Chapter 01: Nursing and the Health Care System
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th Edition

MULTIPLE CHOICE

	1.	Florence Nightingale’s contributions to nursing practice and education:
a.	are historically important but have no validity for nursing today.	
b.	were neither recognized nor appreciated in her own time.	
c.	were a major factor in reducing the death rate in the Crimean War.	
d.	were limited only to the care of severe traumatic wounds.	

ANS:	C
By improving sanitation, nutrition ventilation, and handwashing techniques, Florence Nightingale’s nurses dramatically reduced the death rate from injuries in the Crimean War.

DIF:	Cognitive Level: Knowledge	REF:	p. 2	OBJ:	Theory #1
TOP:	Nursing History		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	2.	Early nursing education and care in the United States:
a.	were directed at community health.	
b.	provided independence for women through education and employment.	
c.	were an educational model based in institutions of higher learning.	
d.	have continued to be entirely focused on hospital nursing.	

ANS:	B
Because of the influence of early nursing leaders, nursing education became more formalized through apprenticeships in Nightingale schools that offered independence to women through education and employment.

DIF:	Cognitive Level: Knowledge	REF:	p. 2	OBJ:	Theory #4
TOP:	Nursing History		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	3.	In order to fulfill the common goals defined by nursing theorists (promote wellness, prevent illness, facilitate coping, and restore health), the LPN must take on the roles of:
a.	caregiver, educator, and collaborator.	
b.	nursing assistant, delegator, and environmental specialist.	
c.	medication dispenser, collaborator, and transporter.	
d.	dietitian, manager, and housekeeper.	

ANS:	A
In order for the LPN to apply the common goals of nursing, he or she must assume the roles of caregiver, educator, collaborator, manager, and advocate.

DIF:	Cognitive Level: Comprehension	REF:	p. 3	OBJ:	Theory #2
TOP:	Art and Science of Nursing	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	4.	Although nursing theories differ in their attempts to define nursing, all of them base their beliefs on common concepts concerning:
a.	self-actualization, fundamental needs, and belonging.	
b.	stress reduction, self-care, and a systems model.	
c.	curative care, restorative care, and terminal care.	
d.	human relationships, the environment, and health.	

ANS:	D
Although nursing theories differ, they all base their beliefs on human relationships, the environment, and health.

DIF:	Cognitive Level: Comprehension	REF:	p. 4	OBJ:	Theory #2
TOP:	Nursing Theories		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	5.	Standards of care for the nursing practice of the LPN are established by the:
a.	Boards of Nursing Examiners in each state.	
b.	National Council of States Boards of Nursing (NCSBN).	
c.	American Nurses Association (ANA).	
d.	National Federation of Licensed Practical Nurses.	

ANS:	D
The National Federation of Licensed Practical Nurses modified the standards published by the ANA in 2015 to better fit the role of the LPN. In 2015 the American Nurses Association (ANA) revised the Standards of Nursing Practice which contained 17 standards of national practice of nursing, describing all facets of nursing practice: who, what, when, where, how.

DIF:	Cognitive Level: Comprehension	REF:	p. 6	OBJ:	Theory #2
TOP:	Standards of Care		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	6.	The LPN demonstrates an evidence-based practice by:
a.	using a drug manual to check compatibility of drugs.	
b.	using scientific information to guide decision making.	
c.	using medical history of a patient to direct nursing interventions.	
d.	basing nursing care on advice from an experienced nurse.	

ANS:	B
The use of scientific information from high-quality research to guide nursing decisions is reflective of the application of evidence-based practice.

DIF:	Cognitive Level: Knowledge	REF:	p. 7	OBJ:	Theory #3
TOP:	Evidence-Based Practice	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	7.	Lillian Wald and Mary Brewster established the Henry Street Settlement Service in New York in 1893 in order to:
a.	offer a shelter to injured war veterans.	
b.	found a nursing apprenticeship.	
c.	provide health care to poor persons living in tenements.	
d.	offer better housing to low-income families.	

ANS:	C
Henry Street Settlement Service brought the provision of community health care to the poor people living in tenements.

