Study guide Module 1

Chapter 01: Nursing, Theory, and Professional Practice

1. A group of nursing students are discussing the impact of nonnursing
theories in clinical practice. The students would be correct if they
chose which theory to prioritize patientcare?
a. Erikson’s Psychosocial Theory.
b. Paul’s Critical-Thinking Theory.
c. Maslow’s Hierarchy of Needs.
d. Rosenstock’s Health Belief Model.
ANS: C
Maslow’s hierarchy of needs specifies the psychological and
physiologic factors that affect each person’s physical and mental
health. The nurse’s understanding of these factors helps with
formulating Nursing diagnoses that address the patient’s needs and
values to prioritize care. Erikson’s Psychosocial Theory of Development
and Socialization is based on individuals’ interacting and learning
about their world. Nurses use concepts of developmental theory to
critically think in providing care for their patients at various stages of
their lives. Rosenstock (1974) developed the psychological Health
Belief Model. The model addresses possible reasons for why a patient
may not comply with recommended health promotion behaviors. This
model is especially useful to nurses as they educate patients.

2. A nursing student is preparing study notes from a recent lecture in

nursing history. The student would credit Florence Nightingale for
which definition of nursing?
a. The imbalance between the patient and the environment decreases
the capacity for health.
b. The nurse needs to focus on interpersonal processes between nurse
and patient.
c. The nurse assists the patient with essential functions toward
independence.
d. Human beings are interacting in continuous motion as energy fields.
ANS: A
Florence Nightingale’s (1860) concept of the environment emphasized
prevention and clean air, water, and housing. This theory states that
the imbalance between the patient and the environment decreases the
capacity for health and does not allow for conservation of energy.
Hildegard Peplau (1952) focused on the roles played by the nurse and
the interpersonal process between a nurse and a patient. Virginia
Henderson described the nurse’s role as substitutive (doing for the
person), supplementary (helping the person), or complementary
(working with the person), with the goal of independence for the
patient. Martha Rogers (1970) developed the Science of Unitary
Human Beings. She stated that human beings and their environments
are interacting in continuous motion as infinite energy fields.

3. The nurse identifies which nurse established the American Red Cross
during the Civil War?
a. Dorothea Dix
b. Linda Richards
c. Lena Higbee
d. Clara Barton
ANS: D
Clara Barton practiced nursing in the Civil War and established the
American Red Cross. Dorothea Dix was the head of the U.S. Sanitary
Commission, which was a forerunner of the Army Nurse Corps. Linda
Richards was America’s first trained nurse, graduating from Boston’s
Women’s Hospital in 1873, and Lena Higbee, superintendent of the
U.S. Navy Nurse Corps, was awarded the Navy Cross in 1918.

4. The nursing instructor is researching the five proficiencies regarded

as essential for students and professionals. The nursing instructor
identifies which organization would be found to have added safety as a
sixth competency?
a. Quality and Safety Education for Nurses(QSEN)
b. Institute of Medicine (IOM)
c. American Association of Colleges of Nursing (AACN)
d. National League for Nursing (NLN)
ANS: A
The Institute of Medicine report health professions Education: A Bridge
to Quality (2003), outlines five core competencies. These include
patient-centered care, interdisciplinary teamwork, use of evidence-
based medicine, quality improvement, and use of information
technology. QSEN added safety as a sixth competency. The Essentials
of Baccalaureate Education for Professional Nursing Practice are
provided and updated by the American Association of Colleges of
Nursing (AACN) (2008). The document offers a framework for the
education of professional nurses with outcomes for students to meet.
The National League for Nursing (NLN) outlines and updates
competencies for practical, associate, baccalaureate, and graduate
nursing education programs.

5. The nurse manager is interviewing graduate nurses to fill existing

staffing vacancies. When hiring graduate nurses, the nurse manager
realizes that they will probably not be considered “competent” until
they complete which task?
a. They graduate and pass NCLEX.
b. They have worked 2 to 3 years.
c. Their last year of nursing school.
d. They are actually hired.
ANS: B
Benner’s model identifies five levels of proficiency: novice, advanced
beginner, competent, proficient, and expert. The student nurse
progresses from novice to advanced beginner during nursing school
and attains the competent level after approximately 2 to 3 years of
work experience after graduation. To obtain the RN credential, a
person must graduate from an approved school of nursing and pass a
state licensing examination called the National Council Licensure
Examination for Registered Nurses (NCLEX-RN) usually taken soon
after completion of an approved nursing program.

6. The prospective student is considering options for beginning a

career in nursing. Which degree would best match the student’s desire
to conduct research at the university level?
a. associate degree in nursing (ADN)
b. Bachelor of Science in Nursing (BSN)
c. Doctor of Nursing Practice (DNP)
d. Doctor of Philosophy in Nursing (PhD)
ANS: D
Doctoral nursing education can result in a Doctor of Philosophy (PhD)
degree. This degree prepares nurses for leadership roles in research,
teaching, and administration that are essential to advancing nursing as
a profession. Associate Degree in Nursing (ADN) programs usually are
conducted in a community college setting. The nursing curriculum
focuses on adult acute and chronic disease; maternal/child health;
pediatrics; and psychiatric/mental health nursing. ADN RNs may return
to school to earn a bachelor’s degree or higher in an RN-to-BSN or RN-
to-MSN program. Bachelor’s degree programs include community
health and management courses beyond those provided in an
associate degree program. A newer practice-focused doctoral degree is
the Doctor of Nursing practice (DNP), which concentrates on the
clinical aspects of nursing. DNP specialties include the four advanced
practice roles of NP, CNS, CNM, and CRNA.

7. During a staff meeting, the nurse manager announces that the

hospital will be seeking Magnet status. To explain the requirements for
this award, the nurse manager will contact which organization?
a. American Nurses Association (ANA)
b. American Nurses Credentialing Center (ANCC)
c. National League for Nursing (NLN)
d. Joint Commission
ANS: B
The American Nurses Credentialing Center (ANCC) awards Magnet
Recognition to hospitals that have shown excellence and innovation in
nursing. The ANA is a professional organization that provides standards
of nursing practice. The National League for Nursing (NLN) outlines and
updates competencies for practical, associate, baccalaureate, and
graduate nursing education programs. The Joint Commission is the
accrediting organization for health care facilities in the United States.

8. The nurse is caring for a patient who refuses two units of packed red
blood cells. When the nurse notifies the health care provider of the
patient’s decision, the nurse is acting in which role?
a. Manager
b. Change agent
c. Advocate
d. Educator
ANS: C
As the patient’s advocate, the nurse interprets information and
provides the necessary education. The nurse then accepts and
respects the patient’s decisions even if they are different from the
nurse’s own beliefs. The nurse supports the patient’s wishes and
communicates them to other health care providers. A nurse manages
all of the activities and treatments for patients. In the role of change
agent, the nurse works with patients to address their health concerns
and with staff members to address change in an organization or within
a community. The nurse ensures that the patient receives sufficient
information on which to base consent for care and related treatment.
Education becomes a major focus of discharge planning so that
patients will be prepared to handle their own needs at home.

9. The nursing student develops a plan of care based on a recently

published article describing the effects of bed rest on a patient’s
calcium blood levels. When creating the plan of care, the. nursing
student has the obligation to consider which action?
a. Critically appraise the evidence and determine validity.
b. Ensure that the plan of care does not alter current practice.
c. Change the process even when there is no problem identified.
d. Maintain the plan of care regardless of initial outcome.
ANS: A
Evidence-based practice (EBP) is an integration of the best-available
research evidence with clinical judgment about a specific patient
situation. The nurse assesses current and past research, clinical
guidelines, and other resources to identify relevant literature. The
application of EBP includes critically appraising the evidence to assess
its validity, designing a change for practice, assessing the need for
change and identifying a problem, and integrating and maintaining
change while monitoring process and outcomes by reevaluating the
application of evidence and assessing areas for improvement.

