Any practice described in this book should be applied by the reader in accordance with professional standards of care applicable to the unique circumstances that may apply to each situation. Their support was essential to the completion of this book, and they are loved and appreciated by us.
Acknowledgments
Help students identify and develop their cognitive and personal competencies by exploring the Helix of Critical Thinking. Support students who maximize their critical thinking skills by being positive, reflective, inquisitive and creative.
A Message to Nursing Educators
Have students practice answering the alternative format questions (eg, expository, multiple choice, drag and drop [edited answer], hot spot, fill in the blank, audio) presented in Chapter 6 to develop critical thinking skills. in relation to issues that authentically evaluate unique nursing interventions (eg, calculations, prioritization, interpretation of sounds, analysis of data from multiple sources). When writing the second edition, our goals were to produce more quality nursing fundamentals questions that included alternative format items, a comprehensive 100-point final exam, and a CD with two integrated 75-point tests.
A Message to Nursing Students
The components of a strong foundation in nursing are a comprehensive understanding of the fundamentals of nursing theory, well-developed critical thinking skills, and an inventory of strategies for successful test taking. Allows you to complete two comprehensive examinations that integrate subunits of the basics of nursing content.
Glossary of English Words Commonly Encountered
INTRODUCTION
Definition of Critical Thinking
Fundamentals of Critical Thinking Related to Test
The interactive nature of the Helix of Critical Thinking and the nursing process is demonstrated in Figures 1-3. The interactive nature of the Helix of Critical Thinking and the problem-solving process is demonstrated in Figures 1-4.
MAXIMIZE YOUR CRITICAL-THINKING ABILITIES Be Positive: You Can Do It!
Be Reflective: You Need to Take One Step Backward Before Taking Two Steps Forward!
Taking blood pressure in the left arm and assessing pulse rate, rhythm, and volume were habits because you didn't have to find a new method when responding to the situation. I didn't understand what the question was asking because of the English or medical vocabulary used in the question.
Be Inquisitive: If You Don’t Go There, You’ll Never Get Anywhere!
If I say, "You look very sad," then the patient can discuss the feelings felt at that time. You will realize that you have reached a more advanced level of critical thinking when you determine that your next action is based on the concept of it depends.
O VERCOME B ARRIERS TO B EING I NQUISITIVE
If you are studying for an NCLEX exam, you can choose to study 2 hours per day for 3 months. Only you can determine how much time you need to study or prepare for a test.
Be Creative: You Must Think Outside the Box!
When you are working under a time constraint, you may not have enough time to process and understand information. The length of time to study for a test depends on the amount and type of content to be tested and how much previous study has been done.
O VERCOME B ARRIERS T O C REATIVITY
If you are preparing for a comprehensive exam for a course at the end of the semester, you may choose to study 3 hours per night for 1 to 2 weeks. When you accept these facts, you can be confident that you can take risks with your creativity.
CRITICAL THINKING APPLIED TO TEST TAKING Educational Domains
However, you must realize that throughout your nursing career you will face outcomes that are successful as well as those that are unsuccessful. How you manage your feelings regarding each, especially those that are unsuccessful, will affect your willingness to take future creative risks.
Components of a Multiple-Choice Question
For example, a nursing student may be taught by an instructor to create a sterile field for a sterile dressing change using the inside of a sterile glove package. When following a sterile dressing change procedure in a clinical skills book, the instructions may say to use a separate sterile cloth for the sterile field.
Cognitive Levels of Nursing Questions
CRITICAL-THINKING STRATEGY TO ANSWER
MULTIPLE-CHOICE QUESTIONS: THE RACE MODEL
The following discussion examines this critical-thinking strategy in relation to the thought processes represented in multiple-choice nursing questions. It is important to understand this content in order to apply the critical thinking strategies inherent in each cognitive level question.
Knowledge Questions: Remember Information!
This question does not require complex comprehension, comparative analysis or application skills; only requires recall of information about docusate sodium (Colace). Because 2, 3, and 4 are not the classification names of docusate sodium (Colace), they can be eliminated.
Comprehension Questions: Understand Information!
The word in the stem indicating that this is a comprehension-level question is advance. The word in the stem indicating that this is a comprehension level question prevents.
Application Questions: Use Information!
The nurse replies, "Would you rather not have the surgery now?" Which interview technique did the nurse use. The example in the stem does not use focus because the patient's statement was short and contained one message that the nurse repeated.
Analysis Questions: Scrutinize Information!
Which is an example of the best interviewing skill to use when initially responding to a statement made by the mother of a sick child. This response focuses on the severity of the child's illness, which is not the issue raised in the mother's statement.
SUMMARY
Nursing Within the Context of Contemporary Health Care
KEYWORDS
QUESTIONS
The nurse identifies that the patient is in which stage of the Kübler-Ross stages of grief. The nurse is caring for an immobilized patient admitted to the hospital with a pressure ulcer.
ANSWERS AND RATIONALES
Rapid, shallow breathing is a physiologi- cal response associated with the fight-or-
As the multiplicity of stressors increases, the harder it is for a person to cope. As
Maslow’s Hierarchy of Needs ranks human needs in order of ascending
This action supports achieving a goal in the Value-Belief category, not in the Role-Relationship category. This action supports achieving a goal in the Cognitive-Perceptual category, not in the Role Relationship category.
This action supports achievement of a goal in the Role-Relationship category
Safety and security needs are related to being and feeling protected in the physiological and interpersonal domains. This action supports the achievement of a goal in the Health Perception/Health Management category, not the Role Relationship category.
