2020 Exam 3

Question 1

Contained in this deck

Answer 1

Readings:
Week 7:
Ch 46-Giddens: Collaboration
Ch 17-Yoder-Wise: Leading Change
Ch 18-Yoder-Wise: Building Teams Through Communication and Partnerships
Ch 19-Yoder-Wise: Workforce Engagement and Collective Action
Week 8:
Ch 20-Yoder-Wise: Managing Quality and Risk
Ch 22-Yoder-Wise: Consumer Relationships
Week 9:
Ch 23-Yoder-Wise: Conflict: The Cutting Edge of Change
Ch 24-Yoder-Wise: Managing Personal/Personnel Problems

Question 2

1. A newly licensed nurse is assigned to an experienced nurse for training on a medical unit of a hospital. What type of nurse-to-nurse collaboration does this assignment demonstrate?
   a. Interprofessional
   b. Shared governance
   c. Interorganizational
   d. Mentoring

Answer 2

ANS: D

d. Mentoring

Mentoring is a collaborative partnership between a novice nurse and an expert nurse to help transition a nurse through career development, personal growth, and socialization into the profession. Interprofessional collaboration is working with several disciplines. Shared governance is a type of management for nursing. Interorganizational collaboration often includes teams from inside and outside an organization to meet a common goal.

Question 3

2. The nurse is presenting an in-service on the importance of collaborative communication. The nurse includes which critical event identified by the Joint Commission as an outcome of poor communication among health care team members?
   a. The occurrence of a patient event resulting in death or serious injury
   b. Decreased ability to document expenses of care provided
   c. Longer time to begin surgical cases
   d. Increased time to discharge patients to outpatient care

Answer 3

ANS: A

a. The occurrence of a patient event resulting in death or serious injury

The Joint Commission has identified that poor communication is the primary factor in the occurrence of sentinel events, or events resulting in unintended death or serious injury to patients. Lack of documentation, longer time to begin surgery, and increased delays in discharge all contribute to the management of health care, but do not result in critical patient outcomes.

Question 4

3. Which patient scenario describes the best example of professional collaboration?
   a. The nurse, physician, and physical therapist have all visited separately with the patient.
   b. The nurse, physical therapist, and physician have all developed separate care plans for the patient.
   c. The nurse mentions to the physical therapist that the patient may benefit from a muscle strengthening evaluation.
   d. The nurse and physician discuss the patient’s muscle weakness and initiate a referral for physical therapy.

Answer 4

ANS: D

d. The nurse and physician discuss the patient’s muscle weakness and initiate a referral for physical therapy.

Professional collaboration includes team management and referral to needed providers to meet patient needs. Each discipline retains responsibility for their own scope of practice but recognizes the expertise of other providers. Working separately does not develop a comprehensive plan of care. Casual mentioning of patient needs does not follow professional communication channels and frequently delays needed interventions.

Question 5

4. Which statement correctly describes the nurses’ role in collaboration?
   a. State boards of nursing mandate that collaboration can only occur in hospitals.
   b. Collaboration should occur only with physicians.
   c. Collaboration occurs only between nurses with the same level of education.
   d. Collaboration may occur in health-related research.

Answer 5

ANS: D

d. Collaboration may occur in health-related research.

Nurses collaborate with many different persons, including patients, managers, educators, and researchers. Collaboration does not occur only with physicians or nurses of equivalent educational background, but with anyone who is working towards meeting patient goals. Collaboration occurs in any health care setting as well as community and home settings.

Question 6

5. A nurse manager has recently overheard several negative comments made by nurses on the unit about other nurses on the unit. The manager recognizes that the nurses are exhibiting what type of behavior that is detrimental to collaboration?
   a. Vertical violence
   b. Lateral violence
   c. Descending violence
   d. Personal violence

Answer 6

ANS: B

b. Lateral violence

Lateral violence undermines collaboration and occurs nurse-to-nurse. Vertical or descending violence implies one participant has a higher status than another. Personal violence falls in a legal category, and while it will hinder collaboration, it is not specific to coworkers.

Question 7

6. The nurse and physician are explaining that home care that will be needed by a patient after discharge. The patient’s spouse states angrily that it will not be possible to provide the care recommended. What is the best response by the nurse?
   a. “Let me review what is needed again.”
   b. “It is important that you do what the physician has prescribed.”
   c. “What concerns do you have about the prescribed care?”
   d. “I can come back after you talk with your spouse about the care.”

Answer 7

ANS: C

c. “What concerns do you have about the prescribed care?”

The patient needs to be the focus of developing care plans, and communication is an important part of collaboration with the patient to discover barriers for the patient to follow recommendations. It is important to either provide solutions to the barriers or present other options. Reviewing the care again does not demonstrate willingness to have the patient be part of the team. Insisting that the patient do what is prescribed is autocratic and does not recognize the role the patient has in their care. Leaving the patient and spouse with the situation unresolved fosters distrust and more

Question 8

7. The nurse is caring for a patient with a progressive, degenerative muscle illness. The patient states that she would like to remain in her home with her daughter as long as possible. What action should the nurse take?
   a. Teach the patient muscle strengthening and stretching exercises.
   b. Tell the patient to make plans to move to an assisted-living facility.
   c. Discuss resources to help the patient and make appropriate referrals.
   d. Ask the patient to come in for daily physical therapy.

Answer 8

ANS: C

c. Discuss resources to help the patient and make appropriate referrals.

To honor the patient’s request to stay at home the nurse should make appropriate referrals for needed evaluation and assistance. Most nurses will not have the expertise to teach appropriate exercises for degenerative illness. Asking the patient to move to an assisted-living facility does not account for the patient’s request. The patient has not been assessed for the need of daily therapy, and it is not likely that a patient with a degenerative illness will be able to make daily appointments for treatment as the illness progresses.

Question 9

8. A patient has been admitted to an acute care hospital unit. The nurse explains the hospital philosophy that the patient be an active part of planning their care. The patient verbalizes understanding of this request when they make which statement?
   a. “I will have to do whatever the physician says I need to do.”
   b. “Once a plan is developed, it cannot be changed.”
   c. My insurance will not pay if I don’t do what you want me to do.”
   d. “We can work together to adjust my plan as we need to.”

