Success in Practical Vocational Nursing From Student To Leader 7th Edition by Signe S. Hill, Helen Stephens Howlett

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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

Success in Practical Vocational Nursing 7th Edition by Signe S. Hill, Helen Stephens Howlett -Test Bank

 

Sample  Questions

 

Chapter 06: Personal Health Promotion: A Role Model for Patients

Test Bank

 

MULTIPLE CHOICE

 

  1. Health promotion for patients is facilitated when the nurse encourages changes based on information that diabetes, heart disease, and breast and colon cancer are causally linked to
a. environmental toxins.
b. hypolipidemia.
c. overactivity.
d. obesity.

 

 

ANS:  D

Obesity and lack of exercise are closely associated with the development of diabetes, heart disease, high cholesterol, hypertension, colon cancer, and postmenopausal breast cancer. Environmental toxins have not been linked to these illnesses. Hyperlipidemia is associated with these illnesses. The causal link for heredity is not as strong as for obesity.

 

DIF:    Cognitive Level: Application          REF:   pp. 57-58       OBJ:   3

TOP:   Sequelae of obesity                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When a patient inquires about the 2010 MyPlate recommendations the nurse responds
a. “Protein is the largest part of the plate.”
b. “Delete starch from the plate.”
c. “Half of the plate should be fruits and vegetables.”
d. “2% milk is recommended.”

 

 

ANS:  C

The 2010 MyPlate recommends protein to be the smallest part of the plate, switching to fat free or low fat (1%) milk, make at least half your plate vegetables and fruits, make at least half your grains whole grain, avoid oversize portions, look for lower sodium soup, bread, and frozen meals, and drink water instead of sugary drinks.

 

DIF:    Cognitive Level: Application          REF:   p. 58              OBJ:   1

TOP:   Fats in the diet                                           KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. The student nurse states, “I don’t have time for the bending and stretching routines the textbook advises.” A peer student nurse could be most helpful by saying
a. “We each have to decide what’s best for ourselves.”
b. “I agree; the time could be better spent studying.”
c. “You know how textbooks are heavy on theory.”
d. “The idea of warm-ups preventing injury seems valid.”

 

 

ANS:  D

Proper warm-up prior to exercise is considered by exercise physiologists as a way to avoid muscular injury. The option “deciding what is best for ourselves,” although true, does little to help the student nurse adopt a healthier habit. The other options do nothing to help the student nurse adopt a healthier habit.

 

DIF:    Cognitive Level: Application          REF:   p. 59              OBJ:   4

TOP:   Exercise         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A student nurse tells a peer, “I find myself constantly thinking about patient X and the problems she’s experiencing. Sometimes, it makes me want to cry. If only I had a magic wand and could make things better for her!” The peer to whom this is revealed can correctly determine that the student nurse is experiencing
a. empathy for the patient.
b. sympathy for the patient.
c. therapeutic involvement.
d. burnout.

 

 

ANS:  B

The student nurse describes feelings of sympathy and overinvolvement. Empathy is a respectful, objective concern. Therapeutic involvement suggests overinvolvement, which is not therapeutic. The statements made in the scenario do not constitute burnout; however, sympathetic responses by nurses leave them vulnerable to burnout.

 

DIF:    Cognitive Level: Analysis               REF:   p. 63              OBJ:   7

TOP:   Sympathy vs. empathy

KEY:  Nursing Process Step: Assessment (Data Collection)

MSC:  NCLEX: Physiological Integrity

 

  1. A nursing assistant tells the nurse, “I’m feeling negative about my job and just about everything else these days. Like today, I found myself feeling angry with Mrs. X. because she’s overweight. I felt like telling her if she didn’t eat so much, she’d make my life a lot easier. I need a vacation or a new job.” The nurse can correctly determine that the nursing assistant is experiencing feelings associated with
a. spitefulness.
b. home conflicts.
c. burnout.
d. detachment.

 

 

ANS:  C

Lack of caring about patients, blaming patients for their illnesses, and negative self-views are danger signals of burnout. The scenario describes more than spitefulness; it is not suggestive of home conflicts; and it does not suggest detachment.

 

DIF:    Cognitive Level: Application          REF:   pp. 62-63       OBJ:   7

TOP:   Burnout          KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse who works in the ICU leaves the room of a patient and bursts into tears. She tells a co-worker, “I have to touch the patient to provide care, but when I was turning her, a big piece of skin just sloughed off her back. How can I justify giving care when it seems to do more harm than good?” The nurse is most likely experiencing
a. burnout.
b. detachment.
c. negative outcomes.
d. secondary traumatic stress.

 

 

ANS:  D

Secondary traumatic stress occurs from exposure to horrors associated with a patient’s condition or care the nurse must provide. The nurse experiencing burnout usually becomes angry and cynical about patients. The nurse is not displaying detachment in this situation.

 

DIF:    Cognitive Level: Application          REF:   p. 64              OBJ:   8

TOP:   Secondary traumatic stress             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

  1. The LPN/LVN notices that another nurse has made errors in practice and judgment over the past few weeks. In addition, the nurse’s personality has undergone changes, such as irritability and unpredictability when responding to others. A patient mentioned to the LPN/LVN that when the nurse administered medication for pain relief, it didn’t work as well as it had earlier in the day. Based on this information the LPN/LVN should
a. notify the state board of nursing.
b. confront the nurse with the observations.
c. call Employee Health and discuss the matter.
d. report these findings to the nurse in charge.

 

 

ANS:  D

The observations suggest signs of chemical dependency but are not entirely diagnostic. The LPN/LVN must work within the structure of the agency. This would require involving the individual who is the direct supervisor of the staff member, who will pursue the problem according to agency policy. The LPN/LVN has a duty to report suspected use or abuse of alcohol or other drugs.

 

DIF:    Cognitive Level: Application          REF:   p. 65              OBJ:   9

TOP:   Chemical dependency                               KEY:              Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The LPN/LVN tells the charge nurse, “You can be glad I’m on duty today to pick up the slack for the staff member who called in sick. It’s lucky that I came in early. Oh, and by the way, I can stay late, if necessary. You know how the next shift is. They expect everything to be caught up, even if they aren’t that efficient themselves.” These remarks suggest that the LPN/LVN may be
a. a chronic complainer.
b. a team player.
c. co-dependent.
d. chemically dependent.

 

 

ANS:  C

Co-dependent individuals feel the fate of nursing care rests on their shoulders, feel responsible for solving the problems of others (in this case, the charge nurse’s problems), engage in one-upmanship and intershift rivalries. These behaviors are evident in the scenario. Chronic complainer is incorrect because the scenario is more than an example of chronic complaining. The verbalizations do not suggest that the LPN/LVN is a team player. The verbalizations do not suggest chemical dependency.

 

DIF:    Cognitive Level: Application          REF:   pp. 65-66       OBJ:   10

TOP:   Co-dependence                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. During report, the LPN/LVN relates that although her assigned patient was ambulatory, she provided a bed bath, special foot care, and nail care; she justified the care by saying that the patient seemed very tired. The nurse also mentioned that the patient had a number of personal problems for which she provided counseling. The charge nurse recognizes these behaviors as suggesting
a. conscientious nursing.
b. empathetic response.
c. conflict avoidance.
d. co-dependence.

