Medical Surgical

Huntington’s Disease

Huntington;s disease is a chronic, hereditary disease of the nervous system that results in progressive involuntary choreiform (dance-like) movements and dementia.  Researchers believe that glutamine abnormally collects in certain brain cell nuclei, causing cell death.  Huntington’s disease affects men and women of all races. It is transmitted as an autosomal dominant genetic disorder. Each child of a parent with Huntington’s has a 50% risk of inheriting the illness. Onset usually occurs between 35 and 45 years of age.


  • The most prominent clinical features are abnormal involuntary movements (chorea), intellectual decline, ans emotional disturbance.
  • Constant writhing, twisting and uncontrollable movements of the entire body as the disease progresses.
  • Facial movements produce tics and grimaces; speech becomes slurred, hesitant, often explosive, and then eventually unintelligible.
  • Chewing and swallowing are difficult, and aspiration and choking are dangers.
  • Gait becomes disorganized, and ambulation is eventually impossible; patient is eventually confined to a wheelchair.
  • Bowel and bladder control is lost.
  • Progressive intellectual impairment occurs with eventual dementia.
  • Uncontrollable emotional changes occur but become less acute as the disease progresses. Patient may be nervous, irritable, impatient. During the early stages of illness: uncontrollable fits of anger; profound , often suicidal depression; apathy; or euphoria.
  • Hallucinations, delusions, and paranoid thinking may precede appearance of disjointed movements.
  • Patient dies in 10 to 15 years from heart failure, pneumonia, or infection or as a result of a fall or choking.


  • Diagnosis is made on the basis of clinical presentation, positive family history, and exclusion of other causes.
  • Imaging studies, such as computed tomography (CT), and magnetic resonance imaging (MRI), may show atrophy of striatum.
  • A genetic marker for Huntington;s disease has been located. It offers no hope pf cure or even specific determination of onset.


No treatment stops or reverse the process; palliative care is given.

  • Medications such as phenothiazines (haloperidol), butyrophenones, and thioxanthenes, which block dopamine receptors, and reserpine  and tetrabenazine. Anti-parkinsonism therapy (L-dopa) may improve chorea and temporarily decrease rigidity in some patients.
  • Motor signs are continually assessed and evaluated. Akathisia (motor restlessness) in the overmedicated patient is dangerous and should be reported.
  • Psychotherapy aimed at allaying anxiety and reducung stress may be beneficial; antidepressants are given for depression or suicidal ideation.
  • Patients needs and abilities are the focus of treatment.


  • Reinforcing understanding that Huntington;s disease takes emotions, physical, social and financial tolls on every member of the patients family.
  • Encourage genetic counseling, long-term psychological counseling, marriage counseling, and financial and legal support.
  • Teach patient and family about medications, including signs indicating need for change in dosage and medication.
  • Address strategies to manage symptoms (chorea, swallowing problems, ambulation problems, or altered bowel or bladder function).
  • Arrange for consultation with a speech therapist, if needed.
  • emphasize the need for regular follow-up.
  • Refer for home care nursing assistance, respite care, day care centers, and eventually skilled long-term care to assist patient and family to cope.
  • Provide information about the Huntington’s Disease Foundation of America, which gives information, referrals, education, and support for research.



Handbook for brunner & Suddarth’s textbook in Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp.450-452

Medical Surgical

Hodgkin’s Disease

Hodgkin’s disease is a rare cancer of unknown cause that is unicentric in origin and spreads along the lymphatic system. There is a familial pattern associated with Hodkin’s as well as an association with the Epstein-Barr virus (found 40% to 50% of patients). It is more common in men and tends to peak in the early 20s and after 50 years of age.  The Reed-Sternberg cell, a gigantic morphologically unique tumor cell that is thought to be  of immature lymphoid origin, is the pathologic hallmark and essential diagnostic criterion of Hodgkin’s disease. Most patients with Hodgkin’ disease have the types currently designated “nodular sclerosis” or “mixed cellularity”. The nodular sclerosis type tends to occur more often in young women ans at an earlier stage but has a worse prognosis than the  mixed cellularity subgroup. which occurs more commonly in men and causes more constitutional symptoms but has a better prognosis.


  • Painless enlargement of the lymph nodes on one side of the neck. Individual nodes are firm and painless; common sites are the cervical, supraclavicular, and mediastinal nodes.
  • Mediastinal lymh nodes may be visible on x-ray films and large enough to cause severe pressure symptoms (eg. dyspnea from pressure against the trachea; dysphagia from pressure against the esophagus).
  • Symptoms may result from the tumor compressing other organs, causing cough and pulmonary effusion (from pulmonary infiltrates); jaundice (from hepatic involvement or bile duct obstruction); abdominal pain (from splenomegaly or retroperitoneal adenopathy); or bone pain (due to skeletal involvement).
  • Pruritus is common and can be distressing; unclear etiology Herpes zoster  infection is common.
  • Some patients (20%) experience brief but severe pain after drinking alcohol, usually at the site of the tumor.
  • Mild anemia develops; the white blood cell count may be elevated or decreased; and energy (an absence of or decreased response to skin sensitivity tests such as candidal infection, mumps) may be noted.
  • Constitutional symptoms for prognostic purpose referred to as B symptoms, include fever (without chills), drenching sweats (particularly at night), and unintentional loss of more than 10% of body weight (found in 40% of patients and more common in advanced disease).


Diagnostic depends on identification of characteristic histologic features in an excised lymph node. After the diagnosis is confirmed, the total extent of tumor involvement is assessed and its distribution is defined.

  • Laboratory studies: complete blood count; platelet count, sedimentation rate, liver and renal function studies, RBC sedimentation rate and serum copper levels are used by some clinicians to assess disease activity.
  • Excisional  lymph node biopsy, bone marrow biopsy, characteristic presence of Reed-sternberg cell; staging of node.
  • Chest x-ray and computed tomography (CT) of chest, abdomen, and pelvis; positron emission tomography (PET) to detect residual disease.


Treatment id determined by the stage of the disease instead of the histologic type.

  • Chemotherapy followed by radiation therapy is used in early-stage disease.
  • Combination chemotherapy alone is now the standard treatment for more advanced disease.
  • When Hodgkin;s does recur, the use of high doses of chemotherapeutic medications, followed by autologous bone marrow or stem-cell transplantation, can be very effective.


  • Help patients to cope with undesirable effects of radiation therapy including esophagitis, anorexia, loss of taste, dry mouth, nausea and vomiting, diarrhea, skin reactions, and lethargy.
  • Serve bland, soft foods at mild temperature.
  • Teach patient about proper dental hygiene.
  • Administer antiemetics during peak times of nausea.
  • Teach patient that skin reactions are common; rubbing the area and applying heat, cold or lotion should be avoided.
  • Encourage patient to rest and sleep to maintain a  reasonable energy level; lethargy accompanies radiation.
  • Help patient to prepare for alopecia by encouraging him or her to purchase a wig before hair loss.
  • Encourage patient to report any sign of infection for immediate treatment.
  • Instruct patient to use contraception during chemotherapy to prevent cytotoxic effects on the fetus.
  • Encourage patient to keep all follow-up appointments.



Handbook for Brunner & Suddarth’s textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp.447-450




Medical Surgical

Hyperthyroidism (Grave’s disease)

Hyperthyroidism is the second most common endocrine disorder and Grave’s disease is the most common type. It results from an excessive output of thyroid hormones due to abnormal stimulation of the thyroid gland  by circulating immunoglobulins. Long-acting thyroid stimulator (LATS) is found significant in concentrations in the serum of many of these patients. The disorder affects women eight times more frequently than men and peaks between the second and fourth decades of life. It may appear after an emotional shock, stress, or infection, but the exact significance of these relationships is not understood. Other common causes include thyroiditis and excessive ingestion of thyroid hormone (eg. from treatment of hypothyroidism)


Hyperthyroidism presents a characteristic  group of signs and symptoms (thyrotoxicosis).

  • Nervousness (emotionally hyperexcitable), irritability, apprehensiveness; inability to sit quietly; palpitations, rapid  pulse on rest and exertion.
  • Poor tolerance of heat; excessive perspiration; skin that is flushed and likely to be warm, soft and moist
  • Dry skin and diffuse pruritus in the elderly
  • Fine tremor of the hands
  • Exophthalmos (bulging eyes) in some patients
  • Increased appetite and dietary intake, progressive loss of weight, abnormal muscle fatigability, weakness, amenorrhea, and changes in bowel function (constipation or diarrhea)
  • Pulse ranges between 90 and 160 beats/min with sinus tachycardia or dysrhythmias; systolic (but not diastolic) blood pressure elevation (increased pulse pressure).
  • Atrial fibrillation; cardiac decompensation in the form of congestive heart failure, especially in the elderly
  • Osteoporosis and fracture
  •  May include remissions and exacerbations, terminating with spontaneous recovery in a few months or years
  • May progress relentlessly; causing emaciation, intense nervousness, delirium, disorientation, and eventually myocardial hypertrophy and heart failure.


  • Thyroid glands is enlarged; it is soft and may pulsate; a thrill may be felt and a bruit heard over thyroid arteries
  • Laboratory tests show a decrease in serum TSH, an increase in serum thyroxine (T4) level and an increase in 123I or 125I uptake in excess of 50%.

Gerontologic Considerations

Elderly patients commonly presents with vague and nonspecific signs and symptoms. The major symptoms in the elderly patient may be depression and apathy, accompanied by significant weight loss and constipation in some. The patient may report cardiovascular symptoms and difficulty climbing stairs  or rising from a chair because of muscle weakness; congestive failure may be noted. Elderly patients may experience a single manifestation, such as atrial fibrillation, anorexia, or weight loss.  These general symptoms may mask underlying thyroid disease. Spontaneous remission of hyperthyroidism is rare in the elderly. Measurement of thyroid-stimulating hormone (TSH) uptake is indicated in elderly patients with unexplained physical or mental deterioration . Use of 123I or 131I is generally recommended for treatment of thyrotoxicosis rather than surgery unless an enlarged thyroid gland is pressing on the airway. Thyrotoxicosis must be controlled by antithyroid drugs before 131I is used because radiation may precipitate thyroid storm, which has a high mortality rate in the elderly.  Beta-blockers may be indicated. Use these agents with extreme caution ans monitor closely for granulocytopenia. Modify dosages of other medications because of the altered rate of metabolism in hyperthyroidism.


Treatment is directed toward reducing thyroid hyperactivity for symptomatic relief and removing the cause of complications. These forms of treatment are available:

  • Irradiation involving the administration of 131I or 123I for destructive effects on the thyroid gland.
  • Pharmacotherapy with antithyroid medications.
  • Surgery with the removal of the most of the thyroid gland.

Radioactive Iodine (131 I)

  • 131 I is given to destroy the overactive thyroid cells (most common in the elderly).
  • 131 I is contraindicated in pregnancy and nursing mothers because radioiodine crosses the placenta and is secreted in breast milk.