10. The nurse is delegating frequent blood pressure (BP)

measurements for a patient admitted with a gunshot wound to a
licensed practical nurse (LPN). When delegating, the nurse
understands which fact?
a. He/she may assume that the LPN is able to perform this task
appropriately.
b. The LPN is ultimately responsible for the patient findings and
assessment.
c. The LPN may perform the tasks assigned without further supervision.
d. He/she retains ultimate responsibility for patient care and
supervision is needed.
ANS: D
The RN retains ultimate responsibility for patient care, which requires
supervision of those to whom patient care is delegated. In the process
of collaboration, the nurse delegates certain activities to other health
care personnel. The RN needs to know the scope of practice or
capabilities of each health care member for delegation to be effective
and safe.

11. The nurse is preparing to discharge a patient admitted with fever

of unknown origin. The patient states, “I never got past the fifth grade
in school. Don’t read much. Never saw much sense in it. But I do OK. I
can read most stuff. But my doctor explains things good and doesn’t
think that my sickness is serious.” Considering this patient response,
what action should the nurse carry out?
a. Provide discharge medication information from a professional source
to provide the most information.
b. Expect that the patient may return to the hospital if the discharge
process is poorly done.
c. Assume that the physician and the patient have a good rapport, and
that the physician will clarify everything.
d. Defer offering the patient the opportunity to sign up for wellness
classes due to the low literacy rate.
ANS: B
Low health literacy is associated with increased hospitalization, greater
emergency care use, lower use of mammography, and lower receipt of
influenza vaccine. A goal of patient education by the nurse is to inform
patients and deliver information that is understandable by examining
their level of health literacy. The more understandable health
information is for patients, the closer the care is coordinated with
need.

12. A nurse is caring for a patient who lost a large amount of blood
during childbirth. The nurse provides the opportunity for the patient to
maintain her activity level while providing adequate periods of rest and
encouragement. Which nursing theory would the nurse most likely
choose as a framework for addressing the fatigue associated with the
low blood count?
a. Watson Human Caring Theory
b. Parse’s Theory of Human Becoming
c. Roy’s Adaptation Model
d. Rogers’ Science of Unitary Human Beings
ANS: C
Roy’s Adaptation Model is based on the human being as an adaptive
open system. The person adapts by meeting physiologic-physical
needs, developing a positive self-concept–group Identity, performing
social role functions, and balancing dependence and independence.
Stressors result in illness by disrupting the equilibrium. Nursing care is
directed at altering stimuli that are stressors to the patient. The nurse
helps patients strengthen their abilities to adapt to their illnesses or
helps them to develop adaptive behaviors. Watson’s theory is based on
caring, with nurses dedicated to health and healing. The nurse
functions to preserve the dignity and wholeness of humans in health or
while peacefully dying. Parse’s theory is called the Human Becoming
School of Thought. Parse formulated the Theory of Human Becoming
by combining concepts from Martha Rogers’ Science of Unitary Human
Beings with existential-phenomenologic thought. This theory looks at
the person as a constantly changing being, and at nursing as a human
science. Martha Rogers (1970) developed the Science of Unitary
Human Beings. She stated that human beings and their environments
are interacting in continuous motion as infinite energy fields.

13. The nurse recognizes which nursing theorist who described the
relationship between the nurse and the patient as an interpersonal and
therapeutic process?
a. Virginia Henderson
b. Betty Neuman
c. Imogene King
d. Hildegard Peplau
ANS: D
Hildegard Peplau focused on the roles played by the nurse and the
interpersonal process between a nurse and a patient. The
interpersonal process occurs in overlapping phases: (1) orientation, (2)
working, consisting of two subphases: identification and exploitation,
and (3) resolution. Betty Neuman’s Systems Model includes a holistic
concept and an open-system approach. The model identifies energy
resources that provide for basic survival, with lines of resistance that
are activated when a stressor invades the system. Virginia Henderson
described the nurse’s role as substitutive (doing for the person),
supplementary (helping the person), or complementary (working with
the person), with the ultimate goal of independence for the patient.
Imogene King developed a general systems framework that
incorporates three levels of systems: (1) individual or personal, (2)
group or interpersonal, and (3) society or social. The theory of goal
attainment discusses the importance of interaction, perception,
communication, transaction, self, role, stress, growth and
development, time, and personal space. In this theory, both the nurse
and the patient work together to achieve the goals in the continuous
adjustment to stressors.
14. When a nursing class volunteers to serve hot meals at a local
homeless shelter on a Saturday afternoon, which term identifies this
focus on serving the community?
a. Altruism
b. Accountability
c. Autonomy
d. Advocate
ANS: A
A profession provides services needed by society. Additionally,
practitioners’ motivation is public service over personal gain (altruism).
Service to the public requires intellectual activities, which include
responsibility. This accountability has legal, ethical, and professional
implications. Members of a profession have autonomy in decision
making and practice and are self-regulating in that they develop their
own policies in collaboration with one another. As the patient’s
advocate, the nurse interprets information and provides the necessary
education. The nurse then accepts and respects the patient’s decisions
even if they are different from the nurse’s own beliefs.

15. A patient is being discharged from the hospital with wound care
dressing changes. The nurse recommends a referral for home health
nursing care. The nurse is using which standard of practice?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
ANS: C
As a care provider, the nurse follows the nursing process to assess
patient data, prioritize Nursing diagnoses, plan the care of the patient,
implement the appropriate interventions, and evaluate care in an
ongoing cycle. In recommending a referral, the nurse is, in effect,
planning care.

16. The nurse administers a medication to the patient and then

realizes that the medication had been discontinued. The error is
immediately reported to the physician. The nurse recognizes which
term that identifies complying with the standards of professional
performance?
a. Ethics
b. Socialization
c. Altruism
d. Autonomy
ANS: A
Guiding the nurse’s professional practice are ethical behaviors. Ethics
is the standards of right and wrong behavior. The main concepts in
nursing ethics are accountability, advocacy, autonomy (be
independent and self-motivated), beneficence (act in the best interest
of the patient), confidentiality, fidelity (keep promises), justice (relate
to others with fairness and equality), nonmaleficence (do no harm),
responsibility, and veracity (be truthful). Ethical guidelines direct the
nurse’s decision making in routine situations and in ethical dilemmas.
Socialization to professional nursing is a process that involves learning
the theory and skills necessary for the role of nurse. A profession
provides services needed by society. Additionally, practitioners’
motivation is public service over personal gain (altruism). Members of
a profession have autonomy in decision making and practice and are
self-regulating in that they develop their own policies in collaboration
with one another.
17. A newly licensed registered nurse is curious about the scope of
care that he or she has in caring for patients undergoing conscious
sedation. Which would be the best source of information for this nurse?
a. National Student Nurses Association
b. Nurse Practice Act
c. ANA Standards of Professional Performance
d. National League for Nursing
ANS: B
Nurse practice acts provide the scope of practice defined by each state
or jurisdiction and set forth the legal limits of nursing practice. Nursing
organizations enable the nurse to have access to current information
and resources as well as a voice in the profession. Nursing
organizations include the ANA, the NLN, the ICN, Sigma Theta Tau
International Honor Society of Nursing, and the National Student
Nurses Association (NSNA).

18. The nursing student is writing a paper about the direct patient care
role of advanced practice nurses. Which advanced practice role would
the student include in the report?
a. Nurse Administrator
b. Clinical Nurse Leader
c. Clinical Nurse Specialist
d. Nurse Educator
ANS: C
There are four specialties in which nurses provide direct patient care in
advanced practice roles: certified nurse midwife (CNM), nurse
practitioner (NP), clinical nurse specialist (CNS), and certified
registered nurse anesthetist (CRNA). Four additional advanced practice
roles that do not always involve direct patient care are clinical nurse
leader (CNL), nurse educator, nurse researcher, and nurse
administrator.