 

 

ANS:  D

Co-dependent individuals have a pathological need to be needed by others. They are often controlling, robbing patients of autonomy and opportunities to problem-solve. These behaviors go beyond conscientious nursing to the pathological; they do not suggest use of empathy; and they do not suggest conflict avoidance.

 

DIF:    Cognitive Level: Application          REF:   pp. 65-66       OBJ:   10

TOP:   Co-dependence                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The key to modifying co-dependent behavior is
a. recognition.
b. recreation.
c. intensive therapy.
d. establishing vulnerability.

 

 

ANS:  A

In order to change or modify co-dependent behavior, the individual must recognize that the behavior is co-dependent and must come to understand its effects on patients and peers. Recreation is not the key to modifying co-dependent behavior. Intensive therapy may not be required to modify co-dependent behavior. Establishing vulnerability has nothing to do with modifying co-dependent behavior.

 

DIF:    Cognitive Level: Analysis               REF:   p. 66              OBJ:   10

TOP:   Co-dependence                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A student nurse asks a peer, “What’s the difference between recreation and relaxation?” The best response would be
a. “They’re essentially the same.”
b. “Relaxation usually lowers stress, but recreation can create stress.”
c. “Relaxation exercises and recreation activities always lower stress.”
d. “Relaxation requires knowledge of special techniques, but recreation takes no special skills.”

 

 

ANS:  B

Relaxation, by definition, interferes with the stress response. Recreation may create stress, especially if one engages in competitive activity. The statement, “They’re essentially the same,” is incorrect. Relaxation exercises elevate stress for about 3% of the population. “Relaxation requires knowledge of special techniques, but recreation takes no special skills” is an untrue statement.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 67              OBJ:   11

TOP:   Relaxation-recreation                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. A patient tells a student nurse, “I unwind by going to a quiet place, sitting in a comfortable chair, closing my eyes, and concentrating on my breathing.” The patient is describing use of
a. imagery.
b. meditation.
c. relaxation.
d. recreation.

 

 

ANS:  B

Meditation uses the techniques described. Imagery requires the patient to focus on a pleasant scene. The scenario does not describe relaxation or recreation, although the end result of meditation should be relaxation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 67              OBJ:   12

TOP:   Meditation      KEY:  Nursing Process Step: Assessment (Data Collection)

MSC:  NCLEX: Physiological Integrity

 

  1. How can nurses avoid burnout?
a. Put patients’ needs before their own needs.
b. Accept that as nurses, their vocational and personal lives are one.
c. Understand their own needs and maintain balance between work and personal life.
d. Use sympathy for the patient as a key to personal growth and professional development.

 

 

ANS:  C

Understanding one’s own needs and maintaining balance between work and personal life is the only strategy listed that is a recommendation for avoiding burnout.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 64              OBJ:   7

TOP:   Burnout          KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse in the workplace has little opportunity to receive positive feedback from peers or supervisors. What can be substituted?
a. A revisit from a former nursing instructor
b. Self-evaluation
c. Seeking compliments from the patient
d. An alcoholic beverage after work

 

 

ANS:  B

Learning to objectively review and evaluate one’s own performance, remembering to include positive outcomes, is an effective strategy for replacing the positive feedback one becomes accustomed to as a student nurse. A revisit from a former nursing instructor and seeking compliments from the patient are ineffective. Having an alcoholic beverage after work is counterproductive.

 

DIF:    Cognitive Level: Analysis               REF:   p. 63              OBJ:   7

TOP:   Preventing burnout                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A telltale sign of a chemically impaired nurse is
a. an increasing number of practice errors.
b. an objective, assertive manner.
c. willingness to admit to substance abuse.
d. an effort to seek treatment.

 

 

ANS:  A

Making errors in practice is common if a nurse suffers from chemical impairment. An objective, assertive manner is not consistent with chemical impairment. Willingness to admit substance abuse and seeking treatment are also inconsistent, because the impaired nurse usually uses denial.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 65, Box 6-2

OBJ:   9                    TOP:   Chemically impaired nurse             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse is overheard telling a patient, “No, you do not need to bathe yourself. It doesn’t make any difference if that’s what the other nurses have you do. I will do that for you. I enjoy doing things for others, and I know you’ll appreciate my taking this time with you.” The most accurate assessment of this nurse’s behavior is that she’s
a. weird.
b. a good nurse.
c. hoping for a raise.
d. co-dependent.

 

 

ANS:  D

Co-dependent behaviors by the nurse interfere with patient autonomy. There are insufficient data to choose one of the other options.

 

DIF:    Cognitive Level: Analysis               REF:   pp. 65-66       OBJ:   10

TOP:   Co-dependence                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. How does co-dependence relate to nursing?
a. It is a necessary quality to develop a mutually rewarding relationship with the patient.
b. It is potentially destructive, because the nurse’s co-dependency may prevent meeting the patient’s needs.
c. Co-dependent nurses find nursing a healthy way to expand on nursing learned during school.
d. Co-dependency is the long-term goal of nursing instructors for nursing students.

 

 

ANS:  B

Nurse co-dependence may interfere with patient autonomy (e.g., learning self-care skills). Co-dependency is not necessary, nor is it a healthy way to expand on nursing learned during school. Co-dependence is not a goal of nursing instructors for nursing students.

 

DIF:    Cognitive Level: Comprehension   REF:   pp. 65-66       OBJ:   10

TOP:   Co-dependence                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which cycle is associated with being a co-dependent individual?
a. Experience fear, resort to manipulation, develop angry feelings toward victim
b. Rescue someone, view the rescued individual disrespectfully, experience feelings of victimization
c. Abuse a loved one, feel remorse, try to undo, experience increasing tension, abuse again
d. Express love, experience dissatisfaction, engage in violence

 

 

ANS:  B

Co-dependent people need to be needed. They become overinvolved with patients and go to extremes to rescue them by trying to solve their problems. Next, they devalue the rescued individual by implying that the individual cannot participate in his or her own care. Finally, they feel angry, unappreciated, and used as a result of the additional work and responsibility they have assumed.

 

DIF:    Cognitive Level: Knowledge          REF:   pp. 65-66       OBJ:   10

TOP:   Co-dependence                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. Which statements are relevant to the problem that use of proper body mechanics does not wholly protect nurses from back injuries? (Select all that apply.)
a. Small workspaces may contribute to injuries.
b. There is increased obesity among nurses and patients.
c. Some musculoskeletal injuries are the result of cumulative stress.
d. Body mechanics studies were performed on men, providing results that may not be true for women.
e. Some nursing tasks require unnatural positions, such as bending from the torso, twisting, and so on.

 

 

ANS:  A, B, C, D, E

All of these statements are true and help to explain the reason back injuries continue to occur among nurses who have been taught the use of proper body mechanics.