Answer 9

ANS: D

d. “We can work together to adjust my plan as we need to.”

Treatment plans need to be developed, evaluated, and adapted as needed based on the patient status and willingness to complete the prescribed care. Stating that the patient has to do whatever the care provider prescribes does not include the principle of collaboration. Care plans can be altered based on patient status. Insurance providers do not determine a patient’s ability to complete prescribed care, although they do reimburse for standard care given.

Question 10

9. The management of a community hospital is trying to encourage a more collaborative environment among staff members. Which concept is most important for management to develop first?
   a. Post educational posters about how well collaboration is being performed
   b. Highlight that no single profession can meet the needs of all patients
   c. Provide meetings for each department on how their role affects patients
   d. Begin implementing evaluations of collaborative skills on annual performance reviews

Answer 10

ANS: B

b. Highlight that no single profession can meet the needs of all patients

Recognizing that collaboration needs all professions to provide patient-centered care is an important first step to implementing a different philosophy in the hospital. Posting an evaluation of performance before education will not encourage participation. Collaboration requires an understanding of more than your own discipline. It is unfair to evaluate staff on a requirement that they have not been introduced to.

Question 11

1. Which activities are appropriate for the nurse to collaborate with a patient? (Select all that apply.)
   a. Prescribing a new medication dose
   b. Health promotion activities
   c. End-of-life comfort decisions
   d. Interpreting laboratory results
   e. Lifestyle changes to improve health

Answer 11

ANS: B, C, E

b. Health promotion activities
c. End-of-life comfort decisions
e. Lifestyle changes to improve health

Nurses should include patients and their families when exploring health promotion activities, end-of-life decisions, lifestyle changes, and treatment options. Prescribed medication doses are initiated by educated professionals, although the patient gives feedback on the effectiveness of medications. Patients are not trained to interpret lab results, but patients rely on health professionals to explain results to them.

Question 12

1. When goals/outcomes are somewhat unclear in early preparation for a complex change, the manager and the change management team develop several acceptable goals/outcomes. This change in management approach is termed:
   a. Unfreezing.
   b. Nonlinear.
   c. Cybernetic.
   d. Linear.

Answer 12

ANS: B

b. Nonlinear.
While Lewin’s theory was designed to describe planned or first-order changes, many scholars think the theory is too simplistic to address how unplanned or second-order change occurs. In complex situations with an uncertain change environment, a nonlinear approach that involves flexibility improves overall outcomes. Linear change is appropriate to stable, less complex, and more predictable situations.

Question 13

2. The home health agency hired an expert in financial management to evaluate and propose a plan for reversing growing expenses and decreasing revenues. The expert is well respected, both personally and professionally, by members living in this small community. To be effective, staff will need to perceive this change agent as:
   a. Trusted, quiet.
   b. Flexible, informal.
   c. Credible, enthusiastic
   d. Communicative, personable.

Answer 13

ANS: C

c. Credible, enthusiastic

To influence the decision, the expert must be seen as having knowledge of what matters to the people that they lead and of the change area itself. The expert also must be enthusiastic and communicative and have referent power.

Question 14

3. The nurse manager frequently interacts with staff and other hospice facility employees. Communication is purposeful because the manager assesses current issues, such as specific satisfactions and dissatisfactions with the newly implemented computerized documentation system. Informally, the manager gathers available staff members to address similar learning needs. Many times, staff members are found coaching other staff about improving use of the new system. According to Senge (1990), the activities demonstrated in this example are:
   a. Dialogue, team learning.
   b. Resilience, personal mastery.
   c. Shared vision, systems thinking.
   d. Mental models, teachable moments.

Answer 14

ANS: A

a. Dialogue, team learning.

Building shared vision occurs when leaders involve all members in moving personal visions of the future into a consolidated vision common to members and leaders

Question 15

4. The clinical coordinator expects the position description of the new wound care specialist to change nurses’ responsibilities in caring for clients with skin integrity problems. The best approach to address this need for change, yet to have the best outcomes for clients, staff nurses, and the organization, is to:
   a. Select one of the change models.
   b. Use Lewin’s model and principles of change.
   c. Apply both planned and complexity theory approaches.
   d. Form a task force of nursing staff and wound care specialists.

Answer 15

ANS: C

c. Apply both planned and complexity theory approaches.

In the second stage, the moving or changing stage of Lewin’s theory, planned interventions and strategies, such as education, vision building, and incremental steps towards the change, are executed to support the implementation of the change. This situation potentially also involves complexity theories that recognize that change involves engagement of individuals and subsystems throughout the unit and organization.

Question 16

5. Complex change situations require that the change leader promote ongoing visioning among staff members. One strategy is to:
   a. Consciously evaluate invisible mental models.
   b. Allow for individual outcomes.
   c. Encourage cooperative activities.
   d. Operate between order and disorder.

Answer 16

ANS: A

a. Consciously evaluate invisible mental models.

Senge’s theory on change suggests that each individual or organization bases activities on a set of assumptions, or a set of beliefs, or mental pictures about the way that the world should work. When these invisible models are uncovered and consciously evaluated, it is possible to determine their influences on work accomplishment.

Question 17

6. To effectively achieve a change goal/outcome in a change situation, the wound care specialist will:
   a. Preserve the status quo.
   b. Diminish facilitators and reinforce barriers.
   c. Weigh the strength of forces.
   d. Strengthen facilitating forces.

Answer 17

ANS: D

d. Strengthen facilitating forces.

For change to be effective, the facilitators must exceed the force of the barriers; thus, strengthening the facilitating forces would achieve this aim.

Question 18

7. The wound care nurse decided to involve those to be affected by change early in the change management process. This can positively result in:
   a. Coordination.
   b. Resistance.
   c. Anticipation.
   d. Participation.

Answer 18

ANS: D

d. Participation.

Successful change means persistence and advancement of the change, which requires the undivided focus of all team members. Early involvement and participation are critical to capturing the undivided focus of team members.

Question 19

8. The oncology clinic manager and the educational coordinator asked nursing staff to complete a brief written survey to assess their attitudes and knowledge related to having used the new infusion equipment for 6 weeks. The stage of change in this situation is:
   a. Developing awareness.
   b. Experiencing the change.
   c. Integrating the change.
   d. Perceiving awareness.

