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Comprehensive Review for the NCLEX-RN® EXAMINATION Edition4 HESIThis page intentionally left blankHESI Comprehensive Review for the NCLEX-RN® EXAMINATION Edition 4 EDITORS Sandra Upchurch,... PhD, RN Traci Henry, MSN, RN Rosemary Pine, PhD, RN, BC, CDE Amy Rickles, MA3251 Riverport Lane St. Louis, Missouri 63043 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION, FOURTH EDITION ISBN: 978-1-4557-2752-0 Copyright © 2014, 2011, 2008 by Elsevier Inc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. NANDA International Nursing Diagnoses: Definitions and Classifications 2012-2014; Herdman T.H. (ED); copyright © 2012, 1994-2012 NANDA International; published by John Wiley & Sons, Limited. NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks and service marks of the National Council of State Boards of Nursing, Inc. Library of Congress Cataloging-in-Publication Data HESI comprehensive review for the NCLEX-RN examination / editors, Sandra Upchurch, Traci Henry, Rosemary Pine, Amy Rickles. –Edition 4. p. ; cm. Comprehensive review for the NCLEX-RN examination Includes index. ISBN 978-1-4557-2752-0 (pbk. : alk. paper) I. Upchurch, Sandra L., editor of compilation. II. Henry, Traci, editor of compilation. III. Pine, Rosemary. editor of compilation. IV. Rickles, Amy, editor of compilation. V. HESI (Firm), issuing body. VI. Title: Comprehensive review for the NCLEX-RN examination. [DNLM: 1. Nursing, Practical–Examination Questions. 2. Nursing, Practical–Outlines. 3. Nursing Care–Examination Questions. 4. Nursing Care–Outlines. 5. Nursing Process–Examination Questions. 6. Nursing Process–Outlines. WY 18.2] RT55 610.73076–dc23 2013023800 Executive Content Strategist: Kristin Geen Associate Content Development Specialist: Laura Goodrich Marketing Manager: Danielle LeCompte Publishing Services Manager: Deborah L. Vogel Project Manager: Bridget Healy Senior Designer: Amy Buxton Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1v Joanna E. Cain, BSN, BA, RN President & Founder Auctorial Pursuits, Inc. Austin, Texas Shelby L. Garner, PhD, RN, CNE Lecturer Baylor University Louise Herrington School of Nursing Dallas, Texas Robert F. Shaw, PharmD, MPH Clinical Pharmacist Iowa City VA Health Care System Iowa City, Iowa Edith Summerlin, PhD, RN Assistant Professor University of Texas Health Science Center at Houston Houston, Texas CONTRIBUTING AUTHORSThis page intentionally left blankvii Margaret Barnes, MSN, RN Assistant Professor Indiana Wesleyan University Marion, Indiana Reitha Cabaniss, MSN, C.N.E. Nursing Program Director Bevill State Community College Jasper, Alabama Barbara Coles, PhD (c), MA, RN BC Adjunct Instructor University of South Florida Tampa, Florida Amber Essman, MSN, RN, CNE Assistant Professor Chamberlain College of Nursing Columbus, Ohio Brenda Forrest, RN, MS, FNP, CNS Associate Professor of Nursing Cayuga Community College Auburn, New York Margie L. Francisco, Ed.D (c), MSN, RN Nursing Professor Illinois Valley Community College Oglesby, Illinois Beth Bates Gaul, RN, PhD Professor Nursing Grand View University Des Moines, Iowa Susan Golden, MSN, RN Interim Dean of Health Eastern New Mexico University-Roswell Roswell, New Mexico Rose A. Harding, MSN, RN Instructor Lamar University Beaumont, Texas Rosanna M. Henry, RN, MSN Instructor & Director, Clinical Lab Duquesne University, School of Nursing Pittsburgh, Pennsylvania Donna Walker Hubbard, MSN, RN, CNNe Assistant Professor Texas Christian University Fort Worth, Texas Celeste Hughes, MSN, RN Nursing Faculty Georgia Northwestern Technical College Rome, Georgia Cheryl Lehman, PhD RN, CNS-BC, RN-BC, CRRN Clinical Associate Professor School of Nursing University of Texas Health Science Center at San Antonio San Antonio, Texas Karen M. Lettre, RN, MSN, CEN, CPEN, EMT Clinical Manager Children's Medical Center Dallas Legacy Campus Emergency Department Dallas, Texas Gail B. Rea, RN, PhD, CNE Assistant Dean, Pre-Licensure Programs Goldfarb School of Nursing at Barnes-Jewish Hospital St. Louis, Missouri Susan K. Rice, PhD, RN, CPNP, CNS Professor University of Toledo Toledo, Ohio REVIEWERSviii REVIEWERS Debra Rurup, MNSc, RN, CNE Assistant Professor University of Arkansas at Little Rock Little Rock, Arkansas Valerie Steiner, RNC, MA, MSN, CNE A.D.N. Program Director Midland College Midland, Texas Donna Wilsker, MSN, RN Assistant Professor Lamar University Beaumont, Texas Nancee Wozney, PhD, RN Dean of Nursing/Allied Health Director of Nursing Southeast Technical Red Wing, Minnesota Mary Anderson, MSN, RN, CNS Elizabeth Arnold, MSN, RN, CNS Sara Bishop, PhD, RNC Mary Ann Boyd, PhD, DNS, APRN, BC Robin Britt, EdD, RNC Mary Cassem, MS, RN Rita D. Cinquemani, RN, MSN, FNP-BC Daria M. Close, MSN, RN Carol L. Collins, MS, RN Pat Crotwell, MSN, RN Debra Danforth, MS, RN, ARNP Deborah Davenport, MSN, RN, CCRN Judith Driscoll, MEd, RN, MSN Karen F. Duncan, MS, RN Laurie K. Erford, MSN, RN Jean Flick, MS, RN Judy Hammond, PhD, RNC Mary M. Hinds, PhD, RN, CNS Florence Jemes, RN, MSN, CS Barbara Kearney, PhD, RN Robin Lockhart, PhD(c), RN Ann Lovric, RN, MSN Mary Lou Martin, MSN, RN, CPNP Jane Mathis, MSN, RNC, CCE Susan Morrison, PhD, RN Ainslie Nibert, PhD, RN Cynthia K. Peterson, MSN, RN Judy Siefert, MSN, RN Betty Tracy, MN, RN Mary Yoho, PhD, RN The editors and publisher would like to acknowledge the following individuals for contributions to the previous editions of this book.ix Welcome to HESI Comprehensive Review for the NCLEXRN® Examination with online study exams by HESI. Congratulations! This outstanding review manual with online study exams is designed to prepare nursing students for what is very likely the most important examination they will ever take—the NCLEX-RN® Licensing Examination. As a graduate of an RN nursing program, the student has the basic knowledge required to pass tests and perform safely and successfully in the clinical area. HESI Comprehensive Review for the NCLEX-RN® Examination allows the nursing student to prepare for the NCLEX-RN® licensure examination in a structured way. • Organize nursing basic knowledge previously learned. • Review content learned during basic nursing curriculum. • Identify weaknesses in content knowledge so study effort can be focused appropriately. • Develop test-taking skills so application of safe nursing practice from knowledge previously learned can be demonstrated. • Reduce anxiety level by increasing predictability of ability to correctly answer NCLEX-type questions. • Boost test-taking confidence by being well prepared and knowing what to expect. Organization Chapter 1, Introduction to Testing and the NCLEX-RN® Exam, gives an overview of the NCLEX-RN licensing exam history and test plan for the examination. A review of the nursing process, updated with the latest NANDAapproved nursing diagnoses, client needs, and prioritizing nursing care, is also presented. Chapter 2, Leadership and Management, reviews the legal aspects of nursing, leadership and management, and disaster nursing. Chapter 3, Advanced Clinical Concepts, presents nursing assessment, analysis (nursing diagnoses), and planning and intervention at the highest level of practice. Topics reviewed include respiratory failure, shock, disseminated intravascular coagulation (DIC), resuscitation, fluid and electrolyte balance, IV therapy, acid-base balance, ECG, perioperative care, HIV, pain, and death and grief. Chapters 4 through 8, Medical-Surgical Nursing, Pediatric Nursing, Maternity Nursing, Psychiatric Nursing, and Gerontologic Nursing, are presented in traditional clinical areas. Each clinical area is divided into physiologic components, with essential knowledge about basic anatomy, growth and development, pharmacology and medication calculation, nutrition, communication, client and family education, acute and chronic care, leadership and management, and clinical decision making threaded throughout the different components. Open-ended style questions with the answers appear at the end of each chapter, which encourage the student to think in depth about the content that is presented throughout the particular chapter. When a variety of learning mechanisms are used, students have the opportunity to comprehensively prepare for the NCLEX exam; these strategies include: • Reading the manual. • Discussing content with others. • Answering open-ended questions. • Practicing with study exams that simulate the licensure examination. These learning experiences are all different ways that students should use to prepare for the NCLEX exam. The purpose of the open-ended questions appearing at the end of the chapter is not a focused practice session on managing NCLEX-style, multiple-choice questions, but rather a learning approach that allows for more in-depth thinking about specific topics in the chapter. Practice with multiplechoice questions alone cannot provide the depth