DIF:	Cognitive Level: Comprehension	REF:	p. 2	OBJ:	Theory #4
TOP:	Growth of Nursing		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	8.	An educational pathway for an LPN/LVN refers to an LPN/LVN:
a.	learning on the job and being promoted to a higher level of responsibility.	
b.	moving from a maternity unit to a more complicated surgical unit.	
c.	obtaining additional education to move from one level of nursing to another.	
d.	learning that advancement requires consistent work and commitment.	

ANS:	C
By broadening the educational base, an LPN/LVN may advance and build a nursing career.

DIF:	Cognitive Level: Knowledge	REF:	p. 7	OBJ:	Theory #7
TOP:	Nursing Education Pathways	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	9.	When diagnosis-related groups (DRGs) were established by Medicare in 1983, the purpose was to:
a.	put patients with the same diagnosis on the same unit.	
b.	attempt to contain the costs of health care.	
c.	increase the availability of medical care to older adults.	
d.	identify a patient’s condition more quickly.	

ANS:	B
The purpose of instituting DRGs was to contain skyrocketing costs of health care.

DIF:	Cognitive Level: Knowledge	REF:	p. 9	OBJ:	Theory #10
TOP:	Health Care Delivery		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	10.	The advent of diagnosis-related groups (DRGs) required that nurses working in health care agencies:
a.	record supportive documentation to confirm a patient’s need for care in order to qualify for reimbursement.	
b.	use the DRG rather than their own observations for patient assessment.	
c.	be aware of the specific drugs related to the diagnosis.	
d.	acquire cross-training to make staffing more flexible.	

ANS:	A
DRGs required that nurses provide more supportive documentation of their assessments and identified patient’s needs to qualify the facility for Medicare reimbursement. Observant assessment might also indicate another DRG classification and consequently more reimbursement for the facility.

DIF:	Cognitive Level: Comprehension	REF:	p. 10	OBJ:	Theory #10
TOP:	Managed Care			KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	11.	If a member of a health maintenance organization (HMO) is having respiratory problems such as fever, cough, and fatigue for several days and wants to see a specialist, the person is required to go:
a.	directly to an emergency room for treatment.	
b.	to any general practitioner of choice.	
c.	directly to a respiratory specialist.	
d.	to a primary care provider for a referral.	

ANS:	D
Participants in an HMO must see their primary provider to receive a referral for a specialist in order for the HMO to pay for the care.

DIF:	Cognitive Level: Comprehension	REF:	p. 10	OBJ:	Theory #11
TOP:	Managed Care			KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	12.	An advantage of preferred provider organizations (PPOs) is that:
a.	they make insurance coverage of employees less expensive to employers.	
b.	there are fewer physicians to choose from than in an HMO.	
c.	long-term relationships with physicians are more likely.	
d.	patients may go directly to a specialist for care.	

ANS:	A
The use of PPOs allows insurance companies to keep their premiums low and in turn makes insurance coverage less expensive for the employers. There are usually more physicians from which to choose than from an HMO, but long-term relationships between physician and patient cannot be established easily. Patients still must see their primary physician before being referred to other specialties.

DIF:	Cognitive Level: Knowledge	REF:	p. 11	OBJ:	Theory #11
TOP:	Preferred Provider Organizations	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	13.	After passing the National Council Licensure Examination for Practical Nurses (NCLEX PN), the nurse is qualified to take an additional certification in the field of:
a.	pharmacology.	
b.	care of infants and children.	
c.	operating room technology.	
d.	community health.	

ANS:	A
After becoming an LPN, the nurse may apply for additional certification in pharmacology or long-term care.

DIF:	Cognitive Level: Knowledge	REF:	p. 7	OBJ:	Theory #6
TOP:	Educational Opportunities	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	14.	Nursing interventions are best defined as activities that:
a.	are taken to improve the patient’s health.	
b.	involve researching methods to maintain asepsis.	
c.	include the family in nursing care.	
d.	review guidelines for handling infectious wastes.	

ANS:	A
Interventions are actions taken to improve, maintain, or restore health.