Answer 19

ANS: C

c. Integrating the change.

This particular initiative assesses the success with which the change has been integrated into everyday practice after it has been experienced, or the degree to which staff members have accepted using the new infusion equipment.

Question 20

9. An example of one strategy to improve participation in the change process by staff fitting the behavioral descriptions of laggards, early majority, late majority, and rejecters is to:
   a. Encourage teamwork.
   b. Transfer to a different unit.
   c. Require attendance at staff meetings.
   d. Delegate the roles and tasks of change.

Answer 20

ANS: D

d. Delegate the roles and tasks of change.

According to Rogers’s work, the individual’s decision-making actions pass through five sequential stages. The decision to not accept the new idea may occur at any stage. However, peer change agents and formal change managers can facilitate movement through these stages by encouraging the use of the idea and providing information about its benefits and disadvantages.

Question 21

10. An example of one strategy used to improve participation in the change process by staff fitting the behavioral description of innovators and early adopters is to:
    a. Repeat the benefits of the change.
    b. Share change experiences early in the process.
    c. Initiate frequent interactions among staff.
    d. Provide select information to the staff.

Answer 21

ANS: B

b. Share change experiences early in the process.

Connecting innovators and early adopters to new ideas and with new peers keeps them at the cutting edge.

Question 22

11. As a new manager, you are shocked to learn that your unit is still using heparin in heparin locks. You are aware of evidence related to this practice and want to change this practice as quickly as possible on your unit. You are in which stage of Lewin’s stages of change?
    a. Unfreezing
    b. Experiencing the change
    c. Moving
    d. Refreezing

Answer 22

ANS: A

a. Unfreezing

Although you may be at a higher level of change in relation to your individual practice and knowledge of the use of change, in this situation, you are recognizing the need for change in relation to practice on the unit that you are managing. This phase is the initial phase in first-order change and will involve listening to staff to see if they perceive a similar problem.

Question 23

12. To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. This learning approach is an example of which change management approach?
    a. Linear
    b. First-order
    c. Facilitative
    d. Integrative

Answer 23

ANS: A

a. Linear

In the second stage, the moving or changing stage of Lewin’s first-order, planned change process, planned interventions and strategies are executed to support the implementation of the change. One commonly used method is educating staff about the need for the change

Question 24

13. To engage your staff in awareness of their current practice and how it is affirmed or not by evidence, you plan a short series of learning presentations on evidence and use of heparin and saline to maintain IV patency. You meet with the educator to plan out the goals for each session with the overall purpose of increasing knowledge and awareness of staff in readiness to consider questions related to the IV practice. Staff nurses who gain information on current IV therapy practices are engaging in which phase of Rogers’ decision-making process?
    a. Persuasion
    b. Knowledge
    c. Confirmation
    d. Decision

Answer 24

ANS: B

b. Knowledge

Rogers’ innovation-decision process involves five stages for change in individuals, the first of which is knowledge.

Question 25

14. Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because “the unit has been using heparin for years and there has never been any adverse effects.” According to Havelock (1973), this comment may originate from failure in which phase of the six phases of planned change? a. Generating self-renewal b. Choosing the solution c. Diagnosing the problem d. Building a relationship

Answer 25

ANS: D d. Building a relationship The first phase of this model of planned change involves building a relationship as a basis for later phases, which include diagnosing the problem and choosing the solution. At this point, as a new manager, the relationship may not have yet developed sufficiently with Elizabeth.

Question 26

15. Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because “the unit has been using heparin for years and there has never been any adverse effects.” You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that “what she has been doing all these years means that she is incompetent and doesn’t care about her patients.” Your response to her indicates that: a. Elizabeth will never adopt the change. b. Elizabeth is insecure in her practice. c. Elizabeth requires more information about the practice. d. Change involves emotions.

Answer 26

ANS: D d. Change involves emotions. Change, whether proactively initiated at the point of change or imposed from external sources, affects people. Responses to all or part of the change process by individuals and groups may vary from full acceptance and willing participation to outright rejection or even rebellion. It is critical to be able to “read” people and to recognize that communication should involve people’s emotions and feelings.

Question 27

16. Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because “the unit has been using heparin for years and there has never been any adverse effects.” You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that “what she has been doing all these years means that she is incompetent and doesn’t care about her patients.” Which of the following would be the most effective response to Elizabeth? a. “I understand how you feel, but you are going to have to change.” b. “It is unfortunate that you feel this way. Others seem quite excited about the new information.” c. “It is difficult sometimes to change what we know very well. Sometimes it can be frightening.” d. “Perhaps I can arrange some more information sessions for you, so you can see just how important this change is to patient safety.”

Answer 27

ANS: C c. “It is difficult sometimes to change what we know very well. Sometimes it can be frightening.” Dialogue can reveal areas where individuals feel inept or overwhelmed, providing the leader with an understanding of what programs need to be developed to increase personal ability to change and what educational initiatives need to be implemented to support change. To promote dialogue, leaders must serve as facilitators, promoting the sharing of ideas, fears, and honest reactions to the change proposal.