Belonging and love needs are directly below self-esteem needs on Maslow’s
This does not meet the needs at the safety and security level of Maslow's hierarchy of needs. This does not meet the needs at the love and belonging level of Maslow's hierarchy of needs.
The Superego monitors the ego. The superego is concerned with social
This does not satisfy needs at the physiological level of Maslow's hierarchy of needs. Love and belonging needs are related to giving and receiving affection, trying to avoid loneliness and isolation, and wanting to feel like we belong.
Reactions to stress are both conscious and unconscious. In the General and
Physiological needs are related to having enough air, food, water, rest, shelter and the ability to eliminate and regulate body temperature.
A patient in the bargaining stage of grieving seeks to avoid the loss and will
Self-actualization needs are after, not before, self-esteem needs on Maslow's Hierarchy of Needs model. Self-actualization is a higher-level need than self-esteem needs, therefore self-esteem needs must be satisfied before self-actualization needs.
There is little consensus about any one definition of health, wellness, and ill-
A person who is able to perform daily tasks, interact successfully with others, manage stress and emotions, and strive for continued growth and who has meaning or purpose in life has a sense of well-being regardless of the severity of illness or disability. Not all definitions of health identify that a person is able to control factors that affect health.
People living on the street most likely have a multiplicity of stressors in many
For example, the Clinical Model has a narrow interpretation that sees health as the absence of signs and symptoms of disease or injury. The Adaptive Model is one of the few that addresses a person's ability to use intentional adaptive responses and processes in response to internal and external stimuli to achieve health.
Shortness of breath is a response to the physiological stress of walking up a hill
An external locus of control least describes self-actualized people
A strict interpretation of the Role-Performance Model of Health would most likely describe a police officer who changes jobs due to a physical or emotional inability to continue the first job as unhealthy. According to Maslow's hierarchy of needs, freedom from pain is considered a safety and security need.
Health and illness are on opposite ends of the health-illness continuum and
According to the Social Readjustment Rating Scale by Holmes and Rahe, retirement ranks 10th on the list of life events likely to cause stress-related illness, with a life-changing unit score of 45 out of 100. According to the Social Readjustment Rating Scale By Holmes and Rahe, pregnancy ranks ranked 12th on the list of life events most likely to cause stress-related illness, with a life-changing unit score of 40 out of 100.
The Libido refers to the psychic energy derived from basic biological urges
According to the Role Performance Model of Health, a person who cannot fulfill responsibilities associated with one's work is considered ill. According to Maslow's Hierarchy of Needs, freedom from hunger is considered a first-level physiological need, not a safety and security need.
According to the Social Readjustment Rating Scale by Holmes and Rahe,
Adaptive capacity refers to the physical, emotional, mental, and spiritual
Keeping a deceased child’s room un- changed for years is outside the usual
Love and belonging needs identified in Maslow’s Hierarchy of Needs are asso-
Individuals must replace work roles with new roles that are a source of self-esteem. According to Havighurst, developmental tasks associated with each age group are the source of conflict, not responses that attempt to reduce anxiety.
Defense mechanisms are unconscious coping techniques that deny, distort, or
The force of pressure is a physical stressor. Pressure is the continuous
Adaptations do not limit stressors, but are responses to stressors. Internal or
Freud believed that all behavior has meaning and called this theory psychic
Adjustments are an attempt to find balance and are based on many variables, including a person's available physiological, psychosocial, spiritual, and emotional resources, as well as interactive factors, and not just the nature of the stressor. This model states that health is defined in terms of a person's ability to fulfill social roles; if the roles are fulfilled, people consider themselves healthy even if they have a disease.
This theory focuses on perceived threats, severity, benefits, barriers, cues
It is an ongoing process that is constant and dynamic and is essential for physical, psychosocial, spiritual and emotional well-being.
Impaired immunity is a serious threat caused by prolonged periods of stress
This statement characterizes the denial stage of the grieving process. During
Beginning at the child’s level of under- standing is essential when preparing a
Anxiety is the most common response to all new experiences that serve as an
Freud believed that libidinal or instinc- tual drives are the underlying stimulus
This is an example of a health belief. A health belief is a conviction or opinion
This is an example of a health belief. If a person believes that smoking ciga-
This statement reflects “doctor shop- ping,” which is a form of denial, the
This statement reflects the anger stage, the second stage of the Kübler-
This statement characterizes the bar- gaining stage, the third stage of the
This statement reflects depression, the fourth stage of the Kübler-Ross theory
This statement characterizes accept- ance, the fifth stage of the Kübler-Ross
The nurse provides information about the medication, but the patient continues to refuse the medication. How does the nurse function when administering a medication for which PRN is stated on the prescription?
The National Council of State Boards of Nursing is responsible for the NCLEX
Notifying the doctor will eventually be necessary, but this is not a priority at this time. The patient has been instructed about the medication and refuses the medication adamantly.
Narcotics depress the central nervous system, including decision-making
Compassion and good intentions are not an acceptable basis for action outside the scope of nursing practice. Sigma Theta Tau, the international honor society of nursing, recognizes academic achievement and leadership qualities, encourages high professional standards, fosters creative endeavors, and supports excellence in the profession of nursing.
This is the safest intervention because it goes to the original source of the pre-
Risk-management committees use statistical data about accidents and
Nurses have a professional responsibility to know or investigate the standard dose
A professional nurse is able to explain these standards as they apply to a litigation situation. The role of the registered nurse is not to judge the laws that apply to the practice of nursing.
