NCLEX Exam 3|55 Questions with Verified Answers,100% CORRECT

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NCLEX Exam 3|55 Questions with Verified Answers A nurse caring for patients in the intensive care unit develops values from experience to form a personal code of ethics. Which statements best descr... ibe a characteristic of the development of a personal value system? Select all that apply. a. People are born with values. b. Values act as standards to guide behavior. c. Values are ranked on a continuum of importance. d. Values influence beliefs about health and illness. e. Value systems are not related to personal codes of conduct. f. Nurses should not let their values influence patient care. - CORRECT ANSWER b, c, d. A value is a belief about the worth of something, about what matters, which acts as a standard to guide one's behavior. A value system is an organization of values in which each is ranked along a continuum of importance, often leading to a personal code of conduct. A person's values influence beliefs about human needs, health, and illness; the practice of health behaviors; and human responses to illness. Values guide the practice of nursing care. An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family, and culture. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. Five-year-old Bobby has dietary modifications related to his diabetes. His parents want him to value good nutritional habits and they decide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission? a. Modeling b. Moralizing c. Laissez-faire d. Rewarding and punishing - CORRECT ANSWER d.When rewarding and punishing are used to transmit values, children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values. Through modeling, children learn what is of high or low value by observing parents, peers, and significant others. Children whose caregivers use the moralizing mode of value transmission are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values. Those who use the laissez-faire approach to value transmission leave children to explore values on their own (no single set of values is presented as best for all) and to develop a personal value system. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse who is working in a hospital setting after graduation from a local college uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply. a. A patient decides to quit smoking following a diagnosis of lung cancer. b. A patient shows off a new outfit that she is wearing after losing 20 pounds. c. A patient chooses to work fewer hours following a stress-related myocardial infarction. d. A patient incorporates a new low-cholesterol diet into his daily routine. e. A patient joins a gym and schedules classes throughout the year. f. A patient proudly displays his certificate for completing a marathon. - CORRECT ANSWER b, f. Prizing something one values involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, one chooses freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts by combining choice into one's behavior with consistency and regularity on the value, such as joining a gym for the year and following a low-cholesterol diet faithfully. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. The American Association of Colleges of Nursing identified five values that epitomize the caring professional nurse. Which of these is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? a.Altruism b. Autonomy c. Human dignity d. Integrity - CORRECT ANSWER d. The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A professional nurse with a commitment to social justice is most apt to: a. Provide honest information to patients and the public b. Promote universal access to health care c. Plan care in partnership with patients d. Document care accurately and honestly - CORRECT ANSWER b. The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honestly are examples of integrity, and planning care in partnership with patients is an example of autonomy. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. When an older nurse complains to a younger nurse that nurses just aren't ethical anymore, which reply reflects the best understanding of moral development? a. "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." b. "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" c. "Ethics is genetically determined ... it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had." d. "I agree! It's impossible to be ethical when working in a practice setting like this!" - CORRECT ANSWER a. The ability to be ethical, to make decisions, and to act in an ethically justified manner begins in childhood and develops gradually. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A home health nurse who performs a careful safety assessment of the home of a frail elderly patient to prevent harm to the patient is acting in accordance with which of the principles of bioethics? a. Autonomy b. Beneficence c. Justice d. Fidelity e. Nonmaleficence - CORRECT ANSWER e. Nonmaleficence is defined as the obligation to prevent harm. Autonomy is respect for another's right to make decisions, beneficence obligates us to benefit the patient, justice obligates us to act fairly, and fidelity obligates us to keep our promises. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A professional nurse committed to the principle of autonomy would be careful to: a. Provide the information and support a patient needed to make decisions to advance one's own interests b. Treat each patient fairly, trying to give everyone his or her due c. Keep any promises made to a patient or another professional caregiver d. Avoid causing harm to a patient - CORRECT ANSWER a. The principle of autonomy obligates nurses to provide the information and support patients and their surrogates need to make decisions that advance their interests. Acting with justice means giving each person his or her due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. Janie wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. She believes his dying is being prolonged painfully. She is troubled when the patient's doctor tells her that she'll be fired if she raises questions about his care or calls the consult. This is a good example of: a. Ethical uncertainty b. Ethical distress c. Ethical dilemma d. Ethical residue - CORRECT ANSWER b. Ethical distress results from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, fear of losing her job). Ethical uncertainty results from feeling troubled by a situation but not knowing if it is an ethical problem. Ethical dilemmas occur when the principles of bioethics justify two or more conflicting courses of action. Ethical residue is what nurses experience when they seriously compromise themselves or allow themselves to be compromised. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A student nurse begins a clinical rotation in a long-term care facility and quickly realizes that certain residents have unmet needs. The student wants to advocate for these residents. Which statements reflect a correct understanding of advocacy? Select all that apply. a. Advocacy is the protection and support of another's rights. b. Patient advocacy is primarily done by nurses. c. Patients with special advocacy needs include the very young and the elderly, those who are seriously ill, and those with disabilities. d. Nurse advocates make good health care decisions for patients and residents. e. Nurse advocates do whatever patients and residents want. f. Effective advocacy may entail becoming politically active. - CORRECT ANSWER a, c, f. Advocacy is the protection and support of another's rights. Among the patients with special advocacy needs are the very young and the elderly, those who are seriously ill, and those with disabilities; this is not a comprehensive list. Effective advocacy may entail becoming politically active. Patient advocacy is the responsibility of every member of the professional caregiving team—not just nurses. Nurse advocates do not make health care decisions for their patients and residents. Instead, they facilitate their decision making. Advocacy does not entail supporting patients in all their preferences. (Taylor 110) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? a. Public law b. Private law c. Civil law d. Criminal law (Taylor 134) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. Criminal law concerns state and federal criminal statutes, which define criminal actions such as murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry. (Taylor 135) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. Newly hired nurses in a busy suburban hospital are required to read the state Nurse Practice Act as part of their training. Which topics are covered by this act? Select all that apply. a. Violations that may result in disciplinary action b. Clinical procedures c. Medication administration d. Scope of practice e. Delegation policies f. Medicare reimbursement (Taylor 134) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a, d. Each state has a Nurse Practice Act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state Nurse Practice Act. Nurse Practice Acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing Medicare reimbursement are enacted through Federal legislation. (Taylor 135) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. "Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. (Taylor 134) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. Those bringing the charges against Jean are called: a. Appellates b. Defendants c. Pl - CORRECT ANSWER c. The person or government bringing suit against another is called the plaintiff. Appellates are courts of law, defendants are the ones being accused of a crime or tort, and attorneys are the lawyers representing both the plaintiff and defendant. (Taylor 135) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. "Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. (Taylor 134) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. Jean's attorney was careful to explain in her defense that Jean had specialty knowled - CORRECT ANSWER c. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing. (Taylor 135) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. "Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. (Taylor 134) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. If review of this patient's record revealed that she had never consented to the eye s - CORRECT ANSWER b. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact by another person unless consent is granted. The Fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute false imprisonment. (Taylor 136) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. "Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. (Taylor 134) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. What must be established to prove that malpractice or negligence has occurred in this - CORRECT ANSWER d. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse-patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient. (Taylor 136) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. "Jean," a veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75-year-old woman who died after slipping into a coma during routine outpatient eye surgery at an eye surgery center. Jean admitted that she failed to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. As part of her plea arrangement, the nurse agreed to serve 6 months of probation—the first 2 months on house arrest—and surrender her nursing license. (Taylor 134) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. When the attorney representing the patient's family calls Jean and asks to talk with - CORRECT ANSWER a. One of the cardinal rules for nurse defendants is: Do not discuss the case with anyone at your agency (with the exception of the risk manager), with the plaintiff, with the plaintiff's lawyer, with anyone testifying for the plaintiff, or with reporters. (Taylor 136) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse administers the wrong