Question 28

``` 17. (Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because “the unit has been using heparin for years and there has never been any adverse effects.”) Elizabeth is an example of a(n): a. Early adopter. b. Late majority. c. Laggard. d. Resister. ```

Answer 28

ANS: C c. Laggard. Laggards prefer keeping traditions alive (“We have always done it this way”) and openly express their resistance to ideas (speaking out against the change). Late majority individuals are openly negative but will engage with new ideas when most others adopt the change.

Question 29

18. Elizabeth, an RN with approximately 15 years of service on your unit, walks away from one of the learning sessions on IV care and you overhear her telling a colleague that she thought the session was a waste of time because “the unit has been using heparin for years and there has never been any adverse effects.” You follow up with Elizabeth and discover that she is really quite angry about the information sessions because she feels that you are implying that “what she has been doing all these years means that she is incompetent and doesn’t care about her patients.” After speaking with Elizabeth a few days later you discover that she is now fine with the change but is concerned that other areas of the organization might resist the change because of perceptions related to patient safety and cost. She suggests that it is important to bring pharmacy on board as they have had previous concerns about the use of heparin. In relation to change theory, this is indicative of: a. Systems level thinking. b. Linear thinking. c. Interprofessional collaboration. d. First-order change.

Answer 29

ANS: A a. Systems level thinking. Senge’s complexity theory, Bevan’s Seven Change Factors, and general systems theory all highlight connectivity and the idea that changes are not isolated events.

Question 30

19. Based on Elizabeth’s insights and suggestions, you involve pharmacy, only to discover that the change in practice involves practice committees, a medical practice committee, and concerns from administration about potential costs and safety of the proposed change to the IV protocols. The change process at this point is: a. Linear. b. Nonlinear. c. Sabotaged. d. Neutralized.

Answer 30

ANS: B b. Nonlinear. Complex change involves nonlinear processes and a variety of strategies to negotiate influences on change. Complexity theories alter the traditional systems thinking approach by asserting that system behavior is unpredictable. This theory views change as emergent, nonlinear, and highly influenced by all individuals and subsystems in an organization.

Question 31

20. Resistance is most likely when change: a. Is not well understood. b. Involves many layers in an organization. c. Involves nonprofessional workers. d. Threatens personal security.

Answer 31

ANS: D d. Threatens personal security. Resistance and reluctance commonly occur when personal security is threatened and may involve loss of confidence in abilities or loss of job or financial security.

Question 32

21. As the unit manager on the unit that is leading changes to heparin locks, you find that Elizabeth is very valuable in terms of her observations about other units and her knowledge of organizational processes, and now in discussing the new procedure with others. Elizabeth might be considered an: a. Engager. b. Innovator. c. Informal change agent. d. Informant.

Answer 32

ANS: C c. Informal change agent. Informal change agents are those who do not have formal, positional power but who have credibility through expertise and can model the new way of thinking, or who offer suggestions, ideas, and concerns.

Question 33

22. As the unit manager, you spend a day performing direct patient care and work with a new system that is designed to capture patient documentation at the bedside. During discussions with staff while giving care, you discover that the number of screens that need to be opened during documentation makes charting more complex and time-consuming than traditional manual charting approaches. On the basis of this feedback, you: a. Assume that the system is doing what it needs to do. b. Provide reassurance to staff that the unit has achieved its goals in implementation of the system. c. Ask some of the staff if they have had similar experiences with the system. d. Consult chart audit data and end user consultation reports to determine if errors and problems are occurring.

Answer 33

ANS: D d. Consult chart audit data and end user consultation reports to determine if errors and problems are occurring. In Kotter’s eight-step change model, removing obstacles means keeping alert for barriers in structure and processes that limit the ability to change and then removing those barriers once they have been found.

Question 34

23. You anticipate that your region will soon move towards an e-health record system. You begin to discuss this with your staff and are disappointed that you receive little positive response from the staff about this possibility. One staff member, in particular, seems to sum it up by saying “e-health? Won’t happen in my working life! There are too many problems with it, like privacy issues.” This response is most likely motivated by: a. Lack of urgency regarding the need to change. b. Lack of evidence to support importance of technology. c. Deficits in education and experience. d. Lack of organizational support for change.

Answer 34

ANS: C c. Deficits in education and experience. For leaders to inspire change, they must have intimate knowledge of what matters to the people they manage. Kotter (2012) characterizes this as establishing a sense of urgency, and this involves overcoming complacency. This is especially hard when there doesn’t seem to be any visible crisis, or the crisis seems irrelevant to the people being asked to change (Kotter, 2012).

Question 35

24. Sarah, RN, is one of your most enthusiastic staff members and has been to a workshop on preparing educational materials for patients. On the basis of this workshop, she would like to develop an information Website for patients who are being admitted to the ward. An appropriate response to Sarah’s suggestion would be: a. “That is a great suggestion, but we have no resources for such an expensive undertaking right now.” b. “Perhaps you can keep that in mind as we redesign our charting system.” c. “We have too many seniors as patients, and you know that they don’t use technology.” d. “There is a great group here that meets to look at technology pilots. Let’s see if you can join them and discuss your idea further.”

Answer 35

ANS: D d. “There is a great group here that meets to look at technology pilots. Let’s see if you can join them and discuss your idea further.” Involving Sarah with others who enjoy new ideas and who are able to try out new ideas in pilot projects enables her to remain on the cutting edge and to try out innovative solutions with the least amount of disruption.

Question 36

25. Edith has been vocal about her negative concerns related to a new charting system and frequently expresses the view that keeping the “old system” would have been “just fine.” In facilitating change, your best approach to Edith would be to: a. Put her in the pilot planning group for the change. b. Determine if she has considered retirement. c. Schedule her work assignment so that it coincides with those of two staff members who are confident with technology and the change. d. Avoid discussion of the change, and trust that with sufficient training and information, she will change.

Answer 36

ANS: C c. Schedule her work assignment so that it coincides with those of two staff members who are confident with technology and the change. Laggards prefer keeping traditions and openly express their resistance to new ideas. Having a group of change agents and innovators on board to champion an idea builds what Patterson et al. call “social motivation” and “social ability.” This group can help staff, such as laggards, who are less adept at change.

Question 37

1. Which of the following are examples of application of the Leadership Rounding Tool? (Select all that apply.) a. “What is working well for you during bedside reporting?” b. “What has not worked for you today?” c. “Is there someone on your team who deserves special recognition for her efforts in the implementation?” d. “Did you have a good vacation?”

