INSTRUCTOR ANSWER GUIDE
openstaх™
Clinical
Nursing
Skills
,OpenStax Clinical Nursing Skills Instructor Answer Guide
OpenStax Clinical Nursing Skills
Instructor Answer Guide
Chapter 1: The Role of the Nurse in Comprehensive Care............................................................. 3
Chapter 2: The Evolution of the Nurse’s Role................................................................................. 9
Chapter 3: Patient Communication and Interviewing.................................................................. 15
Chapter 4: Obtaining a Complete Health History......................................................................... 20
Chapter 5: Cultural Competence and Assessment....................................................................... 25
Chapter 6: Infection Prevention Techniques and Safety in Clinical Setting...................................32
Chapter 7: Hygiene....................................................................................................................... 38
Chapter 8: Wound and Burn Assessment Care.............................................................................44
Chapter 9: Activity Assessment and Management.......................................................................50
Chapter 10: Specimen Collection and Lab Testing........................................................................57
Chapter 11: Principles of Medication Administration.................................................................. 66
Chapter 12: Medication Administration Procedures.................................................................... 73
Chapter 13: Intravenous Administration...................................................................................... 83
Chapter 14: Miscellaneous Medication Administration............................................................... 90
Chapter 15: General Survey, Anthropometric Measurement, and Vital Signs..............................97
Chapter 16: Pain Assessment..................................................................................................... 103
Chapter 17: Nutrition Assessment..............................................................................................110
Chapter 18: Oxygenation and Perfusion.....................................................................................116
Chapter 19: Fluids, Electrolytes, and Elimination....................................................................... 122
Chapter 20: Psychosocial Assessment........................................................................................ 128
Chapter 21: Assessment of the Integumentary System..............................................................136
Chapter 22: Assessment of the Head and Neck......................................................................... 140
Chapter 23: Assessment of the Thorax, Lungs, Breast, and Lymphatic System.......................... 148
Chapter 24: Assessment of the Cardiovascular and Peripheral Vascular System....................... 153
Chapter 25: Assessment of the Musculoskeletal System........................................................... 160
Chapter 26: Assessment of the Neurological System................................................................. 165
Chapter 27: Assessment of the Abdomen.................................................................................. 170
Chapter 28: Clinical Judgment and Critical Thinking...................................................................176
2
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,OpenStax Clinical Nursing Skills Instructor Answer Guide
Chapter 1: The Role of the Nurse in Comprehensive Care
Review Questions
1. Florence Nightingale is considered the founder of ____________, which emphasizes the
healing of the whole person, including mind, body, and soul.
a. caring nursing
b. the seven ethical principles of nursing
c. holistic nursing
d. systems nursing
[Answer: C]
2. The ethical principle defined as “acting in the best interest of patients and promoting their
well-being” is known as
a. fidelity
b. beneficence
c. justice
d. nonmaleficence
[Answer: B]
3. The nurse’s ability to develop and implement appropriate actions or interventions based on
the interpretation of the collected data and identified patient needs is the ___________
step of the clinical judgment model.
a. noticing
b. interpreting
c. responding
d. reflecting
[Answer: C]
4. When a nurse takes a role centered around empowering individuals, families, and
communities to take control of their well-being and make positive choices, this is known as
___________.
a. care planning
b. health promotion
c. role modeling
d. community nursing
[Answer: B]
5. What is the purpose of integrating interdisciplinary theories with nursing theory and
practice?
a. to break down current nursing theories and dictate the formation of future nursing
theory
b. to assist in the development of nursing models and frameworks that guide the delivery
of patient care, and help nurses understand and work better with the interdisciplinary
team
c. to discourage overreliance on nursing theory alone
3
,OpenStax Clinical Nursing Skills Instructor Answer Guide
d. to encourage other disciplines to learn about nursing theory and integrate it into their
practice
[Answer: B]
6. What is the importance of the evolution of nursing to include evidence-based practice
(EBP)?
a. The emergence of EBP has contributed to the scientific quality of nursing practice. It
integrates research findings into nursing practice, ensuring that decisions are based on
the best available evidence.
b. EBP provides a scientific foundation for informed nursing practice and discourages the
use of other, nonscientific issues such as cultural differences and patient preference in
nursing practice.
c. EBP ensures that nursing practice remains based in tradition and is not adaptable to
changes in current scientific recommendations.
d. EBP provides suggestions to nurses on improving patient care, but the nurse is still able
to reject EBP in clinical practice if they disagree with it.
