Answers and Rationales for In-Text Review Questions for the NCLEX

Williams: Fundamental Concepts and Skills for Nursing,

5th Edition Answers and Rationales for In-Text Review Questions for the NCLEX ® Examination

Chapter 01: Nursing and the Health Care System

1. 2; Rationale: The American Red Cross was founded by Clara Barton; Civil

War.

2. 1, 2, 3, and 4; Rationale: Florence Nightingale believed in nutrition;

fresh, clean air; occupational and recreational therapy; patient’s personal needs should be identified and met, including emotional support; that nursing should be directed at both health and illness; and that nursing is distinct from the practice of medicine and should be taught by nurses.

3. 1, 2, 3, and 5; Rationale: Core concepts that should be inherent in any

philosophy of nursing include promoting wellness, preventing illness, facilitating coping, and restoring health.

4. 4; Rationale: A main difference between a licensed practical nurse and a

professional registered nurse is that the practical nurse must work under supervision.

5. 3; Rationale: The Baccalaureate nursing program prepares the RN for a

management role, although the ADN curriculum contains segments of management theory.

6. 1, 2, 3; Rationale: Evidence-based practice is based on evidence from

research that guides decision making. Evidence-based nursing is where the best research evidence, patient values and preferences, and professional nursing expertise come together.

7. 2; Rationale: The advantage of being a patient in an HMO is paying lower

health insurance costs and small co-payments.

8. 2, 4 and 5; Rationale: Examples of illness prevention activities are

promoting vision screenings, promoting prenatal care, and providing patient education about nutrition.

Chapter 02: Concepts of Health, Illness, Stress, and Health

Promotion

1. 3; Rationale: Health is defined as the state of functioning well physically,

mentally, and socially.

2. 4; Rationale: Assess patients of Asian, African, and Hispanic descent for

lactose intolerance because it is prevalent in people of those groups.

3. 1; Rationale: Assess the patient’s actual cultural beliefs because not all

persons within a culture adhere to the mainstream cultural beliefs.

4. 2, 3, 5, 6; Rationale: When considering patient needs according to

Maslow’s hierarchy, consider airway first; safety is always a high priority,

activity needs should come before belonging needs, and consider elimination needs before rest and comfort needs.

5. 3; Rationale: Administer pain medication first and then you should help

her contact her children, someone to coach the team, and her husband.

6. 1; Rationale: The best description of homeostasis from those provided is

the tendency of the body to constantly adjust to changing conditions.

7. 4; Rationale: The effects of stress on a person usually depend on the

person’s perception of the stressor.

8. 4, 5, 6; Rationale: Sympathetic reactions to a stressor include pounding

of the heart with rapid pulse, dilation of the pupil, and increased blood pressure.

Chapter 03: Legal and Ethical Aspects of Nursing

1. 1, 2, 5; Rationale: Patient medical information is private, and all of these

examples would constitute an invasion of the patient’s privacy about medical information, be against the HIPAA privacy rule, and be unethical according to nursing standards.

2. 3; Rationale: Assault is a threat to do bodily harm or to touch someone

against their permission. Battery is unlawful physical contact. In the example, the assistant does both.

3. 2; Rationale: An advance directive is a consent that delineates a

patient’s wishes regarding surgery or diagnostic or therapeutic treatments.These provide direction for making decisions in the event a patient’s condition is such that he cannot make the decision himself.

4. 3; Rationale: This response politely, yet firmly, informs the person

inquiring about the patient that this is not a topic for discussion because doing so would constitute a major violation of your patient’s privacy. Visitors may use this type of statement (which you may agree with) as a means of trying to get you to disclose information about their friend.

5. 3; Rationale: Though they may not be as fast or efficient as a licensed

nurse, students caring for patients in the clinical setting are expected to perform all tasks and duties to which they are assigned at the level of the LPN.

6. 2; Rationale: Nurses have a duty to report any suspected abuse and

cannot keep the information “private.”

7. 2; Rationale: Slander is when one person makes verbal remarks about

another person that are untrue and the remarks damage the other person’s reputation.

Chapter 04: The Nursing Process and Critical Thinking

1. Patient; Rationale: The construction of a plan of care for the patient is a

collaborative process involving the nurse, the patient, and other health team members. With patient input into the process, there is a greater chance the plan will be effective.