Answer 37

ANS: A, B, C, D a. “What is working well for you during bedside reporting?” b. “What has not worked for you today?” c. “Is there someone on your team who deserves special recognition for her efforts in the implementation?” d. “Did you have a good vacation?” The Leadership Rounding Tool suggests establishing and maintaining rapport and asking what is working well, what was a barrier, and who should be recognized, as well as answering tough questions.

Question 38

1. A nurse manager is experiencing conflicts between herself and staff members. She had tried to develop a team by using a shared leadership model to empower the staff. Staff members are functioning: a. As a team. b. Independently. c. Interdependently. d. As a group.

Answer 38

ANS: D d. As a group. A group is a collection of interconnected individuals working together, with a high degree of interdependence, for the same purpose. A team is a unified group that is committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable. The conflict indicates that the staff may not be united in a common purpose.

Question 39

2. The nurse manager used a mediator to help resolve conflicts on the unit. During the mediation process, the nurse manager saw signs of potential team-building. One key concept of an effective team is: a. Conflict. b. Task clarity. c. Commitment. d. A designated leader.

Answer 39

ANS: C c. Commitment. Team-building involves moving toward a common vision, which requires commitment. Conflict and clarification of tasks are components in the development of this commitment.

Question 40

3. A mediator suggested that the nurse manager and staff members decide on a method to resolve conflicts. It is important to have agreements about how team members will work together because: a. If there are no agreements, each member will make up rules about how to handle disagreements and relationships. b. People are naturally difficult and will not work well together without such agreements. c. People will naturally ask for agreements about how to be together. d. A way to eliminate nonproductive team members must be available.

Answer 40

ANS: A a. If there are no agreements, each member will make up rules about how to handle disagreements and relationships. People must agree on the goals and mission with which they are involved. They have to reach some understanding of how they will exist together. Tenets or agreements such as “I will respectfully speak promptly with any team member with whom I have a problem” go a long way to avoid gossiping, backbiting, bickering, and misinterpreting others. Without agreement, people have implicit permission to behave in any manner they choose toward one another, including angry, hostile, hurtful, and acting-out behavior.

Question 41

4. By following a shared leadership model, the nurse manager believes that staff members will learn to function synergistically. Some teams function synergistically because members: a. Do not volunteer unwanted information. b. Actively listen to each other. c. Listen to the person who believes he or she is an expert. d. Do not speak unless they are absolutely sure they are correct in their views.

Answer 41

ANS: B b. Actively listen to each other. Active listening in a group creates synergy in that team members really hear one another’s ideas and share in decision making.

Question 42

5. The chief nursing officer decided that the nurse managers need a series of staff development programs on team-building through communication and partnerships. She understood that the nurse managers needed to build confidence in ways of handling various situations. The greatest deterrent to confidence is: a. Lack of clarity in the mission. b. Lack of control of the environment. c. Fear that one can’t handle the consequences. d. Fear that the boss will not like one’s work.

Answer 42

ANS: C c. Fear that one can’t handle the consequences. Fear of not being able to manage consequences undermines confidence and a sense of competency.

Question 43

6. The mediator noticed that tension was still evident between the nurse manager and staff members. He informed the chief nursing officer that to begin team-building, it would be important that everyone: a. Work together in a respectful, civil manner. b. Use avoidance techniques when confronted with a conflict. c. Develop a personal friendship with each other. d. Socialize frequently outside of work.

Answer 43

ANS: A a. Work together in a respectful, civil manner. For team-building to occur, team members need to be able to listen actively and respect one another’s opinions, while feeling comfortable in openly expressing their own

Question 44

7. The state of being emotionally impelled, demonstrated by a sense of passion and dedication to a project or event, describes: a. Commitment. b. Control. c. Willingness to cooperate. d. Communication.

Answer 44

ANS: A a. Commitment. Commitment is described as having a sense of passion and commitment to a project without necessarily having a need to control.

Question 45

8. The mediator suggested to the unit staff that a group agreement needed to be made so meetings could become productive. For example, the group agreement, “We will speak supportively,” prevents: a. Expression of opposing ideas. b. Gossip and making negative comments about absent team members. c. Efforts to ensure that everyone thinks alike. d. Votes that oppose motions.

Answer 45

ANS: B b. Gossip and making negative comments about absent team members. This is an example of a rule that a team can implement to prevent certain negative behaviors such as gossip, backbiting, and bickering that undermine the productivity and functioning of a group.

Question 46

9. The mediator asked each staff member to reflect on his or her communication style. Which of the following best describes communication? Communication: a. Is a reflection of self-analysis. b. Is a result of thoughtful consideration. c. Consists of thoughts, ideas, opinions, emotions, and feelings. d. Focuses on the sender of the message.

Answer 46

ANS: C c. Consists of thoughts, ideas, opinions, emotions, and feelings. Communication involves both senders and receivers and may or may not be a reflection of self-analysis and thoughtful consideration. It always, however, involves thoughts, ideas, opinions, emotions, and feelings.

Question 47

10. The staff development educator developed strategies to help nurse managers actively listen. Guidelines for active listening include which of the following? a. Speed up your internal processes so that you can process more data. b. Realize that the first words of the sender are the most important. c. Be prepared to make an effective judgment of the communication sender. d. Cultivate a desire to learn about the other person.

Answer 47

ANS: D d. Cultivate a desire to learn about the other person Active listening means suspending judgment about what is about to be said and listening to all that is said (and not just the first or last words). It is motivated by a genuine desire to learn about the other person.

Question 48

11. The nurse manager was upset with the staff nurse and said, “You did not understand what I said.” Which element in the communication process was she referring to? a. Feedback between receiver and sender b. A message channel c. A receiver who decodes the message d. A set of barriers that may occur between sender and receiver

Answer 48

ANS: D d. A set of barriers that may occur between sender and receiver Problems can occur at any point in communication and result in miscommunication. In this instance, it can be assumed that there was a sender, a receiver, a channel, and feedback. In this scenario, barriers such as distractions, inadequate knowledge, differences in perceptions, and emotions and personality may have resulted in misunderstanding between the manager and the staff nurse.

Question 49

