apply.)
a. students worked without pay.
b. the core curriculum was the same.
c. instruction was presented by physicians at the bedside.
d. the educational focus was on nursing care.
e. classes were held separately from the clinical experience.
ANS: A, C
In the United States, the students staffed the hospital and worked without pay. There were no
formal classes; education was achieved through work. There was no set curriculum, and content
varied depending on the type of cases present in the hospital. Instruction was done at the bedside
by the physician and therefore came from a medical viewpoint.
Chapter 2
MULTIPLE CHOICE
1. The nurse is aware that any description of health would include the concept that:
a. health is the absence of illness, and illness is the presence of chronic disease.
b. culture, education, and socioeconomic status influence one’s definition of health or illness.
c. illness is a biologic malfunction, and health is biologic soundness.
d. lifestyle factors are the major determinant of health or illness.
ANS: B
The concept of health is influenced by culture, education, and socioeconomic factors.
DIF: Cognitive Level: Comprehension REF: p. 15 OBJ: Theory #1
TOP: Views of Health and Illness KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease
2. The nurse takes into consideration that the patient with an admitting diagnosis of type 2
diabetes mellitus and influenza is described as having:
a. two chronic illnesses.
b. two acute illnesses.
c. one chronic and one acute illness.
d. one acute and one infectious illness.
ANS: C
Chronic illnesses are those that develop slowly over a long period and last throughout a lifetime.
Acute illnesses develop suddenly and resolve in a short time. Type 2 diabetes mellitus would be
considered chronic, whereas influenza would be considered acute.
DIF: Cognitive Level: Application REF: p. 15 OBJ: Theory #1
TOP: Classification of Illnesses KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease
3. The nurse explains that an idiopathic disease is one that:
a. is caused by inherited characteristics.
b. develops suddenly, related to new viruses.
c. results from injury during labor or delivery.
d. has an unknown cause.
ANS: D
Idiopathic disease is defined as disease whose cause is unknown.
DIF: Cognitive Level: Knowledge REF: p. 13 OBJ: Theory #1
TOP: Classification of Illnesses KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease
4. The nurse assesses a terminal illness in a:
a.
76 year old admitted to a nursing home with Alzheimer’s disease who is pacing and asking
to go home.
b. 43 year old with Lou Gehrig’s disease who is refusing food and fluid.
c.
2 year old child who burned her esophagus by drinking drain cleaner and who is being fed
by a tube.
d.
52 year old diagnosed with lung cancer who had part of one lung removed and has a closed
chest drainage device in place.
ANS: B
A terminal illness is defined as one in which a person will live only a few months, weeks, or
days. A person who refuses food and hydration will generally not live more than a few days.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: Theory #1
TOP: Stages of Illness KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: physiological adaptation
5. The nurse clarifies to a patient who now has an abscess following a ruptured appendix that the
abscess is considered to be:
a. a secondary illness.
b. a life threatening complication.
c. an expected event following any surgery.
d. a disorder easily treated with antibiotics.
ANS: A
A secondary illness is an illness that arises from a primary disorder.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: Theory #1
TOP: Views of Health and Illness KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: physiological adaptation
6. The nurse uses a diagram to demonstrate how Dunn’s theory of health and illness can be
compared with a:
a. plant that grows from a seed, blossoms, wilts, and dies.
b.
continuum, with peak wellness and death at opposite ends; the person moves back and forth
in a dynamic state of change.
c.
ladder; from birth to death the individual moves progressively downward a ladder to
eventual death.
d. state of mind dependent on the individual perception of their own health or illness.
ANS: B
Dunn’s theory of a health continuum shows how an individual moves between peak wellness and
death in a constant process.
DIF: Cognitive Level: Knowledge REF: p. 14 OBJ: Theory #1
TOP: Views of Health and Illness KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: physiological adaptation
7. A patient has been advised by the physician to take medication for high cholesterol and to
change eating habits after discharge home. The home health nurse discovered that the patient
refused to follow the medical and nutritional directions. The nurse’s best initial response to this
situation is to:
a. emphasize to the patient how important it is to follow the doctor’s advice.
b.
determine whether any cultural, socioeconomic, or religious values conflict, thus interfering
with the patient’s compliance.
c.
explain that without diet and medication the condition will worsen and serious problems
will develop.
d. inform the physician that the patient is unable to understand the instructions.
ANS: B
The patient may have cultural, socioeconomic, or religious values that cause conflicts that
prevent her from following the doctor’s instructions.
DIF: Cognitive Level: Application REF: p. 15 OBJ: Theory #5
TOP: Concepts of Health and Illness | Cultural Influences
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychological Integrity: coping and adaptation
8. A nurse practicing a holistic approach to nursing care must:
a.
recognize that a change in one aspect of the person’s life can alter the whole of that person’s
life.
b. take responsibility for health care decisions.
c. promote state of the art technology.
d. discourage the use of more natural remedies and alternative methods of health care.
ANS: A
Holistic nursing requires that the nurse recognize that a change in one aspect of the patient’s life
(biological, sociological, psychological, and spiritual) will bring about changes in that patient’s
whole life.
DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: Theory #6
TOP: Holistic Approach to Caring KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
9. According to Maslow’s hierarchy, physiological needs are those that:
a. nurture intimacy.
b. foster independence.
c. encourage social interaction.
d. are essential to human life.
ANS: D
Physiological needs are those that are essential to human life, such as oxygenation, nutrition, and
elimination.
DIF: Cognitive Level: Application REF: p. 17 OBJ: Theory #7
TOP: Maslow’s Hierarchy of Needs KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
10. The factors involved in assessing the importance the patient attaches to the relief of a
particular deficit include:
a.
needs that the nurse must assess to prioritize care, because they may be different from
person to person.
b.
ordering needs according to Maslow’s hierarchy, with lower level needs being least
compelling.
c.
needs based on a hierarchy in which higher level needs are more prominent and demand
attention before lower level needs.
d. needs that are usually not known to the patient and that must be determined by the nurse.
ANS: A
A person’s concern relative to a needs deficit must be assessed by the nurse to meet the needs of
each patient. Needs are viewed differently from one person to the next.
DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: Theory #7
TOP: Maslow’s Hierarchy of Needs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: physiological adaptation
11. The nurse believes that teaching a patient how to give insulin and monitor blood glucose
levels will improve the level of the patient’s:
a. physiological well being.
b. security, by providing psychological comfort.
c. self esteem, by promoting independence and learning.
d. self actualization, by seeking knowledge and truth.
ANS: C
Teaching activities to a patient that are to be used after discharge enhances independence and
promotes self esteem.
DIF: Cognitive Level: Application REF: p. 19 OBJ: Theory #7
TOP: Maslow’s Hierarchy of Needs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: psychosocial adaptation
12. Homeostasis can be described as:
a. the unchanging steady condition of humans in a changing external environment.
b.
a tendency of biological systems toward stability of the internal environment by
continuously adjusting to survive.
c. biological wellness that comes from the ability of the body to change and respond to
physical changes in the environment.
d.
a response to stress that results from a person’s choice of coping mechanisms to deal with
the stress.
ANS: B
Homeostasis results from the constant adjustment of the internal environment in response to
change; it is mental, emotional, and biological, as well as conscious and unconscious.
DIF: Cognitive Level: Comprehension REF: p. 20 OBJ: Theory #8
TOP: Homeostasis KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
13. A patient admitted for diagnostic tests is frightened of hospital procedures and is nervous
about the possible outcome of the tests. She states that her mouth is dry and her heart is
pounding. Her blood pressure is 168/78 mm Hg (her usual blood pressure is 140/80 mm Hg),
pulse is 112 beats/min, and respirations are 22 breaths/min. The nurse will recognize that these
signs and symptoms are:
a.
indicative of serious, acute health problems and should be reported to the physician
immediately.
b. most likely related to the disease for which the patient is admitted to the hospital.
c. the effects of the parasympathetic nervous system and can be ignored.
d. the effects of the sympathetic nervous system that can negatively affect the patient’s health.
ANS: D
Fear stimulates the sympathetic nervous system to produce the symptoms identified in the
question. If prolonged, they negatively affect a person’s health.
DIF: Cognitive Level: Analysis REF: p. 22, Table 2-2
OBJ: Theory #10 TOP: Stress KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: coping and adaptation
14. According to Hans Selye’s general adaptation syndrome (GAS), a person who has
experienced excessive and prolonged stress is likely to:
a. develop an illness or disease such as allergy, arthritis, or asthma.
b. become resistant to biological methods of treatment.
c. seek treatment for imagined illnesses and nonexistent symptoms.
d. be admitted to the hospital during the alarm stage.
ANS: A
Many diseases are known to be caused or exacerbated by prolonged stress. Seyle concluded that
stress induced illnesses respond to biological methods of treatment.
DIF: Cognitive Level: Comprehension REF: p. 22, Box 2-2
OBJ: Theory #10 TOP: Adaptation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: coping and adaptation
15. The nurse is aware that a stressor as experienced by an individual is usually perceived:
a. as a negative event or stimulus that affects homeostasis in maladaptive ways.
b. in different ways based on previous experience and personality traits.
c. as an opportunity for growth and learning.
d. in similar ways if age and education are similar.
ANS: B
Stressors are not perceived the same way by different people or even by the same person at
different times. The experience of a stressor depends on previous experience and personality, as
well as factors such as physical or emotional conditions, age, and education.
DIF: Cognitive Level: Comprehension REF: p. 22 OBJ: Theory #9
TOP: General Adaptation Syndrome KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychological Integrity: psychosocial adaptation
16. In 1946, the World Health Organization redefined health as the:
a. absence of disease or infirmity.
b. state of complete physical, mental, and social well being.
c. presence of disease or infirmity.
d. state of incomplete physical, mental, and social well being.
ANS: B
In 1946, the World Health Organization redefined health as “the state of complete physical,
mental, and social well being and not merely the absence of disease or infirmity.”