  • The objective of pharmacotherapy is to inhibit hormone synthesis or release and reduce the amount of thyroid tissue.
  • The most commonly used medicatioins are propylthiouracil (Propacil, PTU) and methimazole (Tapazole) until patient is euthyroid.
  • Maintenance dose is established, followed by gradual withdrawal of the medication over the next several months.
  • Antithyroid drugs are contraindicated in late pregnancy because of the risk for goiter and cretinism in the fetus.
  • Thyroid hormone may be administered to put the thyroid to rest.

Adjunctive Therapy

  • Potassium iodide, Lugol’s solution, and saturated solution of potassium iodide (SSKI) may be added.
  • Beta-adrenergic agents may be used to control the sympathetic nervous system effects that occur in hyperthyroidism; for example; propanolol is used for nervousness, tachycardia, tremor, anxiety, and heat intolerance.

Surgical Intervention

  • Surgical intervention (reserved for special circumstances)removes about five sixths of the thyroid tissue.
  • Before surgery, the patient is given propylthiouracil until signs of hyperthyroidism have disappeared.
  • Iodine is prescribed to reduce the thyroid size and vascularity and blood loss. Patient is monitored carefully for evidence of iodine toxicity (swelling buccal mucosa, excessive salivation, skin eruptions).
  • Risk for relapse and complications necessitates long-term follow-up of patient undergoing treatment of hyperthyroidism.
  • Surgery to treat hyperthyroidism is performed after thyroid function has returned to normal (4 to 6 weeks).



Handbook for Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams and Wilkins pp.461-464

Medical Surgical

Parkinson’s Disease

Parkinson’s disease is a slowly progressive degenerative  neurologic disorder affecting the brain center that are responsible for control and regulation of movement. The degenerative or idiopathic form of Parkinson’s disease is the most common; there is also a secondary form with a known or suspected cause. The cause of the disease is mostly unknown. The disease usually first appears in the fifth decade of life and is the fourth most common neurodegenerative disease.


Stores of the neuotransmitter dopamine are lost in the substantia nigra ans the corpus striatum because of a degenerative process. The loss pf dopamine stores in this area of the brain results in excitatory neurotransmitter than inhibitory neurotransmitters, leading to an imbalance that affects voluntary movement . Other neurotransmitter pathways (responsible for cell metabolism, growth, nutrition, and so forth) may be involved as well. Cellular degeneration causes impairment of the extrapyramidal tracts that control semiautomatic functions and coordinated movements. Regional cerebral blood flow  is reduced, and there is a high prevalence of dementia. Biochemical and pathologic data suggest  that patients with Parkinson’s disease and dementia may have coexistent Alzheimer’s disease.


The three cardinal signs of Parkinson’s disease are tremor, rigidity, and bradykinesia (abnormally slow movements).

  • Impatient movement: bradykinesia includes difficulty in initiating, maintaining, and performing motor activities, muscle stiffness or rigidity
  • Resting tremors: a slow unilateral turning of the forearm and hand and pill-rolling motion of the thumb against the fingers; tremors at rest and increasing with concentration and anxiety
  • Muscle weakness
  • Hypokinesia (abnormally diminished movement), gait disturbances, flexed posture, and postural instability (loss of postural reflexes, and the freezing phenomenon)


Patients tend to develop micrographia (shrinking, slow hand-writing) as dexterity declines. Additional characteristics include:

  • Dysphonia (soft, slurred, low-pitched, and less audible speech)
  • Masklike facial expression
  • Loss of postural reflexes: patients stand with head bent forward and walks with propulsive gait ( shuffling gait); difficulty pivoting and loss of balance, resulting in risk for falls.
  • Depression and psychiatric manifestaitons (personality changes, psychosis, dementia, and confusion)
  • Sleep disorders, uncontrolled sweating, orthostatic hypotension, gastric and urinary retention, and constipation


  • Patient’s history and presence of two of the three cardinal manifestations: tremor, muscle rigidity, and bradykinesia
  • Positron emission tomography (PET) scanning
  • Neurologic examination and response to pharmacologic management


Goal of treatment is to control symptoms and maintain functional independence; no approach prevents disease progression.

Pharmacologic Therapy

  • Levodopa therapy ( converts to dopamine): most effective agent to relieve symptoms; usually given in combination with carbidopa (Sinemet), which prevents levodopa breakdown.
  • Budipine is a non-dopaminergic, antiparkinson medication that significantly reduce akinesia, rigidity, and tremor.
  • Antihistamine drugs to allay tremors.
  • Dopamine agonists (eg. pergolide [Permax], bromocriptine mesylate [Parlodel], ropinirole, and pramipexole are used to postpone the initiation of carbidopa and levodopa therapy.
  • Anticholinergic therapy to control the tremor and rigidity.
  • Amantadine hydrochloride  (Symmetrel), an antiviral agent, to reduce rigidity, tremor and bradykinesia.
  • Monoamine oxidase inhibitors (MAOI’s) to inhibit dopamine breakdown
  • Anntidepressant drugs
  • Trials of catechol-O-methyltransferase (COMT) inhibitors.

Surgical Management

  • Surgery to destory a part of the thalamus (stereotactic thalamotomy and pallidotomy) to interrupt nerve pathways and alleviate tremor or rigidity.
  • Transplantation of neural cells from fetal tissue of human or animal source to reestablish normal dopamine release.
  • Deep brain stimulation with pacemaker-like brain implants shows promise but is waiting for FDA approval.




Handbook for Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 11th edition by Joyce Young Johnson

Lippincott Williams & Wilkins pp. 594-596

Medical Surgical

Cancer of the Cervix


Cancer of the cervix is predominantly (90%) squamous cell cancer and can include adenocarcinomas. It is less common than it once was because of early detection by the Pap test, but it remains the third most common reproductive cancer in women. it occurs most commonly between the ages of 35 and 45 years but can occur in women as young as 18 years. Risk factors vary from multiple sex partners to smoking to chronic cervical infection (exposure to HP virus).



  • Cervical cancer is most often asymptomatic. When discharge, irregular bleeding, or bleeding after sexual intercourse occurs, the disease may be advanced.
  • Vaginal discharge gradually increases in amount, becomes watery, and finally is dark ans foul-smelling because of necrosis of the tumor mass.
  • Bleeding occurs at irregular intervals between periods or after menopause, may be slight (enough to spot the undergarment), and is usually noted after mild trauma (intercourse, douching, or defecation). As disease continues, bleeding may persist and increase.
  • Nerve involvement, producing excruciating pain the back and legs, occurs as cancer advances and tissues outside the cervix are invaded, including the fundus and lymph glands anterior to the sacrum.
  • Extreme emaciation and anemia, often with fever due to secondary infection and abscesses in the ulcerating mass, and fistula formation may occur in the final stage.


  • Pap smear and biopsy results show severe dysplasia, HGSIL, or carcinoma in situ.
  • Abnormal Pap test may be followed by biopsy, dilation and curettage (D & C), computed tomography (CT), magnetic resonance imaging (MRI), intravenous utrography (IVU), cystogram and barium radiopgraphs.


Disease may be staged based on the International Classification staging system or TNM classification to determine treatment as well as progress of the cancer.

  • Conservative treatments include cryotherapy (freezing with nitrous oxide), laser therapy, loop electrosurgical excision procedure (LEEP), or conization (removing a cone shaped portion of the cervix).
  • Simle hysterectomy if invasion is less than 3 mm. Radical trachelectomy is an alternative to hysterectomy.
  • For invasive cancer , radical hysterectomy, radiation (external-beam or brachetherapy), or chemotherapy (cisplatin, carboplatin, and paclitaxel [Taxol] or a combination of these approaches may be used.
  • For recurrent cancer, pelvic exenteration is considered.
Chapter 1 - Thorax Grant's Atlas of Anatomy, 12th Edition Nursing

1.3 Superficial dissection, female pectoral region

  • On the specimen’s right side, the skin is removed; on the left side, the breast is sagittally sectioned.
  • The breast extends from the 2nd to the 6th ribs. The axillary process (tail) of the breast consists of glandular tissue projecting toward the axilla.
  • The region of loose connective tissue between the pectoral fascia and the deep surface of the breast, the retromammary bursa, permits the breast to move on the deep fascia.
  • Interference with the lymphatic drainage by cancer may cause lymphedema (edema, excess fluid in the subcutaneous tissue), which in turn may result in deviation of the nipple and a leathery, thickened appearance of the breast skin. Prominent (puffy) skin between dimpled pores may develop, which gives the skin an orange-peel appearance (peau d’orange sign). Larger dimples may form if pulled by cancerous invasion of the suspensory ligaments of the breast.

Chapter 1 - Thorax Grant's Atlas of Anatomy, 12th Edition Nursing

1.2 Superficial dissection, male pectoral region

  • The platysma muscle, which descends to the 2nd or 3rd rib, is cut short on the right side of the specimen; together with the supraclavicular nerves, it is reflected on the left side.
  • The thin pectoral fascia covers the pectoralis major.
  • The clavicle lies deep to the subcutaneous tissue and the platysma muscle.
  • The cephalic vein passes deeply in the clavipectoral (deltopectoral) triangle to join the axillary vein.
  • Supraclavicular (C3 and C4) and upper thoracic nerves (T2 to T6) supply cutaneous innervation to the pectoral region.
  • The clavipectoral (deltopectoral) triangle, bounded by the clavicle superiorly, the deltoid muscle laterally, and the clavicular head of the pectoralis major muscle medially, underlies a surface depression called the infraclavicular fossa.
Chapter 1 - Thorax Grant's Atlas of Anatomy, 12th Edition Nursing

1.1 Surface anatomy of male pectoral region

  • The subject is adducting the shoulders against resistance to demonstrate the pectoralis major muscle.
  • The pectoralis major muscle has two parts, the sternocostal and clavicular heads.
  • The anterior axillary fold is formed by the inferior border of the sternocostal head of the pectoralis major muscle.
  • The axillary fossa (“armpit”) is a surface feature overlying a fat-filled space, the axilla.




Chapter 1:

Health Promotion and Disease Prevention


1.The nurse explains that the belief advancing the idea that disease is a result of an organically caused disorder is the

a.    biomedical model.

b.    biopsychosocial theory.

c.    Dunn’s high-level wellness model.

d.    Travis’ health model.

Answer:    A

The biomedical model describes disease as an organically caused disorder with consistent clinical manifestations. The biopsychosocial theory claims that disease is caused by the interaction of environmental, physical, and social factors. Dunn wrote about high-level wellness. The model by Travis emphasizes that wellness requires work and attention.

2. The nurse explains that the client’s ability to cope with stress dynamically will play a significant role in the client attaining maximum potential. This approach is most consistent with the model of

a. King

b. Leninger

c. Levine

d. Neuman

Answer: A

King’s theory suggets that continous adjustment to stressors, both internal and external, with the use of one’s resources allows the person to attain maximum potential.