of critical thinking and analysis possible with the short-answer questions at the end of the chapter. In addition, the open-ended questions presented at the end of the chapter provide a summary experience that helps students focus on the main topics that were covered in the chapter. Teachers use openended style questions to stimulate the critical thinking process, and HESI Comprehensive Review for the NCLEX-RN® Examination facilitates the critical thinking process by posing the same type of questions the teacher might ask. PREFACEx PREFACE When students need to practice multiple-choice questions, the online study exams on Evolve offer extensive opportunities for practice and skill-building to improve their test-taking abilities. The online study exams include six content-specific exams (Medical-Surgical Nursing, Pharmacology, Pediatrics, Fundamentals, Maternity, and Psychiatric-Mental Health Nursing) and two comprehensive exams patterned after categories on the NCLEX-RN® exam. The online study exams on Evolve can be accessed as many times as necessary, and the questions from one study exam are not contained on another study exam. For instance, the Medical-Surgical study exam does not contain questions that are on the Pediatrics study exam. The purpose of the study exams is to provide practice and exposure to the critical thinking–style questions that students will encounter on the NCLEX-RN exam. However, the study exams should not be used to predict performance on the actual NCLEX exam. Only the HESI Exit Exam, a secure, computerized exam that simulates the NCLEX test plan and has evidence-based results from numerous research studies indicating a high level of accuracy in predicting NCLEX success, is offered as a true predictor exam. Students are allowed unlimited practice on each online study exam so that they can be sure to have the opportunity to review all of the rationales for the questions. Here is a plan for a student to use with the online study exams: • Step 1:Take the RN study exam without studying for it to see where your strengths and weaknesses are. • Step 2: After going over the content that relates to the study questions on a particular clinical area (for example, Pediatrics, Medical-Surgical, or Maternity), review that section of the manual, and take the test again to determine if you have been able to improve your scores. • Step 3: Purposely miss every question on the exam so that you can view the rationales for every question. • Step 4:Take the exam again under timed conditions at the pace that you would have to progress in order to complete the NCLEX in the time allowed (approximately 1 minute per question.) See if being placed under time constraints impacts your performance. • Step 5: Put the exam away for a while, and continue review and remediation with other textbooks, other resources, and the results of any HESI secure exams that you have taken at your school. Then, take the study exams again to see if your performance improves after in-depth study and following a few weeks' break from these questions. Step 5 represents a good activity in preparation for the HESI Exit Exam presented in your final semester of the nursing program, especially if you have not used the online study exams for several weeks. Repeated exposure to the questions, however, will make them less useful over time because students tend to memorize the answers. For this reason, these tests are useful only for practice, and not prediction of NCLEX-RN success. The tendency to memorize the questions after viewing them multiple times falsely elevates a student's score on the study exams. Additional assistance for students studying for the NCLEX-RN Licensing Examination can be obtained from a variety of online products in the Elsevier family. Many nursing schools have also adopted the following: • HESI Examinations—A comprehensive set of examinations designed to prepare nursing students for the NCLEX exam. They include customized electronic remediation from current Elsevier textbooks and multimedia, as well as additional practice questions. Each student is given an individualized report detailing exam results and is allowed to view questions and rationales for items that were answered incorrectly. The electronic remediation, a complementary feature of the specialty and exit exams, can be filed by the student for later study. • HESI Practice Test—This is the ideal way to practice for the NCLEX exam. With more than 1200 practice questions included in this online test bank, nursing students can access practice exams 24 hours a day, 7 days a week. HESI Practice Test questions are written at the critical thinking level so that students are tested not for memorization but for their skills in clinical application. Students select a test option (either a clinical specialty or a comprehensive exam) and HESI Practice Test automatically supplies a series of critical-thinking practice questions. NCLEX exam-style questions include multiple-choice and alternate-item formats, and are accompanied by correct answers and rationales. • HESI RN Case Studies—These prepare students to manage complex patient conditions and to make sound clinical judgments. These online case studies cover a broad range of physiologic and psychosocial alterations, plus related management, pharmacology, and therapeutic concepts. • HESI Patient Reviews—These are designed to teach and assess students' retention of core nursing content. These online interactive reviews provide a firsthand look at safe and effective nursing care. • HESI Live Review —A live review course is presented by an expert faculty member who has additional instruction in working with students who are preparing to take the NCLEX. Students are presented with a workbook and practice NCLEX-style questions that are used during the course. • Evolve eBooks—Online versions of all of the Mosby, Saunders and Elsevier textbooks used in the student's nursing curriculum are presented. Search across titles, highlight, make notes, and more—all on your computer. • Elsevier Simulations—Virtual versions simulate the clinical environment. These multilayered, complex, supplemental simulations enable students to experience clinical assignments without the need for actual clinical space. • Elsevier Courses—These are created by experts using instructional design principles. This interactive content engages students with reading, animation, video, audio, interactive exercises, and assessments.xi 1 INTRODUCTION TO TESTING AND THE NCLEX-RN® EXAM 1 Test-Taking Tips 1 The NCLEX-RN® Licensing Exam 3 Job Analysis Studies 3 The NCLEX-RN® Computer Adaptive Testing 7 Gentle Reminders of General Principles 9 2 LEADERSHIP AND MANAGEMENT 10 Legal Aspects of Nursing 10 Prescriptions and Health Care Providers 12 Leadership and Management 15 Disaster Nursing 18 3 ADVANCED CLINICAL CONCEPTS 24 Respiratory Failure 24 Shock 26 Disseminated Intravascular Coagulation (DIC) 28 Resuscitation 31 Fluid and Electrolyte Balance 34 Electrocardiogram (ECG or EKG) 41 Perioperative Care 45 HIV Infection 48 Pediatric HIV Infection 50 Pain 53 Death and Grief 57 4 MEDICAL-SURGICAL NURSING 59 Respiratory System 59 Renal System 74 Cardiovascular System 81 Gastrointestinal System 100 Endocrine System 111 Musculoskeletal System 122 Neurosensory System 131 Neurologic System 135 Hematology and Oncology 148 Reproductive System 157 Burns 166 5 PEDIATRIC NURSING 172 Growth and Development 172 Pain Assessment and Management in the Pediatric Client 175 Child Health Promotion 175 Respiratory Disorders 185 Cardiovascular Disorders 189 Neuromuscular Disorders 195 Renal Disorders 202 Gastrointestinal Disorders 206 Hematologic Disorders 210 Metabolic and Endocrine Disorders 214 Skeletal Disorders 216 6 MATERNITY NURSING 221 Anatomy and Physiology of Reproduction 221 Antepartum Nursing Care 226 Fetal and Maternal Assessment Techniques 231 Intrapartum Nursing Care 239 Normal Puerperium (Postpartum) 253 The Normal Newborn 260 High-Risk Disorders 269 Postpartum High-Risk Disorders 290 Newborn High-Risk Disorders 294 Effects on the Neonate of Substance Abuse 300 7 PSYCHIATRIC NURSING 303 Therapeutic Communication 303 Coping Styles (Defense Mechanisms) 303 CONTENTSxii CONTENTS Treatment Modalities 303 Anxiety 307 Anxiety Disorders 308 Somatoform Disorders 311 Dissociative Disorders 313 Personality Disorders 314 Eating Disorders 317 Mood Disorders 318 Thought Disorders 325 Substance Abuse 329 Abuse 333 Organic Disorders 336 Childhood and Adolescent Disorders 337 8 GERONTOLOGIC NURSING 340 Theories of Aging 340 Physiologic Changes 340 Dementia 348 Psychosocial Changes 349 Health Maintenance and Preventive Care 350 APPENDIXES 353 A Normal Values 353 B Recommended Daily Requirements and Food Sources 361 Index 3631 INTRODUCTION 1 TO TESTING AND THE NCLEX-RN® EXAM Three cheers for you! You have made the wise decision to prepare, in a structured way, for the NCLEX-RN. A. You have already successfully completed a basic nursing program and are well acquainted with your ability to take and pass tests and to perform successfully in the clinical area. B. You have the basic knowledge required to pass the licensing exam. However, it is wise to: 1. Organize your knowledge. 