 

DIF:    Cognitive Level: Analysis               REF:   pp. 60-61       OBJ:   6

TOP:   Back injury    KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nurse is to present a mini-class on burnout prevention strategies at a nursing team meeting. Which topics would be appropriate to include? (Select all that apply.)
a. Use sympathetic responses to patients.
b. Seek daily evaluation from other health care team members.
c. Practice time management.
d. Use humor to reduce tension.
e. Keep nursing skills current.
f. Maintain perspective about work.

 

 

ANS:  C, D, E, F

Time management, humor, keeping current, and maintaining perspective are all good strategies for preventing burnout. Sympathetic responses to patients leave the nurse vulnerable to burnout. Seeking daily evaluation from other health care team members puts the nurse at the mercy of others who may not give a balanced evaluation. It is also excessive to think that other team members can provide a peer with daily evaluative feedback. Nurses should use objective self-evaluation.

 

DIF:    Cognitive Level: Analysis               REF:   pp. 63-64       OBJ:   7

TOP:   Burnout prevention                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Telltale signs of chemical dependency in nurses include which of the following behaviors? (Select all that apply.)
a. Complaints by staff, students, and patients
b. A greater number of injuries caused while moving patients
c. Arriving early or staying late to assist in the narcotic count
d. Frequent absenteeism after days off and for personal emergencies
e. Increased visits to the employee health department or emergency room
f. Work performance that consistently exceeds the expectations of the supervisor

 

 

ANS:  A, B, C, D, E

Telltale signs of chemical dependency in nurses include behaviors such as complaints by staff, students, and patients; accidents, errors in documentation, a greater number of injuries caused while moving patients or equipment, errors in practice, and poor judgment; increased visits to the employee health department or emergency room, increased volunteering to take calls for others (especially true for evening and night shifts if there are fewer staff members, because this makes stealing patients’ drugs easier); arriving early or staying late to assist in the narcotic count; frequent absenteeism after days off and for personal emergencies, especially on a Monday; irritability and mood swings; performing only the minimum amount of work required; inability to perform psychomotor skills, owing to intoxication or tremors.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 65, Box 6-2

OBJ:   9                    TOP:   Chemical dependency                               KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

Chapter 07: How Practical/Vocational Nursing Evolved: 1836 to Present

Test Bank

 

MULTIPLE CHOICE

 

  1. The “first real school of nursing” was located in
a. Israel
b. Greece.
c. Italy.
d. Germany.

 

 

ANS:  D

The first real school of nursing was founded by the Lutheran Order of Deaconesses under the supervision of a German pastor, Theodor Fleidner, in Kaiserswerth, Germany. The other options are incorrect.

 

DIF:    Cognitive Level: Knowledge          REF:   pp. 72-73, Table 7-1

OBJ:   1                    TOP:   History           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The best reason for studying nursing history is to
a. prepare for the NCLEX-PN examination.
b. make nurses more professional.
c. help nurses adapt to change.
d. learn from nursing’s past mistakes.

 

 

ANS:  C

Knowledge of the changes that have occurred in nursing prepares one to better understand and adapt to continuing changes. The other options have lesser degrees of validity.

 

DIF:    Cognitive Level: Analysis               REF:   p. 71              OBJ:   1

TOP:   Change in nursing                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. When was the first U.S. school of practical nursing founded?
a. 1830
b. 1853
c. 1892
d. 1902

 

 

ANS:  C

The first class for formal training of practical nurses was offered in 1892 at the YWCA in Brooklyn, NY.

 

DIF:    Cognitive Level: Knowledge          REF:   pp. 72-77, Table 7-1

OBJ:   3                    TOP:   History—first PN school                KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. In what year was practical nurse licensure utilized for the first time?
a. 1903
b. 1914
c. 1938
d. 1941

 

 

ANS:  B

Mississippi law provided for practical nurse licensure in 1914.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 72, Table 7-1

OBJ:   4                    TOP:   Practical nurse licensure                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The emergence of modern nursing is usually attributed to the influence of
a. Florence Nightingale.
b. Clara Barton.
c. Lillian Wald.
d. Sairy Gamp.

 

 

ANS:  A

Miss Nightingale’s insistence that nurses be women of good character helped nursing emerge from its “Dark Ages” and elevated it to a respectable vocation. In addition, she established a school for nurse training and wrote several books on nursing. Although Barton and Wald are positive examples in nursing history, neither influenced nursing to the extent that Nightingale did. Sairy Gamp is a negative character associated with nursing history.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 73              OBJ:   2

TOP:   Florence Nightingale                       KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The first formal training for practical nurses focused on
a. care for victims of war injuries.
b. home care for children and people with chronic illness.
c. training visiting nurses and public health nurses.
d. creating nursing instructors for nursing programs.

 

 

ANS:  B

The school at the Brooklyn YWCA placed the focus of training for practical nurses on home health care for patients with chronic illness, the aged, and children. The first program, created in 1892, was not affected by war. When visiting nurses and public health nurses went into the community, they were armed with their basic education, as described. Any trained nurse could teach in a practical nurse program at this point in time.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 77              OBJ:   1

TOP:   History           KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The event that had the greatest influence on the role of practical nurses in modern hospital nursing was
a. the Crusades.
b. the Industrial Revolution.
c. the U.S. Civil War.
d. World War II.

 

 

ANS:  D

World War II and the shortage of nurses it created greatly expanded the practice sites available to practical nurses. In the face of the nursing shortage, hospitals gradually increased the responsibilities designated for the practical nurse. The other options had a lesser impact on modern hospital nursing.

 

DIF:    Cognitive Level: Analysis               REF:   p. 80              OBJ:   2

TOP:   PN role change                               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. When in history was it first recommended that tasks of the RN and LPN be differentiated and that practical nurses should function under the supervision of registered nurses?
a. 1750-1760
b. 1826-1850
c. 1949-1950
d. 1965-1980

 

 

ANS:  C

In 1949, the Joint Committee on Practical Nurses and Auxiliary Workers in Nursing Services recommended the title licensed practical nurse to differentiate between the tasks of PNs and LPNs; the joint committee also recommended that LPNs work under the supervision of RNs.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 81              OBJ:   2

TOP:   LPN task differentiation                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The role of self-defined practical nurses throughout history has been to
a. care for the ill, injured, and dying and for birthing mothers.
b. compete with physicians and surgeons.
c. perform complex nursing skills independently.
d. make contact with the gods on behalf of the ill person.

 

 

ANS:  A

History has seen people called attendants, midwives, and self-proclaimed nurses who had special skills in helping those who were ill. These self-proclaimed nurses were the original home health nurses and visiting nurses, who cared for patients who were ill, injured, or dying and for mothers who were giving birth. The other options were never considered roles of the practical nurse.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 77              OBJ:   1

TOP:   Role of self-proclaimed nurses       KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The event that had the most profound influence in changing practical/vocational nursing was the
a. depression of the 1930s, when nurses worked for room and board in lieu of salary.
b. post–World War II movement of practical/vocational nurses into hospital positions.
c. American Medical Association (AMA) proposal to develop registered care technicians as new health care workers.
d. first computer-adaptive test for practical/vocational nursing graduates.