3.When the nurse encourages a Native American to seek health counsel from the tribe’s shaman, the nurse is following the tenets of:

a. King

b. Leninger

c. Pender

d. Rogers

Answer: B

Leninger postulates that health refers  to culturally known and utilized practices that maintain personal and group well-being.

4. The nurse using the World Health Organization (WHO) description of health bases care on the premise that health is

a.    a gift from a higher being.

b.    any disease-free condition.

c.    complete mental, physical, and social well-being.

d.    high-level functioning despite illness.

Answer: C

The most widely accepted definition is the classic 1947 WHO description of health as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.”

5. The nurse planning a health promotion program with clients in the community will focus least on

a.    assisting the clients to make informed decisions.

b.    organizing methods to achieve optimal mental health.

c.    providing information and skills to maintain lifestyle changes.

d.    reducing genetic risk factors for illness.

Answer: D

Health promotion programs are designed to improve the health and well-being of individuals and communities by providing people with information, skills, services, and support they need to undertake and maintain positive lifestyle changes. Genetic risks for illness cannot be controlled to promote health.

6.    A holistic belief system by the nurse would be most evident if the nurse

a.    accepts death as an outcome of life.

b.    encourages behavior modification programs.

c.    incorporates client perceptions of health when planning care.

d.    supports goal-directed learning to improve health.

Answer: C

The theories of Orem, Rogers, and Roy focus on the holistic view, which takes the client and the client’s beliefs, values, and culture as necessary considerations to comprehensive care.

7.    The nurse understands that the document he/she can use to plan community teaching projects addressing the federal population-based health objectives is

a.    Healthy People 2010.

b.    Nursing’s Agenda for Healthcare.

c.    the federal Medicare/Medicaid Acts.

d.    the Goldmark Report.

Answer:    A Healthy People2010 contains federal population-based health objectives and identifies leading indicators of health that apply to adults.

8.    The nurse recognizes the activity that reflects primary prevention is

a.    a self-initiated walking regimen.

b.    collaboration with a physical therapist.

c.    physician-prescribed exercise after a heart attack.

d.    tuberculosis screening.

Answer:    A

Primary prevention is an activity that is done before any illness, but as a preventive effort to avoid illness. Collaboration with a physical therapist and physician-prescribed exercise after a heart attack are both tertiary prevention: measures intended to reduce the effects of an established health problem. Screening activities, designed for early detection, are secondary prevention.

9.    The nurse is planning a community STD (sexually transmitted disease) screening fair. This activity would be considered

a.    epidemiologic prevention.

b.    primary prevention.

c.    secondary prevention.

d.    tertiary prevention.

Answer: C

Secondary prevention activities are those that include screening and early diagnosis.

10.The nurse is developing a teaching plan for a 60-year-old man who experienced a cerebrovascular accident (CVA). The nurse works with the client to prevent aspiration when eating. This is an example of

a.    epidemiologic prevention.

b.    primary prevention.

c.    secondary prevention.

d.    tertiary prevention.

Answer:    D

Tertiary prevention is directed toward rehabilitation after a disorder already exists. The interventions are directed toward minimizing disability and improving quality of life.

11. The nurse is counseling an overweight young man on entry into a weight reduction and exercise program. The nurse is aware that the client is most likely to begin and maintain the program if he

a.    can envision himself as thinner.

b.    feels competent about making the change.

c.    has read about the program.

d.    is aware of being overweight.

Answer:    B

Clients are more likely to be motivated to change if they feel competent to do it and have social support.

12.    The nurse is caring for a 35-year-old client at risk for cardiovascular disease. The client states he is aware that he must “maintain a low-fat diet.” Using the Transtheoretical Model and Stage of Change, the nurse assesses that this client is at the stage of

a.    action.

b.    contemplation.

c.    maintenance.

d.    pre-contemplation.

Answer:    B

The contemplation phase describes the client as seriously thinking about a change. In the action phase, the client is implementing the behavior change; in the maintenance phase the client continues to move forward with the change, and in the pre-contemplation phase the client has not yet thought about changing his behavior.

13.The nurse can “empower” a client in adjusting to the changes associated with the chronic effects of non–insulin-dependent diabetes mellitus by

a.    explaining that concerns about vision changes are premature at this point.

b.    explaining the pathophysiology of the disease.

c.    informing the client about the different types of insulin.

d.    teaching the client how to minimize complications.

Answer:    D

Empowering gives the client information, skills, and contact with services available to deal with the client’s disease.

14.Suggestions that a home health nurse could make to an elderly client with cataracts to reduce the risk of falls in his home would include

a.    arranging scatter rugs to prevent slipping on the hardwood floor.

b.    using lower-illumination bulbs to prevent eyestrain.

c.    using night lights in every room.

d.    wearing soft-soled house shoes indoors.

Answer:    C

The visual impairment requires increased illumination and an uncluttered environment. Soft-soled shoes enhance the fall potential as do scatter (or “throw”) rugs.

15.During a nursing history before a physical exam, a nurse identifies a client as being in a violent relationship. The most important intervention by the nurse at this time is to

a.    ask the physician to order a series of x-rays to look for old broken bones.

b.    call the police if the abusive partner is in the waiting room.

c.    help the woman develop an individual plan to diminish future abuse.

d.    refer her to the local battered women’s shelter.

Answer:    C

The priority intervention at this time is to help the woman develop an individualized plan to avoid future abuse. The emphasis must be on safety because the woman has a high risk for significant injury or death. Part of the safety plan can include information on shelters available in the local area, but referral to a shelter does not diminish the nurse’s responsibility to help the woman remain safe.

16.A client is having a physical examination and asks the nurse if his father, age 76, should have the same prostate cancer screening that he is having. The nurse bases her answer on knowledge that

a.    a simple blood test is all that is required for prostate cancer screening.

b.    all men, regardless of age, need routine prostate cancer screening.

c.    men over age 70 generally do not need routine prostate screening.

d.    only members of certain high-risk ethnic groups need regular screening.

Answer:    C

Generally, men over the age of 70 or who have a significant illness that will probably result in a life span of less than 10 more years are not routinely screened for prostate cancer. Screening should start at age 50 or earlier for high-risk ethnic groups and consists of a prostate-specific antigen test and digital rectal examination.

17.A nurse is teaching women breast self-examination (BSE). When designing a teaching program, the nurse is aware that the biggest barrier to women doing BSE is

a.    better screening tools like mammograms.

b.    discomfort and pain when doing the exam.

c.    lack of confidence when performing the exam.

d.    realization that breast cancer is not a leading cause of cancer death in women.

Answer:    C

A major barrier to BSE is a lack of confidence. Breast cancer is the second leading cause of cancer death in women. While mammogram is a more sensitive tool, it is costly and is only recommended every 1 to 2 years, while BSE is recommended monthly. A BSE is not uncomfortable.

18.     A nurse is presenting information at a community forum related to pneumonia. The nurse informs the audience that people who should receive the pneumococcal vaccine include those who (select all that apply).

a.    are over age 65 and had a vaccination more than 5 years ago.

b.    are under age 65 and are alcoholics.

c.    are under age 65 with chronic illnesses.

d.    are over age 65 and have never had pneumococcal pneumonia before. e.    are over the age of 65.

Answer:    A, B, C, D

All adults over age 65 should have a pneumococcal pneumonia vaccination and they should be re-vaccinated if it has been more than 5 years since their previous vaccination. Individuals younger than 65 are considered high risk and should have the vaccination if they are alcoholics, have chronic illnesses, are members of certain high-risk ethnic and social groups, or have sickle cell anemia or have had their spleen removed.

19. Place the steps for breast self-examination (BSE) in the order a nurse should teach a client to do them (select all that apply).

a.    Feel both breasts while lying down.

b.    Feel both breasts while sitting or standing.

c.    Gently squeeze each nipple to look for discharge.

d.    Look at your breasts in the mirror with your arms on your hips.

e.    Look at your breasts in the mirror with your arms raised.

Answer:    A, B, C, D, E

This is the proper sequence for BSE. BSE should be done at the end of the menses in women who still menstruate, and on the same day of each month in post-menopausal women.

20. Strategies a nurse should use when teaching a client include (select all that apply)

a.    using plain, lay language.

.    providing comprehensive information at each session.

c.    having the client “teach back” what has been taught.

d.    using written material written at a low literacy level.

Answer:    A, C, D

Strategies for teaching include (1) using plain, lay language; (2) limiting the amount of information given at any one time; (3) using teach-back techniques; (4) using diagrams; and (5) using written material that is at a low literacy level. Estimates are that one third to one half of people in the United States experience low health literacy.

21. A nurse teaching a client using self-management support strategies would include measures to help the client increase his/her (select all that apply)

a.    compliance with recommendations.

b.    decision-making abilities.

c.    health literacy.

d.    problem-solving skills.

e.    resource utilization

Answer:    B, C, D, E

The five self-management skills that form the core of Loring’s self-management support program are problem-solving, decision-making, resource utilization, empowered client role, and health literacy.

Chapter 2: Health Assessment

1.A nurse is collecting a health history from a client and feels the client is not reliable. One recommended way to verify some of the client data is to

a.    ask the client the same questions but in a different manner.

b.    confront the client with your suspicions.

c.    find and question a secondary source.

d.    have another nurse try to get data from the client

ANS:    C

Clients may be poor historians and unable to provide accurate data. If there is a secondary source such as a significant other or family member available, ask them some of the health history questions. A client who is confused will not be able to answer accurately even if you ask questions in different ways. Confrontation can lead to alienation. Having another nurse question an unreliable client is unlikely to garner valid data.

2.The nurse is collecting a health history on a middle-aged African American male. The nurse asks about past blood pressure screening because the incidence of hypertension is higher in this ethnic group than in others. This is an example of

a.a generalization based on the nurse’s limited experience with African Americans.

b.bias, and the nurse should not question the client about blood pressure screening.

c.stereotyping the client based on the client’s ethnic/racial group.

d.using valid research data to focus questions on the client’s specific risks.

ANS:    D

Reliable research finding concerning group characteristics or similarities may be applied to a specific client who belongs to that group. Generalizations, stereotypes, and biases have no place in nursing care.

3.A client had surgery yesterday and is complaining of pain. The best action by the nurse is to

a.ask the patient which pain medication she/he took last. a complete assessment of the pain.

c.prepare to administer the ordered pain medication.

d.record the client’s complaints thoroughly and get the pain medication.

ANS:    B

This is an example of symptom analysis. Nurses should use a recognized approach to fully assess each client complaint, such as the OLDCART or PQRST method. It is best to understand the source of a complaint before treating it. In this case, the postoperative client could be having a nonrelated problem such as angina. Without a further assessment, the nurse would administer the postoperative pain medication, which might mask the new symptoms or delay diagnosis and treatment.

4.A client is being admitted to the hospital and the nurse has the client’s electronic record, including past medical history. What should the nurse do with this information?

a.Copy the information from the electronic database to the admission database.

b.Not use it because it is preferred to ask clients about past history at each encounter.

c.Save time and skip this part of the history-taking because the record is electronic.

d.Verify with the client that the list is current, complete, and correct.