2. Review content learned during the years of your basic nursing curriculum. 3. Identify weaknesses in content knowledge so that you can focus your study time appropriately. 4. Develop test-taking skills so you can demonstrate the knowledge you have. 5. Reduce your level of anxiety by increasing your predictability. 6. Know what to expect. Remember: Knowledge is power. You are powerful when you are well prepared and know what to expect. Test-Taking Tips There are no absolute ways to ensure that exam questions will always be answered correctly. These test-taking tips are guidelines to help the student study and understand the exam questions. On the NCLEX-RN exam, many different areas are tested with each question. For example, a question may on the surface be a medical/surgical or pediatric question but included in the question can be such topics as communication, nutrition, growth and development, medication, client and family education, and safety. A. Understanding the question 1. Determine if the question is written in a positive or negative style. a. A positive style may ask what the nurse should do or ask for the best or first action to implement. HESI Hint • Most questions are written in a positive style. b. A negative style may ask what the nurse should avoid, which prescription the nurse should question, or which behavior indicates the need for re-teaching the client. HESI Hint • Negative style questions will contain key words that denote the negative style. EXAMPLES 1. “Which response indicates to the nurse a need to re-teach the client about…?” (Which information/ understanding by the client is incorrect?) 2. “Which prescription (order) should the nurse question?” (Which prescription is unsafe, not beneficial, inappropriate to this client situation, etc…?) 2. Find the key words in the question. a. Ask yourself which words or phrases provide the critical information. b. This information may be the age of the client, the setting, the timing, a set of symptoms or behaviors, or any number of other factors. c. For example, the nursing actions for a 10-yearold 1 day postop are different than those for a 70-year-old 1 hour postop. 3. Rephrase the question in your own words. a. This will help you eliminate nonessential information in the question and help you determine the correct answer. b. Ask yourself, “What is this question really asking?” c. While keeping the options covered, rephrase the question in your own words. 4. Rule out options. a. Based on your knowledge, you can probably identify one or two options that are clearly incorrect. b. Physically mark through those options on the test booklet if allowed. Mentally mark through those options in your head if using a computer.2 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION c. Now differentiate between the remaining options, considering your knowledge of the subject and related nursing principles, such as roles of the nurse, the nursing process, the ABCs (airway, breathing, and circulation), CAB (circulation, airway, and breathing for cardiopulmonary resuscitation [CPR]), and Maslow’s Hierarchy of Needs. B. General guidelines about test taking 1. Consider the content of the question and what the question is asking. 2. Generally, an assessment of the client occurs before an action is taken. 3. Identify the least invasive intervention before taking action. 4. Have all the necessary information and take all possible relevant actions before calling the physician or health care provider. 5. Determine which client to assess first (e.g., most at risk, most physiologically unstable). 6. Identify opposites in the answers. a. Example: Prone/supine; elevated/decreased b. Read VERY carefully; one is likely to be the answer, BUT not always c. If you do not know the answer, choose the most likely of the “opposites” and move on. 7. Take into account a client’s lifestyle, culture, and spiritual beliefs when answering a question. C. Use CRITICAL THINKING, reasoning, and common sense to answer questions. 1. DO respond based on… a. ABCs b. CAB for CPR c. Scientific, behavioral, sociologic principles d. Principles of teaching/learning e. Maslow’s Hierarchy of Needs f. Nursing process g. What’s in the stem: No more, no less (Do not read more into the question than is already there.) h. NCLEX-RN ideal hospital i. Basic anatomy and physiology 2. DON’T respond based on… a. YOUR past client care experiences or agency b. A familiar phrase or term c. “Of course, I would have already…” d. What YOU think is REALISTIC e. YOUR children, pregnancies, parents, elders, personal response to a drug, etc. f. The “what ifs” D. Keep memorizing to a minimum. 1. Growth and developmental milestones 2. Death and dying stages 3. Crisis intervention 4. Immunizations schedule 5. Principles of teaching/learning 6. Stages of pregnancy and fetal growth 7. Nurse Practice Act: Standards of Practice and Delegation E. Know commonly used lab ranges (Appendix A), what variations mean, and the BEST nursing actions. 1. H&H 2. WBCs, RBCs, platelets 3. Electrolytes: K+, Na+, Ca++, Mg++, Cl−, PO4− 4. BUN and creatinine 5. Relationship of Ca++ and PO4− 6. ABGs 7. PT, INR, PTT (Don’t get them confused.) F. Nutrition 1. Know commonly used nutrition information. a. High or low Na+ b. High or low K+ c. High PO4− d. Iron e. Vitamin K f. Proteins g. Carbohydrates h. Fats 2. Foods and diets related to a. Gastrointestinal/genitourinary disturbances b. Chemotherapy diets and restrictions c. Pregnancy and fetal growth needs d. Dialysis e. Burns 3. Remember concepts a. Introducing one food at a time (infants, allergies) b. Progression “AS TOLERATED” (What nursing assessment guides decisions regarding progression?) G. Medications—SAFE medication administration is more than just knowing the name, classification, and action of the medication. 1. “Six Rights,” including techniques of skill execution 2. Drug interactions 3. Vulnerable organs a. What to assess b. Which lab values relate to specific organs 4. Allergies 5. Presence of suprainfections 6. Concepts of peak and trough 7. How you would know a. The drug is working b. There’s a problem 8. Nursing actions 9. Client education should include a. Safety b. Empowerment c. ComplianceCHAPTER 1 INTRODUCTION TO TESTING AND THE NCLEX-RN® EXAM 3 The NCLEX-RN® Licensing Exam A. The main purpose of a licensing exam like the NCLEXRN is to protect the public. B. The NCLEX-RN: 1. Was developed by the National Council of State Boards of Nursing (the Council; this abbreviation is used to refer to the NCSBN throughout this book) 2. Is administered by the State Board of Nurse Examiners 3. Is designed to test candidates’ a. Capabilities for safe and effective nursing practice b. Essential entry-level nursing knowledge Job Analysis Studies A. Essential knowledge is determined by job analysis studies. HESI Hint • The Council wants to ensure that the licensing exam measures current entry-level nursing behaviors. For this reason, job analysis studies are conducted every 3 years. These studies determine how frequently various types of nursing activities are performed, how often they are delegated, and how critical they are to client safety, with criticality given more value than frequency. B. Job analysis studies indicate that newly licensed registered nurses are using all five categories of the nursing process and that such use is evenly distributed throughout the five nursing process areas. Therefore, equal attention is given to each part of the nursing process in selecting test items (Table 1-1). Nursing Diagnoses A. Nursing diagnoses are formulated during the analysis portion of the nursing process. They give form and direction to the nursing process, promote priority setting, and guide nursing actions (Table 1-2). B. To qualify as a nursing diagnosis, the primary responsibility and accountability for recognition and treatment rest with the nurse. C. The National Conference of the North American Nursing Diagnosis Association (NANDA) provided the following definition of a nursing diagnosis: “Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (Box 1-1). TABLE 1-1 The Nursing Process Category Activities Associated with Nursing Process Assessment • Gather objective and subjective data. • Verify data. Analysis • Interpret data. • Collect additional data when necessary. • Identify and communicate nursing diagnoses. • Determine health team’s ability to meet client’s needs. Planning • Determine and prioritize outcomes of care. Include client, significant others, and health team in setting outcomes. • Develop and modify plan for delivery of client’s