DIF:	Cognitive Level: Comprehension	REF:	p. 3	OBJ:	Theory #2
TOP:	Art and Science of Nursing	KEY:	Nursing Process Step: Planning
MSC:	NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease

	15.	Nurse Practice Acts define the legal scope of an LPN’s practice, which are written and enforced by:
a.	American Nurses Association.	
b.	National Council Licensure Examiners.	
c.	each state.	
d.	each health care agency.	

ANS:	C
Each state writes and enforces the Nurse Practice Act, which defines the legal scope of nursing practice.

DIF:	Cognitive Level: Comprehension	REF:	p. 6	OBJ:	Theory #3
TOP:	Nurse Practice Act		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	16.	Women volunteers were organized to give nursing care to the wounded soldiers during the Civil War by:
a.	Florence Nightingale.	
b.	Dorothea Dix.	
c.	Clara Barton.	
d.	Lillian Wald.	

ANS:	B
The Union government appointed Dorothea Dix, a social worker, to organize women volunteers to provide nursing care for the soldiers during the Civil War.

DIF:	Cognitive Level: Knowledge	REF:	p. 2	OBJ:	Theory #4
TOP:	Nursing History		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	17.	The nursing theory presented by Sister Calista Roy is based on:
a.	reduction of stress.	
b.	achievement of maximum level of wellness.	
c.	relief of self-care deficit.	
d.	adaptation modes.	

ANS:	D
Adaptation modes (physiological, psychological, sociological, and independence) are the basis of the nursing theory of Sister Calista Roy.

DIF:	Cognitive Level: Knowledge	REF:	p. 5|Table 1-1		
OBJ:	Theory #2	TOP:	Nursing Theory		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	18.	The founding of the Red Cross is attributed to:
a.	Lillian Wald.	
b.	Dorothea Dix.	
c.	Florence Nightingale.	
d.	Clara Barton.	

ANS:	D
Clara Barton founded the Red Cross.

DIF:	Cognitive Level: Knowledge	REF:	p. 2	OBJ:	Theory #4
TOP:	Nursing History		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	19.	The nursing theorist whose practice framework is based on 14 fundamental needs is:
a.	Dorothy Johnson.	
b.	Jean Watson.	
c.	Virginia Henderson.	
d.	Martha Rogers.	

ANS:	C
Virginia Henderson’s nursing theory framework is based on 14 fundamental needs.

DIF:	Cognitive Level: Knowledge	REF:	p. 5|Table 1-1		
OBJ:	Theory #2	TOP:	Nursing Theorists		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	20.	The nursing theory that uses seven behavioral subsystems in an adaptation model is:
a.	Betty Neumann.	
b.	Sister Calista Roy.	
c.	Dorothy Johnson.	
d.	Patricia Benner.	

ANS:	C
Dorothy Johnson’s practice framework is based on seven behavioral subsystems in an adaptation model.

DIF:	Cognitive Level: Knowledge	REF:	p. 5|Table 1-1		
OBJ:	Theory #2	TOP:	Nursing Theorists		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	21.	The Standards of Nursing Practice are designed to direct LPNs to:
a.	advance their nursing career.	
b.	seek a scientific basis for their interventions.	
c.	deliver safe, knowledgeable care.	
d.	a leadership role.	

ANS:	C
The Standards of Nursing Practice are designed to guide the LPN to deliver safe, knowledgeable care.

DIF:	Cognitive Level: Knowledge	REF:	p. 6	OBJ:	Theory #2
TOP:	Nursing Standards		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: Safe, Effective Care Environment	

	22.	A state’s Nurse Practice Act is designed to protect the:
a.	physician.	
b.	nurse.	
c.	public.	
d.	hospital.	

ANS:	C
Nurse Practice Acts are designed to protect the public.

DIF:	Cognitive Level: Knowledge	REF:	p. 6	OBJ:	Theory #5
TOP:	Nurse Practice Act		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	23.	It is appropriate for practical nurses to provide direct patient care to persons in a hospital under the supervision of a:
a.	medical assistant.	
b.	registered nurse on the unit.	
c.	supervising nurse who is responsible for care on several units.	
d.	more experienced LPN on the unit.	

ANS:	B
Practical nurses provide direct patient care under the direct supervision of a registered nurse, physician, or dentist.