DIF: Cognitive Level: Knowledge REF: p. 13 OBJ: Theory #1
TOP: Views of Health and Illness KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
17. The nurse assesses that a person is in the acceptance stage of illness when the patient:
a. looks to home remedies to become well.
b. reassumes usual responsibilities and roles.
c. assumes the “sick” role.
d. rejects medical treatment.
ANS: C
When a person enters the acceptance stage of illness, he or she assumes the “sick role” and
withdraws from usual responsibilities and will frequently seek medical treatment at this time.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: Theory #1
TOP: Acceptance Stage KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: physiological adaptation
18. The nurse instructs a patient that according to Selye’s GAS theory, when stress is strong
enough and occurs over a long enough period, the patient will enter the stage of:
a. convalescence.
b. alarm.
c. transition.
d. exhaustion.
ANS: D
The exhaustion stage in the GAS occurs when the stressor has been present for such a period that
the patient will deplete the body’s resources for adaption.
DIF: Cognitive Level: Comprehension REF: p. 18 OBJ: Theory #1
TOP: Exhaustion Stage of GAS KEY: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity: coping and adaptation
19. The nurse explains defense mechanisms as a patient’s attempt to:
a. justify the patient’s assumption of the “sick” role.
b. reduce anxiety.
c. problem solve.
d. increase dependence.
ANS: B
Defense mechanisms are unconscious strategies to reduce anxiety.
DIF: Cognitive Level: Knowledge REF: p. 22, Table 2-3
OBJ: Theory #9 TOP: Defense Mechanisms
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychological Integrity: coping and adaptation
20. In giving nursing care to persons of Asian origin, the nurse should:
a. keep the room warm and free of drafts.
b. look the patient directly in the eye.
c. ask permission before touching the patient.
d. warmly clasp the patient’s hand in greeting.
ANS: C
Seek permission before touching persons of Asian extraction because they may be sensitive to
physical personal contact.
DIF: Cognitive Level: Application REF: p. 16, Table 2-1
OBJ: Theory #4 TOP: Cultural Sensitivity
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychological Integrity: coping and adaptation
21. Sickle cell anemia is an example of a biological trait found primarily in _____ populations.
a. Asian
b. African
c. American Indian
d. Hispanic
ANS: B
Sickle cell anemia is a biological variation found predominantly in people of African descent.
DIF: Cognitive Level: Knowledge REF: p. 16, Table 2-1
OBJ: Theory #5 TOP: Cultural Influences KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
22. When a young family man hospitalized after a breaking his leg confides to the nurse that he is
concerned about the well being of his family and financial stress, the nurse can best support his
sense of security by:
a. reassuring him that his leg will heal quickly.
b. actively listening to his concerns.
c. encouraging family to make frequent visits.
d. distracting him from his concerns by socialization.
ANS: B
A nurse’s ability to use active listening will enhance the sense of security when patients feel that
their needs are perceived accurately.
23. The nurse assesses successful adaptation in a post stroke patient when the patient:
a. learns to walk and maintain balance with the aid of a walker.
b. consistently takes antihypertensive drugs.
c. attempts to get out of bed unassisted.
d. refuses assistance with feeding.
ANS: A
Adaptation is a readjustment in habits to limitations and disabilities. Learning to walk and
maintain balance with the aid of a walker is an example of this.
DIF: Cognitive Level: Application REF: p. 20 OBJ: Theory #1
TOP: Adaptation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: physiological adaptation
24. The nurse takes into consideration that in the stage of resistance in Selye’s GAS, the patient:
a. regresses to a dependent state.
b. continues to battle for equilibrium.
c. becomes maladaptive.
d. begins to develop stress related disorders.
ANS: B
The resistance stage is the second stage in the GAS when a patient is still attempting to find
equilibrium.
DIF: Cognitive Level: Comprehension REF: p. 22 OBJ: Theory #10
TOP: Selye’s GAS KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: physiological adaptation
25. A patient states, “I am not obese. My entire family is large.” The nurse assesses that the
patient is using the defense mechanism of:
a. sublimation.
b. projection.
c. denial.
d. displacement.
ANS: C
Denial is a defense mechanism that allows a person to live as though an unwanted piece of
information or reality does not exist. There is a persistent refusal to be swayed by the evidence.
DIF: Cognitive Level: Application REF: p. 25, Table 2-3
OBJ: Theory #8 TOP: Defense Mechanisms
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: coping and adaptation
26. A child who has just been scolded by her mother proceeds to hit her doll with a hairbrush. The
nurse recognizes the child’s actions are characteristic of:
a. denial.
b. displacement.
c. rationalization.
d. repression.
ANS: B
Displacement is a defense mechanism that characterizes discharging intense feelings for one
person onto an object or another person who is less threatening, thereby satisfying an impulse
with a substitute object.