The nurse is initiating the referral to the member of the clergy and is there-
The nurse does not need a practitioner's order to make a referral to a member of the clergy.
Informed consent is an agreement by a client to accept a course of treatment
Fecal material in the intestines can interfere with the visualization,
When a nurse renders emergency care, the nurse has an ethical responsibility
The National League for Nursing (NLN) promotes the development and improvement of nursing education and nursing service. Its goals are to promote high standards of nursing practice and to support the educational and professional advancement of nurses.
A nurse is not permitted legally to prescribe wound care. The nurse
The American Nurses Association (ANA) is the national professional organization for nursing in the United States. The actual duties, such as maintaining a list of nurses who can legally work in the state, may be delegated to another official body, such as a State Board of Nursing or a State Education Department.
The Nurse Practice Act in a state stipulates the requirements for
In the United States, graduates of educational programs that prepare students to become Licensed Practical Nurses or Registered Professional Nurses must successfully complete the National Council Licensure Examination-PN (NCLEX-PN) and the National Council Licensure Examination-RN. (NCLEX-RN), respectively, as part of the criteria for licensure. In this situation, the nurse is not working with other health care professionals to carry out a physician's order.
Liable means a person is responsible (accountable) for fulfilling a contract
Nurse salaries are determined through negotiations between nurses or their representatives, such as a union or professional nursing organization, and the representatives of the agency for which they work. Changing a dry sterile dressing is an interdependent action by the nurse when the physician's wound care order states: Dry sterile dressing PRN.
This is an example of assault. Assault is a verbal attack or unlawful threat caus-
Although this action is essential to the safe administration of a medication to a patient, it is not the first step of this procedure. Although this can be done as a time management practice, it is not the first step when preparing to administer a medication to a patient.
The administration of medications is a dependent function of the nurse. The
Licensure indicates that a person has met minimal standards of
Only malpractice is misconduct performed in professional practice,
Incident Reports help to identify patterns of risk so that corrective
The ancient legal doctrine respondeat superior means “let the master answer.”
Administering a medication is a dependent function of the nurse
An interdependent intervention re- quires a practitioner’s order associated
This statement is an unjust threat
Every state has its own Nurse Practice Act that describes and defines the legal
Collegiate Nursing Education and state education departments are the primary organizations that accredit nursing education programs in the United States. Educational standards are set by accrediting bodies such as the Accreditation Commission of the National League for Nursing, the Commission on Advanced Nursing Education, and state departments of education.
A client living in a protected environ- ment such as a home for developmen-
It is the responsibility of the practi- tioner to provide all the information
Patients must be competent to sign a consent form. The patient must be
Patients must give their consent voluntarily and without coercion
The health-care provider witnessing the signing of the consent must ensure
This is an example of slander. Slander is a false spoken statement resulting in
This is an example of slander. It is a malicious, false statement that may
Several nurses complain to the nurse manager that one of the patient care workers continually takes extended lunch breaks. What is the nurse manager's most important action to overcome resistance to change?
This is an example of expert power
A leader bases coercive power on the fear of punitive withholding of rewards or retributions. Referent power is associated with respect for the leader due to his charisma and previous successes.
The one who delegates a task is responsible for ensuring that the task
As a nurse manager grows into the role, peers will recognize the nurse manager's leadership ability. Influence is the use of persuasive and communication skills to exercise power informally without using the power associated with formal authority.
Delegating tasks within the scope of nursing practice is an independent func-
Primary nursing is a case management approach in which one nurse is respon-
Recognition of a problem is the first step in the problem-solving process
When the nurse manager follows policies and procedures, the manager is
The word consultative is most closely related to the democratic leadership
Legally required activities must be accomplished because they are depen-
This is an example of the directing function of management. Directing in-
Students are accountable for the tasks assigned by the instructor or preceptor
Change causes one to move from the comfortable to the uncomfortable and
Obtaining vital signs can be delegated to a nursing assistant because it is not
The nursing supervisor is higher up in the chain of command in a Chart of Organization than another employee who is the best person for the staff nurse to seek assistance when help is needed to solve a complex problem. The employee may be fully aware of the requirements of the job description and does not need to have them described.
This is the issue that the nurse man- ager needs to explore. The employee
Generally, in the chain of command of an organization the staff nurse works
Safety of the patient is the priority
Demonstration is the safest way to assess whether a person has the
This is the most appropriate leadership style in a crisis when urgent decisions
The person assigned a task is responsible for the outcome of the assigned task. However, the registered nurse who delegates the task is not relieved of responsibility, but is responsible for the actions of the person to whom the task is delegated as well as for the result of the intervention.
Problem recognition is the first step in the problem-solving process. Once the
The registered nurse must take into account the qualifications and scope of practice of each professional and non-professional nursing team member and assign tasks accordingly.
Cooperation and teamwork are essen- tial for the achievement of any goal
This action is an appropriate example of the adage, “A stitch in time saves
Delegation allows the Registered Nurse to assign tasks to various indi-
Evaluating the performance of a subordinate does not fall under the planning function of management. The evaluation of the performance of a subordinate does not fall under the organizing function of management.
The controlling function of manage- ment includes the evaluation of staff
Planning activities include assessment, problem identification, setting goals, planning interventions based on the identified priority, and how results will be evaluated. Assessing the performance of a subordinate does not fall under the directing function of management.
Systems theory is a cyclical process in which a whole is broken down into
Because the manager is responsible for delegating tasks to subordinates, the manager is also responsible for ensuring that policies and procedures clearly describe standards of care and expected outcomes.
Emptying and recording the volume of output collected from a urine collec-
Discharge teaching requires the knowledge and judgment of a Regis-
Evaluation requires the knowledge and judgment of a Registered Nurse. The
Answer: 2, 1, 3
The first phase is called “unfreezing”
The second phase is called “moving/
The third phase is called “refreezing”
Which group poses the greatest challenge to health care financing in the United States. The nurse is examining research results on receiving health care benefits in the United States.
The acute care setting is the organiza- tional center of the United States
The clinic setting is not the organizational center of the United States health care system.
Critical pathways are a case manage- ment system that identifies specific
In addition, ethical issues are becoming prominent in response to advances in areas such as organ transplantation and technology for the initiation of life. Although some people strive to sustain life at all costs, most people prefer to seek ways to support and maintain quality of life over longevity.
The patient is the center of the health- care team and has primary responsibility
Social issues include who will pay for health care, who has access to health care, and who will care for older adults and the uninsured (both of which are on the rise). The growing hospice movement is based on the concept of preserving quality of life by caring for dying people in their homes, surrounded by family and friends, and making their remaining days as comfortable and meaningful as possible.
As soon as a patient is diagnosed with a problem, rehabilitation interventions
Congruity must exist between what nurses say and what they do. For nurses
Although a health goal may conflict with a role one sets for oneself, another option has a greater ability to contribute to anxiety than one's role. A value is an abiding attitude toward something that is valued and held dear to one's heart and should not cause anxiety.
Change almost always causes anxiety because it requires one to move from
Hospitals are satisfied when they can discharge a person earlier than the specified length of stay specified by the DRGs because the hospital keeps the unused portion of the DRG reimbursement. A belief is an opinion or conclusion that someone accepts as true and may be based on faith and/or facts and may not cause anxiety.
Reengineering is concerned with training a less educationally prepared
Although this is a concern for some individuals, if patients receive a supportive emotional intervention and are ready for discharge from the first day of admission, they will generally prefer home to hospital.
Demographics are changing rapidly in the United States as we become a
Studies report that one-third of older adults 75 years of age and older
This is an example of the primary level of health-care delivery. Primary care is
Nurses work in a variety of settings;
Nurses comprise the largest group of health-care professionals in the
Studies and position papers from all segments of the health care industry point to the need to provide more health care services in the community rather than the institutional setting. More services should address the primary, not secondary, health care needs of the community.
Health-care delivery in the United States is an extremely complex service indus-
A case manager coordinates and links health care services to clients and their families at separate levels of care (e.g., during hospitalization) and at different levels of care (e.g., progression through hospitalization, extended care facilities, and home care). To meet the health care needs of older adults in the future, efforts must be made now to provide more community-based supportive services so that people can continue to live in their own homes and not have to move into an institutional setting.
Traditional health-care delivery has always centered on activities associated
A primary nurse has full responsibility for the planning and delivery of nursing care to a specific patient during the patient's hospitalization. The job of a nurse manager is to ensure that the organization's objectives are achieved in an appropriate, efficient and cost-effective manner.
A patient classification system, or
Primary nursing is a nursing care delivery system that seeks to prevent fragmentation of care and ensure a comprehensive and consistent approach to the patient encounter. More emphasis should be placed on providing services that meet the primary health care needs of society, which include health promotion, disease prevention, health education, environmental protection, and early detection and treatment.
Consumers are more aware than ever before that change in their own behav-
The percentage of older adults in the United States is expected to increase to
Of the options offered, the word pro- tector best describes the role of the
Although older adults are a vulnerable population, they are not as underserved as a group in another option due to the availability of Medicare. Urgent care is a description of a type of service provided at the secondary level of health care in the health care system.
This is an example of the secondary health-care level of the health-care sys-
Although pregnant women are a vulnerable population, they are not as underserved as a group in another option.
This is the cornerstone of Nursing’s Agenda for Health Care Reform. All
One patient’s physical condition should not interfere with another patient’s
The role of advocate is the most important role of the nurse because
Although this is part of the nursing agenda for health reform, it is not the cornerstone of the document. A case manager's primary role is to coordinate the activities of all the other members of the healthcare team and ensure that the patient receives care in the most appropriate setting.
An extended-care facility is an inpa- tient setting where a client lives while
Care delivery is about identifying and meeting patient needs by helping the patient regain health through the care process. They provide services such as emergency walk-in care, outpatient surgery, and health prevention and health promotion interventions.
The percentage of older adults in the United States is expected to increase
Although some are located in a hospital, more often they are in convenient locations, such as a shopping center or storefront.
The DRGs, pretreatment diagnoses re- imbursement categories, were designed
Providing a special diet is a dependent function of the nurse. The practi-
The diet manual should be reviewed to determine if the requested food is per-
If the requested food is not indicated in the diet in the dietary manual, the
If the food is not permitted on the diet, the nurse can function as a patient ad-
The Veterans Administration is an official organization because it comes
When planning patient care, the nurse and patient work together to identify
When faced with any stressful situation that can lead to feelings of burnout, the
Which role of the nurse receives more emphasis in providing health care at home than in acute care? The nurse is responsible for coordinating the efforts of health care team members in both acute care and home care settings.
Because of the shorter length of hospital stays, patients are being discharged be-
Providing healthy meals to patients is an important responsibility of the nurse in all settings where nurses work. Coordinating the efforts of the healthcare team is an important responsibility of the nurse in all settings in which nurses work.
To inform is an important role of the nurse when functioning as a patient ad-
The delivery of skilled nursing care is an important responsibility of the nurse in all settings in which nurses work. The nurse functions as an advocate for the patient in both acute care and home care.