19. The nurse is determining the patient care assignments for a

nursing unit. The nurse knows which responsibility may be delegated
to the licensed practical nurse?
a. Initiating the nursing care plans
b. Formulating Nursing diagnoses
c. Assessing a newly admitted patient
d. Administering oral medications
ANS: D
LPNs, or LVNs in California and Texas, are not RNs. They complete an
educational program consisting of 12 to 18 months of training, and
then they must pass the National Council Licensure Examination for
Practical Nurses (NCLEX-PN) to practice as an LPN/LVN. They are under
the supervision of an RN in most institutions and are able to collect
data but cannot perform an assessment requiring decision making,
cannot formulate a Nursing diagnosis, and cannot initiate a care plan.
They may update care plans and administer medications except for
certain IV medications.

20. The nursing student is taking a class in Nursing Research. In class

the student has learned which term that identifies the most abstract
level of knowledge?
a. Metaparadigm
b. Philosophy
c. Conceptual framework
d. Nursing theory
ANS: A
A metaparadigm, as the most abstract level of knowledge, is defined
as a global set of concepts that identify and describe the central
phenomena of the discipline and explain the relationship between
those concepts. For example, the metaparadigm for nursing focuses on
the concepts of person, environment, health, and nursing. The next
level of knowledge is a philosophy, which is a statement about the
beliefs and values of nursing in relation to a specific phenomenon such
as health. The third level of knowledge is a nursing conceptual
framework, or model, which is a collection of interrelated concepts that
provides direction for nursing practice, research, and education. The
fourth level of nursing knowledge is a nursing theory, which represents
a group of concepts that can be tested in practice and can be derived
from a conceptual model.

MULTIPLE RESPONSE

1. The nurse recognizes which statements contribute to the

understanding that nursing is considered a profession? (Select all that
apply.)
a. Nursing requires specialized training.
b. Nursing has a specialized body of knowledge.
c. The ANA regulates nursing practice.
d. Nurses make independent decisions within their scope of practice.
e. Once licensure is complete, no further education is required.
ANS: A, B, D
A profession is an occupation that requires at a minimum specialized
training and a specialized body of knowledge. Nursing meets these
minimum requirements. Thus nursing is considered to be a profession.
Members of a profession have autonomy in decision making and
practice and are self-regulating in that they develop their own policies
in collaboration with one another. Nursing professionals make
independent decisions within their scope of practice and are
responsible for the results and consequences of those decisions. A
profession is committed to competence and has a legally recognized
license. Members are accountable for continuing their education. The
ANA is a professional organization that provides standards (not
regulation) of nursing practice.

2. The Institute of Medicine (IOM) Report identified several goals for

nursing in the United States. The nurse identifies that the IOM offered
which suggestions? (Select all that apply.)
a. Nurses should practice to the full extent of their education.
b. Nursing education should demonstrate seamless progression.
c. Nurses should continue to be subservient to physicians in the
hospital lsetting.
d. Policy making requires better data collection and information
infrastructure.
e. Higher levels of education will not be needed by practicing nurses.
ANS: A,B, D The Future of Nursing: Leading Change, Advancing Health
(IOM, 2011) identified several goals for nursing in the United States:
nurses should practice to the full extent of their education and training;
Nurses should achieve higher levels of education and training through
an improved education system that promotes seamless academic
progression; Nurses should be full partners with physicians and other
health care professionals in redesigning health care in the United
States; and Effective workforce planning and policy making require
better data collection and an improved information infrastructure.

3. The nurse is caring for a patient admitted for the removal of an

infected appendix. Which actions by the nurse would indicate an
understanding of the 2018 hospital safety goals? (Select all that apply.)
a. Places an identification band on the right arm.
b. Marks the surgical site with a black-felt pen.
c. Checks medications three times before administration.
d. Washes hands between patients and/or when soiled.
e. Removes allergy bands prior to transfer to surgery.
ANS: A, B, C, D
The Joint Commission identifies each category and has specific
elements of performance that are required for the health care worker
to meet the goals. As new problems in patient care emerge, the safety
goals are reassessed and revised. The 2018 hospital goals include the
following broad categories: improve the accuracy of patient
identification, improve the effectiveness of communication among
caregivers, improve the safety of using medications, reduce the harm
associated with clinical alarm systems, reduce the risk of health care–
associated infections. The organization identifies safety risks inherent
in its patient population. Improve the accuracy of patient identification.
(Placing an ID band on the right are), improve the safety of using
medications (check medications three times before administration),
reduce the risk of health care–associated infections. (Washing hands),
and the organization identifies safety risks inherent in its patient
population. (Mark the surgical site with a black-felt pen) are all
examples of actions that comply with the 2018 safety goals. Removing
allergy bands would prevent identification of that patient’s safety risk.

4. The nurse is conducting a health assessment on a patient from a

foreign country. Which concepts should be addressed by the nurse
during the interview? (Select all that apply.)
a. Food preferences
b. Religious practices
c. Health beliefs
d. Family orientation
e. Politics
ANS: A, B,C, D
Culture is the integrated patterns of human behavior that include the
language, thoughts, communications, actions, customs, beliefs, values,
and institutions of racial, ethnic, religious, or social groups.

5. The nurse documents that patient laboratory results often take 4

hours to populate into the electronic medical record. The lengthy time
frame has contributed to delayed antibiotic administration. From this
point, what should the nurse do to produce change using Evidence-
Based practice? (Select all that apply.)
a. Identify a problem affecting patient care.
b. Realize the facility resources may influence the decision.
c. Review pertinent journal articles from the literature search.
d. Apply the findings to clinical practice considering patient
preferences.
e. Using the process recommended by the best clinical article.
ANS: A, B, C, D
The process of using evidence-based practice (EBP) starts with the
identification of a
problem. The nurse then conducts a literature search to find the best
evidence pertaining to the problem. Facility resources may impact the
ability to implement the chosen decision. Patient preferences need to
be incorporated into the use of evidence from the literature combined
with clinical expertise. The nurse would not use just one clinical article
to determine a solution to the issue.

Infection Control CH.26Y

MULTIPLE CHOICE

1. The nurse recognizes which term to identify the second line of defense that leads to local

capillary dilation and leukocyte infiltration?

a. Normal flora
b. Inflammatory response

c. Immune response

d. Humoral immunity

ANS: B

The second line of defense is the inflammatory response. Inflammation is a local response to

cellular injury or infection that includes capillary dilation and leukocyte infiltration. Normal

flora is the body’s first line of defense. The immune response is the body’s attempt to
protect

itself from foreign and harmful substances. Humoral immunity is a defense system that

involves white blood cells (B lymphocytes) that produce antibodies in response to antigens
or

pathogens circulating in the lymph and blood.

DIF: Understanding OBJ: 26.1 TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT: Concepts: Infection

2. The nurse knows that the ant

igen

-an

tibo

dy r

ea

tion

M
is an example of what type of immunity?

a. Humoral

b. Cellular

c. Innate

d. Passive

ANS: A

USNTO

Humoral immunity is a defense system that involves antibodies and white blood cells that
are

produced to fight antigens. Cellular immunity involves defense by white blood cells against

any microorganisms that the body does not recognize as its own. The innate (nonspecific)

immune system provides immediate defense against foreign antigens. Passive immunity

occurs when a person receives an antibody produced in another body.

DIF: Understanding OBJ: 26.1 TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT: Concepts: Infection

3. The nurse uses what term to identify a disease-causing organism?

a. Pathogen

b. Normal flora

c. Germ

d. Microorganism

ANS: A

Chapter 26: Asepsis and Infection Control

Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative

Practice, 3rd Edition

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Infectious agents include any disease-causing agent and are called pathogens. They include

bacteria, fungi, viruses, and parasites. Normal flora is a group of non–disease-causing

microorganisms that live in or on the body. Germ is a term used for microorganism. A

microorganism is bacteria, fungi, or protozoa.