DIF: Cognitive Level: Application REF: p. 25, Table 2-3
OBJ: Theory #8 TOP: Defense Mechanisms
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: coping and adaptation
27. The nurse encourages a patient to participate in health maintenance by maintaining an ideal
body weight as a method of _____ prevention.
a. primary
b. secondary
c. tertiary
d. simple
ANS: A
Primary prevention avoids or delays occurrence of a specific disease or disorder.
DIF: Cognitive Level: Comprehension REF: p. 26 OBJ: Theory #1
TOP: Primary Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease
28. A nurse clarifies that methods of tertiary prevention are designed for:
a. rehabilitation.
b. delay of the development of a disorder.
c. screening for early detection of disease.
d. using an established protocol of therapy for a specific disease.
ANS: A
Tertiary prevention consists of rehabilitation measures after the disease or disorder has stabilized.
Latent prevention does not exist.
DIF: Cognitive Level: Comprehension REF: p. 26 OBJ: Theory #1
TOP: Tertiary Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: physiological adaptation
29. When a new admission to an extended care facility wanders about listlessly, eats only a small
amount of each meal, and keeps himself isolated, the nurse can intervene by:
a. assisting with feeding at each meal.
b. reminding him that he is in a safe and secure area.
c. socializing with him in the privacy of his room.
d. supporting him to interact with an exercise group.
ANS: D
The membership and social interaction in a group may provide a means for a sense of belonging.
DIF: Cognitive Level: Application REF: p. 19 OBJ: Theory #11
TOP: Love and Belonging KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: psychosocial adaptation
COMPLETION
30. Exercise can reduce stress and anxiety by the release of __________.
ANS:
endorphins
The release of endorphins induces a feeling of well being and tranquility.
DIF: Cognitive Level: Knowledge REF: p. 24 OBJ: Theory #11
TOP: Views of Health and Illness KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
31. Adequate __________ is necessary in the communication between nurse and patient in order
to meet the higher basic needs of security, love, belonging, and self esteem.
ANS:
feedback
Adequate feedback and clarification are essential in assisting the patient meet the higher level
needs.
DIF: Cognitive Level: Comprehension REF: p. 20 OBJ: Theory #7
TOP: Communication KEY: Nursing Process Step: Assessment
MSC: NCLEX: N/A
MULTIPLE RESPONSE
32. When the brain perceives a situation as threatening, the sympathetic nervous system reacts by
stimulating which of the following physiological functions? (Select all that apply.)
a. Constriction of the pupils
b. Dilation of the bronchial tubes
c. Decreased heart rate
d. Dilation of the pupils
ANS: B, D
Activation of the sympathetic nervous system causes the pupils and bronchial tubes to dilate. It
also causes the heart rate to increase.
DIF: Cognitive Level: Analysis REF: p. 22, Table 2-3
OBJ: Theory #11 TOP: Sympathetic Nervous System
KEY: Nursing Process Step: Assessment MSC: NCLEX: N/A
33. The nurse describes behaviors of the transition stage of illness, which are: (Select all that
apply.)
a. awareness of vague symptoms.
b. denial of feeling ill.
c. resorts to self medication.
d. withdrawal from roles and responsibilities.
e. recovery from illness begins.
ANS: A, B, C
The transition stage (onset) of illness is demonstrated by the patient’s awareness of vague
symptoms, denial of feeling ill, and initiation of self medication; however, he or she still fulfils
the roles and responsibilities of life.
DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: Theory #1
TOP: Stages of Illness KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: physiological adaptation
34. Which defines the holistic approach to caring for the sick and promoting wellness? (Select all
that apply.)
a. The nurse’s focus is specific to the disease or injury.
b. The nurse realizes that each person has a responsibility for his or her own health.
c.
Health care providers are required to intervene on behalf of all persons to ensure that health
goals are met.
d.
Providers combine traditional methods of health care with relaxation techniques for pain
management.
e. A change in one aspect of a person’s life may or may not alter the person as a whole.
ANS: B, C, D, E
The holistic approach to medicine treats the patient as a whole and may use a mix of traditional
medicine and alternative medicine. Any change in one aspect of the whole may change the entire
whole.
DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: Theory #6
TOP: Holistic Approach KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
35. The responses during the alarm stage of the general adaptation syndrome as defined by Hans
Selye include: (Select all that apply.)
a. slight increase in body temperature.
b. substantial increase in energy.
c. decreased appetite.
d. hormones released for mobilization for defense.
e. the body’s adaptation abilities temporarily overreacting.
ANS: A, C, D
The responses during the alarm stage according to the general adaptation syndrome include: a
slight rise in temperature, a loss of energy, decreased appetite, and a release of hormones that
mobilizes the body’s defenses.
DIF: Cognitive Level: Comprehension REF: p. 21 OBJ: Theory #10
TOP: General Adaptation Syndrome KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
36. The nurse clarifies that a person who is self actualized would have the characteristics of:
(Select all that apply.)
a. having met all other need levels.
b. being certain of their beliefs and values.
c. not being swayed by new ideas.
d. having little need for creative self expression.
e. depending on significant others.