 

 

ANS:  B

The nursing shortage following World War II was responsible for hospitals hiring practical/vocational nurses and for the gradual expansion of the role of the practical/vocational nurse. None of the other options offered had the same degree of influence as World War II and the subsequent nursing shortage.

 

DIF:    Cognitive Level: Analysis               REF:   p. 80              OBJ:   2

TOP:   History           KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. When permitted by the state Nurse Practice Act, under what conditions can the LPN/LVN perform complex nursing skills not taught in the basic educational program?
a. When ordered to do so by the attending physician
b. When the task is delegated to a competent LPN/LVN by a supervising RN
c. When the LPN/LVN has graduated from a nursing program accredited by the National League for Nursing
d. When the state of practice has declared a severe nursing shortage

 

 

ANS:  B

Delegation, if allowed by the Nurse Practice Act of the state, can take place if the RN teaches the skill, observes a return demonstration, documents the teaching/learning process in the LPN/LVN’s file, and provides ongoing direct supervision. LPN/LVNs are under the direct supervision of professional nurses. Accreditation of the school does not confer the right to accept delegation. Nursing shortages cannot dictate the acceptability of delegation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 71|p. 81      OBJ:   2

TOP:   Delegation      KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. A major reason for LPN/LVN graduates to join nursing organizations is that membership
a. keeps one updated on issues that affect practical nursing.
b. enhances one’s standing among registered nurses.
c. provides an opportunity to draft legislation for health care workers.
d. encourages practical nurses to expand their social horizons.

 

 

ANS:  A

Membership in a nursing organization provides access to information relevant to the standing, as well as the practice, of nursing. Proposed changes in the Nurse Practice Act can be disseminated. and the organization can use its collective power to support or call for defeat of such measures. The greater the membership in an organization, the greater the political power the group has. The other options are not considered major reasons for belonging to a nursing organization.

 

DIF:    Cognitive Level: Analysis               REF:   p. 85              OBJ:   5

TOP:   Political action                                KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which statement best explains the “entry into practice” controversy?
a. Nursing shortages would be relieved if all nurses entered into practice as LPN/LVNs.
b. The return to self-proclaimed nurses would save scarce health care dollars.
c. “Entry into practice” refers to discerning the educational level most appropriate for entry into the practice of nursing: ADN, BSN, MSN.
d. After graduation, all professional and vocational nurses should enter practice by serving a 1-year internship in a hospital setting.

 

 

ANS:  C

“Entry into practice,” originally advanced by the ANA, refers to the movement to establish two levels of nursing. More recently it has become a question of determining the most appropriate entry into practice for professional nurses: the ADN, BSN, or master’s level of preparation. The other options are not related to entry into practice.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 85              OBJ:   5

TOP:   Entry into practice                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The outcome that can be predicted for the latest nurse education proposal is that
a. LPN/LVN education will be extended to 2 years.
b. LPN/LVN licensure will be abandoned.
c. the LPN/LVN will be the lower level for entry into practice.
d. the outcome cannot be determined at this time.

 

 

ANS:  D

No single concrete proposal has been advanced for debate; thus, one cannot determine the probable effect on LPN/LVN training and education.

 

DIF:    Cognitive Level: Analysis               REF:   p. 85              OBJ:   5

TOP:   Education       KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Which was the first state to pass a law licensing practical nurses?
a. Alabama
b. California
c. New York
d. Mississippi

 

 

ANS:  D

Mississippi was the first state to pass a law licensing practical nurses.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 72|p. 78, Table 7-1

OBJ:   2                    TOP:   Nursing history                               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The first chapter of the American Red Cross was established by
a. Clara Barton.
b. Sairy Gamp.
c. Dorothea Lynde Dix.
d. Florence Nightingale.

 

 

ANS:  A

Clara Barton established the first chapter of the American Red Cross. Sairy Gamp was a fictional character in Charles Dickens’ novel Martin Chuzzlewit. Dorothea Lynde Dix was appointed superintendent of nurses and organized a corps of female nurses during the Civil War. Florence Nightingale nursed wounded soldiers during the Crimean War.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 72|p. 77, Table 7-1

OBJ:   1                    TOP:   Nursing history                               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

COMPLETION

 

  1. After licensing, the LPN/LVN is permitted to perform complex nursing skills as delegated by the registered nurse (RN) and allowed by the ____________________.

 

ANS:

Nurse Practice Act

After licensing, the LPN/LVN is permitted to perform complex nursing skills as delegated by the registered nurse (RN) and allowed by the Nurse Practice Act.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 71              OBJ:   1

TOP:   Modern practical nurses                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. Which of the following are major concerns associated with the present nursing shortage? (Select all that apply.)
a. Patient safety
b. High patient acuity
c. High nurse-to-patient ratios
d. High stress among nurses
e. High recruitment incentives

 

 

ANS:  A, B, C, D

Patient safety is a concern, because errors are more common when nurse-to-patient ratios are high. Patients in hospitals are sicker than previously. High patient acuity requires increasingly skilled nurses, and the high-acuity patient requires more nursing time; neither may be available during a nursing shortage. Errors increase when one nurse has a patient load that is so large that care is rushed. Nurses leave the workforce as a result of high stress; this worsens the shortage. High recruitment incentives are not considered major concerns associated with the shortage of nurses.

 

DIF:    Cognitive Level: Analysis               REF:   p. 85              OBJ:   5

TOP:   Present nursing shortage                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Practical nurses are referred to as those who, from the beginning of time, chose (or were appointed) to care for individuals who were ill, injured, dying, or having babies. Names used to designate this person have included which of the following? (Select all that apply.)
a. Midwife
b. Attendant
c. Trained nurse
d. Practical nurse
e. Self-proclaimed nurse
f. Babysitter

 

 

ANS:  A, B, C, D, E

Practical nurses have had a varied and colorful evolution. Practical nurses are referred to in a broad sense as those who, from the beginning of time, chose (or were appointed) to care for individuals who were ill, injured, dying, or having babies. Names used to designate this person have included midwife, attendant, trained nurse, practical nurse, and self-proclaimed nurse.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 74|pp. 77-79|p. 81

OBJ:   1                    TOP:   Nursing History                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. After licensing, the LPN/LVN is permitted to perform complex nursing skills as delegated by the registered nurse (RN) and allowed by the Nurse Practice Act. Delegation is allowed as long as which requirements are met? (Select all that apply.)
a. An RN is willing to teach the skill.
b. An RN observes the return demonstration.
c. An RN delegates complex patients to the LPN/LVN.
d. An RN delegates formulating nursing diagnoses to the LPN/LVN.
e. An RN documents the teaching or learning process for the LPN/LVN’s file in the place of employment.