[Answer: A]
7. In the hierarchy of EBP, the strongest sources of evidence at the top of the hierarchy are
a. randomized controlled trials (RCTs)
b. one-on-one patient interviews
c. case studies
d. systematic reviews and meta-analyses
[Answer: D]
8. What type of nursing theories focus on describing and understanding the lived experiences
of individuals in the context of health care?
a. descriptive
b. hierarchical
c. prescriptive
d. systems
[Answer: A]
9. Identifying potential patient concerns is a step in what part of the nursing process?
a. assessment
b. diagnosis
c. implementation
d. evaluation
[Answer: B]
10.What phase focuses on determining the effectiveness of the nursing interventions and the
progress made toward achieving the established goals?
a. assessment
b. planning
c. intervention
d. evaluation
[Answer: D]
4
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7/9/2024
,OpenStax Clinical Nursing Skills Instructor Answer Guide
11.What is patient education an example of?
a. direct care activity
b. collaborative intervention
c. indirect care activity
d. systematic approach
[Answer: C]
12.What is the primary responsibility of The Joint Commission (TJC)?
a. to enforce federal health regulations
b. to provide accreditation for healthcare facilities and organizations based on guidelines
and standards for best practices
c. to ensure that patients receive the best care possible
d. to provide licensing and certifications to healthcare professionals
[Answer: B]
Check Your Understanding Questions
1. Discuss the definition and importance of the ethical principle of fidelity.
[Answer: Answers will vary but should include demonstrating faithfulness, loyalty, and
commitment to patients. Its purpose is to help nurses establish trusting relationships, maintain
confidentiality, and uphold professional standards to ensure the trust and confidence of
patients and the public.]
2. Briefly discuss how and why the goals of nursing have evolved and changed over time.
[Answer: Answers will vary but should include discussion of the response to changes in society,
healthcare systems, and the understanding of healthcare needs. Nursing evolved from ancient
practices of providing basic care, such as nutrition and comfort, during times of illness or injury.
As health care advanced, nursing goals expanded to encompass a broader scope of practice. In
the nineteenth century, Florence Nightingale defined professional nursing and holistic nursing,
which emphasizes the healing of the whole person, including mind, body, and soul. The
twentieth century saw significant progress in nursing education, research, evidence-based
practice, professionalization, and technology. Nurses became actively involved in health
promotion, disease prevention, and patient advocacy.]
3. Discuss the importance of integrating interdisciplinary theories with nursing theories and
practice.
[Answer: Answers will vary but should include discussion of interdisciplinary theories as an
essential part of nursing because they provide a broader perspective and a more
comprehensive understanding of healthcare issues. These theories integrate knowledge and
concepts from multiple disciplines to enhance nursing practice, research, and education. In
nursing, interdisciplinary theories are used in various ways. They assist in the development of
nursing models and frameworks that guide the delivery of patient care, and help nurses
understand and work better with the interdisciplinary team.]
4. Define quantitative and qualitative data and discuss the main differences between the two.
[Answer: Answers will vary but should define quantitative research as a systematic and
empirical approach that involves the collection, analysis, and interpretation of numerical data to
answer research questions and explore phenomena related to health care. It aims to answer the
“how many/much” questions. Qualitative research in nursing refers to a systematic and
5
,OpenStax Clinical Nursing Skills Instructor Answer Guide
subjective approach that focuses on understanding and interpreting human experiences,
meanings, and social phenomena in the context of health care. It aims to answer the “why”
questions.]
5. Define the nursing process and briefly discuss its purpose.
[Answer: Answers will vary but should include the fact that the nursing process is a critical
thinking model based on a systematic approach to patient-centered care. Nurses use the
nursing process to perform clinical reasoning and make clinical judgments when providing
patient care. The nursing process is based on the Standards of Professional Nursing Practice
established by the ANA. These standards are authoritative statements of the actions and
behaviors that all registered nurses, regardless of role, population, specialty, and setting, are
expected to perform competently.]
6. Why is the evaluation phase crucial in nursing care planning?
[Answer: The evaluation phase is essential to determine the effectiveness of nursing
interventions and the progress toward established goals. Nurses can then modify care plans if
patient outcomes have not been met or if they have been resolved, ensuring better patient
outcomes and addressing evolving health needs.]