ANS:    D

A previously recorded past health history is useful to have, but the nurse must verify its accuracy with the client. Diagnoses may change because of second opinions, because they have been cured, or because they have been surgically corrected.

5.To assess precipitating factors, the nurse interviewer would ask

a.“Do you remember the first time you had this problem?”

b.“How many times has the problem been related to activity?”

c.“What measures relieve this problem for you?”

d.“What were you doing when you first noticed the problem?”

ANS:    D

To ask what the client was doing and where he was at the time the manifestation was noticed is an abbreviated way to obtain information as to cause or environmental precipitators. The other options are related to timing, aggravating factors, and remedy.

6.Because the psychosocial assessment includes many more personal aspects of the client’s history, the most significant variable that may affect the quality and usefulness of the collected data is the

a.nurse’s ability to establish a therapeutic relationship.

b.nurse’s difficulty in differentiating normal from abnormal.

c.reluctance of most clients to share information with health care providers.

d.value the client places on the health interview.

ANS:    A

The client must feel comfortable to share some of the information assessed in the psychosocial portion; therefore the nurse’s ability to establish a therapeutic relationship is the major element in securing accurate data.

7.In the preparation of a nursing care plan relative to the client’s mental status, the least helpful data would be those resulting from

a.client’s overall response to the interview.

b.formal psychological tests.

c.notation of appropriateness of affect.

d.observation of nonverbal behavior.

ANS:    B

Mental status assessment consists of evaluation of verbal and nonverbal responses to the individualized questions, as well as evaluation of mood and affect. Psychological tests cannot measure these factors.

8. A client is brought to the emergency department in serious condition and needs an operation within the next hour. Which of the following principles does the nurse use to guide the health history? (Select all that apply.)

a.Assess the client’s current health status.

b.Collect data pertinent to the immediate problem.

c.Strive to collect only pertinent data while being thorough.

d.Update the database when the client’s condition allows.

e.Use a systematic approach to gather the client’s entire health history.

ANS:    A, B, C, D

Many factors influence the depth of health history the nurse should obtain. In this case, the client is in an emergent situation that does not warrant gathering information on the client’s entire history. However, for client safety, the nurse must assess the client’s current health status, collect data relevant to the current situation, and strive to be as thorough as possible within these limitations. When the client is more stable, more data can be collected.

9. The nurse collecting data on a client’s social history asks questions regarding the client’s (select all that apply)

a.exposure to communicable diseases.

b.home life.

c.immunization history. roles.

ANS:    A, B, D, E

Immunization history, while an important component of health history, is not included in social history.

10. Which principles of assessment does the nurse use when working with hospitalized clients? (Select all that apply.)

a.Assess each client at the beginning of each shift.

b.Base the frequency of assessment on client condition.

c.Begin with the most seriously ill client.

d.Record findings as they are assessed, not later.

e.Wait for physician orders to determine the frequency of assessments.

ANS:    A, B, C, D

These answers are all good principles on which to base nursing assessments. Assessing a client is an independent nursing function. While the physician may write for assessments to be done at a specified minimum time frame, nurses use their own professional judgment to obtain client assessments as appropriate.

Chapter 3: Critical Thinking

1. The process by which a nurse uses purposeful thinking, informed reasoning, reflections, and thinking about thinking in clinical situations is called a.    clinical judgment.

b.    critical thinking.

c.    decision making.

d.    problem solving.

ANS:    B

Critical thinking is a process of thinking that ensures conclusions are self-correctable, reasonable, informed, and precise. This is done through informed reasoning, purposeful thinking, reflecting on situations, and thinking about one’s thinking. Clinical judgment uses experience to guide assessments and decision making. Decision making involves using the scientific process to identify a specific problem, assess and weigh all options, test possibilities, and consider the consequences of the choice of action. Problem solving is more focused with the selection of only pertinent information about the problem and evaluating the solution over time. All are part of critical thinking but none are as broad.

2.It is crucial for the nurse to be able to make sound decisions using critical thinking because is the most efficient use of the nurse’s time and resources. uses previously learned knowledge in predictable situations.

c.most clients have problems for which there are no textbook answers.

d.nurses can recognize problems rapidly and provide speedy responses to situations.

ANS:    C

Most client care situations are unique—not predictable—and nurses must adapt previously learned knowledge to new circumstances, drawing from multiple sources of information. It may well be more efficient and rapid, but that is not the primary reason critical thinking is valuable.

3.A nurse with 6 year’s labor and delivery experience is floated to the intensive care unit. In this situation, the nurse would most likely function at the level of

a.    advanced beginner.

b.    competent.

c.    novice.

d.    proficient.

ANS:    C

According to Benner’s Five Levels of Competency in Nurses, a novice is one who has no experience in situations in which they are expected to perform. This nurse would need specific rules to guide action. An advanced beginner has seen enough real situations to note recurring and meaningful components of the situation. A competent nurse has been on the job or in similar situations for 2-3 years. A proficient nurse has a great deal of situational perception as the result of 3-5 years of experience.

4.A nurse is working in the intensive care unit. When assessing the clients, the nurse notes one of them, who was scheduled to transfer to a step-down unit as soon as a bed becomes available, has a respiratory rate change from 18 to 20 breaths/min and an oxygen saturation (O2 sat) of 92%, when earlier it was 93%. The client denies complaints. The nurse calls the physician and requests a chest x-ray and arterial blood gases (ABGs). This nurse is working at which Benner Level of Competency in Nurses?

a.    Advanced beginner

b.    Competent

c.    Expert

d.    Proficient

ANS:    C

The expert nurse is able to grasp the important components of a situation intuitively, noticing subtle changes, and zeroing in on the problem immediately. This nurse is also flexible. The advanced beginner is not flexible, is slow to act, and still needs rules to guide practice. The competent nurse is beginning to be able to master many situations in nursing but is still somewhat slow. The proficient nurse is perceptive and sees subtle changes rapidly, but would not be able to zero in on the problem as rapidly as the expert nurse.

5.A nurse is confused about the best way to confirm placement of a small flexible feeding tube before giving a bolus feeding. Colleagues on the unit suggest several different methods. The best process by which to determine a policy outlining the appropriate course of action is

a.    critical reasoning.

b.    evidence-based practice.

c.    problem solving.

d.    professional judgment.

ANS:    B

Evidence-based practice (EBP) is a process by which nurses make clinical decisions using the best available research evidence, clinical expertise, and client preferences to guide actions. There are several steps necessary to solve problems using this method. None of the other options provides as broad a foundation for a practice change as EBP, which utilizes research in the literature to inform practice changes, which are then evaluated for institutional fit and feasibility.

6.A nurse who is alert to changes, confident, open-minded, proactive, and questioning is displaying which characteristics?

a.Alfaro’s Attitudes and Characteristics of a Critical Thinker

b.Benner’s Five Levels of Competency in Nurses

c.Hawk’s Model of Critical Thinking in Registered Nurses

d.Universal Intellectual Standards

ANS:    A

There are 29 attitudes and characteristics of a critical thinker listed in Box 3-1, 5 of which are listed here. Benner’s model has 5 levels of nursing competency: novice, advanced beginner, competent, proficient, and expert. The Universal Intellectual Standards encourage thoughtful examination of clinical problems. There is no Hawk’s Model of Critical Thinking in Registered Nurses.

7. A nurse brings a client a medication that is scheduled once daily with food. The medication administration record lists it as being due at 9:00 AM. The client refuses the medication, asking to take it later. The nurse replies “That’s OK. I can give it to you with your lunch if you like.” Which statement about the nurse is correct? The nurse

a.    is being flexible and logical.

b.    just made a medication error.

c.    needs to call the doctor.

d.    should tell the patient to take the medication now

. ANS:    A

Flexible and logical are two attitudes and characteristics of a critical thinker. Hospital pharmacies often schedule once-a-day medications at 9:00 AM. The important aspect of this medication is that it is indeed given once a day and with food. The time of day does not matter as long as it is consistent. The nurse could call the pharmacy and ask them to change the time on the medication administration record. The other three options all demonstrate inflexibility and rule-bound behavior.

8. At the beginning of the shift a student nurse is meeting with the registered nurse (RN) assigned to the student’s client. The student nurse should provide the RN with which information? (Select all that apply.)

a.Assessments the student will make

b.Documentation the student will complete

c.Medications the student will administer

d.Treatments the student can perform

e.What time the student is going to lunch

ANS:    A, B, C, D

These are all important components of the student’s report to the RN. The time the student will take lunch is not crucial to discuss at this time and may well change depending on client status and needs at lunchtime.

Chapter 4: Complementary and Alternative Therapies

1. According to the National Center for Complementary and Alternative Medicine, complementary medicine is

a.prescribed and overseen by a medical physician.

b.treatment of a physical illness by a spiritual intervention.

c.used in place of conventional medicine.

d.used together with conventional medicine.


Complementary medicine is used together with conventional medicine, such as using aromatherapy to help reduce discomfort after surgery.

2.Of the many complementary and alternative medicine (CAM) modalities available in the United States, the most rapidly growing area is



c.dietary supplementation.



Dietary supplementation is currently the most rapidly growing CAM modality in the United States.

3.A nurse taking the history of a client with rheumatoid arthritis might be alerted to the client’s use of CAM when the client says

a.“A bunch of nuts believe that putting nice smells in the air cures arthritis.”

b.“Doctors don’t know everything, you know.”

c.“I’ve heard something about alternative medicine. What is that?”

d.“What do you think about biofeedback?”


The most “nondisclosing” client remark is asking the nurse about a specific alternative modality and “testing the waters” relative to the nurse’s response to that specific modality.

4.When the client asks the nurse about the use of therapeutic herbs, the nurse’s most instructional response would be

a.“Herbs are not regulated and may pose health risks if used with prescribed drugs.”

b.“Herbs have many qualities; some effects are good, and some are not.”

c.“I have heard many people have used some herbal remedies and had good results.”

d.“If you are getting relief from some herbal remedy, there is probably no harm in it.”


Herbs are not regulated, and some herbs can interfere with the therapeutic effects of some drugs and can react unfavorably with anesthesia and surgical intervention.

5.The nurse reminds a client that the Dietary Supplement and Health Act of 1994 prevented manufacturers of dietary supplements from

a.making specific therapeutic claims for the product on their labels.

b.manufacturing products that are not tested or proven.

c.offering products for sale except through pharmacies.

d.publishing outrageous claims for the product on promotional materials.


This act forbids claims for specific results from being placed on the label, although outrageous claims may be made on websites and in promotional materials.

6.When the client asks the nurse what “placebo effect” means, the nurse includes in the response that the placebo effect describes a

a.deterioration of the product to the point that it renders the product incapable of offering any therapeutic benefit.

b.phenomenon of a person taking the placebo and claiming positive effects because of psychological factors unrelated to the product.

c.practice of manufacturers to make hugely inflated claims to induce the potential user to believe in the worth of the product.

d.product that, although producing therapeutic effects for many users, has no effect on others.