DIF: Understanding OBJ: 26.1 TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT: Concepts: Infection

4. The nurse is explaining to the patient why antibiotics are being administered. The answer

would be correct if the nurse stated antibiotics are effective against which microorganism?

a. Viruses

b. Fungi

c. Parasites

d. Bacteria

ANS: D

Antibiotics are effective against bacteria, and exact antibiotic sensitivity is tested so that

appropriate antibiotics are prescribed. Infections that are caused by fungi are treated with

antifungal medications. Certain antiviral medications are used to manage the symptoms of a

viral infection. These medications, if given during the early phases of illness, can decrease
the

amount of time that the patient has viral symptoms. Treatment for parasitic infections varies

depending on type of parasite.

DIF: Understanding OBJ: 26.2 TOP: Teaching/Learning

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT: Concepts: Infection

NURSINGTB.COM

5. The nurse anticipates correctly that what medication category would be ordered to treat

athlete’s foot?

a. Antiviral

b. Antibiotic

c. Antihelminth

d. Antifungal

ANS: D

The nurse would expect to treat athlete’s foot with an antifungal because it is a fungal

infection. An antibiotic treats bacterial infections, antivirals treat viral infections, and

antihelminth treats parasitic worms.

DIF: Applying OBJ: 26.2 TOP: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT: Concepts: Infection

6. The nurse recognizes that the stethoscope most correctly represents which possible link
in the

chain of infection?

a. Source

b. Portal of exit

c. Portal of entry

d. Mode of transmission

ANS: D

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The stethoscope would be a means for the pathogen to travel from source to host. The
source

is the reservoir or host. The portal of exit is where the pathogen escapes from the reservoir
of

infection, and the portal of entry is where the microorganism enters the susceptible host.

DIF: Understanding OBJ: 26.2 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

7. The nurse is teaching a group of patients about diseases that are transmitted by ticks.
Which

term would the nurse use when identifying the function of a tick in spreading disease?

a. Vectors

b. Bacteria

c. Viruses

d. Fungi

ANS: A

Vectors carry pathogens from one host to another. Bacteria are single-cell organisms.
Viruses

are the smallest organisms. Fungi are single-cell organisms that can cause infection.

DIF: Understanding OBJ: 26.2 TOP: Teaching/Learning

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT: Concepts: Infection

8. What response would the nurse provide to correctly identify the most effective method to

prevent hospital-acquired infections?

a. Use of sterile technique

b. Isolation protocols

c. Antibiotic use

d. Handwashing

ANS: D
NURSINGTB.COM

Handwashing is the most effective method to prevent hospital-acquired infections. Sterile

technique is only used for certain procedures and isolation protocols are used for patients

already infected or for protective isolation in immune-compromised patients and are not
used

for every patient. Antibiotics are used to treat infections.

DIF: Understanding OBJ: 26.2 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

9. The nurse correctly identifies which patient as having the greatest risk for infection?

a. An 80-year-old male with an enlarged prostate

b. A 24-year-old female long-distance runner

c. A 50-year-old obese male

d. A 40-year-old sexually active female

ANS: A

The 80-year-old male has more risk factors because he is elderly and has increased risk of

urinary tract infection related to prostate enlargement, so he has two risk factors. A

24-year-old female runner is likely healthy with no additional risk factors. The 50-year-old

obese male has one additional risk factor. The 40-year-old sexually active female may not

have additional risk factors if she is using protection and does not have multiple partners.

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N R I G B.C M

DIF: Analyzing OBJ: 26.2 TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT: Concepts: Infection

10. The nurse understands that which set of vital signs most likely indicates infection?

a. T: 98.6 °F (37.0 °C), P: 75 beats/min, R: 18 breaths/min, BP 120/80 mm Hg

b. T: 99 °F (37.2 °C), P: 80 beats/min, R: 18 breaths/min, BP: 110/70 mm Hg

c. T: 100.5 °F (38 °C), P: 96 beats/min, R: 22 breaths/min, BP: 150/100 mm Hg

d. T: 98.9 °F (37.1 °C), P: 66 beats/min, R: 18 breaths/min, BP: 98/62 mm Hg

ANS: C

With infection, temperature will rise and blood pressure will increase along with pulse and

respiratory rate.

DIF: Analyzing OBJ: 26.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT: Concepts: Infection

11. A patient admitted after abdominal surgery has a Nursing diagnosis of risk for infection.
The

nurse identifies which goal to be most appropriate?

a. Patient will ambulate length of hallway this shift.

b. Patient will consume 20% of meals by the end of the week.

c. Patient’s incision will be without signs or symptoms of infection at discharge.

d. Patient will verbalize need to stop antibiotics medication when symptom free.

ANS: C

Maintaining skin integrity is an appropriate goal for this patient to ensure the patient does
not

develop a wound infection. AmUbul

SatinNg wTill assisOt in preventing skin breakdown be getting

the patient out of bed, but it is not the priority goal for a patient with an incision. Consuming

only 20% of meals will not ensure adequate nutrition and verbalizing the end of antibiotic

administration to be when symptoms end is inappropriate. Antibiotics should be taken until

the prescription is complete.

DIF: Analyzing OBJ: 26.4 TOP: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

NOT: Concepts: Infection

12. The nurse is caring for a patient who is comatose. When preforming oral hygiene, which

interval is most appropriate?

a. Every shift

b. Twice daily

c. Every 4 hours

d. Daily

ANS: C

Oral care should be performed every 4 hours to prevent the colonization of bacteria. Less

often than every 4 hours is not effective.

DIF: Applying OBJ: 26.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

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DIF: Applying U S N T O

13. The nurse knows which skill does not require the use of sterile technique?

a. NG tube insertion

b. Foley catheterization

c. Tracheostomy care
d. PICC line insertion

ANS: A

NG tube insertion requires a clean, not sterile, technique as the gastrointestinal tract is not

sterile. Use strict aseptic technique when inserting an intravenous (IV) or Foley catheter and

when performing suctioning of the lower airway.

DIF: Applying OBJ: 26.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

14. The nurse recognizes which situation to be inappropriate to use alcohol-based hand
sanitizer?

a. Patient with pneumonia

b. Patient with Clostridium difficile

c. Status post-appendectomy

d. Patient with HIV

ANS: B

Soap and water must be used to thoroughly clean hands if there is any visible soiling or dirt

and with certain infections such as Clostridium difficile and vancomycin-resistant enterococci

when preparing for a sterile or surgical procedure, before and after eating, and after using
the

restroom. In the other situations, a hand sanitizer is as effective as soap and water.

N R I G B.C M

OBJ: 26.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

15. The nurse is preparing to perform suctioning on a new tracheostomy with the potential
for

forceful expulsion of secretions and identifies what PPE (personal protective equipment)

should be worn?
a. Gloves and eyewear

b. Gloves, gown, and mask

c. Eyewear and gown

d. Eyewear, mask, gown, and gloves

ANS: D

Use gloves routinely when blood or body fluid might be present. If splashing is possible, use

your nursing judgment about what other PPE might be necessary. Forceful expulsion of

secretions would require all PPE—gown, mask, eyewear, and gloves—to provide adequate

protection.

DIF: Applying OBJ: 26.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

16. Which isolation precaution should the nurse implement for the patient who has been

diagnosed with hepatitis A?

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USNT

a. Airborne

b. Contact

c. Droplet

d. Protective

ANS: B
Contact precautions are used when a known or suspected contagious disease may be
present

and is transmitted through direct contact with the patient or indirect contact with items in
the

patient’s environment. Airborne precautions are used when known or suspected contagious

diseases can be transmitted by means of small droplets or particles that can remain
suspended

in the air for prolonged periods. Droplet precautions are used when known or suspected

contagious diseases can be transmitted through large droplets suspended in the air.
Protective

isolation is used for patients who have compromised immune systems.