care. Implementation • Organize and manage the client’s care, including assignment and delegation of tasks. • Perform or assist in performance of client’s care. • Counsel and teach client, significant others, and health team. • Provide care specifically directed toward achieving outcomes. Evaluation • Compare actual outcomes with expected outcomes. • Evaluate compliance with the established regimen or plan. • Record and describe client’s response to plan. • Modify plan as indicated and set priorities. TABLE 1-2 Components of a Nursing Diagnosis Component Explanation Response • Includes potential or actual health response • Describes measurable outcomes that can be derived • Cites potential for changes based on nursing actions • Example: Alteration in comfort, pain Etiology • Includes potential or actual health response • Addresses independent, interdependent, and dependent nursing functions • Example: Related to fractured left ankle4 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION BOX 1-1 NANDA-Approved Nursing Diagnoses A Activity Intolerance Risk for Activity Intolerance Ineffective Activity Planning Risk for Ineffective Activity Planning Risk for Adverse Reaction to Iodinated Contrast Media Ineffective Airway Clearance Risk for Allergy Response Anxiety Risk for Aspiration Risk for Impaired Attachment Autonomic Dysreflexia Risk for Autonomic Dysreflexia B Disorganized Infant Behavior Risk for Disorganized Infant Behavior Readiness for Enhanced Organized Infant Behavior Risk for Bleeding Risk for Unstable Blood Glucose Level Disturbed Body Image Risk for Imbalanced Body Temperature Insufficient Breast Milk Ineffective Breastfeeding Interrupted Breastfeeding Readiness for Enhanced Breastfeeding Ineffective Breathing Pattern C Decreased Cardiac Output Caregiver Role Strain Risk for Caregiver Role Strain Readiness for Enhanced Childbearing Process Ineffective Childbearing Process Risk for Ineffective Childbearing Process Impaired Comfort Readiness for Enhanced Comfort Readiness for Enhanced Communication Impaired Verbal Communication Acute Confusion Risk for Acute Confusion Chronic Confusion Constipation Perceived Constipation Risk for Constipation Contamination Risk for Contamination Defensive Coping Ineffective Coping Readiness for Enhanced Coping Ineffective Community Coping Readiness for Enhanced Community Coping Compromised Family Coping Disabled Family Coping Readiness for Enhanced Family Coping D Death Anxiety Risk for Sudden Infant Death Syndrome Decisional Conflict Readiness for Enhanced Decision-Making Ineffective Denial Impaired Dentition Risk for Delayed Development Diarrhea Risk for Disuse Syndrome Deficient Diversional Activity Risk for Dry Eye E Risk for Electrolyte Imbalance Disturbed Energy Field Impaired Environmental Interpretation Syndrome F Adult Failure to Thrive Risk for Falls Dysfunctional Family Processes Interrupted Family Processes Readiness for Enhanced Family Processes Fatigue Fear Ineffective Infant Feeding Pattern Readiness for Enhanced Fluid Balance Risk for Imbalanced Fluid Volume Deficient Fluid Volume Risk for Deficient Fluid Volume Excess Fluid Volume G Impaired Gas Exchange Dysfunctional Gastrointestinal Motility Risk for Dysfunctional Gastrointestinal Motility Risk for Ineffective Gastrointestinal Perfusion Grieving Complicated Grieving Risk for Complicated Grieving Risk for Disproportionate Growth Delayed Growth and Development H Deficient Community Health Risk-Prone Health Behavior Ineffective Health Maintenance Impaired Home Maintenance Readiness for Enhanced Hope Hopelessness Risk for Compromised Human Dignity Hyperthermia Hypothermia I Readiness for Enhanced Immunization Status Ineffective Impulse Control Bowel Incontinence Functional Urinary Incontinence Overflow Urinary Incontinence Reflex Urinary IncontinenceCHAPTER 1 INTRODUCTION TO TESTING AND THE NCLEX-RN® EXAM 5 Stress Urinary Incontinence Urge Urinary Incontinence Risk for Urge Urinary Incontinence Risk for Infection Risk for Injury Insomnia Decreased Intracranial Adaptive Capacity J Neonatal Jaundice Risk for Neonatal Jaundice K Deficient Knowledge Readiness for Enhanced Knowledge L Latex Allergy Response Risk for Latex Allergy Response Sedentary Lifestyle Risk for Impaired Liver Function Risk for Loneliness M Risk for Disturbed Maternal-Fetal Dyad Impaired Memory Impaired Bed Mobility Impaired Physical Mobility Impaired Wheelchair Mobility Moral Distress N Nausea Unilateral Neglect Noncompliance Readiness for Enhanced Nutrition Imbalanced Nutrition: Less Than Body Requirements Imbalanced Nutrition: More Than Body Requirements O Impaired Oral Mucous Membrane P Acute Pain Chronic Pain Readiness for Enhanced Parenting Impaired Parenting Risk for Impaired Parenting Risk for Peripheral Neurovascular Dysfunction Disturbed Personal Identity Risk for Disturbed Personal Identity Risk for Poisoning Risk for Perioperative Positioning Injury Post-Trauma Syndrome Risk for Post-Trauma Syndrome Readiness for Enhanced Power Powerlessness Risk for Powerlessness Ineffective Protection R Rape-Trauma Syndrome Readiness for Enhanced Relationship Ineffective Relationship Risk for Ineffective Relationship Readiness for Enhanced Religiosity Impaired Religiosity Risk for Impaired Religiosity Relocation Stress Syndrome Risk for Relocation Stress Syndrome Risk for Ineffective Renal Perfusion Impaired Individual Resilience Readiness for Enhanced Resilience Risk for Compromised Resilience Parental Role Conflict Ineffective Role Performance S Bathing Self-Care Deficit Dressing Self-Care Deficit Feeding Self-Care Deficit Toileting Self-Care Deficit Readiness for Enhanced Self-Care Readiness for Enhanced Self-Concept Chronic Low Self-Esteem Risk for Chronic Low Self-Esteem Situational Low Self-Esteem Risk for Situational Low Self-Esteem Ineffective Self-Health Management Readiness for Enhanced Self-Health Management Self-Mutilation Risk for Self-Mutilation Self-Neglect Sexual Dysfunction Ineffective Sexuality Pattern Risk for Shock Impaired Skin Integrity Risk for Impaired Skin Integrity Sleep Deprivation Readiness for Enhanced Sleep Disturbed Sleep Pattern Impaired Social Interaction Social Isolation Chronic Sorrow Spiritual Distress Risk for Spiritual Distress Readiness for Enhanced Spiritual Well-Being Stress Overload Risk for Suffocation Risk for Suicide Delayed Surgical Recovery Impaired Swallowing T Ineffective Family Therapeutic Regimen Management Risk for Thermal Injury Ineffective Thermoregulation Impaired Tissue Integrity Ineffective Peripheral Tissue Perfusion BOX 1-1 NANDA-Approved Nursing Diagnoses—cont’d Continued6 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION D. NCLEX-RN questions regarding nursing diagnosis can take several forms: 1. You may be given the nursing diagnosis in the stem and asked to select an appropriate nursing intervention based on the stated nursing diagnosis. 2. You may be asked to select, from the four choices, an appropriate nursing diagnosis for the described case. 3. You may be asked to choose, from four nursing diagnoses, the one that should have priority based on the data in the stem. HESI Hint • A nursing diagnosis is not a medical diagnosis. It must be subject to oversight by nursing management. The cause may or may not arise from a medical diagnosis. Client Needs A. Job analysis studies have identified categories of care provided by nurses called Client Needs. The test plan is structured according to these categories (Table 1-3). Prioritizing Nursing Care A. Many NCLEX-RN test items are designed to test your ability to set priorities—for example: 1. Identify the most important client needs. 2. Which nursing intervention is most important? 3. Which nursing action should be done first? 