12. As the nurse manager on a rehab unit, you are asked to come to the tub room immediately because two nursing assistants are having a loud disagreement in front of a patient. You ask the nursing assistants to meet you outside and after ensuring that a third nursing assistant is able to care for the patient, you speak with the two nursing assistants. Which of the following would you ask first? a. “How long have you two been working together?” b. “Have you experienced disagreements like this before?” c. “How do you think this patient’s perception of her care has been changed?” d. “What happened to bring on this disagreement today?”

Answer 49

ANS: D d. “What happened to bring on this disagreement today?” Conflicts are usually based on attempts to protect a person’s self-esteem or to alter perceived inequities in power. When a nurse recognizes upset and reaction, the following steps can be helpful (Sportsman, 2005): Identify the triggering event (“What happened to bring on this disagreement today?”). Discover the historical context for each person. Assess how interdependent each person is on the other. Identify the issues, goals, and resources involved in the situation.

Question 50

13. Sally (RN) and Melissa (RN) have shared an ongoing conflict since the first day that Melissa worked on the unit. Sally has confided to another colleague that she doesn’t even know why the conflict started or what it was about. This is an example of: a. How expectations and objectives need to be made clear in team situations. b. The need to encourage open discussion of disagreements in opinions. c. The importance of involving all staff in discussions in group settings. d. The enduring nature of first impressions.

Answer 50

ANS: D d. The enduring nature of first impressions. First impressions are lasting and, as Sally indicates to her colleagues, are often an unconscious response.

Question 51

14. After staff meetings lately, Sharon, the head nurse, observes her staff in small groups, having animated discussions that end abruptly when she approaches. Sharon reflects on this observation and realizes that: a. Two very outspoken members tend to dominate discussions in meetings. b. This behavior is indicative of a high level of communication among her staff. c. Staff members are very committed to the team and have strong opinions. d. Ongoing discussion outside of meetings is conducive to creativity.

Answer 51

ANS: C c. Staff members are very committed to the team and have strong opinions. When team communication is dominated by a few members, leaving others uninvolved or bored, disagreement is not expressed openly. As a result, team members “stuff” their feelings and wait until after meetings to voice their opinions.

Question 52

15. You are charged with developing a new nursing curriculum and are committed to developing a curriculum that reflects the needs of the profession and of the workplace. To address deficits that may already be present in nursing curricula related to the workplace, you include more content and skills development related to: a. Therapeutic communication with patients. b. Effective communication in the workplace. c. Increased emphasis on sender-receiver dyads. d. Generational differences in communication.

Answer 52

ANS: B b. Effective communication in the workplace. Nursing programs teach therapeutic communications with patients and their families. Little focus, however, is placed on effective communication in the workplace, although communication is essential to building and maintaining smoothly functioning teams

Question 53

16. The SBAR system of communications is one of the most used communication systems in health care because: a. It deals with all aspects of communications in patient care except communication with the physician. b. The nurse is on the same communication level as administration. c. It honors a familiar, structured transfer of information among health professionals. d. It honors an unstructured transfer of information.

Answer 53

ANS: C c. It honors a familiar, structured transfer of information among health professionals. The SBAR system was developed by professionals in the California Kaiser Permanente System and involves direct, respectful communication skills among professionals with the aim of quality patient care.

Question 54

17. In the cardiac intensive care unit, there has been simmering discontent about the new nurse manager, who avoids any discussion about her scheduling and practice decisions. The staff have begun to sort into “different camps” depending on how they feel about the manager or the decisions. Which of the following statements MOST accurately describes this situation? a. The tension that has been generated will result in creative solutions. b. Staff will become a cohesive group that takes a stand against the manager. c. The conflict will result in increased dialogue about practice and scheduling options. d. Patient care may suffer because attention and energy is being diverted toward the unit relationships.

Answer 54

ANS: D d. Patient care may suffer because attention and energy is being diverted toward the unit relationships. Destructive conflict polarizes groups, saps group morale, deepens differences in values, and diverts energy from more important activities, such as patient care. Constructive conflict opens up issues of importance, results in solutions to problems, and enables authentic communication.

Question 55

18. From the information presented in this chapter, which of the following statements best defines an accomplished team? Effective teams: a. Can create a form of synergism in which the outcome is greater than the sum of the individual performances. b. Do not necessarily need goals, objectives, vision, and a clearly stated purpose. c. Do not always have effective communication patterns. d. May or may not have a clear plan that is followed and revisited and has an ongoing evaluation scheme.

Answer 55

ANS: A a. Can create a form of synergism in which the outcome is greater than the sum of the individual performances. Research on team-building over many years has established that high-functioning teams are characterized by synergy that takes the team from a collection of individuals to an outcome that is greater than the sum of the parts.

Question 56

19. “I really wish that my supervisor would realize and acknowledge all the things I do well.” In nursing, this has been identified as a problem. Which statement is part of the solution? Focus on: a. New staff. b. Care assignments with which the individual is not familiar. c. Making corrections. d. The strengths of the individual rather than the weaknesses.

Answer 56

ANS: D d. The strengths of the individual rather than the weaknesses. The research of Rath (2007) included many recommendations, one of which was that focusing on mediocre behaviors and on a person’s weaknesses will not lead to excellence. Focusing on weaknesses tends to decrease the appreciation, and thus the acknowledgements.

Question 57

20. Trust is an important aspect of helping relationships, therapeutic communications, and the positive communications model. Which statement does not involve or define trust? Trust: a. Involves decisions to manipulate situations to gain advantage over another. b. Is the basis by which leaders facilitate the activities and progress of a team. c. Is low among members and leaders in poorly performing teams. d. Involves what we say and not necessarily what we do.

Answer 57

ANS: A a. Involves decisions to manipulate situations to gain advantage over another. Trust is high in high-performing teams and involves not consciously taking advantage of others and behaving in a way that inspires trust. It is the basis by which leaders facilitate the activities and progress of a team.

Question 58

21. Team Member A and Team Member B engage in heated disagreements on a frequent basis in team meetings. Their behavior is characterized by insistence on their points of view and refusal to back down or to negotiate alternative solutions once their ideas have been expressed. This behavior is characteristic of: a. Autocratic leadership. b. Constructive conflict. c. Dualism. d. Creativity.

Answer 58

ANS: C c. Dualism. Our society tends to be dualistic in nature. Dualism means that most situations are viewed as right or wrong, black or white. Answers to questions are often reduced to “yes” or “no.” As a result, we sometimes forget a broad spectrum of possibilities actually exists. Exercising creativity and exploring numerous possibilities are important. This allows the team to operate at its optimal level.