ANS: A, B
Chapter3
MULTIPLE CHOICE
1. A student nurse who is not yet licensed:
a. may not perform nursing actions until he or she has passed the licensing examination.
b. is not responsible for his or her actions as a student under the state licensing law.
c. may perform nursing actions only under the supervision of a licensed nurse.
d. must apply for a temporary student nurse permit to practice as a student.
ANS: C
Students may perform nursing actions before they are licensed but only under the supervision of
a licensed nurse. The student is responsible for his or her own actions; however, the supervising
nurse may also be responsible, depending on the situation. No special permit is required to
practice as a student in an approved school of nursing.
DIF: Cognitive Level: Knowledge REF: p. 30 OBJ: Theory #1
TOP: Practice Regulations for the Student Nurse KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
2. During an employment interview, the interviewer asks the nurse applicant about HIV status.
The nurse applicant can legally respond:
a. “No,” even though he or she has a positive HIV test.
b. “I don’t know, but I would be willing to be tested.”
c. “I don’t know, and I refuse to be tested.”
d. “You do not have a right to ask me that question.”
ANS: D
In employment practice, it is illegal to discriminate against people with certain diseases or
conditions. Asking a question about health status, especially HIV or AIDS infection, is illegal.
DIF: Cognitive Level: Application REF: p. 31 OBJ: Clinical Practice #1
TOP: Discrimination KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
3. An example of a violation of criminal law by a nurse is:
a. taking a controlled substance from agency supply for personal use.
b. accidentally administering a drug to the wrong patient, who then has a serious reaction.
c. advising a patient to sue the doctor for a supposed mistake the doctor made.
d. writing a letter to the newspaper outlining questionable or unsafe hospital practices.
ANS: A
Theft of a controlled substance is a federal crime and consequently a crime against society.
DIF: Cognitive Level: Application REF: p. 30 OBJ: Theory #2
TOP: Criminal Law KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
4. The LPN (LVN) assigns part of the care for her patients to a nursing assistant. The LPN is
legally required to perform which of the following for the residents assigned to the assistant?
a. Toilet the residents every 2 hours and as needed.
b. Feed breakfast to one of the residents who needs assistance.
c. Give medications to the residents at the prescribed times.
d. Transport the residents to the physical therapy department.
ANS: C
Toileting, feeding, and transporting residents or patients are tasks that can be legally assigned to
a nurse’s aide. Administering medications is a nursing act that can be performed only by a
licensed nurse or by a student nurse under the supervision of a licensed nurse.
DIF: Cognitive Level: Application REF: p. 31 OBJ: Theory #3
TOP: Delegation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe Effective Care Environment: coordinated care
5. If a nurse is reported to a state board of nursing for repeatedly making medication errors, it is
most likely that:
a. the nurse will immediately have his or her license revoked.
b. the nurse will have to take the licensing examination again.
c. a course in legal aspects of nursing care will be required.
d. there will be a hearing to determine whether the charges are true.
ANS: D
The nurse may have his or her license revoked or be required to take a refresher course, but this
would be based on the evidence presented at a hearing. The licensing examination is not usually
required as a correction of the situation as described.
DIF: Cognitive Level: Knowledge REF: p. 31 OBJ: Theory #3
TOP: Professional Discipline KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
6. A nurse co-worker arrives at work 30 minutes late, smelling strongly of alcohol. The fellow
nurses’ legal course of action is to:
a. have the nurse lie down in the nurses’ lounge and sleep while others do the work.
b. state that, if this happens again, it will be reported.
c. report the condition of the nurse to the nursing supervisor.
d. offer a breath mint and instruct the nurse co-worker to work.
ANS: C
Nurses must report the condition. It is a nurse’s legal and ethical duty to protect patients from
impaired or incompetent workers. Allowing the impaired nurse to sleep enables the impaired
nurse to avoid the consequences of his or her actions and to continue the risky behavior.
Threatening to report “the next time” continues to place patients at risk, as does masking the
signs of impairment with breath mints.
DIF: Cognitive Level: Application REF: p. 31 OBJ: Theory #3
TOP: Professional Discipline KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
7. When a student nurse performs a nursing skill, it is expected that the student:
a. perform the skill as quickly as the licensed nurse.
b. achieve the same result as the licensed nurse.
c. not be held to the same standard as the licensed nurse.
d. always be directly supervised by an instructor.
ANS: B
Students are not expected to perform skills as quickly or as smoothly as experienced nurses, but
students must achieve the same result in a safe manner.
DIF: Cognitive Level: Comprehension REF: p. 30 OBJ: Theory #1
TOP: Practice Regulations for the Student Nurse KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
8. If a nurse receives unwelcome sexual advances from a nursing supervisor, the first step the
nurse should take is to:
a. send an anonymous letter to the nursing administration to alert them to the situation.
b.
tell the nursing supervisor that she is uncomfortable with the sexual advances and ask the
supervisor to refrain from this behavior.
c. report the nursing supervisor to the state board for nursing.
d. resign and seek employment in a more comfortable environment.
ANS: B
The first step in dealing with sexual harassment in the workplace is to indicate to the person that
the actions or conversations are offensive and ask the person to stop. If the actions continue, then
reporting the occurrence to the supervisor or the offender’s supervisor is indicated.