4. Which response is best? B. Setting priorities 1. What should be done first or next? 2. Those taking the NCLEX-RN should “Remember Maslow” (Table 1-4). Risk for Decreased Cardiac Tissue Perfusion Risk for Ineffective Cerebral Tissue Perfusion Risk for Ineffective Peripheral Tissue Perfusion Impaired Transfer Ability Risk for Trauma U Impaired Urinary Elimination Readiness for Enhanced Urinary Elimination Urinary Retention V Risk for Vascular Trauma Impaired Spontaneous Ventilation Dysfunctional Ventilatory Weaning Response Risk for Other-Directed Violence Risk for Self-Directed Violence W Impaired Walking Wandering BOX 1-1 NANDA-Approved Nursing Diagnoses—cont’d TABLE 1-3 Client Needs Category of Client Needs NCLEX-RN (%) Activities Safe and Effective Care Environment • Management of care • Safety and infection control 17%-23% 9%-15% • Coordination of care; quality assurance; goal-oriented care; environmental safety • Preparation for treatments and procedures • Safe and effective treatments and procedures Health Promotion and Maintenance 6%-12% • Continued growth and development • Self-care • Integrity of support systems • Prevention and early treatment of health problems Psychosocial Integrity 6%-12% • Promotion and support of emotional, mental, and social well-being Physiologic Integrity • Basic care and comfort • Pharmacologic and parenteral therapies • Reduction of risk potential • Physiologic adaptation 6%-12% 12%-18% 9%-15% 11%-17% • Physiologic adaptation • Reduction for risk potential • Activities of daily living • Care room temperature, medication administration, and parental therapies • Provision of basic comfort and care Note:The percentage of test questions assigned to each Client Needs category and subcategory of the 2013 NCLEX-RNTest Plan is based on the results of the Report of Findings from the 2011 RN Practice Analysis: Linking the NCLEX-RN Examination to Practice: NCSBN, 2012. Adapted from National Council of State Boards of Nursing. Test plan for the NCLEX-RN examination. Copyright 2013, National Council of State Boards of Nursing, Inc., Chicago.CHAPTER 1 INTRODUCTION TO TESTING AND THE NCLEX-RN® EXAM 7 3. The Five Rights of Delegation (see Chapter 2, p. 16) HESI Hint • Answering NCLEX-RN questions correctly often depends on setting priorities properly, on making judgments about priorities, and on analyzing the case and formulating a decision about care (or the correct response) based on priorities. Using Maslow’s Hierarchy of Needs can help you to set priorities. The NCLEX-RN® Computer Adaptive Testing A. Computer adaptive testing (CAT) is used for implementation of the NCLEX-RN. B. The CAT is administered at a testing center selected by the Council. C. Pearson VUE is responsible for adapting the NCLEXRN to the CAT format, processing candidate applications, and transmitting test results to its data center for scoring. D. The testing centers are located throughout the United States. E. The Council generates the NCLEX-RN test items. The Way It Works A. The NCLEX-RN consists of 75 to 265 multiple-choice or alternative-format questions (15 of which are “pilot items”) presented on a computer screen. B. The candidate is presented with a test item and possible answers. C. If the candidate answers the question correctly, a slightly more difficult item will follow, and the level of difficulty will increase with each item until the candidate misses an item. D. If the candidate misses an item, a slightly less difficult item will follow, and the level of difficulty will decrease with each item until the candidate has answered an item correctly. E. This process will continue until the candidate has achieved a definite pass or a definite fail score. There will be no borderline pass or fail scores because the adaptive testing method determines the candidate’s level of performance before she or he has finished the exam. F. The fewest number of items a candidate can answer to complete the exam is 75; 15 of them will be pilot items and will not count toward the pass or fail score; 60 of them will determine the candidate’s score. TABLE 1-4 Maslow’s Hierarchy of Needs Need Definition Nursing Implications Physiologic Biologic needs for food, shelter, water, sleep, oxygen, sexual expression The priority biologic need is breathing (i.e., an open airway). Review Table 1-3, Client Needs activities associated with physiologic integrity. If you were asked to identify the most important action, you would identify needs associated with physiologic integrity (e.g., providing an open airway) as the most important nursing action. Safety Avoiding harm; attaining security, order, and physical safety Review Table 1-3, the activities associated with Safe and Effective Care Environment. Ensuring that the client’s environment is safe is a priority (e.g., teaching an older client to remove throw rugs that pose a safety hazard when ambulating would have a greater priority than teaching him or her how to use a walker).The first priority is safety, then coping skills. Love and Belonging Esteem and Recognition Giving and receiving affection; companionship; and identification with a group Self-esteem and respect of others; success in work; prestige Although these needs are important (described in Table 1-3, Client Needs, activities associated with psychosocial integrity), they are less important than physiologic or safety needs. For example, it is more important for a client to have an open airway and a safe environment for ambulating than it is to assist him or her to become part of a support group. However, assisting the client in becoming a part of a support group would have higher priority than assisting him or her in developing self-esteem.The sense of belonging would come first, and such a sense might help in developing self-esteem. Self-actualization Aesthetic Fulfillment of unique potential Search for beauty and spiritual goals It is important to understand the last two needs in Maslow’s Hierarchy.They could deal with Client Needs associated with Health Promotion and Maintenance, such as continued growth and development and self-care, as well as those associated with Psychosocial Integrity. However, you will probably not be asked to prioritize needs at this level. Remember, it is the goal of the Council to ensure safe nursing practice, and such practice does not usually deal with the client’s self-actualization or aesthetic needs.8 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION G. The number of the item the candidate is currently answering will appear on the upper right area of the screen. H. When the candidate has answered enough items to determine a definite pass or fail score, a message will appear on the screen notifying the candidate that he or she has completed the exam. I. The most number of items a candidate can answer is 265, and the longest amount of time the candidate can take to complete the exam is 6 hours. J. Candidates will have up to 6 hours to complete the NCLEX-RN examination; total examination time includes a short tutorial, two preprogrammed optional breaks, and any unscheduled breaks they may take. The first optional break is offered after 2 hours of testing. The second optional break is offered after 3.5 hours of testing. The computer will automatically tell candidates when these scheduled breaks begin. 1. All breaks count against testing time. 2. When candidates take breaks, they must leave the testing room, and they will be required to provide a palm vein scan before and after the breaks. K. If a candidate has not obtained a pass/fail score at the end of the 6 hours and has not completed all 265 items in the 6-hour limit but has answered all of the last 60 questions presented correctly, he or she will pass the exam. L. If a candidate has not obtained a pass/fail score at the end of the 6 hours, has not completed all 265 items in the 6-hour limit, and has not answered correctly all of the last 60 questions presented, he or she will fail the exam. M. A specific passing score is recommended by the Council. All states require the same score to pass, so that if you pass in one state, you are eligible to practice nursing in any other state. However, states do differ in their requirements regarding the number of times a candidate can take the NCLEX-RN. N. Although the Council has the ability to determine a candidate’s score at the time of completion of the exam, it has been decided that it would be best for candidates to receive their scores from their individual Board of Nurse Examiners. The Council does not want the testing center to be in a position of having to deal with candidates’ reactions to scores, nor does the Council want those waiting to take their exams to be influenced by such reactions. O. You must answer each question in order to proceed. You cannot omit a question or return to an item presented earlier. There is no going back; this works in your favor! P. The examination is written at a 10th-grade reading level. Q. There is no penalty for guessing; with four choices, you have a 25% chance of guessing the correct answer. HESI Hint • One or more of the choices are likely to be very wrong. You usually will be able to rule out two of the four choices rather quickly. Reread the question and choices again if necessary. Ask yourself which choice answers the question being asked. Even if you have absolutely no idea what the correct answer is, you will have a 50/50 chance of guessing the right answer if you follow this process. Your first response will provide an educated guess and will usually be the correct answer. Go with your gut response! Pace yourself from the beginning of the test. Allow approximately 1.5 minutes per question. HESI Hint • The NCSBN Candidate Bulletin is available at http://www.ncsbn.org. Then select: Examinations/Candidates/Basic Information/Bulletin. Exam Item Formats A. There are a number of different types of exam items presented on the NCLEX-RN examination. The majority of the questions are multiple-choice items with four answers from which the candidate is asked to choose one correct answer. Other format (item types): 1. Multiple-response items require the candidate to select one or more responses. The item will instruct the candidate to choose/select all that apply. 