2. 1, 2, 3, and 4; Rationale: Priorities may change as the patient’s

condition changes; for example, if a patient becomes more acutely ill, some interventions previously thought to be high-priority items suddenly are less important than more life-threatening or time-critical interventions. Likewise, high-priority orders may be written, requiring immediate action. New admissions are often acutely ill and may require nursing interventions that will need to be prioritized above interventions planned for other patients.Timeliness of expensive and difficult to schedule tests and therapies are important in patient diagnosis and treatment. Visitors should not affect prioritization of care.

3. 4; Rationale: Although critical thinking skills may be used in any of the

answer choices, the most comprehensive answer choice is #4, because drawing conclusions requires an analysis of data and synthesizing it.

4. 1, 3, 4, 6, and 7; Rationale: All correct choices involve the elements of

critical thinking described in this chapter; the two incorrect choices require no critical thinking skills, because they are akin to “following orders.”

5. 2; Rationale: Critical thinking skills will help you make sound clinical

decisions much of the time; this is the most comprehensive answer choice.Delegation may require critical thinking skills; however, not every state allows LPNs/LVNs to delegate. Identifying nursing diagnoses and developing care plans is the responsibility of the RN.

6. 1, 2, and 4; Rationale: Concept maps can help you see relationships

within a concept or relationships between interventions, health problems, and nursing diagnoses can be linked and pertinent assessment data is better synthesized. Concept mapping is not typically associated with timelines or color coding.

7. 1; Rationale: Ranking allows for evaluation of what is potentially life-

threatening and what is less harmful. Thinking through all possible options and outcomes allows for the best prioritization.

• 3; Rationale: Clinical judgment is critical thinking in the clinical setting.

Although the first and second choices involve critical thinking, they do not occur in the clinical setting.

Chapter 05: Assessment, Nursing Diagnosis, and Planning

• 2; Rationale: A cue is a piece of data that influences clinical decisions. In

this example, the grimacing of a postoperative patient “cues” the nurse that the patient may be experiencing discomfort.

2. 2; Rationale: Left-sided muscular weakness is the etiology for the

nursing diagnosis of decreased mobility.

3. 4; Rationale: The initial health history and assessment provides a

database of information on the patient’s health status at the time of admission. It is the baseline against which subsequent data will be compared.

4. 2, 4, and 5; Rationale: “I’m very uncomfortable”; complains of being

very tired; and states, “I have a headache” are all subjective data.

5. 2; Rationale: Changing the bed would take priority, and then

administering medication for the headache would come next.

6. 2, 3, 4, and 5; Rationale: The LPN’s role in this situation would be to

obtain an ordered urine specimen, to take the patient’s history, to assist with physical data collection, and to orient the patient to the unit.

7. 4; Rationale: A nursing diagnosis is a description, using specific

taxonomy, of a patient’s response (physiologically and/or psychologically) to a medical condition, any treatments, their life situation and their environment.

8. 2; Rationale: Patient will walk to the end of the hall this week is the

correctly written expected outcome because it contains a subject, an action, and a time frame for the action to be accomplished.

Chapter 06: Implementation and Evaluation

1. 1, 3 Rationale: (1) Diet is prescribed by the primary care provider and

the dietary patient education is done by the dietitian. The nurse reinforcing that patient education is an interdependent action. (2) Exercises are prescribed by the primary care provider and taught by the physical therapist.The nurse assisting the patient to do the exercises is an interdependent action. Dressing changes and medication administration are dependent actions; backrub and bath are considered independent nursing actions.

2. 2, 3, 4, 5; Rationale: Before carrying out a dependent nursing action,

the nurse verifies the order, considers whether there is any contraindication to carrying out the order, ensures to follow the agency policy, and gathers all supplies needed to carry out the order.

3. 3; Rationale: Evaluation is performed by considering if the interventions

have achieved the expected outcomes.

4. 1; Rationale: The patient should be reassured to prevent an increase in

anxiety that could make the shortness of breath worse. Then the lungs would be auscultated and the medical record checked for an order for oxygen if breath sounds indicate the need.

5. 1; Rationale: Functional abilities are assessed to determine how much

assistance with activities of daily living the resident will need while in the facility.

6. 1; Rationale: The use of a CPM machine always requires an order, and

starting the machine is a dependent action; a back massage, encouraging fluids, and changing linens when soiled do not require an order.

7. 4; Rationale: Auscultating the lung sounds to obtain data about the

quality of air movement is the most important action for this patient with a respiratory infection.

Chapter 07: Documentation of Nursing Care

1. 3; Rationale: The computer password is your legal signature and must

not be shared under any circumstance. Even viewing the information