DIF: Cognitive Level: Application REF: p. 32 OBJ: Clinical Practice #1
TOP: Sexual Harassment KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
9. A person who has been brought to the emergency room after being struck by a car insists on
leaving, although the doctor has advised him to be hospitalized overnight. The nurse caring for
this patient should:
a. have him sign a Leave Against Medical Advice (AMA) form.
b. tell him that he cannot leave until the doctor releases him.
c. immediately begin the process of involuntary committal.
d. contact the person’s health care proxy to assist in the decision-making process.
ANS: A
A person has the right to refuse medical care, and agencies use the Leave AMA to document the
medical advice given and the patient’s informed choice to leave against that advice.
DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3
TOP: Patients’ Rights KEY: Nursing Process Step: Implementation
MSC: NCLEX: N/A
10. The information in a patient’s chart may legally be:
a. copied by students for use in school reports or case studies.
b. provided to lawyers or insurers without the patient’s permission.
c. shared with other health care providers at the patient’s request.
d. withheld from the patient, because it is the property of the doctor or agency.
ANS: C
A release or consent is required to provide information from a patient’s chart to anyone not
directly caring for that patient. The patient must provide consent to provide information to
insurers, lawyers, or other health care agencies or providers. The patient has the right to access
the information in his or her chart (copies), but the agency or doctor retains ownership of the
document.
DIF: Cognitive Level: Application REF: p. 34 OBJ: Theory #5
TOP: Legal Documents KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
11. If a patient indicates that he is unsure if he needs the surgery he is scheduled for later that
morning, the nurse would best reply:
a. “Your doctor explained all of that yesterday when you signed the consent.”
b. “Your doctor is in the operating room; she can’t talk to you now.”
c. “You should have the surgery; your doctor recommended that you have it.”
d. “I will call the doctor to speak with you before you go to the operating room.”
ANS: D
A consent can be withdrawn at any time before the treatment or procedure has been started. The
physician should be notified by the supervising nursing staff of the unit.
DIF: Cognitive Level: Application REF: p. 36 OBJ: Clinical Practice #4
TOP: Informed Consent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: basic care and comfort
12. A 16-year-old boy is admitted to the emergency room after fracturing his arm from falling off
his bike while visiting with his stepfather who is not the custodial parent. The nurse is preparing
him to go to the operating room but must obtain a valid informed consent by:
a. having the patient sign the consent for surgery.
b. obtaining the signature of his stepfather for the surgery.
c. declaring the patient to be an emancipated minor.
d. obtaining permission of the custodial parent for the surgery.
ANS: D
The patient is a minor and cannot legally sign his own consent unless he is an emancipated
minor; the guardian for this patient is the custodial parent. A step-parent is not a legal guardian
for a minor unless the child has been adopted by the step-parent. The hospital does not have the
authority to declare the patient an emancipated minor.
DIF: Cognitive Level: Application REF: p. 36 OBJ: Clinical Practice #3
TOP: Consent KEY: Nursing Process Step: Intervention
MSC: NCLEX: Safe Effective Care Environment: coordinated care
13. A patient has advance directives spelled out in a durable power of attorney, with the
appointment of his daughter as his health care agent. The daughter will be responsible for:
a. paying all the medical bills associated with the father’s illness.
b. making all informed consent decisions for her father.
c. making all choices about her father’s health care if the father is unable.
d. paying only for those health care decisions based on the advance directives.
ANS: C
A health care agent makes decisions for the patient only when a patient is unable, according to
the wishes made known by the patient in advance directives. A health care agent is not
responsible for financial decisions or payments.
DIF: Cognitive Level: Application REF: p. 36 OBJ: Clinical Practice #5
TOP: Advance Directives KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
14. A patient has signed a do-not-resuscitate (DNR) order. If a nurse performs cardiopulmonary
resuscitation (CPR) when the patient stops breathing and then successfully revives the patient,
the:
a. nurse could be found guilty of battery.
b. patient would have no grounds for legal action.
c. patient could charge the nurse with false imprisonment.
d. nurse could be found guilty of assault.
ANS: A
A nurse who attempts CPR on a patient who had a doctor’s order for a DNR could be found
guilty of battery.
DIF: Cognitive Level: Comprehension REF: p. 9 | p. 36 OBJ: Clinical Practice #3
TOP: DNR KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
15. A patient refuses to take his medications or to eat his breakfast. He is alert, mentally
competent, and fairly comfortable. The nurse should:
a. give the medications by injection if the patient will not take them orally.
b. respect the patient’s right to refuse medications or food, because he is competent.
c. tell the patient that he must cooperate with his care.
d. contact the doctor to insert a feeding tube to supply both medicine and food.
ANS: B
The competent patient has the right to refuse medicine, food, treatments, and procedures. Giving
(or threatening to give) medications by injection over the patient’s objections is considered
battery. Threatening the patient or overriding the patient’s wishes is a violation of the patient’s
bill of rights and constitutes assault or battery.
DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3
TOP: Patients’ Rights KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
16. A nurse remarks to several people that “Dr. X must be getting senile because she makes so
many mistakes.” If that remark results in some of Dr. X’s patients changing to another doctor, Dr.
X would have grounds to sue the nurse for:
a. slander.
b. libel.
c. invasion of privacy.
d. negligence.
ANS: A
A person who makes untrue, malicious, or harmful remarks that damage a person’s reputation
and cause injury (loss of business) is guilty of defamation and slander. Libel is defamation that is
written.
DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #5
TOP: Defamation/Slander KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
17. A licensed nurse is liable for charges of malpractice when she:
a. does not show up for work and fails to call to notify the agency.
b. clocks in for another nurse to prevent that nurse from having pay docked.
c. falsifies data, causing the patient to suffer problems resulting in death.
d. assists in performing CPR that is unsuccessful, and the patient dies.
ANS: C
Malpractice is professional negligence or, in this case, doing (falsifying) something the
reasonable and prudent nurse would not do. It is the proximate cause of the patient injury. This is
a case of causation.
DIF: Cognitive Level: Application REF: p. 37, Box 3-6
OBJ: Theory #5 TOP: Negligence and Malpractice KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
18. A postoperative patient in the intensive care unit (ICU) is so confused and agitated that staff
have not been able to safely care for him. He has pulled out his central line once, and he slides to
the bottom of the bed, where he attempts to climb out, pulling and disrupting the various tubes
and monitors. The nurse’s best course of action is to:
a. place him in a protective vest device.
b. use a sheet to tie him in a chair at the nurses’ station.
c. request that the doctor write an order for a protective device and/or medication.
d. call a family member to stay with the patient.
ANS: C
A protective device may not be used (except in an emergency) without a doctor’s order, and it is
used only when other less restrictive means do not provide safety for the patient.
DIF: Cognitive Level: Application REF: p. 39 OBJ: Clinical Practice #3
TOP: False Imprisonment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe Effective Care Environment: safety and infection control
19. An elderly, slightly confused patient sustains an injury from a heating pad that was wrongly
applied by the nurse. The nurse should:
a. pretend to be unaware of the injury to the patient.
b. report the incident to the risk management team via an incident report.
c. document in the patient’s chart that an incident report was filled out.
d. not chart anything about the injury in the patient’s chart.
ANS: B
When an incident occurs that has potential for a future lawsuit, the risk management team should
be aware of it as soon as possible. An incident report should be filled out, and the patient chart
should be documented to describe the injury. No mention of the incident report is usually made
in the patient chart. Honesty and a forthright explanation to the patient reduce the risk of
lawsuits.
DIF: Cognitive Level: Application REF: p. 40 OBJ: Theory #5
TOP: Incident Reports KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
20. Nursing liability insurance is a policy purchased and put into effect by the nurse for the
purpose of:
a. providing protection against being sued.
b. reducing the chance of litigation.
c. paying attorney fees and any award won by the plaintiff.
d. providing the hospital with added protection.
ANS: C
Nursing liability pays attorney fees and any award won by the plaintiff.
DIF: Cognitive Level: Comprehension REF: p. 40 OBJ: Theory #5
TOP: Nursing Ethics KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
21. Ethics and law are different from each other in that ethics:
a. bear a penalty if violated.
b. are voluntary.
c. rarely change.
d. can always direct all decisions.
ANS: B
Ethics are voluntary and are based on values. Ethics may change as parameters of health care
change. There is no penalty for violation.
DIF: Cognitive Level: Analysis REF: p. 40 OBJ: Theory #6
TOP: Nursing Ethics KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
22. To best protect himself or herself from being sued, the nurse should:
a. continue to do procedures as taught in school.
b. purchase malpractice insurance.
c. maintain competency.
d. use evidence-based practice.
ANS: C
Keeping up with continuing education, maintaining competency, and seeking to improve one’s
own practice by self-evaluation will best protect the nurse.
DIF: Cognitive Level: Comprehension REF: p. 39, Box 3-7
OBJ: Theory #5 TOP: Avoiding Lawsuits KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
23. The Health Insurance Portability and Accountability Act’s (HIPAA) main focus is in keeping:
a. patients safe from harm.
b. patient information in a secure office area.
c. medications in a locked area.
d. hospital infections under control.
ANS: B
HIPAA regulates the way patient information is conveyed and stored.
DIF: Cognitive Level: Comprehension REF: p. 34, Box 3-4
OBJ: Clinical Practice #1 TOP: HIPAA KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
24. When a patient asks a nurse to witness the signing of a will, the nurse should refer the request
to the:
a. nurse supervisor.
b. hospital legal department.
c. notary public for the hospital.
d. nurse’s attorney.
ANS: C
Although witnessing a legal document for a patient is not illegal, most agencies have a policy
regarding the proper course of action by referring the patient to the notary public.
DIF: Cognitive Level: Application REF: p. 36 OBJ: Theory #1
TOP: Witnessing Wills and Other Legal Documents
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe Effective Care Environment: safety and infection control
25. Criteria that justify becoming an emancipated minor and able to sign a medical consent
include all of the following except:
a. independence established through a court order.
b. service in the armed forces.
c. a 14-year-old whose parents are dead.
d. a 17-year-old pregnant female.
ANS: C
Criteria are that the minor be independent by court order, be a member of the military, be
pregnant, or be married.
DIF: Cognitive Level: Application REF: p. 36 OBJ: Clinical Practice #33
TOP: Emancipated Minor KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
26. A written statement expressing the wishes of a patient regarding future consent for or refusal
of treatment in case the patient is incapable of participating in decision making is an example of:
a. a privileged relationship.
b. a health care agent.
c. an advance directive.
d. witnessed will.
ANS: C
An advance directive makes the patient’s wishes known regarding medical decisions and consent
in the event that he or she is unable to participate in decision making.
DIF: Cognitive Level: Knowledge REF: p. 36 OBJ: Clinical Practice #5
TOP: Legal Terms KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
27. A nurse is caring for an unmarried 16-year-old patient who has just given birth to a baby boy.
The nurse will get the consent to perform a circumcision on the patient’s son from the:
a. patient’s father.
b. patient’s physician.
c. patient’s mother.
d. 16-year-old patient.
ANS: D
Pregnancy qualifies as the basis for the 16-year-old to be treated as an emancipated minor.
DIF: Cognitive Level: Application REF: p. 36 OBJ: Clinical Practice #3
TOP: Patients’ Rights KEY: Nursing Process Step: Implementation
MSC: NCLEX: N/A
28. A 48-year-old man refuses to take a medication ordered for the control of his blood pressure.
The nurse’s most effective response would be:
a. “Your doctor expects you to be compliant.”
b. “You have the right to refuse. This medication keeps your blood pressure under control.”
c. “Fine. I will document that you are refusing this drug.”
d. “Are you aware that you could have a stroke?”
ANS: B
Patients have the right to refuse medication, but it is the nurse’s responsibility to explain the
reason for the particular drug.
DIF: Cognitive Level: Application REF: p. 37 OBJ: Theory #1
TOP: Legal Standards KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease
29. The Occupational Safety and Health Act includes all of the following except:
a. regulations for handling infectious materials.
b. radiation and electrical equipment safeguards.
c. staffing ratios and delegation criteria.
d. regulations for handling toxic materials.
ANS: C
The Occupational Safety and Health Act was passed in 1970 to improve the work environment in
areas that affect workers’ health or safety. It includes regulations for handling infectious or toxic
materials, radiation safeguards, and the use of electrical equipment.
DIF: Cognitive Level: Comprehension REF: p. 31 OBJ: N/A
TOP: OSHA KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
30. The most frequently cited cause of a sentinel event by the Joint Commission is a problem in:
a. applying physical restraints.
b. methods of patient transportation.
c. medication errors.
d. inadequate communication.
ANS: D
The most frequently cited cause of a sentinel event by the Joint Commission is communication.
During “handoff” communication, there is a risk that critical patient care information might be
lost due to lack of communication.
DIF: Cognitive Level: Knowledge REF: p. 33 OBJ: Clinical Practice #2
TOP: Communication KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
31. The acronym SBAR is a method to communicate with a physician that clarifies a situation
that may result in litigation. The acronym stands for:
a. situation, background, alterations, results.
b. subjective, believable, actual, recommendation.
c. situation, background, assessment, recommendation.
d. situation, basis, assessment, recommendation.
ANS: C
SBAR is an acronym that stands for situation, background, assessment, and recommendation.
This undetailed analysis clarifies the situation in a manner that is concise yet complete.
DIF: Cognitive Level: Knowledge REF: p. 33 OBJ: Theory #5
TOP: SBAR Reporting KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
32. The patient who cannot legally sign his or her own surgical consent is a(n):
a. 17-year-old who is serving in the armed forces.
b. 16-year-old who is legally married.
c. 17-year-old emancipated minor.
d. 18-year-old who received a narcotic 30 minutes ago.
ANS: D
The person giving the consent must be able to take part in the decision making. A sedated person
does not have this ability.
DIF: Cognitive Level: Application REF: p. 36 OBJ: Clinical Practice #3
TOP: Patients’ Rights KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
33. The nurse who may be liable for invasion of privacy would be the nurse who is:
a. refusing to give patient information to a relative over the phone.
b. firmly closing the door prior to bathing the patient.
c. discussing her patients with a fellow nurse.
d. reporting the patient as a possible victim of elder abuse.
ANS: C
Discussing a patient with anyone, even another health professional, who is not involved in the
patient’s care can put a nurse at risk for invasion of privacy.
DIF: Cognitive Level: Application REF: p. 38 OBJ: Clinical Practice #3
TOP: Patients’ Rights KEY: Nursing Process Step: Implementation
MSC: NCLEX: N/A
34. A characteristic of an advance directive is that:
a. advance directives do not expire.
b. only some states recognize advance directives.