DIF:	Cognitive Level: Knowledge	REF:	p. 7	OBJ:	Theory #9
TOP:	Scope of Practice		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	24.	An example of tertiary health care is:
a.	hospice care.	
b.	restorative care.	
c.	emergency care.	
d.	home health care.	

ANS:	A
Tertiary health care includes extended care, chronic disease management, medical homes, in-home personal care, and hospice care.

DIF:	Cognitive Level: Comprehension	REF:	p. 11|Box 1-2		
OBJ:	Theory #8	TOP:	Health Care Services		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	25.	Which nursing care delivery systems have some nursing schools adopted as the foundation of their education programs?
a.	Relationship-based care	
b.	Team nursing	
c.	Patient-centered care	
d.	Total patient care	

ANS:	A
Relationship-based care appeared in the early 2000s (Koloroutis, 2004) and emphasizes three critical relationships: (a) the relationship between caregivers and the patients and families they serve; (b) the caregiver’s relationship with him- or herself; (c) the relationship among health team members (UCLA Department of Nursing, 2015). The motivation behind relationship-based care was to promote a cultural transformation by improving relationships to foster care for the patient. Some schools of nursing have adopted relationship-based care as the foundation of their nursing education curriculum.

DIF:	Cognitive Level: Knowledge	REF:	p. 9	OBJ:	Theory #8
TOP:	Delivery of Nursing Care	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	26.	Which nursing care delivery system has been fully embraced by the nursing community and is identified as one of the seven QSEN competencies?
a.	Relationship-based care	
b.	Team nursing	
c.	Patient-centered care	
d.	Total patient care	

ANS:	C
Patient-centered care has been described since the 1950s, but came to the forefront in 2001 when the Institute of Medicine (IOM) targeted six areas for improvement in the US health care system, including safety, effective, patient-centered, timely, efficient, and equitable (Cliff, 2012). Patient-centered care has been fully embraced by the nursing community, and is identified as one of the seven QSEN competencies (QSEN.org, 2015).

DIF:	Cognitive Level: Knowledge	REF:	p. 18	OBJ:	Theory #8
TOP:	Delivery of Nursing Care	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	27.	Which of the following is considered a positive aspect of the Affordable Care Act?
a.	A 38-year-old mother is penalized on her taxes for not purchasing health insurance.	
b.	A 42-year-old laborer who has chronic kidney disease is denied insurance coverage.	
c.	Jamie, age 24, cannot continue insurance coverage on his parent’s insurance since he has graduated from college.	
d.	Maria, age 60, is able to obtain health insurance at a rate that is manageable on her income.	

ANS:	D
The Patient Protection and Affordable Care Act is being phased in over several years. There are positive and negative aspects to this act, and many people have strong opinions about it. Since 2013 there have been insurance exchanges, along with requirements for uninsured people to purchase health insurance. Starting in 2015 people who have failed to purchase health insurance are being penalized on their income taxes. Provisions in the bill now prevent denial of insurance to those with preexisting illnesses who formerly could not buy health insurance, and young adults have been allowed to remain on their parents’ insurance through age 26. Starting in 2013 affluent people began paying an extra 3.8% tax on unearned income; drug manufacturers and the insurance industry are paying large annual fees to help cover the overall costs. Costs of the Medicare program will be contained by reducing payments to hospitals and health care providers. As coverage under the Affordable Care Act has expanded, the national uninsured rate has fallen from 16% to 11% of people under age 65 (people over age 65 are generally have universal coverage by Medicare). People who have benefitted the most from this coverage include people ages 18-34, blacks, Hispanics, and those living in rural areas (Quealy and Sanger-Katz, 2014). It is expected that the emphasis on prevention and coordinated care will produce a shift in nursing from the hospital to the community. There are many controversial parts of the bill, and the country is divided about whether the bill should be repealed and other health care legislation written. What happens in the Congress in the coming years will determine if all parts of the legislation will remain.