Question 59

22. The unit manager was addressing nursing students in the lounge area and was discussing team leadership and team effectiveness. She stated, “One can agree to disagree with another team member’s perspective even when one doesn’t necessarily see that perspective as being the correct one.” In being creative, what did she mean? a. Championing one’s own opinion. b. Being compassionate c. Being flexible d. Committing to resolution

Answer 59

ANS: D d. Committing to resolution Caregivers must listen to the other person’s perspective, listen to the message accurately, identify differences, and creatively seek resolutions.

Question 60

23. Which of the following would not be a characteristic of an effective team nurse leader? a. An autocratic perspective b. Excellent communication skills c. Awareness of everyone’s abilities d. A genuine interest in team members

Answer 60

ANS: A a. An autocratic perspective In ineffective teams, leadership tends to be autocratic and rigid, and the team’s communication style may be overly stiff and formal. Members tend to be uncomfortable with conflict or disagreement, avoiding and suppressing it rather than using it as a catalyst for change. When criticism is offered, it may be destructive, personal, and hurtful rather than constructive and problem-centered. Team members may begin to hide their feelings of resentment or disagreement, sensing that they are “dangerous.” This creates the potential for later eruptions and discord.

Question 61

24. As a nurse manager, you notice that one of your new nurses has provided exceptional care for a patient with especially complex needs. What would be the MOST effective way of recognizing the nurse’s performance? a. At the next performance review, note specifically what the nurse did to make the patient comfortable. b. To avoid embarrassing the nurse in front of others, find a way to compliment the nurse in private. c. When the nurse comes out of the room, tell the nurse specifically what you appreciated about the care that was provided. d. Encourage the patient to note the care on the patient feedback form so that the institution can recognize the nurse’s efforts.

Answer 61

ANS: C c. When the nurse comes out of the room, tell the nurse specifically what you appreciated about the care that was provided. Acknowledgement is most effective when it is specific, timely, given in public, sincere, and on an eye-to-eye basis. The more time that elapses between the event and acknowledgement, the less effective it becomes.

Question 62

25. What is not a key concept in a well-functioning team? a. Absence of disagreement or conflict b. Special work that is understood and supported by all c. Willingness to work together respectfully d. Dedication to a mission

Answer 62

ANS: A a. Absence of disagreement or conflict The challenge in teams is not to eliminate disagreement or conflict but to recognize when a breakdown in communication occurs. Singleness of mission, willingness to cooperate, and commitment are all key concepts in a well-functioning team.

Question 63

1. Mobilizing others to accomplish extraordinary things requires what leadership behaviors? (Select all that apply.) a. Celebrating the successes of others b. Demonstrating exceptional technical skills c. Imagining possibilities d. Establishing a sense of “being in this together”

Answer 63

ANS: A, C, D a. Celebrating the successes of others c. Imagining possibilities d. Establishing a sense of “being in this together” Leaders who inspire teams to accomplish extraordinary things or to display synergy model the way, inspire shared vision, challenge the status quo, and encourage the heart by celebration of success.

Question 64

1. The staff members in a local Emergency Department are experiencing stress and burnout as the result of excessive overtime. The staff decides to unionize to negotiate for better working conditions. The increase in unionization within health care may be attributed to the: a. Movement from being “blue-collar workers” to being “knowledge workers.” b. Excess profits in health care. c. Level of risk that exists for health care. d. Number of people who are involved in health care.

Answer 64

ANS: D d. Number of people who are involved in health care. As technology replaces unskilled workers, fewer workers are available for trade-union organizing, which has led to declines in union memberships. Nurses represent a large pool of workers who may be available for union organizing in the face of the declining pool available elsewhere.

Question 65

2. The Emergency Department nurses’ decision to organize for the purpose of collective bargaining is being driven by a desire to: a. Establish the staffing pattern that will be used. b. Determine the hours that one is willing to work. c. Create a professional practice environment. d. Protect against arbitrary discipline and termination.

Answer 65

ANS: C c. Create a professional practice environment. Historically, nurses were reluctant to unionize. However, concern with safety of care and quality of care, especially when tension is present in a work environment, makes unionization more desirable. U.S. Supreme Court rulings have provided for RN-only units and protection to practice according to what the profession and licensure status require nurses to do.

Question 66

3. The Emergency Department staff decides to use a collective bargaining model for negotiation rather than a traditional trade union model. A traditional trade union model is characterized by: a. Positional conflict. b. Management support of labor’s initiatives. c. A spirit of trust between management and labor. d. An ability to resolve complaints.

Answer 66

ANS: A a. Positional conflict. Collective bargaining encompasses management support of labor’s initiative, a spirit of trust between labor and management, and resolution of problems. It replaces the positional conflict that has been associated with traditional trade unions. Models such as the interest-based problem solving (IBPS) model seek to avoid positional conflicts such as those between labor and management that do not take into account the opposing party in any way.

Question 67

4. The chief nursing officer utilizes the hospital’s workplace advocacy to help the overwhelmed Emergency Department staff. Workplace Advocacy is designed to assist nurses by: a. Creating professional practice climates in their institutions. b. Equipping them to practice in a rapidly changing environment. c. Negotiating employment contracts. d. Representing them in labor-management disputes.

Answer 67

ANS: B b. Equipping them to practice in a rapidly changing environment. Workplace advocacy encompasses a number of activities that enable nurses to control the practice of nursing and to address challenges that they face in the practice setting. These activities include career development, employment rights, employment opportunities, and the labor-management relationship. The aim of workplace advocacy is to proactively equip nurses to practice within a rapidly changing environment, rather than to negotiate contracts or provide representation in employment disputes.

Question 68

5. Nursing labor management partnerships: a. Engage nurses at all levels in problem solving for better patient care. b. Require unions and management to negotiate in good faith regarding hours of work and wages. c. Have been shown to have negligible effects on nurse turnover and patient outcomes. d. Have typically resulted in increased polarization of nurses and management, leading to formation of collective bargaining units.

Answer 68

ANS: A a. Engage nurses at all levels in problem solving for better patient care. The development of a nursing labor management partnership is an approach that can be used in most professional nursing environments. This process recognizes nurses as leaders on all levels and provides formal and informal mechanisms for professional nurses to work together to achieve shared goals through collaboration and shared decision making or decentralized decision making. A study of a nursing labor management partnership suggested that nurse satisfaction was higher, turnover was lower, and more time was available for patient care.