Placebo effect is the phenomenon of persons given the placebo in testing and then claiming positive benefits from the product based on psychological factors unrelated to the product.

7.A nurse understands that many conventional drugs are derived from plants, such as

a.meperidine (Demerol).





Quinine is derived from cinchona. The other options are manufactured from chemical compounds or derived from hormones.

8.The nurse cautions that, when consumed in large quantities, antioxidants can become pro-oxidants, which

a.absorb large quantities of free radicals.

b.can produce free radicals.

c.create a free radical “shield.”

d.enhance the immune system.


Pro-oxidants, which can develop from the concentrated use of large amounts of antioxidants, can produce millions of free radicals. They do not absorb free radicals, create a free radical shield, or enhance the immune system.

9.A young Hispanic woman tells the nurse that she is going to have a healing ritual to center her spirit after the recent death of her husband. The nurse recognizes the alternative medicine system of




d.Tai Chi.


Curanderismo is the practice prevalent in the Hispanic culture of spiritual rites and rituals to promote healing. Ayurveda is practiced primarily in the Indian subcontinent and includes diet, herbal remedies, and massage. Reiki is the Japanese health belief that when spiritual energy is channeled through a Reiki practitioner, the client’s spirit is healed, subsequently healing the physical body. Tai Chi is an ancient form of martial arts that uses slow, controlled movements, meditation, and breathing to improve overall health and well-being.

10.An elderly Chinese woman tells the nurse that she must improve the flow of her Qi. The nurse asks the client how long she has been using



c.Tai Chi.


Acupuncture is an ancient Oriental practice of placing needles in certain points of the body to improve the energy flow of Qi throughout the body to improve health. Ayurveda is practiced primarily in the Indian subcontinent and includes diet, herbal remedies, and massage. Tai Chi is an ancient form of martial arts that uses slow, controlled movements, meditation, and breathing to improve overall health and well-being. Yoga is an exercise that teaches specific postures and breathing exercises. It has been shown to reduce stress levels and improve relaxation.

Chapter 5: Ambulatory Health Care

1. Ambulatory care nursing is an emerging field of nursing practice in which the nurse

a. deals with clients who are ambulatory and able to walk into the clinic.
b. is part of an interdisciplinary team offering primary, secondary, and tertiary care.
c. offers an integrated system of care to persons within walking distance of the clinic.
d. works only with clients who are not acutely ill.

Answer: B
The ambulatory nurse takes care of clients who are healthy, acutely ill, and chronically ill. Ambulatory nurses function as a member of an interdisciplinary team.

2. Ambulatory care centers include available 24 hours a day, 7 days a week. for short-term medical-surgical procedures. for those unable to provide self-care after a procedure.
d.sleeping accommodations for a family member.

Answer: B
Technological advances allow treatment in a short-term facility that previously required a hospital stay. Ambulatory care centers meet the needs of these clients and avoid a costly inpatient stay. They may or may not be open 24 hours, 7 days a week. A person who needed help with self-care would probably need in-home or hospital care. And since care duration is less than 24 hours, sleeping accommodations are not provided as part of ambulatory care centers.

3. The nurse manager of an ambulatory care center assesses the center for environmental hazards to comply with guidelines of both the local state health department and the

a.Ambulatory Care Nursing Administration and Practice.
b.American Nurse’s Credentialing Center.
c.Nurse Practice Act.
d.Occupational Safety and Health Administration.

Answer: D
The Occupational Safety and Health Administration (OSHA) and the state health department oversee environmental factors. The other three options address professional practice and credentials.

4. The facility that could best represent an ambulatory care center is a

a.home health care agency. with less than 50 beds.
c.rehabilitation center.
d.student health center.

Answer: D
The student health center is an ambulatory care center. The other options provide care to clients in their home, to inpatients, or as a prescribed follow-up service.

5. In comparing the ambulatory care setting to an inpatient hospital setting, the nurse- instructor is correct in stating that the ambulatory care setting

a.has had so many cost increases that a visit is just as costly as the hospital. already in decline and offers limited employment opportunities.
c.may create a feeling of greater stress to the client than a hospital setting.
d.provides an environment where the client is less at risk for nosocomial infection.

Answer: D
The client using an ambulatory care center is exposed less to nosocomial infection and other hazards of hospitalization. Care is much more cost-efficient in ambulatory care centers. Employment opportunities are increasing in ambulatory care. Ambulatory care centers often are less stressful than hospitals for clients.

6.A nurse working in an ambulatory care setting would provide secondary prevention activities such as

a.carrying out hypertension screening. instructions after minor surgery.
c.providing cardiac rehabilitation.
d.teaching young adults the benefits of good nutrition.

Answer: A
Screening activities are secondary prevention. Teaching nutrition and giving instructions to prevent complications after minor surgery are both primary prevention. Cardiac rehabilitation is an example of tertiary prevention.

7.The nurse instructor describes an integrated delivery system and cites the example of

a.a hospital’s alignment with several physician groups to increase hospital referral. outpatient clinic in the hospital.
c.enrollees of the system being “locked” into the system of care for services.
d.providers concerned about generating revenue.

Answer: A
Hospitals have aligned themselves with groups of physicians to increase hospital referral and provide greater coordination of care.

8.A health care service that provides a defined population with a stated range of services through prepayment of an annual or monthly capitation fee is a(n) maintenance organization (HMO).
b.nurse-managed ambulatory center.
c.outpatient service of a community hospital.
d.preferred provider organization (PPO).

Answer: A
An HMO provides services to members for an annual or monthly capitation fee. Physicians who contract with a preferred provider organization get paid at a reduced rate for each service they provide.

9.The facility least suited to the provision of primary health care is a(n)

a.ambulatory care center.
b.emergency department.
c.HMO. outpatient clinic.

Answer: B
Emergency departments (EDs) are organized according to the clinical model and are essentially dedicated to meet acute care needs. Providing primary care is a basic function of the ambulatory care center. An HMO is an organization with which physicians contract to receive payment for caring for enrollees. Primary health care could be provided at a hospital outpatient clinic.

10.The nurse-manager explains to a new nurse at the ambulatory clinic that the service for which the telephone nursing practice is not feasible is

a.assessing a client’s needs based on the nurse’s perception.
b.developing a collaborative plan of care with a client.
c.evaluating outcomes of practice and care.
d.prioritizing the urgency of a client’s needs.

Answer: A
To assess a client’s needs based on a nurse’s perceptions, the nurse would need to be able to assess the nonverbal responses, which usually are not available on a phone. All other options are feasible by phone.

11. The nurse contacts a client by follow-up telephone call after the client’s visit to an ambulatory care center. The client who would benefit most from this intervention

a.has undergone cast removal.
b.has undergone same-day surgery. having blood pressure monitored. having blood sugar monitored.

Answer: B
Telephone follow-up calls are used for clients who have had ambulatory surgery or for those subject to daily changes in condition.

12. The nurse who is seeking legal guidance in delegating assignments to assist workers in an ambulatory care setting would best consult protocols.
b.recently published texts.
c.the agency’s legal counsel.
d.the state nurse practice act.

Answer: D
Nurse practice acts (NPAs) for each state define legal delegation guidelines. Agency protocols cannot override the NPA; the legal counsel would certainly reference the NPA; and texts cannot address each state’s NPA.

13. The purpose of the mutual recognition model (MRM), implemented through an interstate contract, is to

a.ensure an increasing supply of nurses entering the work force.
b.monitor the number of nurses working in more than one field of specialty.
c.provide educational incentives for nurses to continue working full-time.
d.reduce barriers to interstate nursing practice.

Answer: D
The MRM allows nurses to communicate and recommend health practices to persons out of state, thus reducing the barriers to interstate nursing practice, especially as it applies to telehealth services.

14. One challenge for nurses working in ambulatory care centers is

a.clients give overall responsibility for self-care to the center.
b.duties are rigidly defined within the interdisciplinary team.
c.length of client visit is short, reducing assessment time.
d.use of telephones and computers eases assessment potential.

Answer: C
The short time of the ambulatory care visit makes assessment difficult and makes omissions in the assessment almost impossible to correct.

15. When considering culture as the nurse is designing health plans for clients, the ambulatory care center nurse will consider least the cultural concept of

a.making food modifications culturally appropriate.
b.recognizing that cultural family roles may be rigidly defined.
c.reflecting on research data describing culturally motivated responses.
d.understanding that some cultures reject female authority.

Answer: C
Although all options are significant, options a, b, and d are considerations for client welfare and, consequently, are more important.

16. In a telephone consultation, the ambulatory care center nurse may

a.assess cardiac or fetal monitoring.
b.decide how soon the client should be seen at the center.
c.give advice based on the nurse’s phone assessment.
d.teach a specific procedure based on approved protocols.

Answer: D
The telephone consult is designed for teaching or advising the client based on prescribed protocols, not on phone assessment (option c). Triage (option b) and surveillance (option d) are not considered within the definition of “consult.”

17. After each telehealth communication the nurse should

a.immediately document the content of the call in the client’s record.
b.inform the physician of the information or teaching given.
c.schedule a later call to check on the client’s progress.
d.send the client a written form of the pertinent information.

Answer: A
All information pertinent to the call should be recorded in the client record.

18. An ambulatory care center nurse who is counseling a young client with sickle cell anemia can best access evidence-based practice (EBP) guidelines from current nursing texts or journals.
b.integrated hospital care plans and protocols.
c.the Occupational Safety and Health Administration (OSHA).
d.the Agency for Healthcare Research and Quality (AHRQ).

Answer: D
AHRQ has evidence-based guidelines for many common problems, including sickle cell anemia, and would be the best source of up-to-date evidence-based practice guidelines. “Current” textbooks are written approximately 2 years before publication. Journals have up-to-date information but might not have the subject matter needed. Hospital care plans and protocols should be based on current EBP practice, but are often outdated and based on what has always been done. OSHA’s role has nothing to do with EBP.

19. The ambulatory care center nurse assures a dubious client that she has been certified as an ambulatory nurse by

a.application to the Accreditation Association for Ambulatory Health Care.
b.membership in the National Committee for Quality Assurance.
c.passing a specialized examination.
d.working as an ambulatory care nurse for 5 years.

Answer: C
Ambulatory care nurses may be certified by passing a practice-specific examination. To qualify for the examination, nurses must have worked in ambulatory care for a certain minimum number of hours. The first two options involve agency-accrediting organizations.

20. The nurse explains that to work at an independent, nurse-supervised ambulatory care center, there is a minimum requirement of a(n)

a.associate degree.
b.bachelor’s degree.
d.master’s degree.

Answer: B
A bachelor’s degree is the minimum requirement for a nurse to work at an independent ambulatory care center.

Chapter 6: Acute Health Care

1.The prepayment plan developed in 1929 is

a.Blue Cross Health Insurance.
b.Medicare Insurance.
c.Medicaid Insurance.
d.Health Maintenance Organization.

Answer: A
The 1929 Blue Cross Plan offered a form of prepayment insurance. Medicare and Medicaid are government entitlement programs. Health maintenance organizations arose as cost-containment measures, and physicians are reimbursed at a fixed rate for each person enrolled.

2.A hospital staff nurse is collaborating with a nurse case manager in planning the care of a client with a below-the-knee amputation. The primary role of the case manager is

a.client education on specialized care.
b.coordination of care for the client. care of the client’s medical problems. of the staff nurse.

Answer: B
Case managers are nurses who coordinate the care of a group of clients, monitor the implementation of interdisciplinary care plans, and maintain communication with third-party payers and referral sources.

3.A registered nurse (RN) seeking work in a voluntary health agency would choose a hospital.
b.proprietary hospital.
c.state university hospital.
d.veterans administration (VA) hospital.

Answer: A
Voluntary agencies are not-for-profit, tax-exempt organizations designed to meet health care needs of the public.

4.A client experiences chest pain with electrocardiographic changes during an appointment with the primary care physician, and the physician orders hospital admission for cardiac monitoring. This type of admission is a(n)

a.elective admission.
b.emergency admission. admission.
d.scheduled admission.

Answer: C
A direct admission is the process followed when a client is determined to need hospital or nursing care while in a physician’s office.

5.A client for whom the nurse would provide post–acute care is the

a.38-year-old following cesarean birth.
b.40-year-old recovering from kidney stone removal.
c.60-year-old receiving a regulated regimen of anti-hypertensive medication.
d.76-year-old needing rehabilitation after cardiac surgery.

Answer: D
Post–acute care areas are designed for clients who are out of the fragile phase of their illness and need routine monitoring and rehabilitation. After childbirth and kidney stone removal, the client would most likely need inpatient care at a hospital. A client receiving anti-hypertensive medications would most likely be followed in an ambulatory care setting.

6.While administering an antibiotic to a client with an infection, the nurse explains the importance of completing the full course of antibiotic therapy. This is an example of

a.formal education. advice.
c.informal education.
d.setting an example.

Answer: C
Informal education continues throughout the course of nursing care in the form of directions and explanations. Formal education is a formal presentation.

7.When unit staffing includes unlicensed assistive personnel, the nurse is aware that

a.delegating tasks to unlicensed assistive personnel is not in the scope of RN practice.
b.licensed personnel are accountable for the tasks delegated to the unlicensed personnel.
c.unlicensed assistive personnel do not have clinical duties on a client care unit.
d.unlicensed assistive personnel have formal training and function independently.

Answer: B
Nurses remain accountable for client outcomes whether or not the specific tasks are performed by nurses or by nurse extenders.

8.When a nurse is able to work effectively in more than one care area (e.g., general medical-surgical, and cardiac care unit), the nurse is said to be

b.flexibly assigned.
c.nursing intense.
d.skill mixed.

Answer: A
In an attempt the make the most effective use of available personnel, nurses may be cross-trained to work skillfully in two or more specialty care areas. A skill mix is the ratio of RNs to LPNs and assistive personnel to deliver the highest quality care while controlling cost.

9.An applicant was denied employment with a health care agency because she is a recovering alcoholic. This action by the agency violates the

a.Age Discrimination and Employment Act.
b.Americans with Disabilities Act.
c.Civil Rights Act.
d.Occupational Safety and Health Act.

Answer: B
In 1990 the Americans with Disabilities Act was passed to eliminate discrimination against persons with physical or mental disabilities. The Age Discrimination and Employment Act protects individuals over the age of 65. The Civil Rights Act protects individuals from employment discrimination on the basis of qualifications unrelated to job performance (such as race) and promotes employment based on ability and merit. The Occupational Safety and Health Act requires places of employment to be free of hazards and requires they write and enact safety policies.

10.A planned program of loss prevention and liability control best defines

a.client satisfaction.
b.clinical pathway.
c.quality assurance.
d.risk management.

Answer: D
Risk management is a planned program of loss prevention to identify and analyze risks in an effort to reduce accidents and injuries. Client satisfaction data are usually collected after a client is discharged from a hospital or other care setting. Quality assurance is a multi-leveled plan with components such as strategic planning, budgeting, performance improvement, and other elements. A clinical pathway is a plan that directs client care and recovery from predictable problems.

Chapter 7: Critical Care

1.The population that is increasingly using critical care units and needing specialized nursing care is the population of

b.middle-age adults.
c.underserved pregnant women.

Answer: A
Clients needing critical care do span the life span; however, those ages 65 and older comprise an increasing number of such clients. Of all hospital beds, more than 50% are filled with the elderly. The physiologic changes that accompany aging, plus chronic conditions seen in this age group, lead to an increased need for critical care beds.

2.The ICU nurse planning care for a critically ill client tries to arrange care to minimize the most disruptive stressor for the client, which is

a.alteration in sleep.
b.fear of the unknown.
c.persistent pain.
d.sense of isolation.

Answer: A
There are many stressors to the ICU client, but alteration in sleep patterns supercedes all the other options.

3.Critical care units (CCUs) have been developed in almost all hospitals because such units

a.allow for concentration of expert personnel.
b.can offer special services to the family.
c.contain costs.
d.separate the seriously ill from the other clients.

Answer: A
The CCU offers a space in which a concentration of expert personnel can be assigned to monitor and apply highly technological machines such as ventilators. The concentration of personnel does not reduce cost.

4.The nurse admitting clients to the critical care unit understands that priority clients for this area are those who need

a.a cleaner environment to prevent nosocomial infections.
b.continuous physiologic monitoring.
c.frequent vital sign checks.
d.private rooms conducive to rest and sleep.

Answer: B

5. The nurse admitting clients to an intensive care unit understands that research demonstrates best client outcomes when clients

a.are in an area that allows liberal family visitation.
b.have consistent nurses caring for them.
c.have state of the art physiologic monitoring.
d.receive multidisciplinary care led by an intensivist.

Answer: D
Studies showed a 30% reduction in intensive care unit stay when care was delivered by an intensivist-lead multidisciplinary team as opposed to an attending physician.

6.A nurse who is acting in a manner that respects and supports the client’s and family’s basic rights, values, and beliefs is functioning in which professional role?

c.Critical thinker

Answer: A
See Box 7-3 for more description of advocacy in critical care. A nurse functioning in the caregiver role provides bedside care. A critical thinker evaluates all options and chooses the best response when faced with a dilemma. A manager coordinates care.

7.A nurse working in critical care would plan interactions with clients’ families based on the understanding that families most need

d.spiritual support.

Answer: A
Studies consistently show that the family’s need for knowledge is consistent. While all options are valid, need-to-know is most important. Nurses tend to greatly underestimate their role in keeping families’ needs satisfied. Providing information from one consistent nurse is very valuable and helpful to most families.

8.A nurse working in the critical care unit would assess the client’s complexity by asking questions related to

a.ability of the client and family to make sound decisions.
b.effect of family, stress, and environmental factors on the client.
c.interplay of multiple medical problems on the current condition.
d.the client’s ability to use compensatory coping mechanisms.

Answer: B
Complexity is a client characteristic that assesses the intricate entanglement of two or more systems, such as physiologic, emotional, family, and environment. Option a refers to participation in decision-making, option c is not a client characteristic, and option d is resiliency.

9.The essential nurse competency that the critical care nurse uses when providing best care practices is

b.clinical inquiry.
c.clinical judgment. thinking.

Answer: B
Advocacy is working on another’s behalf when that person is not capable of advocating for himself/herself. Clinical judgment is the reasoning used by a health care provider when delivering care. Systems thinking is using tools and knowledge to work within the interconnected health care system. Clinical inquiry is the ongoing process of questioning and evaluating practice, providing informed practice, and innovating through research and experiential learning. All are essential nurse competencies for the critical care nurse.

10. A critical care nurse understands that stressors affecting both the client and the client’s family include (Select all that apply)


Answer: A, B, C, D
Clients and their families have multiple stressors in the critical care environment. Lack of privacy is one of them as are the other four options.

Community Health Nursing

VII. Conceptual Approaches to Care


            The term ‘nursing model’ was probably introduced to you in your basic education, and used for assignment work. Nursing models are supposed to be used in practice but in reality they are generally not used well, and appear to serve more as checklists for care plans rather than to inform the direction of nursing care. You may now be questioning the value of models of nursing, if they are simply used as a theoretical exercise in nurse education and a checklist in routine practice, but nursing models can, properly used, facilitate thinking about care and the philosophy that underpins it.

            Most nurses have used one or more nursing models. You are likely to be familiar with the Activities of Living model (Roper, Logan and Tierney 1980, 2000) and the Self Care model (Orem 1971, 1991). There are many models that can inform nursing and health practice. Models are not simple; they have been very rigorously contemplated by experts and each one serves as a representation of nursing. An interesting point about nursing models is the way in which they vary quite considerably, so that the purpose and intention of one, and the way in which it informs nursing, is quite different from these aspects in another model, and each is helpful to different branches of nursing.This will be discussed as the chapter develops.


           It is unlikely that anyone has a blank sheet, mentally, when approaching patient care, and this indicates that professionals take a considered approach in this matter. There are several labels for these general approaches. One approach to nursing is known as task-orientated – referring to the clinical task being carried out in isolation from any other aspects that influence the patient’s condition. Thus the nurse dresses the wound and does not consider other factors that could influence the healing of the wound or the patient’s comfort. Most nurses have heard the term biomedical model, which refers to treating the medical condition of the patient in isolation from the patient as a person. For instance, the patient’s heart condition would be treated but their excess weight and sedentary lifestyle, and the anxiety they might have about their health, would be ignored. Pearson et al. (1996) consider that many nurses still use the biomedical model as the basis for their practice.

            A term that is often used in relation to a general philosophy of care is holistic. The holistic approach takes into account a range of physiological and personal considerations for each individual and also places them in the context of contemporary society and of current health care provision. Holism is concerned with balance, i.e. with balancing the physical, psychosocial, and economic relationships of the person, with the environment in which they live (Aggleton and Chalmers 2000). Some branches of nursing, for example the nursing of those with learning disabilities, are more likely to take a holistic approach, as clients are not perceived in terms of a medical condition.

          The underlying philosophy of our approach to nursing very much reflects our individuality. ‘Philosophy’ refers to the beliefs and values that shape the way each of us thinks and acts. You will certainly have heard the word used in the context of philosophy to life. Some common sayings exemplify such philosophies: Live now pay later; A short life but a good one; You reap what you sow. These sayings demonstrate our use of the term philosophy in this context: how our beliefs and values shape thinking and influence actions. It is to be expected that life experiences, education, professional  socialisation  and professional experience will shape a nurse’s philosophy of care. Thus our underlying philosophy of care says something about us as individuals with unique personal experience.


           Nurse theorists have examined the concept of nursing and have illustrated their ideas through nursing models. The full term is ‘conceptual model’, differentiating this kind of model from the sort that are exact miniatures of real objects – model cars, boats, buildings, for example. Each of these can be perfectly recreated as a working model. Is it possible to build such a model of nursing? The answer is, of course, No; and the reason for this is that nursing is a concept. A concept is a collection of images and ideas that help to classify things and it is not possible to build anything material from images and ideas. The notion of a concept can be explained through something that is familiar, for example the concept of spring. There are certain aspects that embody spring: lambs, daffodils, buds on trees, sunshine and warmer days. Put all these together and a set of images that creates a picture of the season of spring comes to mind. Nursing is a concept that is built around a set of images.

          Your concept may involve images about caring, knowledge about health and illness, prevention of ill  health, rehabilitation and enabling people to help themselves, partnerships with patients and other health workers, the list goes on. When nursing is viewed in this way it is easy to determine why models of nursing are conceptual. It would be impossible to build such a set of images into a visible working model.

       It is possible to see that models may differ quite considerably because nurses think differently and hold divergent views about the concept. The difference in views will also reflect the varied concepts that are embodied in the different specialities of nursing. Take, for example, the conceptual difference between mental health and acute nursing. The concepts that make up the two roles will vary because the nature of nursing is different in each role; mental health nursing treating psychological disorders and imbalances while acute nursing is concerned with physical illness or disability. As conceptual models are developed for the nursing role it is logical that they will differ in accordance with the differences between branches of nursing.

         Fawcett (1984) identified some common ground by analysing four key concepts that are embodied in all nursing models. These are: (1) the person or individual; (2) the environment in which nursing takes place; (3) health; and (4) nursing itself. Whatever other concepts make up a particular model, these four are found in all. Nurse theorists have attempted to build conceptual models that illustrate ‘systematically constructed, scientifically based, and logically related sets of concepts which identify the essential components of nursing practice’ (Riehl and Roy 1980: p. 6).

Building Nursing Models

         Models must be put down in writing/text to enable them to be shared and used by other nurses. It is in this state that you have probably encountered nursing models. You might imagine how difficult it is to represent a complex set of concepts in writing. All models require to be portrayed through the written word and with the use of diagrams.

        Before any model can be effectively used it must be interpreted and understood. It may take time to work through some of the terminology, but this is necessary if the is model to be used as intended. You can see that Orem’s model (1980) is based on the ability of people to care for themselves. The model represents a balance between what people need to be able to do, which Orem refers to as ‘universal self care needs’ and a person’s ability to perform their care, which Orem refers to as ‘self care’. The model also lists areas where, for various reasons, an individual may require nursing intervention and suggests, under methods of helping, the form that such intervention might take.

       The model proposed by Orem has several components that relate to self care, starting with the premise that individuals wish to be independent and listing areas where people normally meet their own self care needs. There are health-related reasons that interfere with people’s ability to be independent and to care for themselves. The model looks at general reasons why a person may need help and makes suggestions about ways in which a nurse may support a patient in their striving for self care. The overall philosophy is to support self care and independence, and this sets the tone of this particular model and the direction that nursing care will take.

       Representing this conceptual model is not easy and Orem supports the concepts embodied in the model with detailed explanatory text. To use any model well, the whole model should be applied, with all concepts captured, in its application to patient care. Nurses tend to take what they consider to be the useful ideas from models and apply them in isolation. A prime example of this is the use of the Activities of Living model (Roper, Logan and Tierney, 1980, 2000), where the list of daily living activities is used as a checklist against which care plans are developed. This action ignores the essence of the model.

       You should now have an understanding of the nature and purpose of a nursing model. One or more models should be used by a care team to guide the process of care, and the model(s) must be supported by all members. The team leader has responsibility to ensure that all team members are sufficiently knowledgeable to be able to use the chosen model(s) competently to follow through the planned programme of care. Effective caring using a nursing model is a team effort.

Models with Differing Philosophies

         You may not feel that a Self Care model is suitable for the patient that you have in mind or for your branch of nursing. There are other options to explore, some similar to the ideas expressed in Orem’s model, others very different. A similar model was developed by Roper, Logan and Tierney (1980, 2000), informed by earlier work from Henderson, who offered a definition of nursing based on 14 activities of daily living (Henderson 1966). The Activities of Living model is well known and much used in the British Isles. It approaches nursing care by considering the activities of living that are common to all people, and how these can be influenced by a range of factors, the origins of which might be physical, psychological, social, cultural, environmental, political or economic. Other aspects that come into the model are the age of the person and the degree to which they are able to lead an independent life. The model focuses strongly on the many factors that influence activities of daily living and requires nurses to take these into consideration in making judgements about nursing care.

          Self care and activities of living tend to be concerned with planning nursing care in order to meet physical health deficits, which is why these two models are widely used to nurse patients with acute and chronic illnesses. They are equally suitable for wider use. Aggleton and Chalmers (2000) illustrate this point by applying the Activities of Living model to bereavement.

        Other models take a very different philosophical approach. Roy (1976) proposed a model based on adaptation. It works from the premise that each person is constantly adapting to an ever-changing environment. Roy suggests that an altered state of health requires a person to adapt to cope with changed circumstances. She sees the role of the nurse as one of facilitating adaptation in the patient by adopting a systematic series of actions, directed towards the goals of adaptation. The role of the nurse in this model is to facilitate the patient to adapt to their altered health circumstances and through adaptation learn to cope with the change. This explanation is much over-simplified but it indicates yet another conceptual approach.

        Neuman’s Systems model (Neuman 1989) takes a very different conceptual approach, based on wellness. It is concerned with the patient’s response to stressors in the environment. Each person develops a range of responses to cope with normal circumstances, with some people appearing to cope better than others with everyday life. There are, however, situations that occur in the lives of all people that deviate from normal and produce stressors that are very difficult to cope with. Neuman defines stressors as inert forces that have the ability to impact on the patient’s steady state (Neuman 1989: pp. 12, 24). Some situations may be positive and enabling whilst others may be detrimental. This model views the nurse’s role as intervening to enable the patient to maintain an optimal state of wellness. There may be opportunities in primary care practice to capitalise on facilitation and enable the patient to manage stressors that face them in order to attain an optimum state of health. Such a model may be well suited for use in school nursing, health visiting and occupational therapy.

     In Peplau’s Interpersonal Relations model (Peplau 1988) the key components are the interpersonal process, nurse, patient and anxiety. Peplau considers that people are motivated towards self-maintenance, reproduction and growth by biological, psychological and social qualities. The model views the interpersonal relationship between nurse and patient as the focal point of interface that will produce benefits for the patient’s health. There are elements of adaptation and coping in this model with the main thrust of nursing intervention coming through the nurse–patient relationship as a therapeutic interpersonal process. A model such as this, based on interpersonal relationships, may be well suited to mental health and learning disability nursing.

        The conceptual models that have been mentioned in this chapter serve to illustrate the wide and varying approaches that contribute to the development of models of nursing. The differing approaches afford choice in decisions that are taken about delivery of care, and consideration should be given by the care team to the most suitable choice of model for the patient. The models are complex and to use any one effectively it will be necessary to refer to texts where the model under consideration is fully examined. It will also be necessary to make sure that others involved in the care know and understand the model in all its aspects.


          The vehicle for implementing a nursing model is the nursing process, a functional approach to the organisation of nursing care. Yura and Walsh (1967) identified a number of stages in nursing care with which all nurses have some familiarity: assess, plan, implement, evaluate. The four stages of the process are used in conjunction with a nursing model and its philosophy. Using Orem’s model as an example, the four stages of the nursing process could be applied as follows.

The assessment stage of the nursing process would take into consideration:

• the philosophy that people are normally self caring

• the ability of people to care for themselves, using universal self-care needs to guide the assessment

• recognition of the reasons an individual may require nursing intervention

• recognition of the way in which lifestyle and the patient’s environment influence the situation.

The care plan would detail:

• the actions that need to be taken to meet identified needs in relation to the patient’s normal lifestyle and wishes

• interventions that could be used to achieve self care, whether they are the responsibility of the nurse, the patient or others

• the type of intervention needed: for example, teaching how to carry out care, or giving care, and providing aids to living that enable the patient to regain independence

• ways in which the planned actions would be evaluated.

The planned care would then be given (implemented), bearing in mind that:

• planned care is given according to good practice;

• current knowledge that is evidence-based underpins the care

• lifestyle and the environment are accommodated in the provision of care

• care given is evaluated against changes in the patient’s physical, psychological and socio- economic condition.

Evaluation of care takes place to determine its effectiveness. This is:

• carried out as an ongoing practice at each visit

• includes, at regular predetermined intervals, an objective review of the care with reference to changes in condition, treatment effectiveness,

introduction of new treatments

• leads to an adjustment of the care plan, if necessary, updating it in accordance with the evidence of the review.

     Thus the nursing process, systematically applying a model, connects theory to what is done on a practical level; and the nursing process and model(s) of care offer a care team a more supportive structure than can be provided by a task-oriented approach to nursing. They enable systematic, logical organisation of care to be developed around a philosophical focus.

     Though we are here referring to ‘nursing process’, in fact the four-stage process outlined above can be applied to any situation that requires organizing. It is a tool that can be just as useful for organizing a charity walk or planning a teaching session.

       Through the use of models of nursing and the nursing process there is good support on which to base nursing and health care practice, in a well  planned manner. All nurses must be thoroughly conversant with models and process, but although these provide a philosophy of care and give structure to care, what else is needed to provide sound practice? Evidence from patient surveys suggests that patients would want competent and caring practitioners (Carey and Posovac 1982) and the next part of this chapter is concerned with competent practice.


          You are taught in formal and informal situations. You read professional journals, books, literature from medical suppliers and drug companies. You observe those who you work with, some of whom you admire as role models. As you progress through your career you gain from experience. Many things that you have done have worked well and the patient has had positive outcomes from your care. These positive outcomes are sources of learning: you learned from something that went well. Learning can also take place following a poor experience. If something did not work well or went wrong a great deal can be gained from reflecting on the event, identifying what went wrong and considering measures that could be taken to improve the situation.

Objectivity in Nursing Practice

         Learning takes place in a variety of ways and everyday work provides a mixture of objective and subjective learning experiences. Information that is evidence-based has been based on research studies, and this is objective knowledge, gained from systematically established evidence. Subjective knowledge is gathered from observations made in practice, from conversations with colleagues and sometimes from teaching sessions. The problem with knowledge gained in this way is that it may not be reliable, and could even be unsound and dangerous. It is important that care is planned on the basis of objective evidence, and this means that knowledge that is gained subjectively must be checked to see that it supported by evidence.

     EBP, a key concept in modern health care, is one element of clinical governance (DOH 1999), a framework for the continual improvement of services and quality in the NHS, the purpose of which is to ensure that clinical decisions are based on the most up-to-date evidence and that clear national standards are set to reduce local variations in access to and outcomes of health care. Clinical governance has the following key elements:

• To set national standards for health services through development of national service frameworks and the National Institute for Clinical Excellence (NICE).

• To provide mechanisms for assessing local delivery of high-quality services, reinforced by a new statutory duty to quality.