Secondary prevention is associated with early detection of disease and prompt
However, interview skills can be used when the nurse explores the nature and consequences of choices together with the patient. The nurse does not have to wait until the patient is admitted to the hospital to prepare for the patient's return to the community.
The members in the community are the primary source of data about the
As soon as there is contact with the patient, planning and teaching should begin so that the patient is prepared for discharge and return to the community.
Adolescents struggle with the develop- mental conflict of identity versus role
The patient is always the center of the healthcare team in all contexts and is.
The patient is always the center of the health-care team in every setting and is
Case management by the nurse in the home care setting includes determin-
A locked area is the safest place to store prescription as well as over-the-
Although individuals with health insurance have better access to health care services, having health insurance is not essential to receiving health care.
For a healthy community, all members of the community must have access to
In 1990, Healthy People 2000, a docu- ment prepared by the United States
This is the most efficient initial ap- proach to meeting the identified needs
A forum is defined as an opportunity for open discussion. Inviting people
In addition, by law, hospital emergency departments are not allowed to refuse patients who require emergency care. Although the general health of a community's members is important, it is not the first data the nurse should collect when assessing a community.
Acquiring core information about the people in the community is the first
A family is defined as a social group whose members are closely related by
Home care agencies are responsible for coordinating and providing for a con-
This usually involves direct laying on of hands. This is not the primary role of the nurse in dealing with infection control issues in the home setting. Of the roles presented in the options, the role of the teacher is the most important.
Of the roles presented in the options, the role of teacher is most important in
The role of advocate is not the most appropriate role provided in the options when dealing with infection control issues in the home setting. In the role of advocate, the nurse protects and supports the rights of patients and helps assert those rights when patients are unable to defend themselves and are not concerned with infection control issues.
Caregiver role strain experienced by a family member is a serious concern of
Counseling is concerned with helping a patient recognize and deal with emotional stressors, improving relationships, and promoting personal growth, not treating infection control issues.
Long-term care lies in the category of tertiary level of health-care delivery
A home health-care agency is designed to coordinate the comprehensive ser-
All prescriptions filled for home use are dispensed in containers with child-
Health-care professionals who have prescriptive licenses (e.g., physicians,
Of the roles presented in the options, the role of educator is the most impor-
Health promotion has taken on new meaning as consumers take more
Generalizations are often based on stereotypes which are preconceived and untested beliefs about people based on their culture, race and/or ethnic backgrounds. Generalizations are often based on stereotypes, which are preconceived and untested beliefs about people based on their culture, race, and/or ethnic background.
Nurses working in rural communities wear many hats. The adage wear many
Among the options presented, nurses working in urban centers are less likely to wear many hats. Urban centers refer to cities with a population of more than 50,000 and usually have a concentration of specialized services where nurses have specific roles and responsibilities.
Resources that support health promo- tion, health protection, and preventive
Most hospice care is delivered in pa- tients’ homes supported by a team of
Teaching a patient how to use a wheel- chair after a stroke is an example of ter-
Hospice is not a setting but a concept
Psychosociocultural Nursing Care
The older adult needs to adjust to mul- tiple changes in social roles to emerge
Additionally, they tend to experience a decrease in meaningful relationships, rather than an increase, due to the deaths of members of their friends and family members. As a person's skin ages, it decreases instead of increasing due to the loss of skin mass.
The skin of the older adult decreases in thickness because of loss of dermal and
This occurs due to flattening of the dermal-epidermal junction, reduced thickness and vascularity of the dermis, and slowing of epidermal proliferation. As a person's skin ages, it increases, not decreases, in dryness due to a reduction in moisture content, sebaceous gland activity, and circulation to the skin.
Toddlers are less able to understand and interpret what is happening to them
It supports sharing common interests and concerns, as well as meeting belongingness and self-esteem needs, as older adults seek status among their peers. Older adults usually seek out people of the same age to share similar interests and find status among their peers.
Middle-aged adults (40 to 60 years) are in a time of transition between young
School-age children (6 to 12 years old) tend to have fewer differences in appearance and behavior from their peers. Although teenagers (ages 12 to 20) may be seen as different from their parents' norms, they are similar to their peers.
A pregnant woman is at risk. Teratogenic refers to a substance that can cross the
Growth and development is a complex process involving multiple influencing variables such as genetics, experience, health, culture and environment. To control anxiety with role confusion, they gravitate towards and conform to peer groups, which provide a sense of security.
Confusion is a common response to sensory overload. Because of excessive
Although there is diversity in the older adult group (≥65 years), individuals must adapt to common experiences such as physical decline, retirement, multiple losses, and changes in social roles. Lawrence Kohlberg, not Erik Erikson, established a framework for understanding the development of moral maturity, which is the ability to independently recognize right and wrong.
Erik Erikson expanded on Freud’s Theory of Personality Development by
The adult 65 years and older (Ego Integrity versus Despair) conducts a
Infants are at the highest risk for iron deficiency anemia because of the in-
Older adults are at the greatest risk for constipation because of decreases in
The major task of middle adulthood is successfully fulfilling lifelong goals that
Erik Erikson believed that 6- to 12-year- old children are in conflict over the
The 25- to 65-year-old adult who is unable to successfully resolve the con-
The most recent statistics from the National Center for Health Statistics
From 18 months to 3 years of age (Autonomy versus Shame and Doubt)
Toddlers can generally regulate body temperature, as long as they are basically healthy. Adolescents are generally able to regulate body temperature as long as there are no associated health problems.
Regulation of body temperature depends on the ability to dilate or
Young adults 18 to 25 years of age who are self-absorbed, egocentric, and
Adolescents (12 to 20 years) have more multiple and complex physiological
Although a pregnant woman has unique needs during surgery, the fetus is supported and safe as long as the mother's cardiovascular, fluid, and electrolyte status is maintained.
Infants are at risk for volume depletion because of a small blood volume and
Although people follow a general pat- tern, they do not grow and develop at
The literature documents that 75% of older adults intentionally do not fully
Adolescents (12 to 20 years—Identity versus Role Confusion) have multiple
A 6-year-old child believes that death is temporary, that it can be the result of bad thoughts and that it can be a punishment, and that magic can bring the dead back to life.
A 9-year-old child has a more realistic understanding of death than a younger
The main developmental task of ado- lescence is forming a sense of personal
Only a small percentage of the population of 18-month- to 3-year-old children faces the challenge of a life-threatening illness.
During early childhood the child gains independence through learning right
Peers often dictate the dietary choices of adolescents. Fad dieting and de-
Older adults generally experience a deterioration of the hyaline cartilage
Young adults (18 to 25 years—Intimacy versus Isolation) strive to establish ma-
Older adults still need 7 to 9 hours of sleep daily but often receive less due to
However, it is more difficult for older adults to obtain the desired quality and quantity of sleep.
The sensorimotor stage (birth to 2 years) is governed by sensations in
The preoperational stage (2 to 7 years) involves thinking that is concrete and
The patient says, "I'm really nervous about having a spinal tap tomorrow." What is the best response from the nurse? The nurse says, "You look very sad today." What interviewing approach did the nurse use?
A focused interview explores a particular topic or obtains specific information
This response requests additional information in an attempt to clarify
The helping relationship (interpersonal relationship, therapeutic relationship) is
This question is an example of reflec- tive technique because it focuses on
This response acknowledges that the husband is in a dilemma and it offers
Leaning forward is a nonverbal behav- ior that conveys involvement. It is a
Nonverbal communication (body language) conveys messages without
Humor is an interpersonal tool and a healing strategy. It releases physical
Understanding is the foundation of therapeutic communication. When the
This is an example of paraphrasing. It repeats the content in the patient’s
This response is not therapeutic because it focuses on the nurse rather than the mother. This response minimizes the loss and focuses on the pain the child is experiencing, which can increase the mother's grief.
The first sentence communicates empathy. The second sentence focuses
The second part of the answer focuses on the pain the baby is experiencing, which can add to the mother's grief.
The patient and significant others and their needs are always the focus of
This is an example of paraphrasing, which restates the patient’s message
Physically caring for a patient involves inspection and touch that invades the
The purposes of the opening stage of an interview are to establish rapport
This is an example of reflective tech- nique. When no solutions to a problem
Persistence during data collection can be perceived by the patient as aggression, which is an obstacle to communication. "Why" statements are direct questions that tend to put the patient on the defensive and interrupt communication.
Active listening is the use of all the senses to comprehend and appreciate
This is an example of the therapeutic interviewing skill of an open-ended
This response lets the patient know that the message has been heard and
Communication is facilitated by inter- viewing techniques that involve atti-
The nurse's response is not an example of paraphrasing, which restates the patient's basic message in similar words. The nurse's response is not an example of reflective technique, which refers back to the basic feelings underlying the patient's statement.
This open-ended statement invites the patient to elaborate on the expressed
The focus must be on the patient's current concerns before refocusing on other problems because anxiety increases if immediate concerns are not addressed. A confrontational or challenging statement fails to consider feelings, puts the patient on the defensive and is a barrier to communication.
During the working phase of the thera- peutic relationship nursing interven-
This may not be understood by the confused patient because the word important involves a conceptual thought.
This response is false reassurance. It denies the patient’s concerns about
The patient may be using projection to cope with the potential for impotence
Open-ended questions or gently pointing out the incongruity between actions and words are more effective techniques than direct questions in this situation.
Reflective technique refers to feelings implied in the content of verbal com-
This statement reflects the working phase of a therapeutic relationship. It
The nurse’s response is an example of paraphrasing because it uses similar
Emotionally charged topics should be approached with respectful, sincere
How can the nurse best help the patient to reduce anxiety? It is the patient who has difficulty understanding the words that need to be repeated, not the nurse.
New experiences require a person to process information and problem solve,
It helps a patient with a hearing impairment to recognize that someone is speaking, and it facilitates lip reading if the patient can read lips.
People can experience anxiety along a continuum from no anxiety to mild,
Empathy is the nurse’s ability to have insight into the feelings, emotions, and
Control is nonessential to a therapeutic relationship. The purpose is not to have
Stress incontinence is unrelated to depression. Stress incontinence is a
Projection is attributing unacceptable thoughts, emotions, motives, or charac-
Defense mechanisms are used to reduce anxiety and achieve or maintain emo-
Respectful interaction demonstrates to patients that they are valuable and
Intellectualization is the use of reasoning to avoid unacceptable stimuli in an effort to protect the ego from fear. Introjection is the incorporation of another person's norms and values into one's personality as a means of reducing anxiety.
This scenario is an example of denial
The patient is the center of the health- care team and is the primary source of
This scenario is an example of rational- ization. Rationalization is used to
During moderate anxiety, the pulse, respirations, and blood pressure are
This scenario is an example of com- pensation. Compensation is an attempt
Using interviewing techniques encour- ages the patient to verbalize feelings
This is an example of repression
Exercise stimulates endorphin produc- tion, which promotes a sense of well-
People who are unable to care for themselves independently often per-
This reaction is too direct and the patient may not consciously know what is wrong. Focusing on positive thoughts is inappropriate because it denies the patient's feelings; the patient must focus on the future loss.