 

 

ANS:  A, B, E

After licensing, the LPN/LVN is permitted to perform complex nursing skills as delegated by the registered nurse (RN) and allowed by the Nurse Practice Act. Delegation is allowed as long as (1) an RN is willing to teach the skill; (2) an RN observes the return demonstration; and (3) an RN documents the teaching or learning process for the LPN/LVN’s file in the place of employment. In addition, most Nurse Practice Acts call for direct supervision by RNs for all complex nursing tasks delegated by them.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 71|p. 77      OBJ:   1

TOP:   Modern practical nurses                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

  1. Which individuals made significant contributions to nursing? (Select all that apply.)
a. Lillian Wald
b. Linda Richards
c. Sairy Gamp
d. Betsy Prig
e. Mary Mahoney

 

 

ANS:  A, B, E

Wald organized the first visiting nurse service for the poor. Linda Richards was America’s first professionally trained nurse; she organized other training schools. Mary Mahoney was the first African-American graduate nurse. Gamp and Prigg were Dickens’ characters who portrayed nurses as scoundrels and women of ill repute.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 77|pp. 85-86, Table 7-2

OBJ:   2                    TOP:   History           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

Chapter 09: Nursing Process: Your Role

Test Bank

 

MULTIPLE CHOICE

 

  1. A student nurse asks, “If RNs use a five-step nursing process and LPN/LVNs use a four-step process, what phase is missing?” The best response would be, “The phase of the nursing process that is the sole responsibility of the registered nurse is
a. assessment.”
b. nursing diagnosis.”
c. planning.”
d. implementation.”
e. evaluation.”

 

 

ANS:  B

The LPN/LVN participates in all phases of the nursing process with the exception of establishing a nursing diagnosis.

 

DIF:    Cognitive Level: Application          REF:   p. 98              OBJ:   4

TOP:   Nursing Diagnosis                          KEY:  Nursing Process Step: Nursing Diagnosis

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The student nurse asks, “How does knowing the nursing diagnosis assist the LPN/LVN?” The best response is based on understanding that
a. a nursing diagnosis identifies the patient’s problems.
b. it permits the practical nurse to go beyond the scope of practice.
c. this step makes the practical nurse equal to the medical doctor.
d. knowledge of the nursing diagnosis ensures a cure for the patient.

 

 

ANS:  A

The LPN/LVN uses the nursing diagnosis to identify a patient’s problems.

 

DIF:    Cognitive Level: Application          REF:   pp. 98-99       OBJ:   5

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Nursing Diagnosis

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which of the following is the primary reason that LPN/LVNs are taught to use the nursing process?
a. To diagnose disease
b. To provide reimbursement
c. To resolve patient problems
d. To communicate with health team members

 

 

ANS:  C

The nursing process provides a structure for nurses to identify and respond to patient needs within the scope of nursing. Diagnosing disease is the domain of the physician. Reimbursement is not the primary purpose of the nursing process. Communication facilitation is not the primary purpose of the nursing process.

 

DIF:    Cognitive Level: Analysis               REF:   p. 97              OBJ:   5

TOP:   Purpose of nursing process             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. During the assessment phase of the nursing process, the LPN/LVN is expected to
a. establish goals and outcome criteria.
b. collect data about the patient.
c. determine whether established goals have been met.
d. plan interventions to implement for the patient.

 

 

ANS:  B

Data are collected as part of the assessment phase. This is the only option that relates to assessment.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 98              OBJ:   3

TOP:   Assessment and data collection      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nursing care plan requires the nurse to ambulate the patient twice daily. The phase of the nursing process in which the nurse is participating is
a. assessment.
b. planning.
c. implementation.
d. evaluation.

 

 

ANS:  C

Carrying out the care plan is termed implementation. Assessment involves data collection. Planning involves creation of the nursing care plan. Evaluation involves determining goal attainment.

 

DIF:    Cognitive Level: Application          REF:   p. 98              OBJ:   3

TOP:   Implementation                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. An LPN/LVN demonstrates to a new mother how to safely bathe her infant. This is an example of the phase of the nursing process called
a. assessment.
b. nursing diagnosis.
c. planning.
d. implementation.

 

 

ANS:  D

Initiating teaching that is within the role of the LPN/LVN and supporting teaching by the RN are examples of implementation.

 

DIF:    Cognitive Level: Application          REF:   pp. 105-106   OBJ:   3

TOP:   Teaching as part of the implementation phase

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. When the LPN/LVN participates in the evaluation phase of the nursing process, she or he compares the patient’s responses with the
a. nursing orders.
b. outcome criteria.
c. nursing diagnosis.
d. database.

 

 

ANS:  B

The process of determining outcome attainment involves comparing actual patient outcomes with desired patient outcomes.

 

DIF:    Cognitive Level: Comprehension   REF:   pp. 106-107   OBJ:   3

TOP:   Evaluation      KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which of the following are considered subjective data?
a. The patient tells the nurse that he has a headache.
b. The nursing assistant tells the nurse that the patient vomited.
c. The patient’s mother tells the nurse that the patient needs a ride to the clinic for follow-up.
d. The physician tells the nurse that the patient needs a chest x-ray.

 

 

ANS:  A

Subjective data are based on the patient’s report or opinion. The only option representing a patient’s report or opinion is the patient telling the nurse that he has a headache.

 

DIF:    Cognitive Level: Analysis               REF:   p. 99              OBJ:   3

TOP:   Data collection

KEY:  Nursing Process Step: Assessment (Data Collection)       MSC:  NCLEX: N/A

 

  1. “I feel like I can’t catch my breath” is an example of
a. effective data.
b. objective data.
c. subjective data.
d. evaluative data.

 

 

ANS:  C

Subjective data are based on the patient’s report or opinion. Objective data are data the nurse can verify. Effective data and evaluative data are not used as data classifications.

 

DIF:    Cognitive Level: Application          REF:   p. 99              OBJ:   3

TOP:   Subjective data

KEY:  Nursing Process Step: Assessment (Data Collection)

MSC:  NCLEX: Physiological Integrity

 

  1. A blood pressure of 110/70 at 8 PM is most accurately described as an example of
a. planning data.
b. subjective data.
c. objective data.
d. reassessment data.

 

 

ANS:  C

Objective data are sometimes called signs. Objective data can be verified. Subjective data are based on the patient’s report. Planning data and reassessment data are not used as data classifications.

 

DIF:    Cognitive Level: Application          REF:   p. 99              OBJ:   3

TOP:   Objective data

KEY:  Nursing Process Step: Assessment (Data Collection)

MSC:  NCLEX: Physiological Integrity

 

  1. When a nurse uses Maslow’s hierarchy of needs to prioritize patient problems, which problem would be considered the highest priority?
a. The patient is unsteady and may become injured.
b. The patient is experiencing marital difficulties.
c. The patient has deficient knowledge about the condition.
d. The patient is acutely short of breath.

 

 

ANS:  D

The priority problem is one that is potentially life-threatening: shortness of breath. Physiologic or survival needs take priority over higher level needs. The problems mentioned in the other options do not threaten survival.

 

DIF:    Cognitive Level: Application          REF:   p. 101            OBJ:   2

TOP:   Priority setting                                           KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following statements regarding short-term goals is accurate?
a. Short-term goals are broad rather than specific.
b. Short-term goals can be accomplished within days or hours.
c. Short-term goals must be accomplished while the patient is hospitalized.
d. Short-term goals are less realistic than long-term goals.

 

 

ANS:  B

Short-term goals can usually be accomplished within hours or days, whereas long-term goals may take weeks.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 103            OBJ:   3

TOP:   Goals             KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The patient’s problem has been identified as insufficient intake of oral fluids. The best outcome statement is:
a. The patient will ingest 1500 ml of oral fluids during each 24-hour period.
b. The patient will request fluids when thirsty.
c. The nurse will encourage fluid intake by the patient.
d. The nurse will provide the patient with 100 ml of fluid hourly.

 

 

ANS:  A

An outcome may be attained by stating the problem in positive terms. It is always a statement of what the patient will do. Stating that the patient will request fluids when thirsty may not result in the desired intake. The remaining options are nurse centered.

 

DIF:    Cognitive Level: Application          REF:   p. 103            OBJ:   3

TOP:   Outcomes       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. A student nurse asks, “What’s the primary purpose of the evaluation phase of the nursing process?” The best response is to
a. establish a time frame for completion of goals.
b. determine whether the nurse completed all nursing interventions.
c. determine which nurses are eligible for raises or promotion.
d. compare actual patient outcomes with desired outcomes.

 

 

ANS:  D

Data collection, with comparison of actual and desired patient outcomes, is the focus of the evaluation phase of the nursing process. The response “to establish a time frame for completion of goals” is initially part of the planning phase. Time frames for goal attainment may be revised during the evaluation phase, but this is not the primary purpose of evaluation. In the remaining options, evaluation is patient centered.

 

DIF:    Cognitive Level: Application          REF:   p. 103|p. 106

OBJ:   3                    TOP:   Evaluation     KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. How does the LPN/LVN use nursing diagnosis in patient care?
a. To set patient-centered goals
b. To convert nursing diagnoses to patient problems
c. To implement independent nursing interventions
d. To justify participation in data collection

 

 

ANS:  B

The LPN/LVN uses the nursing diagnosis as the reference point for identifying patient problems that require intervention. The nursing diagnosis is not required by the LPN/LVN to set goals and outcomes, implement nursing interventions, or participate in data collection.

 

DIF:    Cognitive Level: Comprehension   REF:   pp. 98-99       OBJ:   4

TOP:   Nursing diagnosis                           KEY:  Nursing Process Step: Nursing Diagnosis

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The phases of the nursing process in which the LPN/LVN participates with the greatest degree of independence are
a. goal setting and evaluation.
b. planning and implementation.
c. data collection and implementation.
d. evaluation and data collection.

 

 

ANS:  C

The LPN/LVN curriculum trains graduates to collect data and implement a variety of nursing interventions, making a high degree of independence possible in these areas. Goal setting, evaluation, and planning all require a greater degree of interdependence with the RN.

 

DIF:    Cognitive Level: Analysis               REF:   p. 98              OBJ:   3

TOP:   LPN/LVN relative independence/interdependence          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The RN head nurse is having a busy day. When the LPN/LVN reports data she has collected, the RN states, “Incorporate that into the nursing care plan and write down the intervention you’d use. I’ll co-sign the entry.” The LPN/LVN should
a. do as requested.
b. ask the advice of the shift supervisor later in the shift.
c. tell the RN that this action is not within the LPN/LVN scope of practice.
d. write a letter to the state board of nursing to report the RN’s unprofessional conduct.

 

 

ANS:  C

The RN is responsible for determining the nursing care plan. The LPN/LVN collects data that the RN may use to modify the plan, but the LPN/LVN may not independently modify the plan. If the LPN/LVN functions outside the identified scope of practice, he or she would be breaking the law. The remaining options do not directly address the problem at the time it occurs.

 

DIF:    Cognitive Level: Application          REF:   p. 101            OBJ:   3

TOP:   Scope of practice                            KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The LPN/LVN learns at report that a patient’s priority problems are pain and inability to ambulate associated with arthritis. During the patient’s bath, he becomes short of breath. The LPN/LVN should implement interventions based on
a. the priorities given at the report.
b. the patient’s identified strengths.
c. the patient’s changing status.
d. information obtained from the Nursing Outcomes Classification (NOC) project.

 

 

ANS:  C

Status changes are a priority. Priorities may change rapidly, depending on the patient’s condition. This change challenges survival and assumes priority over the other identified problems.

 

DIF:    Cognitive Level: Application          REF:   p. 103            OBJ:   3

TOP:   Priorities         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Identify the outcome that would be appropriate to include in the nursing care plan of a patient who has undergone total knee replacement.
a. The patient will be stronger by (date).
b. The patient will transfer from the bed to a chair with the assistance of a walker and one staff member by the third postoperative day.
c. The nurse will help the patient ambulate the length of the hall twice daily.
d. The nurse will evaluate the patient’s strength based on his ability to ambulate in the hall on the first postoperative day.

 

 

ANS:  B

“The patient will transfer from the bed to a chair with the assistance of a walker and one staff member by the third postoperative day” contains the elements necessary for a well-written outcome. It is patient centered, realistic, measurable, and time referenced. “The patient will be stronger by (date)” is not measurable. The remaining options are nurse centered.

 

DIF:    Cognitive Level: Analysis               REF:   p. 103            OBJ:   3

TOP:   Outcomes       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. A nurse expresses difficulty deciding which nursing interventions to suggest for a patient with arthritic pain during an upcoming patient-centered conference. A peer suggests referring to the Nursing Interventions Classification (NIC) taxonomy. This would provide the nurse with information on
a. how to provide basic care to patients.
b. identification of nursing measures to help patients progress toward goals.
c. a language for measuring patients’ response to nursing interventions.
d. how to translate nursing diagnoses into nursing problems.

 

 

ANS:  B

NIC standardizes, defines, and assists nurses in choosing the appropriate nursing interventions. It includes physical and psychosocial interventions, health promotion, illness treatment, and independent and collaborative interventions. NIC is not a basic text. NIC does not provide a measurement language. NIC does not give information about translating nursing diagnoses into nursing problems.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 107            OBJ:   6

TOP:   NIC                KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The patient’s nursing diagnosis is pain associated with walking related to knee injury. The LPN/LVN should accurately identify the patient problem as
a. arthritis.
b. unwillingness to exercise.
c. need for knee brace.
d. knee pain.

 

 

ANS:  D

Knee pain is the best translation given for the nursing diagnosis. Arthritis is a medical diagnosis. Unwillingness to exercise assumes information not given in the scenario. Need for a knee brace prescribes a treatment.

 

DIF:    Cognitive Level: Application          REF:   p. 99              OBJ:   3

TOP:   Translating nursing diagnosis to patient problem

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. A beginning nurse asks an experienced nurse, “When should I focus on data collection?” Which statement provides the best description for when a nurse should collect patient-centered data?
a. After report when coming on duty
b. Within 1 hour of reporting off duty
c. While assisting a patient with hygiene
d. During each patient contact

 

 

ANS:  D

Data are collected whenever the nurse and patient interact. The other options limit data collection.

 

DIF:    Cognitive Level: Application          REF:   p. 99              OBJ:   3

TOP:   Data collection

KEY:  Nursing Process Step: Assessment (Data Collection)

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. The nursing process consists of collecting data (assessment), nursing diagnosis, planning, implementation, and evaluating nursing care. Which step of the nursing process is the sole responsibility of the registered nurse?
a. Planning
b. Assessment
c. Implementation
d. Nursing diagnosis

 

 

ANS:  D

The nursing process consists of collecting data (assessment), nursing diagnosis (which is the RN’s responsibility), planning, implementation, and evaluating nursing care. Nursing diagnosis is within the RN’s legal role, but LPN/LVNs have an important role in assisting the RN in the other steps of the nursing process.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 101            OBJ:   4

TOP:   Nursing process

KEY:  Nursing Process Step: Assessment, Diagnosis, Planning, Implementation, Evaluation

MSC:  NCLEX: N/A

 

  1. A nurse is gathering and reviewing information about a patient. The nurse is participating in which step of the nursing process?
a. Planning
b. Evaluation
c. Data collection
d. Implementation

 

 

ANS:  C

The nursing process consists of collecting data (assessment), nursing diagnosis (which is the RN’s responsibility), planning, implementation, and evaluating nursing care. Data collection is a systematic gathering and review of information about the patient, which is communicated to appropriate members of the health team.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 98              OBJ:   3

TOP:   Nursing process

KEY:  Nursing Process Step: Assessment (Data Collection)       MSC:  NCLEX: N/A

 

  1. An LPN/LVN is assisting the RN in the development of goals and interventions for a patient’s plan of care. The LPN/LVN is participating in which step of the nursing process?
a. Planning
b. Evaluation
c. Data collection
d. Implementation

 

 

ANS:  A

The nursing process consists of collecting data (assessment), nursing diagnosis (which is the RN’s responsibility), planning, implementation, and evaluating nursing care. Planning involves assisting the RN in the development of nursing diagnosis, goals, and interventions for a patient’s plan of care and maintaining patient safety.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 98              OBJ:   3

TOP:   Nursing process                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: N/A

 

  1. A nurse is comparing a patient’s outcomes of nursing care to the expected outcomes. The nurse then communicates these findings to members of the health care team. The nurse is participating in which step of the nursing process?
a. Planning
b. Evaluation
c. Data collection
d. Implementation

 

 

ANS:  B

The nursing process consists of collecting data (assessment), nursing diagnosis (which is the RN’s responsibility), planning, implementation, and evaluating nursing care. Evaluation compares the actual outcomes of nursing care to the expected outcomes, which are then communicated to members of the health care team.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 98              OBJ:   3

TOP:   Nursing process                              KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: N/A

 

  1. A nurse reviews a patient’s care plan and finds a goal for the patient to ambulate at least three times a day. The nurse assists the patient to accomplish this goal. The nurse is participating in which step of the nursing process?
a. Planning
b. Evaluation
c. Data collection
d. Implementation

 

 

ANS:  D

The nursing process consists of collecting data (assessment), nursing diagnosis (which is the RN’s responsibility), planning, implementation, and evaluating nursing care. Implementation is the provision of required nursing care to accomplish established patient goals.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 98              OBJ:   3

TOP:   Nursing process                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: N/A

 

  1. A nurse is gathering data about a patient. The nurse determines that which of the following is subjective data?
a. The patient complains of excruciating, crushing chest pain.
b. The patient is short of breath and coughs up green sputum.
c. The patient has gained 1 lb within the past 24 hours.
d. The patient is experiencing sinus tachycardia and peripheral edema.

 

 

ANS:  A

Subjective information is based on the patient’s opinion. Some refer to subjective information as symptoms. This usually includes feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure. The nurse cannot experience subjective symptoms. Objective information includes data that the nurse can verify; these are also known as signs. A physical assessment provides objective data. The terms check, observe, monitor, weigh, measure, and smell are cues that this may be objective data collection. Obtaining initial data, such as vital signs, height, and weight, is often assigned to the LPN/LVN. Objective information helps support or cast doubt on subjective information. The patient complaining of chest pain is the only option that is subjective. The remaining options are all examples of objective data.

 

DIF:    Cognitive Level: Analysis               REF:   p. 99              OBJ:   3

TOP:   Subjective data

KEY:  Nursing Process Step: Assessment (Data Collection)       MSC:  NCLEX: N/A

 

  1. A nurse is gathering data about a patient. The nurse determines that which of the following is subjective data?
a. The patient complains of feeling anxious about her upcoming surgery.
b. The patient is short of breath and has an oxygen saturation level of 86%.
c. The patient has a heart rate of 85 beats per minute and has a sinus rhythm.
d. The patient has consumed 60% of breakfast, 45% of lunch, and 50% of dinner.

 

 

ANS:  A

Subjective information is based on the patient’s opinion. Some refer to subjective information as symptoms. This usually includes feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure. The nurse cannot experience subjective symptoms. Objective information includes data that the nurse can verify; these are also known as signs. A physical assessment provides objective data. The terms check, observe, monitor, weigh, measure, and smell are cues that this may be objective data collection. Obtaining initial data, such as vital signs, height, and weight, is often assigned to the LPN/LVN. Objective information helps support or cast doubt on subjective information. The patient’s complaint of anxiety is the only option that is subjective. The remaining are all examples of objective data.

 

DIF:    Cognitive Level: Analysis               REF:   p. 99              OBJ:   3

TOP:   Subjective data

KEY:  Nursing Process Step: Assessment (Data Collection)       MSC:  NCLEX: N/A

 

  1. A nurse is gathering data about a patient. The nurse determines that which of the following is objective data?
a. The patient complains of phantom pain after receiving a left below-the-knee amputation.
b. The patient complains of crushing chest pain and states, “I feel like there is an elephant sitting on my chest.”
c. The patient complains of feeling anxious about being hospitalized, and states, “I feel like I’m going to die.”
d. The patient has a heart rate of 99 beats per minute, respirations of 20 per minute, and a temperature of 99.2° F.

 

 

ANS:  D

Subjective information is based on the patient’s opinion. Some refer to subjective information as symptoms. This usually includes feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure. The nurse cannot experience subjective symptoms. Objective information includes data that the nurse can verify; these are also known as signs. A physical assessment provides objective data. The terms check, observe, monitor, weigh, measure, and smell are cues that this may be objective data collection. Obtaining initial data, such as vital signs, height, and weight, is often assigned to the LPN/LVN. Objective information helps support or cast doubt on subjective information. Option D, which contains the patient’s heart rate, respirations, and temperature, is the only option that has objective data. The remaining are all examples of subjective data.

 

DIF:    Cognitive Level: Analysis               REF:   p. 99              OBJ:   3

TOP:   Objective data

KEY:  Nursing Process Step: Assessment (Data Collection)       MSC:  NCLEX: N/A

 

COMPLETION

 

  1. A patient states, “I’m feeling left-sided chest pain that radiates to my left arm.” This is an example of ____________________ data.

 

ANS:

subjective

Subjective information is based on the patient’s opinion. Some refer to subjective information as symptoms. This usually includes feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure. The nurse cannot experience subjective symptoms. Objective information includes data that the nurse can verify; these are also known as signs. A physical assessment provides objective data. The terms check, observe, monitor, weigh, measure, and smell are cues that this may be objective data collection. Obtaining initial data, such as vital signs, height, and weight, is often assigned to the LPN/LVN. Objective information helps support or cast doubt on subjective information.

 

DIF:    Cognitive Level: Analysis               REF:   p. 91              OBJ:   3

TOP:   Subjective data

KEY:  Nursing Process Step: Assessment (Data Collection)       MSC:  NCLEX: N/A

 

  1. A nurse notes that a patient is experiencing increased peripheral edema and has urinated 20 cc of urine in the past hour. This is an example of ____________________ data.

 

ANS:

objective

Subjective information is based on the patient’s opinion. Some refer to subjective information as symptoms. This usually includes feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure. The nurse cannot experience subjective symptoms. Objective information includes data that the nurse can verify; these are also known as signs. A physical assessment provides objective data. The terms check, observe, monitor, weigh, measure, and smell are cues that this may be objective data collection. Obtaining initial data, such as vital signs, height, and weight, is often assigned to the LPN/LVN. Objective information helps support or cast doubt on subjective information.

 

DIF:    Cognitive Level: Analysis               REF:   p. 91              OBJ:   3

TOP:   Objective data

KEY:  Nursing Process Step: Assessment (Data Collection)       MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. The LPN/LVN should be alert to possible barriers to data collection, such as which of the following? (Select all that apply.)
a. Inadequate assessment skills
b. Presence of distractions
c. Respectful distancing
d. Insufficient time
e. Inability to speak the language
f. Patient labeling

 

 

ANS:  A, B, D, E, F

Each of the options except respectful distancing may create a barrier to data collection. Respectful distancing suggests calling the patient by title and surname and avoiding overly familiar approaches.

 

DIF:    Cognitive Level: Analysis               REF:   p. 102            OBJ:   1

TOP:   Barriers to data collection

KEY:  Nursing Process Step: Assessment (Data Collection)

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which strategies would facilitate patient data collection? (Select all that apply.)
a. Ensure that the patient knows who you are and what you are going to do.
b. Address the patient with familiarity, using terms of endearment.
c. Repeat questions the patient has previously answered.
d. Clarify what you do not understand with the patient.
e. Judge the patient’s behaviors and attitudes.

 

 

ANS:  A, D

Use of good communication strategies facilitates data collection. Orienting the patient to your role and the purpose of the interaction and clarifying what is not understood facilitates data collection. Addressing the patient with familiarity, using terms of endearment, is disrespectful and creates a barrier to communication. Repeating questions the patient has previously answered suggests to the patient that no one listens to what has already been revealed. Judging the patient’s behaviors and attitudes results in labeling of patients and making judgmental statements to the patient.

 

DIF:    Cognitive Level: Analysis               REF:   p. 100            OBJ:   3

TOP:   Data collection

KEY:  Nursing Process Step: Assessment (Data Collection)

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following are reasons the nursing process and critical thinking are included in the LPN/LVN curriculum? (Select all that apply.)
a. Both are needed to identify patient problems, issues, and risks.
b. They foster making evidence-based judgments.
c. Clearer communication between RN and LPN can take place.
d. Job stress and burnout are diminished.
e. Patient safety is adversely affected.

 

 

ANS:  A, B, C

The nursing process provides a reasoning model for use in planning and implementing care. This model requires the use of critical thinking skills. Diminishing job stress and burnout and adverse effects on patients’ safety are not reasons the nursing process and critical thinking are included in the LPN/LVN curriculum. Job stress and burnout have not been directly associated with use of the nursing process or critical thinking. The aim of both the nursing process and critical thinking is to promote patient safety.

 

DIF:    Cognitive Level: Analysis               REF:   p. 97              OBJ:   5

TOP:   Inclusion of nursing process and critical thinking in LPN/LVN curriculum

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which statements accurately describe the role of the LPN/LVN in relation to use of the nursing process. (Select all that apply.)
a. LPN/LVNs have an interdependent relationship with other health team members.
b. LPN/LVNs act in a more dependent role when participating in the planning and evaluation phases.
c. LPN/LVNs act more independently when participating in data collection and implementation phases than in any other phases of the nursing process.
d. LPN/LVNs are able to use the NANDA list to make nursing diagnoses.
e. LPN/LVN basic education enables them to perform patient interviews and assessment of body systems.

 

 

ANS:  A, B, C

LPN/LVNs implement orders for treatments and medication written by physicians, dentists, nurse practitioners, physician assistants, and other qualified health team members. The LPN/LVN contributes by collecting and sharing data that are used by the RN to plan and evaluate care. The LPN/LVN is skillful in data collection and providing planned nursing interventions. Nursing diagnosis is the domain of the RN. LPN/LVN basic education does not teach interview skills and physical assessment of body systems.

 

DIF:    Cognitive Level: Analysis               REF:   p. 98              OBJ:   2

TOP:   Role in the nursing process             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment

 

  1. Which of the following are examples of subjective data? (Select all that apply.)
a. A patient has an offensive body odor.
b. A patient complains of feeling stressed.
c. A patient complains of feeling anxious.
d. A patient complains of substernal chest pain.
e. A patient falls when ambulating to the bathroom.
f. A patient states, “I feel a sense of impending doom.”

 

 

ANS:  B, C, D, F

Subjective information is based on the patient’s opinion. Some refer to subjective information as symptoms. This usually includes feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure. The nurse cannot experience subjective symptoms. Objective information includes data that the nurse can verify; these are also known as signs. A physical assessment provides objective data. The terms check, observe, monitor, weigh, measure, and smell are cues that this may be objective data collection. Obtaining initial data, such as vital signs, height, and weight, is often assigned to the LPN/LVN. Objective information helps support or cast doubt on subjective information. The patients’ statement and complaints are the only options that are subjective. The remaining options are examples of objective data.

 

DIF:    Cognitive Level: Analysis               REF:   p. 99              OBJ:   3

TOP:   Subjective data

KEY:  Nursing Process Step: Assessment (Data Collection)       MSC:  NCLEX: N/A

 

  1. Which of the following are examples of objective data? (Select all that apply).
a. A patient has an offensive body odor.
b. A patient complains of feeling stressed.
c. A patient complains of feeling anxious.
d. A patient complains of substernal chest pain.
e. A patient falls when ambulating to the bathroom.
f. A patient states, “I feel a sense of impending doom.”

 

 

ANS:  A, E

Subjective information is based on the patient’s opinion. Some refer to subjective information as symptoms. This usually includes feelings of physical discomfort, anxiety, and mental stress that are more difficult to measure. The nurse cannot experience subjective symptoms. Objective information includes data that the nurse can verify; these are also known as signs. A physical assessment provides objective data. The terms check, observe, monitor, weigh, measure, and smell are cues that this may be objective data collection. Obtaining initial data, such as vital signs, height, and weight, is often assigned to the LPN/LVN. Objective information helps support or cast doubt on subjective information. Body odor and a patient falling are examples of objective data. The remaining options are examples of subjective data.

 

DIF:    Cognitive Level: Analysis               REF:   p. 99              OBJ:   3

TOP:   Objective data

KEY:  Nursing Process Step: Assessment (Data Collection)       MSC:  NCLEX: N/A