DIF: Applying OBJ: 26.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

17. When the patient is diagnosed with pertussis, which isolation precaution should the
nurse

implement?

a. Droplet

b. Airborne

c. Contact

d. Protective

ANS: A

Droplet precautions are used when known or suspected contagious diseases can be
transmitted

through large droplets suspenNdedRinIthe Gair.BCo

.nCtactMprecautions are used when a known or

suspected contagious disease may be present and is transmitted through direct contact with
the

patient or indirect contact with items in the patient’s environment. Airborne precautions are

used when known or suspected contagious diseases can be transmitted by means of small

droplets or particles that can remain suspended in the air for prolonged periods.
DIF: Applying OBJ: 26.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

18. When teaching a student nurse about removing PPE, the nurse would include which
correct

order of equipment removal?

a. Gloves, eyewear, gown, and mask

b. Mask, eyewear, gown, and gloves

c. Gown, mask, eyewear, and gloves

d. Gloves, gown, mask, and eyewear

ANS: A

When removing PPE, gloves, which are contaminated, are removed first to prevent

contamination of the face and eyes during removal of the mask and to prevent spread of

microorganisms. Eyewear should then be removed, followed by the gown and finally the

mask.

DIF: Applying OBJ: 26.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

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Control NOT: Concepts: Infection

19. When the nurse is wearing sterile gloves, which action would result in the gloves
becoming

nonsterile?
a. Fold gloved hands until procedure begins.

b. Change a dressing using aseptic technique.

c. Place sterile gloved hands below waist.

d. Use correct protocol when donning sterile gloves.

ANS: C

Once the hands have been placed below the waist, they can longer be considered sterile or
free

from organisms. Asepsis refers to freedom from disease-causing contamination. All other

choices maintain asepsis.

DIF: Applying OBJ: 26.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

MULTIPLE RESPONSE

1. The nurse is planning care for an elderly patient. The nurse recognizes the patient is at
risk for

respiratory infections based on which factors? (Select all that apply.)

a. Decreased cough reflex

b. Decreased lung elasticity

c. Increased activity of the cilia

d. Abnormal swallowing reflex

e. Increased sputum producNtio

nRSINGTB.COM

ANS: A, B, D

The elderly are at an increased risk for respiratory infections because of decreased cough

reflex, decreased elastic recoil of the lungs, decreased activity of the cilia, and abnormal

swallowing reflex. They do not generally have increased sputum production.

DIF: Applying OBJ: 26.2 TOP: Assessment

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection
Control NOT: Concepts: Infection

2. The nurse is providing education to a patient who is being discharged home on antibiotic

therapy. Which statement(s) by the patient indicates further education is needed? (Select all

that apply.)

a. “I should take antibiotics every time I am sick.”

b. “Ishould take all antibiotics as prescribed.”

c. “Ishould save all unused antibiotics.”

d. “I should stop taking antibiotics when I feel better.”

e. “If I develop a rash while taking these I will call the provider.”

ANS: A, C, D

The overuse of antibiotics and inappropriate use, such as not completing prescriptions and

sharing antibiotics, has led to increased resistance. Taking antibiotics as prescribed helps to

ensure the infection will be treated correctly. A rash may indicate an allergic reaction and
the

patient needs to report this to the provider.

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DIF: Evaluating OBJ: 26.2 TOP: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral

Therapies NOT: Concepts: Infection

3. The nurse recognizes which statements by the student nurse regarding handwashing
indicate a

need for further education? (Select all that apply.)

a. Wash hands first, then wrists.

b. Rinse from fingertips to wrists.

c. Dry using a scrubbing motion.

d. Turn off faucet with clean, dry paper towel.

e. Dry the hands in the same order as washing them.

ANS: A, B, C

When washing hands, first wet the wrists and hands; with fingers pointing downward, first

wash the wrists and then the hands below the wrists. Then apply soap, lather, and rub using
a

circular motion for 15 to 20 seconds. When rinsing, rinse from wrist to fingertips, keeping

hands with fingers pointing downward. Using clean paper towels, dry thoroughly in the same

order (from wrists to fingers) using a patting motion. Turn off the faucet with a clean, dry

paper towel.

DIF: Evaluating OBJ: 26.6 TOP: Evaluation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

4. The nurse knows that standard precautions are indicated for which group(s) of patients?

(Select all that apply.)

a. All patients

b. Patients with HIV

c. Patients with MRSA

NURSINGTB.COM

d. Patients with tuberculosis

e. Patients who are bleeding

ANS: A, E

The nurse can take steps at any link in the chain to halt the spread of infection. Standard

precautions are used with all patients to limit direct exposure to blood and body fluids. The

other choices are additional precautions such as airborne precautions are used with patients

who have diseases such as tuberculosis and contact precautions with patients who have
MRSA.

DIF: Applying OBJ: 26.6 TOP: Nursing Process: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Safety and
Infection

Control NOT: Concepts: Infection

5. The patient is on protective precautions. The nurse knows which statements are true
regarding

these precautions? (Select all that apply.)

a. A positive-pressure room with a HEPA filtration system is required.

b. Special respirator masks should be available and one size fits all.

c. No live plants are allowed in the room.

d. The patient may eat any foods desired.

e. Everyone entering the room wears a mask.

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ANS: C, E

Protective precautions may require a positive-pressure room. No live plants, fresh flowers,

fresh raw fruit or vegetables, sushi, or blue cheese may be brought into the room because
they

may harbor bacteria and fungi. The patient cannot eat just any foods because some are

restricted. A mask is required for anyone entering the room and for the patient if leaving the

room.

Chapter 16: Health and Wellness

1. The nurse knows the World Health Organization defines health in which of
the following

terms?

a. The absence of disease

b. The lack of infirmity

c. Complete well-being

d. Being independent of fiscal responsibility

ANS: C

The World Health Organization offers a definition for health: “a state of

complete physical,

mental, and social well-being and not merely the absence of disease or
infirmity.” Nurses are

responsible for helping patients reach their optimal levels of physiologic and
mental health,

but they also must provide health care in a system that requires cost
containment and fiscal

responsibility.

DIF: Remembering OBJ: 16.1 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

2. Several models exist that describe the relationship between health and
wellness. Which model

is used to understand the interrelationship between elements of basic

requirements for survival

and the desires that drive persoUnalSgroN

wthTand dev

Oelopment and is represented as a pyramid?

a. Maslow’s hierarchy of needs

b. Health Belief Model

c. Health Promotion Model

d. Holistic Health Model

ANS: A

Maslow’s hierarchy of needs describes the relationships between the basic

requirements for

survival and the desires that drive personal growth and development. The
model is most often

presented as a pyramid consisting of five levels. The lowest level is related to

physiologic

needs, and the uppermost level is associated with self-actualization needs,

specifically those

related to purpose and identity. The Health Belief Model was developed by
psychologists

Hochbaum, Rosenstock, and Kegels. It explores how patients’ attitudes and

beliefs predict

health behavior. The Health Promotion Model, developed by Pender and

colleagues, defines

health as a positive, dynamic state of well-being rather than the absence of

disease in the

physiologic state. Holistic health models in nursing care are based on the
philosophy that a

synergistic relationship exists between the body and the environment.

Holistic care is an

approach to applying healing therapies. Holistic models focus on the

interrelatedness of body

and mind.

3. The nurse is developing a plan of care for a patient with a hip fracture.
Which model would
the nurse use to prioritize the patient’s care?

a. The Health Belief Model

b. Pender’s Health Promotion Model

c. Maslow’s hierarchy of needs

d. The Holistic Health Model

ANS: C

Maslow’s hierarchy of needs describes the relationships between the basic

requirements for

survival and the desires that drive personal growth and development. The
model is most often

presented as a pyramid consisting of five levels. The lowest level is related to

physiologic

needs, and the uppermost level is associated with self-actualization needs,

specifically those

related to purpose and identity. The Health Belief Model was developed by
psychologists

Hochbaum, Rosenstock, and Kegels. It explores how patients’ attitudes and

beliefs predict

health behavior. The Health Promotion Model, developed by Pender and

colleagues, defines

health as a positive, dynamic state of well-being rather than the absence of

disease in the

physiologic state. Holistic Health Models in nursing care are based on the
philosophy that a

synergistic relationship exists between the body and the environment.

Holistic care is an

approach to applying healing therapies. Holistic models focus on the

interrelatedness of body

and mind.