Question 69

6. A Magnet™ hospital surveys the staff about job satisfaction. This type of environment, in which nurses have authority and autonomy, is linked with: a. Client satisfaction with the healthcare organization. b. Organizations with a limited number of nurse managers. c. Private, specialty organizations in urban areas. d. Sophisticated academic health sciences universities.

Answer 69

ANS: A a. Client satisfaction with the healthcare organization. Autonomy and authority in decision making that is consistent with scope of practice are linked both to higher job satisfaction and to higher patient satisfaction with care. Job satisfaction is an important indicator of the quality of patient care.

Question 70

7. In a nurse managers’ meeting, strategies for ways to help retain staff are discussed. One strategy for assisting nurses in developing collective action skills is: a. Accepting the practice of “going along to get along.” b. Attending as many workshops as practical. c. Spending as much time as possible in clinical settings. d. Taking the opportunity to work with a mentor.

Answer 70

ANS: D d. Taking the opportunity to work with a mentor. Mentoring facilitates development and adoption of positive interaction and other skills that facilitate good decision making. Optimism, trust, and decision making are important in collective action and shared decision making and contribute to job satisfaction and lower turnover in staff.

Question 71

8. While making rounds, a night supervisor finds a unit with a low census and too many staff members. The night supervisor is performing as a statutory supervisor when he or she: a. Assigns nurses to care for specific clients. b. Develops a protocol for unlicensed personnel. c. Recommends transferring a nurse to another service. d. Teaches a nurse to use a new piece of equipment.

Answer 71

ANS: C c. Recommends transferring a nurse to another service. The night supervisor is acting in accordance with the National Labor Relations Act, which would enable the supervisor to assign nurses to care.

Question 72

9. The Emergency Department staff members are concerned that working long hours without rest puts patient safety at risk. One staff member decides that she will risk her job and become a whistleblower. Whistle-blowing is an appropriate recourse when management: a. Disregards due process when disciplining a nurse. b. Delays responding to repeated efforts to provide safe care. c. Hires nurses who are not a part of the union during a strike. d. Refuses to bargain in good faith with the elected bargaining agent.

Answer 72

ANS: B b. Delays responding to repeated efforts to provide safe care. Whistle-blowing is often a result of organizational failure, including failure of the organization to respond to serious danger or wrongdoing created within the environment, which, in this instance, involves conditions that put the patient at risk.

Question 73

10. As a new nurse manager who has “inherited” a unit with high nurse turnover and complaints of patient dissatisfaction, your first course of action would be to: a. Determine levels of nurse engagement on the unit. b. Review the personnel files of nurses who have resigned. c. Interview upper management about their vision for the unit. d. Meet with your staff to clarify your vision for the unit.

Answer 73

ANS: A a. Determine levels of nurse engagement on the unit. Multiple studies demonstrate that a healthcare organization that provides a climate in which nurses have authority and autonomy has better patient outcomes, retains nurses at a higher rate, is more cost-effective, and has evidence of greater patient satisfaction than an organization in which such a climate does not exist (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Dunton, Gajewski, Klaus, & Pierson, 2007). Organizational assessment assists in identifying the reasons for high nurse turnover and patient complaints.

Question 74

11. In an inner-city area, a group of nurses meet and develop a plan to negotiate with local businesses to support a breakfast program for young elementary schoolchildren. This is an example of: a. Community development. b. Collective bargaining. c. Collective action. d. Shared governance.

Answer 74

ANS: C c. Collective action. Collective action refers to activities undertaken by a group of people with common interests and, in this example, by a group of nurses who are interested in the welfare of children in their community.

Question 75

12. In accomplishing the goal of breakfast for children in elementary school, Leanne is particularly effective in approaching businesses with the needs that the group has determined and articulating the ways that the group has found for businesses to participate. Leanne is exemplifying: a. Leadership. b. Followership. c. Professionalism. d. Knowledge of context.

Answer 75

ANS: B b. Followership. Effective followership involves active and loyal involvement in an agenda that has been established. In this role, Leanne is supporting and operationalizing the agenda and strategies that have been established within the group.

Question 76

13. Awareness and use of power have been challenging for nurses in general because of: a. Incidences of punishment by authority figures. b. Too little time in the workplace to collectively develop power strategies. c. Lack of cohesiveness and unity among nurses. d. A tradition of obedience to authority.

Answer 76

ANS: D d. A tradition of obedience to authority. Rituals and traditions such as the Nightingale Pledge have emphasized the need for the “good nurse” to be obedient to authority. This prevailing attitude has made it difficult for nurses, who typically spend considerable time in the workplace and who have opportunity through their work in teams to develop cohesiveness and unity, to develop awareness and use of power.

Question 77

14. Collective action is effective in: a. Ensuring that needs of nurses are placed ahead of other disciplines. b. Defining nursing as a profession. c. Advising patients of the needs of nurses. d. Amplifying the influence of individuals.

Answer 77

ANS: D d. Amplifying the influence of individuals. Individuals may have limited influence in achieving various purposes such as advancement of quality care or of the profession, whereas collective action helps to define and sustain individuals in achieving the desired purposes.

Question 78

15. Nurses on the dialysis unit notice that changes in labeling of fluids have meant several alarming near misses in terms of wrong administration of fluids. They take this concern to the unit manager. As an advocate of nurse autonomy, the most appropriate response in this situation would be to: a. Ensure that the nurses are aware of the reasons for the change and how the decision was made about the new labels. b. Discuss concerns about the labels and develop potential solutions that take into account changes that can be made at the local level and those that need system intervention. c. Suggest that the staff wait until they have become more familiar with the labels before taking further action. d. Tell the staff that you will notify the pharmacy about these concerns and leave it up to the pharmacy to decide what should be done.

Answer 78

ANS: B b. Discuss concerns about the labels and develop potential solutions that take into account changes that can be made at the local level and those that need system intervention. Participation in decision making regarding one’s practice is an appropriate expectation for professional nurses, provides for greater autonomy and authority over practice decisions, contributes to supporting the professional nurse, and is a major component of job satisfaction (Kramer et al., 2008; Pittman, 2007). Autonomy is encouraged through supportive management and through unit-level support of changes without the need for complex, multilevel approval of changes that can be made locally.

Question 79

16. Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Martin’s follow-up to complaints from the community is: a. Appropriate and indicates that he has assumed accountability for the actions of his staff. b. Indicative that he does not clearly understand the concept of accountability. c. Indicative of strong support for his staff and their autonomy. d. