The state board of nursing defines the scope of practice for nurses.
2. ANS: 1, 3, 4
Leadership does not require a specific degree in nursing or other field. Various leadership styles
may be used depending on the situation. However, an autocratic approach is not always the most
effective.
3. ANS: 1
Nonmaleficence means to do no harm. By confirming the right drug and patient identity, the
nurse reduces the risk of harm posed by a drug error.
4. ANS: 4
A tort is a civil wrong against a person which can include an invasion of privacy. Posting the
patient’s photo on social media violates the patient’s right to privacy in the health care setting.
5. ANS: 1, 2, 3, 5
Only option 4 is incorrect. The nurse is not required to directly supervise tasks assigned to others
although he or she may observe at some point to confirm that the individual performs correctly.
6. ANS: 2
The nurse recognizes a change in vital signs and then collects additional data (previous readings)
to analyze the significance of the current readings. This is an example of analyzing cues.
7. Situation: Mrs. A., age 75, had a total hip replacement this morning. She has just returned to
the nursing unit where the LVN/LPN conducts a focused assessment. The assessment data
include the following:
Highlight or place a check mark next to the assessment findings that require follow-up by
the nurse.
ANS: Select the BP, heart rate, and respiratory rate because all are outside the “normal” range.
Therefore, the nurse should collect additional data and possibly notify the RN.
Chapter 02: Medical-Surgical Practice Settings
1. ANS: 1, 3, 4
Medicare reimburses nursing care in the home as long as the care given is skilled and of a type
that only a nurse trained in that kind of care could be expected to do. Sterile technique to clean
and dress a wound, performing a venipuncture, and teaching a client how to inject insulin are all
skilled nursing care. Taking a frail couple for a walk for exercise and removing outdated food
from a refrigerator and pantry are not considered skilled interventions.
2. ANS: 1, 3, 4, 5
Community health nursing focuses on improving the health status of communities or groups of
people through public education, screening for early detection of disease, and providing services
for people who need care outside the acute care setting. The activities include conducting health
education in a senior citizen center, arranging blood pressure screening at a shopping center,
seeing clients in a clinic to monitor chronic illness problems, and giving flu vaccines at a public
location. Monitoring the recovery of a postoperative client at home is a role for the home health
care nurse.
3. ANS: 1
Community-based nursing is based on the delivery of health care services that meet the needs of
citizens at certain levels of wellness and illness based on specific community needs. Meeting
with residents of low-income housing to identify their health needs is an example of community-
based nursing. Phoning a client at home after discharge form the hospital is an example of
hospital-based nursing. Asking nurses to identify health services lacking in their communities is
Handicapped individuals are those who are not able to perform one or more activities of daily
living (ADL). Impaired individuals have a disturbance in functioning that could be either
physiologic or psychologic. Disabled individuals have a measurable loss of function and
generally a diminished capacity to work. Disadvantaged individuals are people who lack certain
opportunities and services such as those of the general population.
5. ANS: 2
The Americans with Disabilities Act prohibits private employers with 15 or more employees,
state and local governments, employment agencies, and labor unions from discriminating against
qualified individuals with disabilities. The Social Security Act gives additional aid to states for
both direct relief and vocational rehabilitation. The Rehabilitation Act and the Vocational Act
gave a comprehensive approach to problems experienced by the disabled, expanded available
resources for vocational training, and defined services to be included in rehabilitation programs.
6. ANS: 2, 3, 4, 5
Medicare reimbursement for home health nursing care must be necessary, skilled, reasonable,
and intermittent. Short-term care is not one of the reimbursement criteria for Medicare.
7. ANS: 4
To care for a head injury client who is having difficulty feeding herself, the best response is to be
sure that her food is accessible and give her praise for her efforts at self-feeding. Offering to feed
her and ordering a liquid diet so that she does not have to use utensils does not help the client to
rehabilitate herself. Telling the client that the sooner she feeds herself, the sooner she can go
home is putting extra stress on the client and is not a therapeutic comment.
8. ANS: 2
A client who is only able to perform 25% of his usual job activities is considered disabled. A
handicapped client is one who is not able to perform one or more activities of daily living
(ADL). An incapacitated client is someone who is unable to work, move, or function in the usual
way. An impaired client has a disturbance in functioning that could be either physiologic or
psychologic.
These efforts are a way to prevent the client from feeling depersonalized. Maintaining the
resident’s dignity is to professionally treat the resident as a person with thoughts and feelings.
This effort is not focused on preventing regression or social withdrawal.
10. Autumn Leaves Long-Term Care facility prides itself on providing a personalized living
environment. A new nurse administrator, who is committed to the concept of personalization, is
making rounds on the skilled care unit. Her observations are as follows:
Nurses’ station is tidy.
Hallways are clear.
Several residents in wheelchairs are seated near the nurses’ station.
Most residents are dressed in agency gowns or pajamas.
Each room has the same print of an outdoor scene on the wall.
Bedspreads are identical but in different shades of green.
Resident room doors have their preferred names and how they like to be addressed.
All residents are served breakfast between 6:00 and 6:30 am.
All residents are escorted to Sunday church services held on the unit.
CNAs have regular resident assignments.
Highlight or place a check mark next to the observations that require follow-up by the
administrator in order to reduce depersonalization.
ANS: All of the highlighted options (residents in agency clothing, same décor and bed linens,
rigid breakfast schedule, all taken to church services) reflect a depersonalized environment.
Some options may be easy for the staff and facility, but they do not maintain a sense of person.
11. ANS: 3
Dependence on activities of daily living (ADLs) is the primary reason why clients need nursing
home placement. The care delivered there is based upon promotion of independence,
maintenance of function, and maintenance of autonomy. It could be a short stay after a surgical
procedure or a temporary admission because of an illness of the family caregiver. It is not based
on one’s medical diagnosis, and the availability of family caregivers would not necessarily
eliminate a client receiving home health nursing services. Nursing home care is not
independently based upon financial resources.
Chapter 03: Medical-Surgical Patients: Individuals, Families, and Communities
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