DIF: Applying OBJ: 16.2 TOP: Implementation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

4. The nurse is preparing a patient teaching plan and is seeking a way to

determine the patient’s

readiness and motivation to a changes to best manage diabetes mellitus.

Which model would be useful for this nurse?

a. Maslow’s hierarchy of needs

b. Holistic Health Model

c. Health Promotion Model

d. Health Belief Model

ANS: D

The Health Belief Model was developed by psychologists Hochbaum,

Rosenstock, and

Kegels. It explores how patients’ attitudes and beliefs predict health

behavior. Maslow’s

hierarchy of needs describes the relationships between the basic

requirements for survival and

the desires that drive personal growth and development. The model is most
often presented as

a pyramid consisting of five levels. The lowest level is related to physiologic

needs, and the

uppermost level is associated with self-actualization needs, specifically those

related to

purpose and identity. Holistic Health Models in nursing care are based on the
philosophy that

a synergistic relationship exists between the body and the environment.

Holistic care is an

approach to applying healing therapies. Holistic models focus on the

interrelatedness of body
and mind. The Health Promotion Model, developed by Pender and colleagues,
defines health

as a positive, dynamic state of well-being rather than the absence of disease

in the physiologic

state.

DIF: Understanding OBJ: 16.2 TOP: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

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5. According to the Health Belief Model, which of the following patients would
be most likely

to change health behavior?

a. The person who perceives that he is at risk for colon cancer

b. The person who recognizes that colon cancer is easily cured

c. The person who believes that behavior can change outcomes

d. The patient who faces multiple social barriers

ANS: A

In the three primary components of the Health Belief Model, six main
constructs influence an
individual’s decision to take action about disease prevention, screening, and
controlling

illness. The model suggests that individuals are motivated to take action if
they believe that

they are susceptible to the condition (i.e., perceived susceptibility), that the
condition has

serious consequences (i.e., perceived severity), that taking action would

reduce the

susceptibility or severity of the condition (i.e., perceived benefit), that the

costs of taking

action (i.e., perceived barriers) are outweighed by the benefits, that those
who are exposed to

factors (e.g., media campaigns, postcard reminders, and advice from others)
will be prompted

to action (i.e., cues to action), and that those who have confidence in their
ability to perform

an action will do so (i.e., perceived self-efficacy).

DIF: Analyzing OBJ: 16.2 TOP: Evaluation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

6. The nurse recognizes that intentional behaviors to circumvent illness,

detect it early, and

maintain the best possible level of mental and physiologic function within the
boundaries of

illness is the definition of which term?

a. Health promotion

b. Self-actualization

c. Health protection

d. Self-transcendence

ANS: C
NURSINGTB.COM

Health protection includes intentional behaviors aimed at circumventing

illness, detecting it

early, and maintaining the best possible level of mental and physiologic
function within the

boundaries of illness. Health promotion is behavior motivated by the desire

to increase

well-being and optimize health status. Maslow considered self-actualization

the highest level

of optimal functioning and involves the integration of cognition,

consciousness, and

physiologic utility in a single entity. In later years, Maslow described a level

above

self-actualization called self-transcendence. He refers to self-transcendence

as a peak

experience, in which analysis of reality or thought changes a person’s view of

the world and

his or her position in the greater structure of life.

DIF: Remembering OBJ: 16.2 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

7. The nurse caring for a patient with chronic pain uses guided imagery,
therapeutic touch, and

relaxation techniques as interventions for pain. The nurse is using what type
of approach?

a. Holistic

b. Eastern holistic

c. Risk factor reduction

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d. Health protection

ANS: A

Nurses participate in holistic care through the use of natural healing

remedies and

complementary interventions. These include the use of art and guided

imagery, therapeutic

touch, music therapy, relaxation techniques, and reminiscence. Eastern

holistic therapists have

been using techniques such as acupuncture, yoga, and tai chi for thousands
of years as

methods of healing and, more recently, in conjunction with modern allopathic

medical

therapies. Risk factor reduction is step-by-step improvement of individual

health factors.

These combined improvements lower the likelihood of developing a disease.

Health

protection includes intentional behaviors aimed at circumventing illness,

detecting it early,

and maintaining the best possible level of mental and physiologic function
within the

boundaries of illness.
DIF: Remembering OBJ: 16.2 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

8. An overweight, sedentary middle-aged smoker with a family history of

cardiac disease has

noticed a steady rise in resting blood pressure over a 3- to 4-year period. The
patient is

concerned about his slightly elevated blood pressure and begins walking 20
to 30 minutes in

the evenings with his wife and reduces his pack-a-day cigarette habit to ten
cigarettes a day.

The nurse identifies these actions are the initial step of which behavior?

a. Risk factor reduction

b. Self-actualization

c. Self-transcendence

d. Health promotion

ANS: A

NURSINGTB.COM

Risk factor reduction is step-by-step improvement of individual health

factors. These

combined improvements lower the likelihood of developing a disease.

Maslow considered

self-actualization the highest level of optimal functioning and involves the

integration of

cognition, consciousness, and physiologic utility in a single entity. In later

years, Maslow

described a level above self-actualization called self-transcendence. He

refers to
self-transcendence as a peak experience, in which analysis of reality or
thought changes a

person’s view of the world and his/her position in the greater structure of life.
Health

promotion is behavior motivated by the desire to increase well-being (as

opposed to

preventing illness) and optimize health status.

DIF: Remembering OBJ: 16.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

9. The nurse recognizes the nursing goal for individuals and families seeking
preventative care is

to have those groups carry out which action?

a. Take responsibility for their health and wellness.

b. Abandon the use of electronic educational media.

c. Make lifestyle changes after diseases occur.

d. Use temporary changes until the danger has passed.

ANS: A

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N R I G B.C
Nursing goals for all individuals and their families seeking preventive care
are improvement

of quality of life through positive lifestyle choices and taking responsibility for
health and

wellness. Nurses can refer patients to a variety of personal health quizzes,

located in the

online version of Healthy People 2020, for risk assessments of their health
status and lifestyle.

The quizzes allow people to track their health and wellness status over a
period of years and

identify trends in disease risk factors that can be modified through lifestyle
interventions or

preventive measures before the disease occurs. The Healthy People 2020
initiative helps

nurses provide educational materials for individuals, families, and

communities, enabling

them to lead healthier lifestyles and to make permanent changes in wellness

habits.

DIF: Understanding OBJ: 16.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

10. The nurse knows that use of seatbelts and airbags in automobiles is an
example of which

term?

a. Secondary prevention

b. Tertiary prevention

c. Holistic care

d. Primary prevention

ANS: D
Primary prevention is instituted before disease becomes established by
removing the causes or

increasing resistance. Examples include the use of seatbelts and airbags in

automobiles,

helmet use when riding bicycles or motorcycles, and the occupational use of
mechanical

devices when lifting heavy objects. Secondary prevention is undertaken in

cases of latent

(hidden) disease. Although the patient may be asymptomatic, the disease

process can be

detected by medical tests. NursUes mSayNuseTscreeni

Ong tests to assess for latent disease in

vulnerable populations. Examples of screening tests used as secondary

prevention strategies

include the purified protein derivative (PPD) skin test for tuberculosis, fecal
occult blood test

for colorectal cancer, and mammograms for breast cancer. Tertiary

prevention, also known as

the treatment or rehabilitation stage of preventive care, is implemented

when a condition or

illness is permanent and irreversible. The aim of care is to reduce the

number and impact of

complications and disabilities resulting from a disease or medical condition.

Interventions are

intended to reduce suffering caused by poor health and assist the patients in
adjusting to

incurable conditions. Nursing care is focused on rehabilitation efforts in the

tertiary stage of

prevention. Holistic care is an approach to applying healing therapies. Nurses

participate in
holistic care through the use of natural healing remedies and complementary
interventions.

These include the use of art and guided imagery, therapeutic touch, music
therapy, relaxation

techniques, and reminiscence.