Reflection Questions
1. Why is the reflection step in the clinical judgment model so crucial for professional
development and growth in nursing?
[Answer: Answers will vary but should include the fact that it allows nurses to identify patterns
or trends in their clinical decision-making, leading to enhanced future performance and more
refined clinical judgment. By engaging in critical reflection, nurses enhance their self-awareness,
improve their clinical reasoning abilities, and promote professional growth. It fosters a culture
of continuous improvement, ensuring that nurses are continually learning from their
experiences to provide the best possible care for their patients.]
2. Why is holistic care a central concept in nursing?
[Answer: Answers will vary but should include recognizing that patients are not just a collection
of symptoms, but unique individuals with physical, emotional, social, and spiritual needs.
Nursing aims to address all these aspects to provide comprehensive and patient-centered care,
promoting better health outcomes and overall well-being.]
3. How does the hierarchy of evidence-based practice help nurses in determining the quality of
EBP?
[Answer: Answers will vary but should discuss the hierarchy of evidence as a ranking system that
classifies different types of research studies based on their reliability and validity. The hierarchy
helps healthcare professionals determine the strength and quality of evidence when making
clinical decisions. The hierarchy of evidence serves as a guide, with studies higher up being
considered more rigorous and providing stronger evidence to inform healthcare practices.
4. Why have Erik Erikson’s psychosocial development theory and Abraham Maslow’s hierarchy
of needs theory had such heavy influence on nursing theory?
[Answer: Answers will vary. Both theories have influenced nursing theorists in recognizing the
importance of addressing the multidimensional needs of patients. They have contributed to the
6
For more free, peer-reviewed, openly licensed resources visit OpenStax.org.
7/9/2024
,OpenStax Clinical Nursing Skills Instructor Answer Guide
development of nursing theories that embrace a holistic perspective, acknowledging the
influence of psychological, social, and developmental factors on patients’ health and
well-being.]
5. How does the nurse decide which nursing interventions to implement?
[Answer: Answers will vary but should discuss that after establishing and planning for patient
outcomes, nurses develop nursing interventions or actions that will help the patient achieve
those outcomes. These interventions should be evidence-based and aligned with the nursing
diagnoses, incorporating the best available research and clinical guidelines.]
6. How does The Joint Commission’s accreditation and standards influence the development
and implementation of individualized nursing care plans?
[Answer: Answers will vary. TJC’s accreditation and standards play a crucial role in shaping
nursing care plans as they set rigorous guidelines for patient care and safety, emphasizing the
need for individualized care plans tailored to meet the specific and unique needs of each
patient, whether through standardized plans with customized interventions or independent
development by nurses.]
7. In the planning phase, nurses collaborate with patients to establish specific, measurable,
attainable, relevant, and timely (SMART) outcomes. Create five SMART goals for yourself
centered around the concept of holistic nursing.
[Answer: Answers will vary, but should include all aspects of a SMART goal and the concept of
holistic nursing. Examples: At the end of every shift, I will ask for feedback about each of my
patients’ day and inquire about improvements to further individualize their care. I can
implement a personalized time management plan to achieve a better school–life balance,
dedicating at least one hour daily to self-care activities, resulting in enhanced overall well-being
and reduced stress within the next month.]
Competency-Based Questions
1. Research the history of holistic nursing and prepare a ten-minute slideshow presentation on
its development in nursing practice.
[Answer: Answers will vary but should include holistic nursing foundations and examples of
incorporating it into nursing practice.]
2. Health promotion is a fundamental role of nursing. In a few sentences, discuss what health
promotion as a nurse means to you. As a nurse, how do you plan to practice health
promotion with your patients? Give specific examples.
[Answer: Answers will vary but should include personal description and example of
incorporating health promotion into daily practice.]
3. In Section 1.1, you learned about the history of holistic nursing. Find at least two examples
of evidence-based research about holistic nursing. Identify the types of research and their
places on Melnyk and Fineout-Overholt’s levels of evidence. The research should be current
(within the past five years).
[Answer: Answers will vary. The student should be able to produce two evidence-based
research studies completed within a five-year time frame. Searches should be completed from
reputable sources. They should also be able to identify the type of each research study
(qualitative or quantitative) and the level of evidence presented.]