• To provide support for life-long learning.

• To develop effective systems for monitoring the delivery of quality standards in the form of the Commission for Health Improvement, the NHS Performance Framework and surveys of patient/user experience (DOH 1999).

All health professionals are accountable for their individual practice and are responsible for making sure that their knowledge and skills are current. This implies that any care given is based on the most up-to-date knowledge available.

         EBP forms an essential element in the quality of health care and is directly related to clinical care in that clinically effective practice is based on national standards, frameworks and research.

A Systematic Approach to Acquiring Evidence

        Systematic acquisition of evidence provides the information from which standards and protocols for care are developed. Standards and protocols related to the provision of care are written by employers to guide the process of care. Health trusts use national guidelines based on the work of the National Institute for Clinical Excellence (NICE) and evidence from research as the basis for protocols. Each employee has a duty to keep up-to-date with, and refer to, guidelines that are supplied by their employer to inform their specific area of care, and to work to protocols.

       Research is the means of gathering evidence, and thus the source of guidelines and protocols. Nurses should have a working knowledge of the research process to enable them to appraise and understand the evidence that is presented as the basis for care, and be able to make a judgement on validity.

        McInness et al. (2001) suggest that evidence is not easily integrated into practice. The reasons that they offer for this are that research literature can be poorly organised and not easy to read, making it particularly hard for busy practitioners to access. The same authors also acknowledge the poor quality of some research. These comments make it clear that evidence is not always easy to access/understand, neither is it always sound. Health professionals must be able to interpret the information that is given to them to enable them to question evidence when it is unclear or unconvincing. The application of EBP lies with each health professional who must exercise judgement about the applicability of knowledge, whether it is evidence-based or subjective. Senior members of the team should have sufficient knowledge to support less experienced nurses, but all registered nurses should have a working knowledge that equips them to question the soundness of practice.

     A part of professional life must be the acquisition of knowledge that informs patient/client care. Access to information through electronic journals and websites makes information readily accessible. Most health trusts have access points for internet searches and this makes it so much easier for nurses to keep informed and current in their practice.

Evidence-based care or patient preference?

       There may be some instances where a treatment or practice, even though based on evidence, may not be appropriate for a patient. Thought and consideration are required to be given by practitioners at each care intervention. This makes the argument for evidence-based practice turn on itself. You may reasonably ask why objective evidence cannot be applied in all cases when it is likely to be effective. The response to this rests in the nature of health care practice, which is described by McCormack et al. (2002) as practice that takes place in a variety of settings, communities and cultures. To add to this complexity, there are other relevant influences, for example psychosocial and economic factors. Taking all these factors into account it is reasonable to assume that thought needs to be given to the application of practice. While practice should be based on evidence, it is also important to establish that the patient is suited to this care, and willing to accept the proposed treatment.

Informed decisions and patient choice

       One example of advocated treatment being found unacceptable to the patient, would arise in the case of a family who do not wish to have their child vaccinated with the triple measles, mumps and rubella (MMR) vaccine. The family might hold strong views about the safety of triple vaccine. Here the parents’ wishes might conflict with those of professionals, who have convincing reasons why children should be protected from childhood infections. There are no easy answers to this type of problem, and decisions taken must be carefully considered in the light of evidence that is presented from a range of sources. The patients’, or in this case the parents’, wishes are vital. When decisions about care are to be made the nurse’s role is to provide information that can enable the patient to make an informed decision, but in the end the choice rests with the patient.

     Planning decisions about care are normally considered by the care team, and a long-term treatment plan, though initially developed by one nurse, would not rest with a single individual. The plan would be discussed by the team to ensure that it was suitable and allow all team members to understand the goals and process of care. Daily evaluation of circumstances would, however, rest with an individual and would rely on informed decision making.

      Professional practice relies on nurses being competent in a range of specified outcomes (UKCC 2001), successful achievement of which equips nurses to practice. Practice requires that decisions are made, and that implies that each professional should be knowledgeable in their subject area and have the ability to translate their knowledge to support practice. Knowledge in itself has only limited value if it is used without due consideration of the effect that it might have on a situation. Thus a key aspect of professional practice is the ability to interpret and apply knowledge in widely varying circumstances. It is around the varying circumstances that decisions must be made that assure that care is appropriate and each nurse is accountable for the decisions that they make about patient care (NMC 2002).


       Many of the issues raised in this chapter illustrate the complexity of nursing practice and demonstrate how thinking skills and decision making are essential to good practice. Not only is nursing practice complex it is also dynamic, and changes with developments in health policy and scientific knowledge. For nurses this means that every patient contact is unique and that over a period of time a great deal of experience is generated from nursing practice. Nursing practice, taken in its widest sense, means working with other health and social care practitioners to provide the assessment, organisation and management of holistic care for patients.

     Reflection is a great way to learn. It enables nurses to capitalise on what they do well and see how to improve the aspects of care that did not go so well. Taylor (2000) stresses this by stating how the unconsidered life is transformed, through the process of reflection, into one that is consciously aware, self-potentiating and purposeful. All recently qualified nurses will have been taught to use reflection as a method of learning, for just as EBP is a key concept in current nursing practice, so is reflection. Reflection has particular value to learning in nursing because of the richness of experience in practice and the direct observation that nurses are able to make about how the care that they and the health care team give affects patients.

Reflection and practice

       Reflection can and should take place during the process of practice. Schon (1983) refers to this as ‘reflection in action’. It also takes place after the event, which Schon refers to as ‘reflection on action’. Sometimes reflection is private, at other times it is shared with colleagues or may even form part of a team meeting.

       The exercise that you have undertaken is an illustration of reflecting on practice, learning from it and using the learning to inform and develop future practice. This is why reflection is so beneficial in nursing. In part it is explained because of the uniqueness of each situation demands new thinking and reasoning and this accumulates over time as experience increases.

      Reflecting on action is a deliberate event. It can be a very effective learning experience for the individual nurse or for the team. Each nurse should regularly take time to reflect on their practice, considering their knowledge and skills, the evidence base from which care is given and the many influences that impinge on care.

     Group reflection probably occurs informally in many teams at hand-over meetings when care is discussed. Reflection by the team in a more formal sense provides opportunity for review of patient care on a planned and regular basis. Like the individual nurse, the care team considers their knowledge and skills, the evidence base from which care is given, the influences on care, that are raised in models of nursing, and take a general reflective view of the care provided for each patient. Group thinking can be productive, with each member contributing an individual perspective, and everyone learning from the others in the group. Shaw (1981) suggests that groups make better- quality decisions than individuals, which has particular significance when so much is at stake for patients. However, some caution needs to be exercised when a group reflects, on account of a phenomenon known as groupthink, whereby pressures for conformity and for keeping within the boundaries of accepted practice stifle creative thinking (Robbins 1986).

     Learning often occurs when something happens that is disappointing or does not turn out the right way. It is this type of experience that most frequently makes people think about what they have or have not done and how it could have been more effectively achieved. It is not enough only to reflect and recognise where things went wrong: that is evaluation of the incident. Reflection is more than evaluation – it involves new learning. For learning to occur it is first necessary to identify what, in the case of a negative experience, went wrong. It is then essential to take the necessary steps to remedy the deficit and put it right. It may be as simple as recognising that work has been done without sufficient thought and that corners have been cut. In this instance the practitioner knows what should be done but has failed to do it correctly. The learning will be in the nature of accepting that however great the pressures, sufficient time must be given to each patient and procedure. It may, however, be that new learning needs to take place, perhaps a new skill needs to be learned, maybe from a colleague who has the necessary expertise. Sometimes knowledge is out of date and must be updated by reading or by attending study days. Very often in primary care nurses come across health problems that are new to them and they have to find the information that is needed to enable them to provide effective care. As you can see, learning involves taking some action. The purpose of reflective practice is to actively enable learning so that it becomes integral to routine practice. If a nurse constantly reflects on practice, learns from it and changes practice in response to learning, practice will not become static and out of date.

Aids to reflection

A number of frameworks have been designed to help the process of reflection. Many nurses are introduced to reflection by using the staged process advocated by Gibbs (1988). Gibbs’s model offers a cycle to guide nurses through the reflective process:

• describe what happened

• explore the thoughts and feelings that occurred as part of the experience

• evaluate what was good and bad about the experience

• analyse the experience in order to better understand it

• consider what else could have been done, and finally

• make an action plan to determine how the situation would be handled should it occur again.

       This cycle of steps gives an easy-to-follow process, guiding the nurse through reflection. There are other frameworks that facilitate the reflective process, for example Burnard (1991), Boud, Keogh and Walker (1985) and Goodman (1984). Goodman’s approach focuses on levels of reflection, suggesting three levels of increasing complexity. The first level consists of a simple approach that involves considering how the job was done with regard to technical efficiency and effectiveness, and in terms of accountability. The second level takes a wider view, looking at the implications and consequences of the nurse’s actions and beliefs, which includes the underlying rationale for practice. The third, most complex, level draws on all the considerations in levels one and two, and adds ethical and political considerations and developments.

       There are distinct differences between the approaches that are taken by Gibbs and Goodman. Gibbs offers a framework to facilitate structured thinking while Goodman pushes the boundaries of thinking to levels of considerable complexity. Examination of different approaches helps nurses to choose the one most suited to the situation. As with models of nursing the most suitable approach to reflection may vary with differing experiences and so it is beneficial to have a range of approaches to draw upon.


        This chapter has covered some of the key factors that influence and inform professional practice in nursing. This should create awareness of sources of nursing knowledge and reinforce earlier learning that introduced the nature and purpose of nursing models. There is no doubt that practice is complex and nurses can only truly attempt to meet the needs of patients if they are able to understand and manage complexity. The value of models of nursing is that, in representing the complex nature of practice, they act as prompts. Because each model is presented in diagrammatic form it enables the same detailed process of assessment, planning, implementation and evaluation to take place for every patient. Professional skill comes into play as infinitely variable information is analysed and interpreted into personal and individual plans of care that take account of very differing needs. The skill of the nurse is needed to manage patient information and translate it, with the patient’s collaboration, into meaningful and appropriate delivery of care. Nurses must therefore be knowledgeable and skilful. The dynamic nature of health care means that new knowledge is constantly emerging, and health practitioners are obliged to keep up to date with the latest developments.

         Knowledge and the validity of information are requirements for planning effective, economic care. Quality in care is high on the government agenda for improving the National Health Service (DOH 2000). Receiving care that is based on objective information is an essential part of provision; application of care without thought or consideration of the individuality of people would go against the ethos of professional practice (Norman and Cowley 1999). Norman and Cowley state that knowledge based on evidence is valuable and should underpin protocols and guidelines. Information that is collated and current greatly assists practitioners. Blind acceptance of evidence is not, however, consistent with professional practice, one criterion of which is autonomy. Reflective practitioners who are constantly learning on the job are fundamental to the profession – nurses who can plan appropriate care on an individual basis, with the patient, and are able to be justify their decisions.