2. Fill-in-the-blank questions require the candidate to calculate the answer and type in numbers. A drop down calculator is provided. 3. Hot-spot items require the candidate to identify an area on a picture or graph and click on the area. 4. Chart or exhibit formats present a chart or exhibit that the candidate must read to be able to solve the problem. 5. Drag-and-drop items require a candidate to rank order or move options to provide the correct order of actions or events. 6. Audio format items require the candidate to listen to an audio clip using headphones and then select the correct option that applies to the audio clip. 7. Graphic format items require the candidate to choose the correct graphic option in response to the question. B. There is no set percentage of alternative items on the NCLEX-RN examination. All examination items are scored either right or wrong. There is no partial credit in scoring any examination questions.CHAPTER 1 INTRODUCTION TO TESTING AND THE NCLEX-RN® EXAM 9 Gentle Reminders of General Principles Take care of yourself. Follow these golden rules for NCLEXRN success. A. Eat well: Consume lots of fresh fruits, vegetables, and lean protein and avoid high-fat foods. B. Sleep well: Get a good night’s sleep the night before the test. This is not the time to cram or to party. You have done your job. Now enjoy the process. C. Eliminate alcohol and other mind-altering drugs: It goes without saying that such substances can inhibit your performance on the exam. D. Schedule study time: Between now and the exam, review nursing content, focusing on areas that you have identified as your weak points when taking the practice tests (review your computer scoring sheets). Use a study schedule to block out the time needed for study. Then be good to yourself, and use that blocked time for yourself: Study. E. Be prepared: Assemble all necessary materials the night before the exam (admission ticket, directions to the testing center, identification, money for lunch, glasses or contacts). 1. Approved items: Candidates are allowed to bring only identification forms into the testing room. Watches, candy, chewing gum, food, drinks, purses, wallets, pens, pencils, beepers, cellular phones, PostIt notes, study materials or aids, and calculators are not allowed. A test administrator will provide each candidate with an erasable note board that may be replaced as needed while testing. Candidates may not take their own note boards, scratch paper, or writing instruments into the exam. A calculator on the computer screen will be available for use. 2. Allow plenty of time: Arrive early; it is better to be early than late. Allow for traffic jams and so forth. The candidate may want to consider spending the night in a hotel or motel near the testing center the night before the exam. 3. Dress comfortably: Dress in layers so that you can take off a sweater or jacket if you become too warm or wear it if you become too cold. F. Avoid negative people: From now until you have completed the exam, stay away from those who share their anxieties with you or project their insecurities onto you. Sometimes this is a fellow classmate or even your best friend. The person will still be there when the exam is over. Right now you need to take care of yourself. Avoid the negative; look for the positive. G. Do not discuss the exam: Avoid talking about the exam during breaks and while waiting to take the exam. H. Avoid distractions: Take earplugs with you and use them if you find that those around you are distracting you, such as those chewing gum, rattling paper, or getting up to leave the exam. I. Think positively: Use the affirmation “I am successful.” Obtain a relaxation and affirmation tape and use it at your hour of sleep PRN (as needed) from now until you take the exam. Use the relaxation tape at night (not on the way to the exam or during breaks while taking the exam; you might fall asleep!). Use the affirmation on the way to the exam or any time you feel the need to boost your confidence. Think, “I have the knowledge to successfully complete the NCLEX-RN.” HESI Hint • The night before taking the NCLEX-RN, allow only 30 minutes of study time. This 30-minute period should be designated for review of test-taking strategies only. Practice these strategies with various practice test items if you wish (for 30 minutes only; do not take an entire test). Spend the night before the exam doing something you enjoy, something that promotes stress reduction, something that does not involve alcohol or other mind-altering drugs. Only you can identify the special something that will work for you. Remember, you can be successful! For more review, go to http://evolve.elsevier. com/HESI/RN for HESI’s online study exams.10 2 LEADERSHIP AND MANAGEMENT Legal Aspects of Nursing Laws Governing Nursing A. Nurse Practice Acts provide the laws that control the practice of nursing in each state. Mandatory Nurse Practice Acts authorize that, under the law, only licensed professionals can practice nursing. All states now have mandatory Nurse Practice Acts. B. Nurse Practice Acts govern the nurse’s responsibility in making assignments. 1. Assignments should be commensurate with the nursing personnel’s educational preparation, experience, and knowledge. 2. The nurse should supervise the care provided by nursing personnel for which he or she is administratively responsible. 3. Sterile or invasive procedures should be assigned to or supervised by a professional nurse (registered nurse [RN]). Torts Description: An act involving injury or damage to another (except breach of contract) resulting in civil liability (i.e., the victim can sue) instead of criminal liability (see Crime). Unintentional Torts A. Negligence and malpractice 1. Negligence: Performing an act that a reasonable and prudent person would not perform. The measure of negligence is “reasonableness” (i.e., would a reasonable and prudent nurse act in the same manner under the same circumstances?). 2. Malpractice: Negligence by professional personnel (e.g., professional misconduct or unreasonable lack of skill in carrying out professional duties). B. Four elements are necessary to prove negligence or malpractice; if any one element is missing, they cannot be proved. 1. Duty: Obligation to use due care (what a reasonable, prudent nurse would do); failure to care for and/or to protect others against unreasonable risk. The nurse must anticipate foreseeable risks. Example: If a floor has water on it, the nurse is responsible for anticipating the risk for a client’s falling. 2. Breach of duty: Failure to perform according to the established standard of conduct in providing nursing care. 3. Injury/damages: Failure to meet standard of care, which causes actual injury or damage to the client, either physical or mental. 4. Causation: A connection exists between conduct and the resulting injury referred to as “proximate cause” or “remoteness of damage.” C. Hospital policies provide a guide for nursing actions. They are not laws, but courts generally rule against nurses who have violated the employer’s policies. Hospitals can be liable for poorly formulated or poorly implemented policies. D. Incident reports alert administration to possible liability claims and the need for investigation; they do not protect against legal action being taken for negligence or malpractice. E. Examples of negligence or malpractice: 1. Burning a client with a heating pad 2. Leaving sponges or instruments in a client’s body after surgery 3. Performing incompetent assessments 4. Failing to heed warning signs of shock or impending myocardial infarction 5. Ignoring signs and symptoms of bleeding 6. Forgetting to give a medication or giving the wrong medication Intentional Torts A. Assault and battery 1. Assault: Mental or physical threat (e.g., forcing [without touching] a client to take a medication or treatment) 2. Battery: Touching, with or without the intent to do harm (e.g., hitting or striking a client). If a mentally competent adult is forced to have a treatment he or she has refused, battery occurs.CHAPTER 2 LEADERSHIP AND MANAGEMENT 11 B. Invasion of privacy: Encroachment or trespassing on another’s body or personality 1. False imprisonment: Confinement without authorization 2. Exposure of a person: Exposure or discussion of a client’s case. After death, a client has the right to be unobserved, excluded from unwarranted operations, and protected from unauthorized touching of the body. 3. Defamation: Divulgence of privileged information or communication (e.g., through charts, conversations, or observations) C. Fraud: Willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Examples of fraud include: 1. Presenting false credentials for the purpose of entering nursing school, obtaining a license, or obtaining employment 2. Describing a myth regarding a treatment (e.g., telling a client that a placebo has no side effects and will cure the disease or telling a client that a treatment or diagnostic test will not hurt, when indeed pain is involved in the procedure) Crime A. An act contrary to a criminal statute. Crimes are wrongs punishable by the state, committed against the state, with intent usually present. The nurse remains bound by all criminal laws. B. Commission of a crime involves the following behaviors: 1. A person commits a deed contrary to criminal law. 2. A person omits an act when there is a legal obligation to perform such an act (e.g., refusing to assist with the birth of a child if such a refusal results in injury to the child). 3. Criminal conspiracy occurs when two or more persons agree to commit a crime. 4. Assisting or giving aid to a person in the commission of a crime makes that person equally guilty of the offense (awareness must be present that the crime is being committed). 5. Ignoring a law is not usually an adequate defense against the commission of a crime (e.g., a nurse who sees another nurse taking narcotics from the unit supply and ignores this observation is not adequately defended against committing a crime). 6. Assault is justified for self-defense. However, to be justified, only enough force can be used as to maintain self-protection. 7. Search warrants are required prior to searching a person’s property. 8. It is a crime not to report suspected child abuse (i.e., the nurse’s legal responsibility is to report suspected child abuse). Nursing Practice and the Law Psychiatric Nursing A. Civil procedures: Methods used to protect the rights of psychiatric clients B. Voluntary admission: Client admits himself or herself to an institution for treatment and retains civil rights. C. Involuntary admission: Someone other than the client applies for the client’s admission to an institution. 1. This requires certification by a health care provider that the person is a danger to self or others. (Depending on the state, one or two health care provider certifications are required.) 2. Individuals have the right to a legal hearing within a certain number of hours or days. 3. Most states limit commitment to 90 days. 4. Extended commitment is usually no longer than 1 year. D. Emergency admission: Any adult may apply for emergency detention of another. However, medical or judicial approval is required to detain anyone beyond 24 hours. 1. A person held against his or her will can file a writ of habeas corpus to try to get the court to hear the case and release the person. 2. The court determines the sanity and alleged unlawful restraint of a person. E. Legal and civil rights of hospitalized clients 1. The right to wear their own clothes and to keep personal items and a reasonable amount of cash for small purchases 2. The right to have individual storage space for one’s own use 3. The right to see visitors daily 4. The right to have reasonable access to a telephone and the opportunity to have private conversations by telephone 5. The right to receive and send mail (unopened) 6. The right to refuse shock treatments and lobotomy F. Competency hearing: Legal hearing that is held to determine a person’s ability to make responsible decisions about self, dependents, or property 1. Persons declared incompetent have the legal status of a minor—they cannot: a. Vote. b. Make contracts or wills. c. Drive a car. d. Sue or be sued. e. Hold a professional license. 2. A guardian is appointed by the court for an incompetent person. Declaring a person incompetent can be initiated by the state or the family. G. Insanity: Legal term meaning the accused is not criminally responsible for the unlawful act committed because he or she is mentally ill12 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION H. Inability to stand trial: Person accused of committing a crime is not mentally capable of standing trial. He or she: 1. Cannot understand the charge against himself or herself 2. Must be sent to psychiatric unit until legally determined to be competent for trial 3. Once mentally fit, must stand trial and serve any sentence, if convicted HESI Hint • Often an NCLEX-RN® question asks who should explain a surgical procedure to the client. The answer is the health care provider. Remember that it is the nurse’s responsibility to be sure that the operative permit is signed and is on the chart. It is not the nurse’s responsibility to explain the procedure to the client. Patient Identification A. The Joint Commission has implemented new patient identification requirements to meet safety goals (http:// www.jointcommission.org/standards_information/ npsgs.aspx). B. Use at least two patient identifiers whenever taking blood samples, administering medications, or administering blood products. C. The patient room number may not be used as a form of identification. Surgical Permit A. Consent to operate (surgical permit) must be obtained prior to any surgical procedure, however minor it might be. B. Legally, the surgical permit must be: 1. Written. 2. Obtained voluntarily. 3. Explained to the client (i.e., informed consent must be obtained). C. Informed consent means the operation has been fully explained to the client, including: 1. Possible complications and disfigurements. 2. Removal of any organs or parts of the body. D. Surgery permits must be obtained as follows: 1. They must be witnessed by an authorized person, such as the health care provider or a nurse. 2. They protect the client against unsanctioned surgery, and they protect the health care provider and surgeon, hospital, and hospital staff against possible claims of unauthorized operations. 3. Adults and emancipated minors may sign their own operative permits if they are mentally competent. 4. Permission to operate on a minor child or an incompetent or unconscious adult must be obtained from a legally responsible family member or guardian. Consent A. The law does not require written consent to perform medical treatment. 1. Treatment can be performed if the client has been fully informed about the procedure. 2. Treatment can be performed if the client voluntarily consents to the procedure. 3. If informed consent cannot be obtained (e.g., client is unconscious) and immediate treatment is required to save life or limb, the emergency laws can be applied. (See the subsequent section, Good Samaritan Act.) B. Verbal or written consent 1. When verbal consent is obtained, a notation should be made. a. It describes in detail how and why verbal consent was obtained. b. It is placed in the client’s record or chart. c. It is witnessed and signed by two persons. 2. Verbal or written consent can be given by: a. Alert, coherent, or otherwise competent adults. b. A parent or legal guardian. c. A person in loco parentis (a person standing in for a parent with a parent’s rights, duties, and responsibilities) in cases of minors or incompetent adults. C. Consent of minors 1. Minors 14 years of age and older must agree to treatment along with their parents or guardians. 2. Emancipated minors can consent to treatment themselves. Be aware that the definition of an emancipated minor may change from state to state. Emergency Care A. Good Samaritan Act: Protects health practitioners against malpractice claims for care provided in emergency situations (e.g., the nurse gives aid at the scene to an automobile accident victim). B. A nurse is required to perform in a “reasonable and prudent manner.” HESI Hint • Often questions are asked regarding the Good Samaritan Act, which is the means of protecting a nurse when she or he is performing emergency care. Prescriptions and Health Care Providers A. A nurse is required to obtain a prescription (order) to carry out medical procedures from a health care provider. B. Although verbal telephone prescriptions should be avoided, the nurse should follow the agency’s policy and procedures. Failure to follow such rulesCHAPTER 2 LEADERSHIP AND MANAGEMENT 13 could be considered negligence. The Joint Commission requires that organizations implement a process for taking verbal or telephone orders that includes a read-back of critical values. The employee receiving the prescription should write the verbal order or critical value on the chart or record it in the computer and then read back the order or value to the health care provider. C. If a nurse questions a health care provider’s prescription because he or she believes that it is wrong (e.g., the wrong dosage was prescribed for a medication), the nurse should do the following: 1. Inform the health care provider. 2. Record that the health care provider was informed and record the health care provider’s response to such information. 3. Inform the nursing supervisor. 