7
,OpenStax Clinical Nursing Skills Instructor Answer Guide
4. Present your research to your group or class. Include discussion of the levels of evidence of
your research. What do you conclude about the strength of recommendation for holistic
nursing?
[Answer: Answers will vary, but the student should be able to tie in the level of evidence
presented by the research article to the strength of recommendation. For example, students
should be able to conclude that a research article created through a meta-analysis of all
research would carry a higher level of recommendation than a research article based on expert
opinion.]
8
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7/9/2024
,OpenStax Clinical Nursing Skills Instructor Answer Guide
Chapter 2: The Evolution of the Nurse’s Role
Review Questions
1. One of the most important contributions that Florence Nightingale made to the development
of professional nursing was ________.
a. the implementation of strict moral codes on female nurses
b. the use of statistical data to drive evidence-based practice
c. the use of herbal medicine as a treatment for various illnesses
d. the use of interprofessional teams to provide care to patients
[Answer: B]
2. What is the purpose of emphasizing DEI in nursing education?
a. to train nurses to identify minority populations
b. to prepare nurses for a career in public health
c. to produce culturally competent, compassionate, and equitable nurses
d. to encourage all nurses on a team to share similar thoughts, beliefs, and behaviors
[Answer: C]
3. ________ is the emotional and physical exhaustion that results from providing empathetic
care to those experiencing trauma or suffering.
a. Compassion fatigue
b. Depression
c. Burnout
d. Moral distress
[Answer: A]
4. What is a fundamental idea patient-centered care?
a. Part of the nurse’s role is to convince the patient to see things reasonably when it comes
to making medical decisions for themselves.
b. Patients are unique individuals with their own life experiences, values, and beliefs that
impact their health and healthcare decisions.
c. Concealing confusing information from the patient may be necessary to prevent them
from mistakenly making the wrong decisions.
d. It is ultimately up to medical professionals to determine what treatment and care the
patient must have.
[Answer: B]
5. Why does patient-centered care lead to better treatment adherence?
a. The majority of patients do not have the capacity to understand complex medical terms
and decisions and instead benefit from having healthcare providers lead them in their
decision-making process.
b. Patients do best when their treatment options are communicated to them in the most
general, least detailed way.
c. Patients who are actively involved in their care, are able to make decisions for
themselves, and have a good understanding of their conditions and treatment options
are more likely to adhere to prescribed treatments and medication regimens.
d. Patients feel more secure when trusted experts are determining and driving their care.
[Answer: C]
9
, OpenStax Clinical Nursing Skills Instructor Answer Guide
6. Why is transparency a crucial part of patient-centered care?
a. Transparent communication ensures that patients have the necessary information to
make autonomous decisions about their care.
b. Transparency allows healthcare team members to access all of the patient’s medical
records in order to find information that may convince the patient to make the correct
decision when it comes to their treatment course.
c. Transparency enables outside parties with an interest in the patient’s care to easily
access the patient’s personal medical information.
d. Transparency offers a way for healthcare providers to provide potentially distressing
news to patients through other avenues instead of speaking directly to the patient
themselves.
[Answer: A]
7. ________ is the concept that patients have the right to make decisions about their own
health care.
a. Autonomy
b. Allocation
c. Self-care
d. Self-determination
[Answer: A]
8. The purpose of the ANA Standards of Practice is to:
a. provide nurses with legal practice guidelines specific to their state.
b. deter nurses from thinking too far “outside of the box” and keep them focused on
nursing duties.
c. offer suggestions to nurses who are uncomfortable with their role.
d. guide nurses in delivering safe, effective, and holistic care using a systematic approach
and critical thinking.
[Answer: D]
9. Why does the Scope of Nursing Practice exist?
a. to define the boundaries, responsibilities, and expectations of nursing professionals in
their respective roles
b. to guide nurses in delivering safe, effective, and holistic care using a systematic approach
and critical thinking
c. to specify punitive measures for nurses who operate outside of their scope of practice
d. to ensure that nurses know they are not equivalent to physicians or advanced practice
providers
[Answer: A]
10.Which of the five rights of nursing delegation remind the nurse to monitor the delegate’s
performance of a task and to provide ongoing support, guidance, and feedback?