DIF:	Cognitive Level: Analysis	REF:	p. 11	OBJ:	Theory #10
TOP:	The Patient Protection and Affordable Care Act	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

MULTIPLE RESPONSE

	1.	Characteristics of primary nursing include: (Select all that apply.)
a.	elimination of fragmentation of care between shifts.	
b.	evolved in the mid-1950s.	
c.	planning and direction performed by one nurse.	
d.	ancillary workers used to increase productivity.	
e.	the care plan covering the entire day.	
f.	associate nurses taking over care and planning when the primary nurse is off duty.	

ANS:	A, C, D, E, F
Primary care reduces fragmentation of care between shifts. Care is planned by one nurse to cover a 24-hour period using ancillary workers to increase the productivity. An associate nurse may take on direction of care in the absence of the primary nurse.

DIF:	Cognitive Level: Knowledge	REF:	p. 8	OBJ:	Theory #8
TOP:	Nursing Care Delivery	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	2.	In 1991, the American Nurses Association (ANA) published the Standards of Nursing Practice. These standards are designed to: (Select all that apply.)
a.	set standards for safe nursing care delivery.	
b.	define the legal scope of practice.	
c.	state legal requirements for clinical practice.	
d.	protect the nurse, patient, and health care agency.	
e.	regulate the nursing profession.	
f.	define activities in which nurses may engage.	

ANS:	A, D, F
The Standards of Nursing Practice generally define activities in which nurses may engage, set standards for nursing care and delivery, and thereby protect the nurse, patient, and health care agency.

DIF:	Cognitive Level: Knowledge	REF:	p. 6|Box 1-1	OBJ:	Theory #2
TOP:	Nursing Practice		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	3.	An example of the role of an LPN as a delegator is: (Select all that apply.)
a.	changing a patient’s wound dressing.	
b.	assisting a patient to complete his or her bath.	
c.	assigning patient care tasks to certified nursing assistants.	
d.	requesting the housecleaning staff to mop the floor of a patient’s room.	
e.	instructing the unit secretary to page a physician to the floor.	

ANS:	C, D, E
Delegation under the scope of the practice of an LPN is the assignment of a certified nursing assistant to certain nursing care or other nonmedical staff to aspects of patient care.

DIF:	Cognitive Level: Comprehension	REF:	p. 3	OBJ:	Theory #5
TOP:	Art and Science of Nursing	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	4.	During the Civil War, nursing schools offered education to women both in England and in the United States. The schools in the United States differed from those in Europe because in US schools: (Select all that apply.)
a.	students worked without pay.	
b.	the core curriculum was the same.	
c.	instruction was presented by physicians at the bedside.	
d.	the educational focus was on nursing care.	
e.	classes were held separately from the clinical experience.	

ANS:	A, C
In the United States, the students staffed the hospital and worked without pay. There were no formal classes; education was achieved through work. There was no set curriculum, and content varied depending on the type of cases present in the hospital. Instruction was done at the bedside by the physician and therefore came from a medical viewpoint.

DIF:	Cognitive Level: Comprehension	REF:	p. 4	OBJ:	Theory #4
TOP:	Early Nursing Education	KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

COMPLETION

	1.	Preferred provider organizations (PPOs) use ____________ to finance their services and pay the physical cost of the service.

ANS:	
capitated cost

The capitated cost is the set fee that is paid to the network for each patient enrolled to finance its services.

DIF:	Cognitive Level: Knowledge	REF:	p. 11	OBJ:	Theory #8
TOP:	Capitated Cost			KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	2.	In the United States, the Young Women’s Christian Association (YMCA) in New York opened The ____________ School, the first practical nursing school.

ANS:	
Ballard

In 1892, the YMCA opened The Ballard School, a 3-month course in practical nursing that was the first school of practical nursing.

DIF:	Cognitive Level: Knowledge	REF:	p. 2	OBJ:	Theory #4
TOP:	Ballard School			KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A		

	3.	Such health services as surgical procedures, restorative care, and home health care would be classified as ________ care.

ANS:	
secondary

Surgical procedures, restorative care, and home health are part of the many services classified as secondary care.

DIF:	Cognitive Level: Comprehension	REF:	p. 11|Box 1-2		
OBJ:	Theory #10	TOP:	Health Care Services		KEY:	Nursing Process Step: N/A
MSC:	NCLEX: N/A