DIF: Understanding OBJ: 16.4 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

11. A 40-year-old patient presents to her provider for a yearly physical. The
provider notes a

family history of breast cancer in the patient’s mother. The provider

schedules the patient for

a mammogram. The nurse recognizes this as what level of prevention?

a. Tertiary

b. Primary

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c. Secondary

d. Holistic

ANS: C
Secondary prevention is undertaken in cases of latent (hidden) disease.
Although the patient

may be asymptomatic, the disease process can be detected by medical

tests. Nurses may use

screening tests to assess for latent disease in vulnerable populations.

Examples of screening

tests used as secondary prevention strategies include the purified protein

derivative (PPD)

skin test for tuberculosis, fecal occult blood test for colorectal cancer, and
mammograms for

breast cancer. Primary prevention is instituted before disease becomes

established by

removing the causes or increasing resistance. Examples include the use of

seatbelts and

airbags in automobiles, helmet use when riding bicycles or motorcycles, and

the occupational

use of mechanical devices when lifting heavy objects. Tertiary prevention,

also known as the

treatment or rehabilitation stage of preventive care, is implemented when a

condition or

illness is permanent and irreversible. The aim of care is to reduce the

number and impact of

complications and disabilities resulting from a disease or medical condition.

Interventions are

intended to reduce suffering caused by poor health and assist the patients in
adjusting to

incurable conditions. Nursing care is focused on rehabilitation efforts in the

tertiary stage of

prevention. Holistic care is an approach to applying healing therapies. Nurses

participate in

holistic care through the use of natural healing remedies and complementary
interventions.
These include the use of art and guided imagery, therapeutic touch, music
therapy, relaxation

techniques, and reminiscence.

DIF: Understanding OBJ: 16.4 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

12. The patient asks the nurse to

exUp

RlaSin

cNol

GlaTbo

ra

.ti

ve

Oh

ealth care partnerships. The nurse gives a

correct description when making which statement regarding collaborative

care?

a. Does not require participation of the patient.

b. Is individual and cannot be mandated or legislated.

c. Education needs are delegated to assistive personnel.

d. Is designed to provide care to the patient as a whole.

ANS: D

Collaborative health care partnerships are designed to deliver well-balanced

care to the patient

as a whole, rather than rendering fragmented care involving a single element

of a disease

process. Prevention is not solely the responsibility of the nurse; it involves

active participation

by the individual and the combined services of practitioners in a spectrum of

health care

disciplines as varied as nutrition, physical therapy, exercise physiology, and

pharmacy.

Collaborative preventive care can be mandated in the form of health care

legislation, with

rates for reimbursement of practitioners determined by the individual

provider’s ability to

collaborate and develop innovative methods for delivering high-quality, cost-

effective health

care services. The role of the professional nurse is to collaborate and

communicate health

education to the patient and family, care provider, or surrogate. Patient

education

responsibilities are not delegated to assistive personnel or other members of

the health care

team and are considered a cornerstone of nursing care.

DIF: Understanding OBJ: 16.4 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

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N R I G B.C

13. A patient is diagnosed with pneumonia after an abrupt onset of fever,

cough, and malaise. The

patient is started on antibiotic therapy and is expected to improve in 2 to 3

weeks. Which

statement by the nurse correctly identifies this illness?

a. Acute

b. Chronic

c. Remission

d. Exacerbation

ANS: A

Acute illness is typically characterized by an abrupt onset and short duration

(<6 months).

Clinical manifestations of acute illness appear quickly. They may be severe or

lethal, or they

may soon resolve because they respond to treatment or are self-limiting.

Chronic illness is

characterized by a loss or abnormality of body function that lasts longer than

6 months and

requires ongoing long-term care. Chronic health conditions may be controlled

with lifestyle
management or drug therapy, but they are considered to be irreversible.
Chronic illness may

be characterized by periods of wellness (i.e., remission) and exacerbation

(worsening) of

clinical manifestations, which can be life threatening. Individuals learn to

adjust their

lifestyles accordingly.

DIF: Understanding OBJ: 16.5 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

14. The nurse needs to consider which approach when caring for patients
with chronic illness?

a. Help the patient face the reality that he will not get better.

b. Emphasize to the patient that the illness is not his fault.

c. Focus on improving qualityUofSlifeNthroTugh preOventive behaviors.

d. Acknowledge the limitations placed on the patient by his suffering.

ANS: C

Nurses can help patients establish a daily routine of care by educating them
about how to

manage their care and the symptoms associated with the condition,
including emergency or

life-threatening situations. Emphasis is on improving quality of life through

preventive

behaviors. The attitude of being a victim, suffering with, or being afflicted by

a chronic illness

is viewed by nurses as a counterproductive behavior that needs positive

intervention. Nurses

can assist patients with strategies that help them cope with their chronic
conditions and
associated feelings of anger, frustration, and depression. Encouragement
and positive support

from a professional nurse can help individuals gain control over the
alternating periods of

health and illness and improve their quality of life.

DIF: Applying OBJ: 16.5 TOP: Implementation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

15. A patient presents to the clinic for illness, and the sick role is legitimized
by the provider. The

nurse recognizes this as what stage of illness according to Suchman’s Model?

a. I

b. II

c. III

d. IV

ANS: C

In stage III (Medical care contact), professional advice from health care
providers is sought by

the individual. A professional health care provider identifies and validates the
illness and

legitimizes the sick role. During stage II (Assumption of the sick role), the
person decides that

the illness is genuine and that care is necessary. This stage gives an
individual permission to

act sick and to be excused temporarily from typical social and personal
obligations. During

stage I (Symptom experience), a clinical manifestation of disease is

experienced, and the

person acknowledges that something is wrong and seeks a cure. The

outcome of stage I is that
the person accepts the reality of symptoms and decides to take action in
seeking care. During

stage IV (Dependent patient role), the person, who is designated as a

patient, usually

undergoes treatment. During this stage, patients often feel dependent on

others and may

experience ambivalent or fearful thoughts that cause them to reject

treatment, the advice of

health care providers, and the illness.

DIF: Remembering OBJ: 16.5 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

16. When considering factors influencing health and the impact of illness,
specifically age, the

nurse would correctly identify which patient as having the greatest risk?

a. 10-year-old girl

b. 23-year-old woman

c. 47-year-old man

d. 85-year-old woman

ANS: D

Assessment of the patient beNginsRwitIh riGsk fBac.toCrs th

Mat take into account the person’s age and

the associated level of immune system function. The very young, especially
neonates and

infants born prematurely, are more susceptible to infections because of the

immaturity of their

immune systems. Likewise, older adults have decreased immune system

function because of
the aging process. Older patients are at risk for opportunistic infections
resulting from

harmless organisms that become pathogenic and illness from the spread of

community-acquired disease. Complications from comorbidities of chronic

disease may also

increase suffering in the aged population.

DIF: Understanding OBJ: 16.6 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

17. When discussing immunizations for infants and children with new
parents, the nurse should

focus on which approach?

a. Providing scientific evidence to parents

b. Stressing that nonimmunization is a crime

c. Acknowledging that immunizations are not needed

d. Informing the parents that they have no choice

ANS: A

Parents need to have scientific, evidence-based information about

immunizations and their

consequences before choosing to accept or reject immunizations for their

children. The

parent’s ability to make an informed decision is the primary goal for nurses
educating people

about childhood immunizations.

DIF: Applying OBJ: 16.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

18. The nurse recognizes which concept that correctly completes the
definition of the genetic
vulnerability of an organism (risk of disease expression based on genotype)?

a. It is involuntarily passed from biologic parents to offspring.

b. It is totally unrelated to environmental factors.

c. It is nonresponsive to alteration by way of lifestyle modification.

d. It is not a factor in mental illness because it is behavioral.

ANS: A

The genetic vulnerability of an organism, or risk of disease expression based

on genotype, is

involuntarily passed from biologic parents to their offspring. Societal

attitudes about testing

and management of high-risk populations depend on the potential for

expression of genetic

disorders that may be triggered by environmental factors. Controlling factors

that place stress

on physiologic function can reduce pathologic genetic expression and

susceptibility to

disease. For example, a person with a family history of hyperlipidemia and

atherosclerosis is

at risk for developing cardiovascular disease later in life. Lifestyle-modifying

factors, such as

weight reduction, daily exercise, and balanced nutritional intake, can help
reduce the

likelihood that the genetic risk factor for heart disease will be expressed.
Diabetes, cancer,

mental illness, and renal dise

aseR

also

hav
G

eg

en

tic c

omponents and are amenable to

interventions that reduce risk.

DIF: Understanding OBJ: 16.6 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

19. The patient is asking about using the Internet for resources regarding
lifestyle behaviors and

benefits of modification. What is the best response that the nurse should
provide the patient?

a. Information on lifestyle behaviors is not available on the Internet.

b. The patient should use websites that are easy to understand.

c. Most websites are designed for health care providers only.

d. Only negative outcomes are evaluated on the Internet.

ANS: B

Information on lifestyle behaviors that lead to disease is available at

research-sponsored

websites that have peer-reviewed material and expert analyses. Website

content should be
easy to read and understandable for the general population. Most sites that
discuss the latest

information about health risks, lifestyle behaviors, and outcomes have

separate information

specifically for health care providers. Research that evaluates positive and
negative

lifestyle-behavior outcomes is constantly evolving as discoveries are made

about the

physiologic changes bodies experience with disease and illness.

DIF: Applying OBJ: 16.6 TOP: Implementation

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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NOT: Concepts: Health Promotion

20. The nurse is assessing a patient’s environment and its impact on outdoor
activity and notes

that the child rarely plays outside. Which is true regarding the indoor
environment?

a. Indoor environments protect the patient from toxics chemicals.

b. Indoor activity is sometimes a result of unsafe outdoor conditions.

c. Indoor activity decreases the risk of respiratory illness.

d. Indoor lifestyles reduce the risk for sedentary behaviors.

ANS: B

Outdoor environments affect individual health in the areas of sanitation and

waste disposal,

water quality, air quality, and safety. Children living in areas where there are
safety issues

related to gang activity, sexual predators, or heavy traffic are less likely to
engage in outdoor

play activities. Their limited access to safe outdoor play space increases their
risk for

sedentary behaviors, excessive calorie intake, and obesity. Indoor

environments may harbor

toxic household cleaning agents, chemicals (e.g., radon, carbon monoxide,

unused drugs),

tobacco smoke, and energy sources (e.g., microwave ovens). Exposure to

mold, household

pests (e.g., dust mites, spiders), and unsanitary living conditions in an

enclosed space

increases the likelihood of respiratory illness and skin disorders.

DIF: Remembering OBJ: 16.6 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

21. The nurse correctly recognizes which one of the following illnesses to
trigger the broadest

range of emotional and behavioral responses?

a. Ear infection

b. Mild concussion

c. Rheumatoid arthritis

d. Influenza

ANS: C
NURSINGTB.COM

Chronic, debilitating disease such as rheumatoid arthritis and severe illness

can produce a

broad range of emotional or behavioral responses in patients and their

families. A short-term,

self-limited illness that is not life threatening does not evoke emotions or
actions that cause

fundamental changes in daily lifestyle. More often, illnesses such as the flu,
ear infections,

and sore throats are viewed as minor irritations or inconveniences. They

usually require a

short-term adjustment in daily routines, and treatment of symptoms is the

priority so that the

individual can continue with normal activities. The emotional and behavioral
changes

associated with non–life-threatening illness are usually minimal, and the

individual quickly

returns to the previous baseline level of emotional functioning.

DIF: Understanding OBJ: 16.6 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

22. Self-concept refers to the way in which individuals perceive unchanging

aspects of

themselves, such as social character, cognitive abilities, physical

appearance, and body image.

Which additional point does the nurse the nurse recognize as part of the
definition of

self-concept?

a. If negative, self-concept will allow the patient to compensate for

weaknesses.
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b. If positive, self-concept will cause the patient to see challenges as

devastating.

c. Self-concept is a concept that is derived from the patient internally.

d. Self-concept depends on relationships with family and friends.

ANS: D

Self-concept refers to the way in which individuals perceive unchanging

aspects of

themselves, such as social character, cognitive abilities, physical

appearance, and body image.

It is a mental image of self in relation to others and the surroundings. If the

image is positive,

the person will develop strengths, compensate for weaknesses, and

experience life in a healthy

way. If the image is negative (e.g., frail), the person will find life’s challenges
devastating and

sometimes insurmountable. The impact of illness on the self-concept of a

patient and the

patient’s family members depends on how secure the parties’ relationships

are with one

another.
DIF: Understanding OBJ: 16.6 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

MULTIPLE RESPONSE

1. Which recommendations would the nurse identify as appropriate screening

guidelines? (Select

all that apply.)

a. Women ages 21 to 29 should have a Pap test every 3 years.

b. Self-breast exams should be addressed with male and female patients.

c. Adolescent males should perform monthly self-testicular exams.

d. Women ages 30 to 65 should receive Pap tests every 10 years.

e. After a total hysterectomNy,

PRap

StIes

tin

Gg

sBho.uCld

bMe more frequent.

ANS: A, B, C

All women should begin cervical cancer screening at the age of 21 years.
Women between the

ages of 21 and 29 years should have a Papanicolaou (Pap) test every 3

years. A priority
assessment task for nurses in a variety of care settings is to ask female and
male patients about

breast self-examination. An adolescent male should be assessed for

testicular self-examination

habits, and older males should have an annual prostate examination. Women
between the ages

of 30 and 65 years should have a Pap test plus a human papillomavirus

(HPV) test (i.e.,

co-testing) every 5 years. Women 65 years of age or older who have had
normal results for

previous Pap tests should no longer be screened. Women who have had a
total hysterectomy

(i.e., removal of the uterus and cervix) should not be tested, unless the
surgery was done as a

treatment for cervical cancer or pre-cancer.

DIF: Understanding OBJ: 16.6 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

2. The nurse recognizes which of the following to be a benefit of regular

physical exercise?

(Select all that apply.)

a. Enhances the immune system.

b. Decreases bone density.

c. Limits joint mobility.

d. Improves mental health.

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e. Helps to prevent type 2 diabetes.

ANS: A, D, E

Exercise is essential for the prevention of illness and promotion of wellness.

Physical exercise

is any bodily activity or movement that enhances or maintains physical

fitness levels and

overall health. Exercise strengthens muscles, improves cardiovascular

performance, hones

athletic skills and endurance, and reduces or maintains weight, and it is

performed for

enjoyment (Powers and Howley, 2012). Regular physical exercise enhances

the immune

system, builds and maintains healthy bone density, increases joint mobility,
and helps to

prevent cardiovascular disease, type 2 diabetes, and obesity. Exercise also

improves mental

health and helps to prevent depression through the release of endorphins

and other

neurotransmitters that are responsible for exercise-induced euphoria (Powers

and Howley,

2012).

DIF: Remembering OBJ: 16.6 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotion

3. The economic stability of individuals or families can determine whether
they are willing to

seek preventive care or screening examinations. The nurse knows which

statements about

screening examinations to be true? (Select all that apply.)

a. Free or low-cost screening ensures patient screening.

b. People may not screen due to fear of testing positive.

c. Early screening ensures minimal treatment costs.

d. Employment stability is enhanced by early screening.

e. Treatment of disorders often means lost wages.

ANS: B, E NURSINGTB.COM

The economic stability of individuals or families can determine whether they

are willing to

seek preventive care or screening examinations. Even if screening is free or

low cost, the

patient or family members may decline because of the potential for testing
positive for a

disease. Treatment of a disorder often requires time spent away from work,
lost wages, and

expensive drug therapies and diagnostic tests. The financial impact can be
devastating to

families or individuals who have a limited or fixed income and fear that
employment stability

may be compromised.

DIF: Understanding OBJ: 16.6 TOP: Assessment

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

NOT: Concepts: Health Promotions