a. right communication
b. right supervision
c. right person
d. right circumstances
[Answer: A]
10
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7/9/2024
openstaх™
Clinical
Nursing
Skills
,OpenStax Clinical Nursing Skills Instructor Answer Guide
OpenStax Clinical Nursing Skills
Instructor Answer Guide
Chapter 1: The Role of the Nurse in Comprehensive Care............................................................. 3
Chapter 2: The Evolution of the Nurse’s Role................................................................................. 9
Chapter 3: Patient Communication and Interviewing.................................................................. 15
Chapter 4: Obtaining a Complete Health History......................................................................... 20
Chapter 5: Cultural Competence and Assessment....................................................................... 25
Chapter 6: Infection Prevention Techniques and Safety in Clinical Setting...................................32
Chapter 7: Hygiene....................................................................................................................... 38
Chapter 8: Wound and Burn Assessment Care.............................................................................44
Chapter 9: Activity Assessment and Management.......................................................................50
Chapter 10: Specimen Collection and Lab Testing........................................................................57
Chapter 11: Principles of Medication Administration.................................................................. 66
Chapter 12: Medication Administration Procedures.................................................................... 73
Chapter 13: Intravenous Administration...................................................................................... 83
Chapter 14: Miscellaneous Medication Administration............................................................... 90
Chapter 15: General Survey, Anthropometric Measurement, and Vital Signs..............................97
Chapter 16: Pain Assessment..................................................................................................... 103
Chapter 17: Nutrition Assessment..............................................................................................110
Chapter 18: Oxygenation and Perfusion.....................................................................................116
Chapter 19: Fluids, Electrolytes, and Elimination....................................................................... 122
Chapter 20: Psychosocial Assessment........................................................................................ 128
Chapter 21: Assessment of the Integumentary System..............................................................136
Chapter 22: Assessment of the Head and Neck......................................................................... 140
Chapter 23: Assessment of the Thorax, Lungs, Breast, and Lymphatic System.......................... 148
Chapter 24: Assessment of the Cardiovascular and Peripheral Vascular System....................... 153
Chapter 25: Assessment of the Musculoskeletal System........................................................... 160
Chapter 26: Assessment of the Neurological System................................................................. 165
Chapter 27: Assessment of the Abdomen.................................................................................. 170
Chapter 28: Clinical Judgment and Critical Thinking...................................................................176
2
For more free, peer-reviewed, openly licensed resources visit OpenStax.org.
7/9/2024
,OpenStax Clinical Nursing Skills Instructor Answer Guide
Chapter 1: The Role of the Nurse in Comprehensive Care
Review Questions
1. Florence Nightingale is considered the founder of ____________, which emphasizes the
healing of the whole person, including mind, body, and soul.
a. caring nursing
b. the seven ethical principles of nursing
c. holistic nursing
d. systems nursing
[Answer: C]
2. The ethical principle defined as “acting in the best interest of patients and promoting their
well-being” is known as
a. fidelity
b. beneficence
c. justice
d. nonmaleficence
[Answer: B]
3. The nurse’s ability to develop and implement appropriate actions or interventions based on
the interpretation of the collected data and identified patient needs is the ___________
step of the clinical judgment model.
a. noticing
b. interpreting
c. responding
d. reflecting
[Answer: C]
4. When a nurse takes a role centered around empowering individuals, families, and
communities to take control of their well-being and make positive choices, this is known as
___________.
a. care planning
b. health promotion
c. role modeling
d. community nursing
[Answer: B]
5. What is the purpose of integrating interdisciplinary theories with nursing theory and
practice?
a. to break down current nursing theories and dictate the formation of future nursing
theory
b. to assist in the development of nursing models and frameworks that guide the delivery
of patient care, and help nurses understand and work better with the interdisciplinary
team
c. to discourage overreliance on nursing theory alone
3
,OpenStax Clinical Nursing Skills Instructor Answer Guide
d. to encourage other disciplines to learn about nursing theory and integrate it into their
practice
[Answer: B]
6. What is the importance of the evolution of nursing to include evidence-based practice
(EBP)?
a. The emergence of EBP has contributed to the scientific quality of nursing practice. It
integrates research findings into nursing practice, ensuring that decisions are based on
the best available evidence.
b. EBP provides a scientific foundation for informed nursing practice and discourages the
use of other, nonscientific issues such as cultural differences and patient preference in
nursing practice.
c. EBP ensures that nursing practice remains based in tradition and is not adaptable to
changes in current scientific recommendations.
d. EBP provides suggestions to nurses on improving patient care, but the nurse is still able
to reject EBP in clinical practice if they disagree with it.
[Answer: A]
7. In the hierarchy of EBP, the strongest sources of evidence at the top of the hierarchy are
a. randomized controlled trials (RCTs)
b. one-on-one patient interviews
c. case studies
d. systematic reviews and meta-analyses
[Answer: D]
8. What type of nursing theories focus on describing and understanding the lived experiences
of individuals in the context of health care?
a. descriptive
b. hierarchical
c. prescriptive
d. systems
[Answer: A]
9. Identifying potential patient concerns is a step in what part of the nursing process?
a. assessment
b. diagnosis
c. implementation
d. evaluation
[Answer: B]
10.What phase focuses on determining the effectiveness of the nursing interventions and the
progress made toward achieving the established goals?
a. assessment
b. planning
c. intervention
d. evaluation
[Answer: D]
4
For more free, peer-reviewed, openly licensed resources visit OpenStax.org.
7/9/2024
,OpenStax Clinical Nursing Skills Instructor Answer Guide
11.What is patient education an example of?
a. direct care activity
b. collaborative intervention
c. indirect care activity
d. systematic approach
[Answer: C]
12.What is the primary responsibility of The Joint Commission (TJC)?
a. to enforce federal health regulations
b. to provide accreditation for healthcare facilities and organizations based on guidelines
and standards for best practices
c. to ensure that patients receive the best care possible
d. to provide licensing and certifications to healthcare professionals
[Answer: B]
Check Your Understanding Questions
1. Discuss the definition and importance of the ethical principle of fidelity.
[Answer: Answers will vary but should include demonstrating faithfulness, loyalty, and
commitment to patients. Its purpose is to help nurses establish trusting relationships, maintain
confidentiality, and uphold professional standards to ensure the trust and confidence of
patients and the public.]
2. Briefly discuss how and why the goals of nursing have evolved and changed over time.
[Answer: Answers will vary but should include discussion of the response to changes in society,
healthcare systems, and the understanding of healthcare needs. Nursing evolved from ancient
practices of providing basic care, such as nutrition and comfort, during times of illness or injury.
As health care advanced, nursing goals expanded to encompass a broader scope of practice. In
the nineteenth century, Florence Nightingale defined professional nursing and holistic nursing,
which emphasizes the healing of the whole person, including mind, body, and soul. The
twentieth century saw significant progress in nursing education, research, evidence-based
practice, professionalization, and technology. Nurses became actively involved in health
promotion, disease prevention, and patient advocacy.]
3. Discuss the importance of integrating interdisciplinary theories with nursing theories and
practice.
[Answer: Answers will vary but should include discussion of interdisciplinary theories as an
essential part of nursing because they provide a broader perspective and a more
comprehensive understanding of healthcare issues. These theories integrate knowledge and
concepts from multiple disciplines to enhance nursing practice, research, and education. In
nursing, interdisciplinary theories are used in various ways. They assist in the development of
nursing models and frameworks that guide the delivery of patient care, and help nurses
understand and work better with the interdisciplinary team.]
4. Define quantitative and qualitative data and discuss the main differences between the two.
[Answer: Answers will vary but should define quantitative research as a systematic and
empirical approach that involves the collection, analysis, and interpretation of numerical data to
answer research questions and explore phenomena related to health care. It aims to answer the
“how many/much” questions. Qualitative research in nursing refers to a systematic and
5
,OpenStax Clinical Nursing Skills Instructor Answer Guide
subjective approach that focuses on understanding and interpreting human experiences,
meanings, and social phenomena in the context of health care. It aims to answer the “why”
questions.]
5. Define the nursing process and briefly discuss its purpose.
[Answer: Answers will vary but should include the fact that the nursing process is a critical
thinking model based on a systematic approach to patient-centered care. Nurses use the
nursing process to perform clinical reasoning and make clinical judgments when providing
patient care. The nursing process is based on the Standards of Professional Nursing Practice
established by the ANA. These standards are authoritative statements of the actions and
behaviors that all registered nurses, regardless of role, population, specialty, and setting, are
expected to perform competently.]
6. Why is the evaluation phase crucial in nursing care planning?
[Answer: The evaluation phase is essential to determine the effectiveness of nursing
interventions and the progress toward established goals. Nurses can then modify care plans if
patient outcomes have not been met or if they have been resolved, ensuring better patient
outcomes and addressing evolving health needs.]
Reflection Questions
1. Why is the reflection step in the clinical judgment model so crucial for professional
development and growth in nursing?
[Answer: Answers will vary but should include the fact that it allows nurses to identify patterns
or trends in their clinical decision-making, leading to enhanced future performance and more
refined clinical judgment. By engaging in critical reflection, nurses enhance their self-awareness,
improve their clinical reasoning abilities, and promote professional growth. It fosters a culture
of continuous improvement, ensuring that nurses are continually learning from their
experiences to provide the best possible care for their patients.]
2. Why is holistic care a central concept in nursing?
[Answer: Answers will vary but should include recognizing that patients are not just a collection
of symptoms, but unique individuals with physical, emotional, social, and spiritual needs.
Nursing aims to address all these aspects to provide comprehensive and patient-centered care,
promoting better health outcomes and overall well-being.]
3. How does the hierarchy of evidence-based practice help nurses in determining the quality of
EBP?
[Answer: Answers will vary but should discuss the hierarchy of evidence as a ranking system that
classifies different types of research studies based on their reliability and validity. The hierarchy
helps healthcare professionals determine the strength and quality of evidence when making
clinical decisions. The hierarchy of evidence serves as a guide, with studies higher up being
considered more rigorous and providing stronger evidence to inform healthcare practices.
4. Why have Erik Erikson’s psychosocial development theory and Abraham Maslow’s hierarchy
of needs theory had such heavy influence on nursing theory?
[Answer: Answers will vary. Both theories have influenced nursing theorists in recognizing the
importance of addressing the multidimensional needs of patients. They have contributed to the
6
For more free, peer-reviewed, openly licensed resources visit OpenStax.org.
7/9/2024
,OpenStax Clinical Nursing Skills Instructor Answer Guide
development of nursing theories that embrace a holistic perspective, acknowledging the
influence of psychological, social, and developmental factors on patients’ health and
well-being.]
5. How does the nurse decide which nursing interventions to implement?
[Answer: Answers will vary but should discuss that after establishing and planning for patient
outcomes, nurses develop nursing interventions or actions that will help the patient achieve
those outcomes. These interventions should be evidence-based and aligned with the nursing
diagnoses, incorporating the best available research and clinical guidelines.]
6. How does The Joint Commission’s accreditation and standards influence the development
and implementation of individualized nursing care plans?
[Answer: Answers will vary. TJC’s accreditation and standards play a crucial role in shaping
nursing care plans as they set rigorous guidelines for patient care and safety, emphasizing the
need for individualized care plans tailored to meet the specific and unique needs of each
patient, whether through standardized plans with customized interventions or independent
development by nurses.]
7. In the planning phase, nurses collaborate with patients to establish specific, measurable,
attainable, relevant, and timely (SMART) outcomes. Create five SMART goals for yourself
centered around the concept of holistic nursing.
[Answer: Answers will vary, but should include all aspects of a SMART goal and the concept of
holistic nursing. Examples: At the end of every shift, I will ask for feedback about each of my
patients’ day and inquire about improvements to further individualize their care. I can
implement a personalized time management plan to achieve a better school–life balance,
dedicating at least one hour daily to self-care activities, resulting in enhanced overall well-being
and reduced stress within the next month.]
Competency-Based Questions
1. Research the history of holistic nursing and prepare a ten-minute slideshow presentation on
its development in nursing practice.
[Answer: Answers will vary but should include holistic nursing foundations and examples of
incorporating it into nursing practice.]
2. Health promotion is a fundamental role of nursing. In a few sentences, discuss what health
promotion as a nurse means to you. As a nurse, how do you plan to practice health
promotion with your patients? Give specific examples.
[Answer: Answers will vary but should include personal description and example of
incorporating health promotion into daily practice.]
3. In Section 1.1, you learned about the history of holistic nursing. Find at least two examples
of evidence-based research about holistic nursing. Identify the types of research and their
places on Melnyk and Fineout-Overholt’s levels of evidence. The research should be current
(within the past five years).