Depression is the fourth stage of griev- ing according to Kübler-Ross; patients
This scenario is an example of identifi- cation. Identification helps a person
Anxiety is a psychological adaptation to a threat to the self or self-esteem. The
This is an example of projection
This statement supports the fact that the patient is experiencing fear. A
This statement identifies feelings and invites further communication
Reaction formation is when a person develops conscious attitudes, behaviors, interests, and feelings that are the exact opposite of unconscious attitudes, interests, and feelings.
This is an example of displacement
When the nurse establishes a nonjudg- mental environment and functions
Repression is the basis of all defense mechanisms. All defense mechanisms
Self-image is derived from all collective beliefs and ideas about oneself as a result of interaction with the environment, society and feedback from others. Confidence in one's ability to complete a task is only one component of self-esteem.
Mild anxiety is a slightly aroused state that enhances perception, learning, and
Moderate anxiety increases the arousal state that precipitates feelings of
Panic is an overwhelming state where the person feels out of control. Percep-
Anxiety is a common and universal response to a threat. Every time people
Which patient factor the nurse considers is most important in determining whether the patient needs a teaching program. Which psychosocial response to the illness will have the greatest impact on the patient's future academic success.
Learners bring their own lifetimes of learning to the learning situation. The
Goal setting is achieved after the nurse has gathered significant information that will influence the goal, especially in relation to the attainable and realistic factors in a goal.
If the patient does not recognize the need to learn or value the information to
Reaction time will slow with aging;
This is an appropriate example of learn- ing on the evaluation level and is the
The nurse should minimize ambiguity, provide a familiar environment, teach at the same time each day, limit environmental distractions, and provide simple learning materials. This action helps the nurse understand what the patient is saying; it does not help the patient with a comprehension disorder to understand.
When a teaching plan is ineffective the nurse must gather more data and
Because achieving success depends largely on motivation, the teacher and patient should design goals that show immediate progress or growth. The teacher must provide a structured environment in which variables are controlled to reduce anxiety and support understanding.
This is the highest level of learning in the cognitive domain of the choices of-
One strategy is to design numerous realistic short-term intermediate goals that are easier to achieve than one long-term goal. A focus group is designed to gather opinions and suggestions from a group of people on a specific topic through a discussion, not survey, format.
A trusting relationship between the patient and the nurse is essential
Varieties of teaching methods facilitate learning because multiple senses are
This is an example of learning on the valuing level in the affective domain
When the patient can identify the correct equipment for a colostomy irrigation, a readiness for action has been demonstrated.
This option reflects the highest level of learning of the options offered. When a
Readiness to learn and motivation, which are closely tied together, are the
This is the best approach because it three to five grades below their highest
Randomized studies demonstrate that the average reading level of individuals
Preschool children are just beginning to interact with peers, have a short attention span and are easily distracted, and therefore need a one-on-one relationship with the teacher. The teacher facilitates the learning specifically for the individual, keeps the learner focused and provides reinforcement on the learner's cognitive level.
Inservice programs generally are provided by health-care agencies to
If the patient does not recognize the need to learn or value the information
Of all the options presented, the pa- tient in denial is the person least ready
Although some older adults may experience a decline in short-term memory, they are not less intelligent. Some older adults may be less motivated to learn if they believe that death is near.
A demonstration is the best strategy for teaching a psychomotor skill. A
When older adults experience a decline in sensory function (eg, vision, hearing) they may feel embarrassed or frustrated, causing withdrawal. However, in this situation, when older adults are shown how learning will improve quality of life and independence, they are motivated to learn.
This option reflects learning in the affective domain. Affective learning is
Complex material is best learned when easily understood aspects of the topic
Role playing is no more or less fun than many other active and creative learning strategies.
Learning activities that actively engage the learner have been shown to be
Individuals have their own beliefs associated with cultural health prac-
Changing a colostomy bag without contaminating the hands is an example
The purpose of teaching patients is to ensure that they have the knowledge
People with an internal locus of control are motivated by personal internal rewards, such as achieving a personal goal, pleasing themselves, returning to a usual lifestyle, and avoiding complications.
Pleasing others precipitates feedback that is often viewed as positive by the
This should be done first because a diet requires a practitioner’s order;
Assessing motivation is one of the most important factors influencing learning
Determining food preferences is part of nursing assessment. Food preferences
Details of the diet can be taught after the order is verified, motivation is de-
Evaluation is the final step of teaching
Essential Components of Nursing Care
When the nurse supports, protects, and defends a patient from a holistic perspec-
The word substitute is not the word that best describes the role of the nurse who provides holistic care.
Evaluation occurs when actual outcomes are compared with expected outcomes
The definitions of the words observe and assess are similar. Observe means to view
As a counselor, the nurse helps the patient improve interpersonal relationships, recognize and deal with stressful psychosocial problems, and promote the achievement of self-actualization. The word data (information) is not associated with the term scientific principles (established rules of action).
The word rationale (justification based on reasoning) is closely associated with
The etiology (also known as related to or contributing factors) are the conditions,
This is an example of the Implementa- tion step of the Nursing Process. It is
A diagnostic statement cannot support a nursing diagnosis because it is the first part of a nursing diagnosis. The associated risk factors cannot support a nursing diagnosis because they are another part of the nursing diagnosis.
The primary purpose of the Assess- ment step of the Nursing Process is to
These are nursing interventions designed to help resolve associated or contributing factors and achieve expected patient outcomes that reflect goal attainment. Although trust can be established during the assessment step of the nursing process, this is not the purpose of the assessment step of the nursing process.
Revising a plan of care takes place in the Evaluation step of the Nursing
A nursing diagnosis consists of two parts: the diagnostic statement (also known as the problem statement) and the associated factors (also known as contributing factors to the problem or etiology). A nursing diagnosis consists of two parts: the diagnostic statement (also known as the problem statement) and the associated factors (also known as factors contributing to the problem or etiology).
The identification of nursing actions designed to help a patient achieve a
If nursing interventions are appropriate and effective, the human response identified in the problem statement portion of the nursing diagnosis will resolve. Secondary factors generally have only a minor influence on the planning stage of the nursing process.
After data are collected, they are clus- tered to determine their significance
Associated factors (ie, contributing factors, etiology) contribute to the problem statement of the nursing diagnosis and directly influence the planning step of the nursing process. The planning step in the nursing process involves setting a goal, identifying outcomes that will reflect goal achievement, and planning nursing interventions.
The first thing the nurse should do to differentiate between two closely
Although the wording of the goal is directly influenced by the diagnostic label (problem statement in the Nursing Diagnosis), the selection of nursing interventions is not. Nursing care is planned after establishing nursing diagnoses and goals, not immediately after data collection.
This is the primary purpose of a nurs- ing admission assessment. Data must
The nurse is concerned with human responses to actual or potential health problems, not with medical diagnosis. Once the data has been collected, the nurse must first organize and cluster the data to determine its meaning and draw conclusions.
This is the correct analogy. The words identify and recognize have the same
The word evaluate does not fit the analogy because the definitions of evaluate and do are different. The word evaluate means to determine the value of something, while the word do means to act or to achieve.
Interviewing a patient is the most ef- fective data collection method when
Potential risk factors are identified during the Analysis step of the Nursing
Subjective data are those reactions, feelings, beliefs, preferences and information that only the patient can confirm.
The amount of food eaten by a patient can be objectively verified. The nurse
The body continuously secretes saliva (approximately 1000 mL/day) that usu-
This is subjective information because it is the patient’s perception and can be
Objective and subjective data must be collected, verified, and communicated
Data are clustered and analyzed, and their significance is determined, lead-
Identifying goals, projecting outcomes, setting priorities, and identifying inter-
Planned actions are initiated and com- pleted during the Implementation step
Identifying responses to care, compar- ing actual outcomes to expected out-
Which characteristic indicates that the nurse should take the patient's temperature via the rectal route. The nurse is assessing a family member who is taking a patient's blood pressure as part of the patient's discharge teaching plan.
A disruption in the clotting mechanism of the body can result in bleeding
This ensures that the openings in the stethoscope earpiece are directed towards the ear canal for uninterrupted sound transmission.
Diurnal variations (circadian rhythms) vary throughout the day with the lowest
It is unsafe to palpate both carotid arter- ies at the same time. Slight compression
An exacerbation is the period during a chronic illness when symptoms reappear
This may result in an inaccurate read-
The sensation of heat is associated with the delay phase (rush) of fever due to sudden vasodilation. The feeling of thirst is associated with the febrile (fever) phase of the fever due to mild to severe dehydration.
The initial stage of shock begins when baroreceptors in the aortic arch and
A cold sensation occurs during the onset (chill) stage of fever due to vasoconstriction, cool skin and chills. Sweating occurs during the defervescence stage (flush) of the fever due to the body's heat loss response.
This is an appropriate interval of time for routine monitoring of body
Although the body temperature drops as shock progresses due to a decreased metabolic rate, this is not one of the first signs of shock. Although the pulse pressure will narrow during shock, other vital signs will first reflect compensation.
Bowel sounds are auscultated before palpation and percussion because
Two other vital signs will change before blood pressure as the heart tries to compensate for a decreased circulating blood volume.
A respiratory rate of 10 is below the expected respiratory rate for an adult
The carotid arteries are located in the neck, while the brachial arteries are located in the arms. The popliteal arteries are located in the legs, while the brachial arteries are located in the arms.
The carotid artery should be palpated with a light touch to prevent an inter-
It is located in the anterior, medial aspect of the thigh, just below the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis. A popliteal pulse site is located in the lateral aspect of the concave area at the back of the knee (popliteal fossa).
This blood pressure is within the pa- rameters of stage I hypertension and is
A carotid pulse site is located on the neck on the side of the larynx, between the trachea and the sternomastoid muscle. Betacyanin, a pigment that gives beets their purple-red color, is excreted in the urine and feces of some people when it is not metabolized (a genetically determined trait).
Activity intolerance is related to the inability to maintain adequate oxygena-
This bright red pigment turns the urine and stool red for several days after eating beets. A carotid pulse site is located on the neck on the side of the larynx, between the trachea and the sternomastoid muscle.
Excessive alcohol intake interferes with thermoregulation by providing a false
Pale, cold skin occurs during the initial stages of fever due to vasoconstriction, which is an attempt to conserve body heat. The inability to sweat does not allow the body to cool down through the evaporation of sweat (evaporation).
With a decrease in circulating red blood cells the respiratory rate will
Cachexia is general ill health and malnutrition marked by weakness
Gloves, personal protective pieces of equipment, are the best way the
Ordering and assessing urine and blood values are not in the independent prac-