medication to a patient and the patient is harmed. The physician who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? a. The nurse is not responsible, because the nurse was merely following the doctor's orders. b. Only the nurse is responsible, because the nurse actually administered the medication. c. Only the physician is responsible, because the physician actually ordered the drug. d. Both the nurse and the physician are responsible for their respective actions. (Taylor 135) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. Nurses are legally responsible for carrying out the orders of the physician in charge of a patient unless an order would lead a reasonable person to anticipate injury if it were carried out. If the nurse should have anticipated injury and did not, both the prescribing physician and the administering nurse are responsible for the harms to which they contributed. (Taylor 136) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe aspects of this procedure? Select all that apply. a. An incident report is used as disciplinary action against staff members. b. An incident report is used as a means of identifying risks. c. An incident report is used for quality control. d. The facility manager completes the incident report. e/ An incident report makes facts available in case litigation occurs. f/ Filing of an incident report should be documented in the patient record. (Taylor 135) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER b, c, e. Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs and in some states, incident reports may be used in court as evidence. A physician completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should not include the fact that an incident report was filed. (Taylor 136) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? a. Students are not responsible for their acts of negligence resulting in patient injury. b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. c. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor. d. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary. (Taylor 135) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER b. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital-controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages in the event of patient injury if an assignment called for clinical skills beyond a student's competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance. (Taylor 136) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appendicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines? Select all that apply. a. 6/12/15 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN b. 6/12/15 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN c. 6/12/15 0945 30 minutes following administration of morphine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d. 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e. 6/12/15 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN f. 6/12/15 0945 Patient states she does not want pain medication despite return of pain. - CORRECT ANSWER c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "seems comfortable today." The nurse should never document an intervention before carrying it out. (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is documenting the care given to a 56-year-old patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? a. Erase or use correcting fluid to completely delete the error. b. Draw a single line through the entry and rewrite it above or beside it. c. Use a permanent marker to block out the mistaken entry and rewrite it. d. Remove the page with the error and rewrite the data on that page correctly. (Taylor 365) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER b. The nurse should not use dittos, erasures, or correcting fluids. A single line should be drawn through an incorrect entry, and the words "mistaken entry" or "error in charting" should be printed above or beside the entry and signed. The entry should then be rewritten correctly. (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? a. "I'm sorry, but patients are not allowed to copy their medical records." b. "I can make a copy of your record for you right now." c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." d. "I will need to check with our records department to get you a copy." (Taylor 365) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of agency policies regarding the patient's right to access and copy records. (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. According to the Health Insurance Portability and Accountability Act of 1996, if a health institution wants to release a patient's health information (PHI) for purposes other than treatment, payment, and routine health care operations, the patient must be asked to sign an authorization. The nurse is aware that there are exceptions to this requirement. In which of the following cases is an authorization form not needed? Select all that apply. a. News media are preparing a report on the condition of a public figure. b. Data are needed for the tracking and notification of disease outbreaks. c. Protected health information is needed by a coroner. d. Child abuse and neglect are suspected. e. Protected health information is needed to facilitate organ donation. f. The sister of a patient with Alzheimer's wants to help provide care. (Taylor 365) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBo - CORRECT ANSWER b, c, d, e. Authorization is not required for tracking disease outbreaks, providing PHI to a coroner, reporting incidents of child abuse, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease. (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A friend of a nurse calls and asks if she is still working at Memorial Hospital. The nurse replies, "Yes." The friend tells the nurse that his girlfriend's father was just admitted as a patient and he wants the nurse to find out how he is. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? a. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." b. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." c. "Because of the Health Insurance Portability and Accountability Act, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" d. "Why do you think Sue isn't talking about her worries?" (Tay - CORRECT ANSWER b. The nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mentioning the real penalties linked to abuses of privacy. Finally, it is appropriate to ask about Sue and her worries, but this should be done after the nurse clarifies what he or she is able to do. (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? a. Every three hours b. Every four hours c. Daily d. As needed (Taylor 365) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. PRN means "as needed." (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the physician's order sheet. The nurse's best response is: a. "Thank you for taking care of this!" b. Get a second nurse to listen to the order, and after writing the order on the physician order sheet, have both nurses sign it. c. "I am sorry, but verbal orders can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." d. Try calling another resident for the order or wait until the next shift. (Taylor 365) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER c. In most agencies, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician/nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? a. Admission sheet b. Admission nursing assessment c. Activity flow sheet d. Graphic record (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the activity flow sheet. (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is using the SOAP format of documentation to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? a. A patient problem list b. Notes describing the patient's condition c. Overall trends in patient status d. Planned interventions and patient outcomes (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Abnormal status can be seen immediately when using charting by exception, and planned interventions and patient expected outcomes are the focus of the case management model. (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a male patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the order in which they should be performed. a. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." d. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." e. "Mr. Sanchez was admitted two days ago following a diagnosis of pancreatic cancer." f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered - CORRECT ANSWER d, a, e, b, f, c. The order for ISBARR is: identity/introduction, situation, background, assessment, recommendation, and read-back. (Taylor 366) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse who is a discharge planner in a large metropolitan hospital is preparing a discharge plan for a patient after a kidney transplant. Which actions would this nurse typically perform to ensure continuity of care as the patient moves from acute care to home care? Select all that apply. a. Performing an admission health assessment b. Evaluating the nursing plan for effectiveness of care c. Participating in the transfer of the patient to the postoperative care unit d/ Making referrals to appropriate agencies e. Maintaining records of patient satisfaction with services f. Assessing the strengths and limitations of the patient and family (Taylor 189) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER b, d, f. The primary roles of the discharge planner as patients move from acute to home care are evaluating the nursing plan for effectiveness of care, making referrals for patients, and assessing the strengths of patients and their families. Although in smaller facilities a discharge planner may perform an admission health assessment and assist with patient transfers, it is not the usual job of the discharge planner. In most facilities, maintaining records of patient satisfaction is the role of the public relations manager or office manager. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A discharge nurse is evaluating patients and their families to determine the need for a formal discharge plan and/or referrals to another agency. Which patients would most likely be a candidate for these services? Select all that apply. a. An older patient who is diagnosed with dementia in the hospital b. A 45-year-old male who is diagnosed with Parkinson's disease c. A 35-year-old female who is receiving chemotherapy for breast cancer d. A 16-year-old who is being discharged with a cast on his leg e. A new mother who delivered a healthy infant via a cesarean birth f. A 59-year-old male who is diagnosed with end-stage bladder cancer (Taylor 189) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a, b, f. The patients who are most likely to need a formal discharge plan and/or referral to another agency are those who are emotionally or mentally unstable (e.g., dementia), have recently diagnosed chronic disease (e.g., Parkinson disease), or have a terminal illness (e.g., end-stage cancer). Other candidates include patients who do not understand the treatment plan, are socially isolated, have had major surgery or illness, need a complex home care regimen, or lack financial services or referral sources. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A home health care nurse is scheduled to visit a 38-year-old female client who has been discharged from the hospital with a new colostomy. Which duties would the nurse perform for this patient in the entry phase of the home visit? Select all that apply. a. Collect information about the patient's diagnosis, surgery, and treatments. b. Call the patient to make initial contact and schedule a visit. c. Develop rapport with the patient and her family. d.Assess the patient to identify her needs. e. Assess the physical environment of the home. f. Evaluate safety issues including the neighborhood in which she lives. (Taylor 189) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER c, d, e. In the entry phase of the home visit, the nurse develops rapport with the patient and family, makes assessments, determines nursing diagnoses, establishes desired outcomes, plans and implements prescribed care, and provides teaching. In the pre-entry phase of the home visit, the nurse collects information about the patient's diagnoses, surgical experience, socioeconomic status, and treatment orders. In the pre-entry phase, the nurse also gathers supplies needed, makes an initial phone contact with the patient to arrange a visit, and assesses the patient's environment for safety issues. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A hospital nurse is admitting a patient who sustained a head injury in a motor vehicle accident. Which activities could the nurse delegate to licensed assistive personnel? a. Collecting information for a health history b. Performing a physical assessment c. Contacting the physician for medical orders d. Preparing the bed and collecting needed supplies (Taylor 189) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. The nurse may delegate preparation of the bed and collection of needed supplies to unlicensed personnel but would perform the other activities listed. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is preparing an infant and his family for a hernia repair to be performed in an ambulatory care facility. What is the primary role of the nurse during the admission process? a. Assist with screening tests. b. Provide patient teaching. c/ Assess what has been done and what still needs to be done. d. Assist with hernia repair. (Taylor 189) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER c. Although all the options may be performed by the ambulatory care nurse, it is the nurse's primary responsibility to assess what has been done and to tailor the plan of care to the patient's needs. Screening tests and teaching are usually completed prior to the patient entering an ambulatory care facility. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A patient is being transferred from the ICU to a regular hospital room. What must the ICU nurse be prepared to do as part of this transfer? a. Provide a verbal report to the nurse on the new unit. b. Provide a detailed written report to the unit secretary. c. Delegate the responsibility for providing information. d. Make a copy of the patient's medical record. (Taylor 189) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file - CORRECT ANSWER a. The ICU nurse gives a verbal report on the patient's condition and nursing care needs to the nurse on the new unit. This information is not given to a unit secretary, nor is it delegated to others. The medical record is transferred with the patient; a copy is not made. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. Which statements or questions would be appropriate in establishing a discharge plan for a patient who has had major abdominal surgery? a. "I'll bet you will be so glad to be home in your own bed." b. "What are your expectations for recovery from your surgery?" c. "Be sure and take your pain medications and change your dressing." d. "You will just be fine! Please stop worrying." (Taylor 189) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER b. It is important to assess the expectations of the patient (and family) when assessing health care needs for discharge planning. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is counseling an older female patient hospitalized for dehydration secondary to a urinary tract infection. The patient tells the nurse: "I don't like being in the hospital. There are too many bad bugs in here. I'll probably go home sicker than I came in." She also insists that she is going to get dressed and go home. She has the capacity to make these decisions. What is the legal responsibility of the nurse in this situation? a. To inform the patient that only the primary health care provider can authorize discharge from a hospital b. To collect the patient's belongings and prepare the paperwork for the patient's discharge c. To request a psych consult for the patient and inform her primary care provider of the results d. To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form (Taylor 189) Taylor, Carol. Fundamentals of Nursing. Wolters K - CORRECT ANSWER d. The patient is legally free to leave the hospital against medical advice (AMA); however, patients who leave the hospital AMA must sign a form releasing the physician and hospital from legal responsibility for their health status. This signed form becomes part of the medical record. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse decides to become a home health care nurse. Which personal qualities are key to being successful as a community-based nurse? Select all that apply. a. Making accurate assessments b. Researching new treatments for chronic diseases c. Communicating effectively d. Delegating tasks appropriately e. Performing clinical skills effectively f. Making independent decisions (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a, c, e, f. Nurses working in the community must have the knowledge and skills to make accurate assessments, work independently, communicate effectively, and perform clinical skills accurately. Community-based nurses may be researchers and occasionally delegate care, but these are not key qualities for this type of nursing. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse ensures that a hospital room prepared by an aide is ready for a new ambulatory patient. Which condition would the nurse ask the aide to correct? a. The bed linens are folded back. b. A hospital gown is on the bed. c. Equipment for taking vital signs is in the room. d. The bed is in the highest position. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. A properly prepared hospital room includes: a bed in the lowest position for an ambulatory patient, an open bed with top linens folded back, routine equipment and supplies and special equipment and supplies assembled, and the physical environment of the room adjusted. (Taylor 190) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is assessing a 49-year-old male patient who complains of migraines that have become "unbearable." The patient tells the nurse, "I just got laid off from my job last week and I have two kids in college. I don't know how I'm going to pay for it all." Which physiologic effects of stress would be expected findings in this patient? Select all that apply. a. Changes in appetite b. Changes in elimination patterns c. Decreased pulse and respirations d. Use of ineffective coping mechanisms e. Withdrawal f. Attention-seeking behaviors (Taylor 1597) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a, b. Physiologic effects of stress include changes in appetite and elimination patterns as well as increased pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress. (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse caring for patients in a hospital setting uses anticipatory guidance to prepare them for painful procedures. Which instruction would the nurse provide in this type of stress management? a. The nurse teaches patients rhythmic breathing to perform prior to the procedure. b. The nurse tells patients to focus on a pleasant place, mentally place themselves in it, and breathe slowly in and out. c. The nurse teaches patients about the pain involved in the procedure and methods to cope with it. d. The nurse teaches patients to create and focus on a mental image during the procedure to become less responsive to the pain. (Taylor 1597) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER c. Anticipatory guidance focuses on psychologically preparing a person for an unfamiliar or painful event. When patients know what to expect, their anxiety is reduced, which occurs when teaching about the pain involved and related pain relief measures. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique. (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse witnesses a street robbery and is assessing a 26-year-old female patient who is the victim. The patient has minor scrapes and bruises and tells the nurse, "I've never been so scared in my life." What other symptoms would the nurse expect to find related to the fight-or-flight response to stress? Select all that apply. a. Increased heart rate b. Decreased muscle strength c. Increased mental alertness d. Increased blood glucose levels e. Decreased cardiac output f. Decreased peristalsis (Taylor 1597) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a, c, d. The sympathetic nervous system functions under stress to bring about the fight-or-flight response by increasing the heart rate, increasing muscle strength, increasing cardiac output, increasing blood glucose levels, and increasing mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is assessing the developmental levels of patients in a pediatric office. Which individual would a nurse document as experiencing developmental stress? a. An infant who learns to turn over b. A school-aged child who learns how to add and subtract c. An adolescent who is a "loner" d. A young adult who has a variety of friends (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER c. The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is caring for an older male patient in a long-term care facility who has a spinal cord injury affecting his neurologic reflex arc. Based on this patient data, what would be a priority intervention for this patient? a. Monitoring food and drink temperatures to prevent burns b. Providing adequate pain relief measures to reduce stress c. Monitoring for depression related to social isolation d. Providing meals high in carbohydrates to promote healing (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a. A patient with a damaged neurologic reflex arc would have a diminished pain reflex response, which would put the patient at risk for burns as the sensors in the skin would not detect the heat of the food or liquids. All patients should be provided adequate pain relief, but this is not the priority intervention in this patient. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a balanced diet based on the ChooseMyPlate dietary guidelines. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is caring for a patient in the shock or alarm reaction phase of the GAS. Which response by the patient would be expected? a. Decreasing pulse b. Increasing sleepiness c. Increasing energy levels d. Decreasing respirations (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER c. The body perceives a threat and prepares to respond by increasing the activity of the autonomic nervous and endocrine systems. The initial or shock phase is characterized by increased energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse interviews a woman who was abused by her partner and is staying at a women's shelter with her three children. She tells the nurse, "I'm so worried that my husband will find me and try to make me go back home." Which data would the nurse most appropriately document? a, "Patient displays moderate anxiety related to her situation." b. "Patient manifests panic related to feelings of impending doom." c. "Patient describes severe anxiety related to her situation." d. "Patient expresses fear of her husband." (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. Fear is a response (feeling of dread) to a known threat. Anxiety, on the other hand, is a vague, uneasy feeling of discomfort or dread from an often unknown source. Panic causes a person to lose control and experience dread and terror, which can lead to exhaustion and death; that is not the case in this situation. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A college student visits the school's health center with vague complaints of anxiety and fatigue. The student tells the nurse, "Exams are right around the corner and all I feel like doing is sleeping." The student's vital signs are within normal parameters. What would be an appropriate question to ask in response to these complaints? a. "Are you worried about failing your exams?" b. "Have you been staying up late studying?" c. "Are you using any recreational drugs?" d. "Do you have trouble managing your time?" (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a. Mild anxiety is often handled without conscious thought through the use of coping mechanisms, such as sleeping, which are behaviors used to decrease stress and anxiety. Based on the complaints and normal vital signs, it would be best to explore the patient's level of stress and physiologic response to this stress. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is interviewing a patient who just received news that he has pancreatic cancer. The patient tells the nurse that getting cancer could never happen to him. Which defense mechanism is this patient demonstrating? a. Projection b. Denial c. Displacement d. Repression (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER b. Denial occurs when a person refuses to acknowledge the presence of a condition that is disturbing. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A visiting nurse is performing a family assessment of a young couple caring for their newborn who was diagnosed with cerebral palsy. The nurse notes that the mother's hair and clothing are unkempt, the house is untidy, and the mother states that she is "so busy with the baby that I don't have time to do anything else." What would be the priority intervention for this family? a. Arrange to have the infant removed from the home. b. Inform other members of the family of the situation. c. Increase the number of visits by the visiting nurse. d. Notify the care provider and recommend respite care for the mother. (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. Reactions of family members to home health care for long periods of time, called caregiver burden, include chronic fatigue, sleep disorders, and an increased incidence of stress-related illnesses, such as hypertension and heart disease. The nurse should address the issue with the primary care provider and recommend a visit from a social worker and/or arrange for respite care for the family. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is teaching a patient a relaxation technique. Which statement demonstrates the need for more teaching? a. "I must breathe in and out in rhythm." b. "I should take my pulse and expect it to be faster." c. "I can expect my muscles to feel less tense." d. "I will be more relaxed and less aware." (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER b. No matter what the technique, relaxation involves rhythmic breathing, a slower pulse, reduced muscle tension, and an altered state of consciousness. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain of childbirth. Which stress reduction activities would be most effective? Select all that apply. a. Progressive muscle relaxation b. Meditation c. Anticipatory socialization d. Biofeedback e. Rhythmic breathing f. Guided imagery (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a, b, e, f. Relaxation techniques are useful in many situations, including childbirth, and consist of rhythmic breathing and progressive muscle relaxation. Meditation and guided imagery could also be used to distract a patient from the pain of childbirth. Anticipatory socialization helps to prepare people for roles they don't have yet but aspire to, such as parenthood. Biofeedback is a method of gaining mental control of the autonomic nervous system and thus regulating body responses, such as blood pressure, heart rate, and headaches. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse teaches problem solving to a college student who is in a crisis situation. What statement best illustrates the student's understanding of the process? a. "I need to identify the problem first." b. "Listing alternatives is the initial step." c. "I will list alternatives after I develop the plan." d. "I do not need to evaluate the outcome of my plan." (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER a. Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is performing an assessment of a female patient who is 8 months pregnant. The woman states, "I worry all the time about being able to handle becoming a mother." Which nursing diagnosis would be most appropriate for this patient? a. Ineffective Coping related to the new parenting role b. Ineffective Denial related to ability to care for a newborn c. Anxiety related to change in role status d. Situational Low Self-Esteem related to fear of parenting (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER c. The nursing diagnosis of Anxiety indicates situational/maturational crises or changes in role status. Ineffective coping refers to the inability to appraise stressors or use available resources. Ineffective denial is a conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety, and leads to detriment of health. Situational Low Self-Esteem diagnoses feelings of worthlessness related to the current situation the person is experiencing, not related to the fear of role changes. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. A nurse is responsible for preparing patients for surgery in an ambulatory care center. Which technique for reducing anxiety would be appropriate for these patients? a. Discouraging over-verbalization of fears and anxieties b. Focusing on the outcome as opposed to the details of the surgery c. Providing time alone for reflection on personal strengths and weaknesses d. Mutually determining expected outcomes of the plan of care (Taylor 1598) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file. - CORRECT ANSWER d. Nurses preparing patients for surgery should mutually determine expected outcomes of the care, as well as encourage verbalizations of feelings, perceptions, and fears. Explain all procedures including sensations likely to be experienced during the procedure, and stay with the patient to promote safety and reduce fear. (Taylor 1599) Taylor, Carol. Fundamentals of Nursing. 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