[Answer: Answers will vary. The student should be able to produce two evidence-based
research studies completed within a five-year time frame. Searches should be completed from
reputable sources. They should also be able to identify the type of each research study
(qualitative or quantitative) and the level of evidence presented.]
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,OpenStax Clinical Nursing Skills Instructor Answer Guide
4. Present your research to your group or class. Include discussion of the levels of evidence of
your research. What do you conclude about the strength of recommendation for holistic
nursing?
[Answer: Answers will vary, but the student should be able to tie in the level of evidence
presented by the research article to the strength of recommendation. For example, students
should be able to conclude that a research article created through a meta-analysis of all
research would carry a higher level of recommendation than a research article based on expert
opinion.]
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Chapter 2: The Evolution of the Nurse’s Role
Review Questions
1. One of the most important contributions that Florence Nightingale made to the development
of professional nursing was ________.
a. the implementation of strict moral codes on female nurses
b. the use of statistical data to drive evidence-based practice
c. the use of herbal medicine as a treatment for various illnesses
d. the use of interprofessional teams to provide care to patients
[Answer: B]
2. What is the purpose of emphasizing DEI in nursing education?
a. to train nurses to identify minority populations
b. to prepare nurses for a career in public health
c. to produce culturally competent, compassionate, and equitable nurses
d. to encourage all nurses on a team to share similar thoughts, beliefs, and behaviors
[Answer: C]
3. ________ is the emotional and physical exhaustion that results from providing empathetic
care to those experiencing trauma or suffering.
a. Compassion fatigue
b. Depression
c. Burnout
d. Moral distress
[Answer: A]
4. What is a fundamental idea patient-centered care?
a. Part of the nurse’s role is to convince the patient to see things reasonably when it comes
to making medical decisions for themselves.
b. Patients are unique individuals with their own life experiences, values, and beliefs that
impact their health and healthcare decisions.
c. Concealing confusing information from the patient may be necessary to prevent them
from mistakenly making the wrong decisions.
d. It is ultimately up to medical professionals to determine what treatment and care the
patient must have.
[Answer: B]
5. Why does patient-centered care lead to better treatment adherence?
a. The majority of patients do not have the capacity to understand complex medical terms
and decisions and instead benefit from having healthcare providers lead them in their
decision-making process.
b. Patients do best when their treatment options are communicated to them in the most
general, least detailed way.
c. Patients who are actively involved in their care, are able to make decisions for
themselves, and have a good understanding of their conditions and treatment options
are more likely to adhere to prescribed treatments and medication regimens.
d. Patients feel more secure when trusted experts are determining and driving their care.
[Answer: C]
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, OpenStax Clinical Nursing Skills Instructor Answer Guide
6. Why is transparency a crucial part of patient-centered care?
a. Transparent communication ensures that patients have the necessary information to
make autonomous decisions about their care.
b. Transparency allows healthcare team members to access all of the patient’s medical
records in order to find information that may convince the patient to make the correct
decision when it comes to their treatment course.
c. Transparency enables outside parties with an interest in the patient’s care to easily
access the patient’s personal medical information.
d. Transparency offers a way for healthcare providers to provide potentially distressing
news to patients through other avenues instead of speaking directly to the patient
themselves.
[Answer: A]
7. ________ is the concept that patients have the right to make decisions about their own
health care.
a. Autonomy
b. Allocation
c. Self-care
d. Self-determination
[Answer: A]
8. The purpose of the ANA Standards of Practice is to:
a. provide nurses with legal practice guidelines specific to their state.
b. deter nurses from thinking too far “outside of the box” and keep them focused on
nursing duties.
c. offer suggestions to nurses who are uncomfortable with their role.
d. guide nurses in delivering safe, effective, and holistic care using a systematic approach
and critical thinking.
[Answer: D]
9. Why does the Scope of Nursing Practice exist?
a. to define the boundaries, responsibilities, and expectations of nursing professionals in
their respective roles
b. to guide nurses in delivering safe, effective, and holistic care using a systematic approach
and critical thinking
c. to specify punitive measures for nurses who operate outside of their scope of practice
d. to ensure that nurses know they are not equivalent to physicians or advanced practice
providers
[Answer: A]
10.Which of the five rights of nursing delegation remind the nurse to monitor the delegate’s
performance of a task and to provide ongoing support, guidance, and feedback?
a. right communication
b. right supervision
c. right person
d. right circumstances
[Answer: A]
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