4. Refuse to carry out the prescription. D. If the nurse believes that a health care provider’s prescription was made with poor judgment (e.g., the nurse believes the client does not need as many tranquilizers as the health care provider prescribed), the nurse should: 1. Record that the health care provider was notified and that the prescription was questioned. 2. Carry out the prescription because nursing judgment cannot be substituted for a health care provider’s judgment. E. If a nurse is asked to perform a task for which he or she has not been prepared educationally (e.g., obtain a urine specimen from a premature infant by needle aspiration of the bladder) or does not have the necessary experience (e.g., a nurse who has never worked in labor and delivery is asked to perform a vaginal exam and determine cervical dilation), the nurse should do the following: 1. Inform the health care provider that he or she does not have the education or experience necessary to carry out the prescription. 2. Refuse to carry out the prescription. HESI Hint • If the nurse carries out a health care provider’s prescription for which he or she is not prepared and does not inform the health care provider of his or her lack of preparation, the nurse is solely liable for any damages. If the nurse informs the health care provider of his or her lack of preparation in carrying out a prescription and carries out the prescription anyway, the nurse and the health care provider are liable for any damages. F. The nurse cannot, without a health care provider’s prescription, alter the amount of drug given to a client. For example, if a health care provider has prescribed pain medication in a certain amount and the client’s pain is not, in the nurse’s judgment, severe enough to warrant the dosage prescribed, the nurse cannot reduce the amount without first checking with the health care provider. Remember, nursing judgment cannot be substituted for medical judgment. HESI Hint • Assignments are often tested on the NCLEX-RN. The Nurse Practice Acts of each state govern policies related to making assignments. Usually, when determining who should be assigned to do a sterile dressing change, for example, a licensed nurse should be chosen—that is, an RN or licensed practical nurse (LPN) who has been checked off on this procedure. Restraints A. Clients may be restrained only under the following circumstances: 1. In an emergency 2. For a limited time 3. For the purpose of protecting the client from injury or from harm B. Nursing responsibilities with regard to restraints 1. The nurse must notify the health care provider immediately that the client has been restrained. 2. The nurse should document the facts regarding the rationale for restraining the client. C. When restraining a client, the nurse should do the following: 1. Use restraints (physical or chemical) after exhausting all reasonable alternatives. 2. Apply the restraints correctly and in accordance with facility procedures. 3. Check frequently to see that the restraints do not impair circulation or cause pressure sores or other injuries. 4. Allow for nutrition, hydration, and stimulation at frequent intervals. 5. Remove restraints as soon as possible. 6. Document the need for and application, monitoring, and removal of restraints. HESI Hint • Restraints of any kind may constitute false imprisonment. Freedom from unlawful restraint is a basic human right and is protected by law. Health Insurance Portability and Accountability Act of 1996 Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to create a national patient-record privacy standard.14 HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN® EXAMINATION A. HIPAA privacy rules pertain to health care providers, health plans, and health clearinghouses and their business partners who engage in computer-to-computer transmission of health care claims, payment and remittance, benefit information, and health plan eligibility information and who disclose personal health information that specifically identifies an individual and is transmitted electronically, in writing, or verbally. B. Patient privacy rights are of key importance. Patients must provide written approval of the disclosure of any of their health information for almost any purpose. Health care providers must offer specific information to patients that explains how their personal health information will be used. Patients must have access to their medical records, and they can receive copies of them and request that changes be made if they identify inaccuracies. C. Health care providers who do not comply with HIPAA regulations or make unauthorized disclosures risk civil and criminal liability. D. For further information, use this link to the DHHS Website, Office of Civil Rights, which contains frequently asked questions about HIPAA Standards for Privacy of Individually Identifiable Health Information: http://aspe.hhs.gov/admnsimp/final/pvcguide1.htm. Review of Legal Aspects of Nursing 1. What types of procedures should be assigned to professional nurses? 2. Negligence is measured by reasonableness. What question might the nurse ask when determining such reasonableness? 3. List the four elements that are necessary to prove negligence. 4. Define an intentional tort, and give one example. 5. Differentiate between voluntary and involuntary admission. 6. List five activities a person who is declared incompetent cannot perform. 7. Name three legal requirements of a surgical permit. 8. Who may give consent for medical treatment? 9. What law protects the nurse who provides care or gives aid in an emergency situation? 10. What actions should the nurse take if he or she questions a health care provider’s prescription—that is, believes the prescription is wrong? 11. Describe the nurse’s legal responsibility when asked to perform a task for which he or she is unprepared. 12. Describe nursing care of the restrained client. 13. Describe six patient rights guaranteed under HIPAA regulations that nurses must be aware of in practice. Answers to Review 1. Sterile or invasive procedures 2. Would a reasonable and prudent nurse act in the same manner under the same circumstances? 3. Duty: Failure to protect client against unreasonable risk. Breach of duty: Failure to perform according to established standards. Causation: A connection exists between conduct of the nurse and the resulting damage. Damages: Damage is done to the client, physical or mental. 4. Conduct causing damage to another person in a willful or intentional way without just cause. Example: Hitting a client out of anger, not in a manner of self-protection. 5. Voluntary: Client admits self to an institution for treatment and retains his or her civil rights; he or she may leave at any time. Involuntary: Someone other than client applies for the client’s admission to an institution (a relative, a friend, or the state); requires certification by one or two health care providers that the person is a danger to self or others; the person has a right to a legal hearing (habeas corpus) to try to be released, and the court determines the justification for holding the person. 6. Vote, make contracts or wills, drive a car, sue or be sued, hold a professional license 7. Voluntary, informed, written 8. Alert, coherent, or otherwise competent adults; a parent or legal guardian; a person in loco parentis of minors or incompetent adults 9. The Good Samaritan Act 10. Inform the health care provider; record that the health care provider was informed and the health care provider’s response to such information; inform the nursing supervisor; refuse to carry out the prescription.CHAPTER 2 LEADERSHIP AND MANAGEMENT 15 11. Inform the health care provider or person asking the nurse to perform the task that he or she is unprepared to carry out the task; refuse to perform the task. 12. Apply restraints properly; check restraints frequently to see that they are not causing injury and record such monitoring; remove restraints as soon as possible; use restraints only as a last resort 13. A patient must give written consent before health care providers can use or disclose personal health information; health care providers must give patients notice about providers’ responsibilities regarding patient confidentiality; patients must have access to their medical records; providers who restrict access must explain why and must offer patients a description of the complaint process; patients have the right to request that changes be made in their medical records to correct inaccuracies; health care providers must follow specific tracking procedures for any disclosures made that ensure accountability for maintenance of patient confidentiality; patients have the right to request that health care providers restrict the use and disclosure of their personal health information, though the provider may decline to do so. Leadership and Management [Show More]

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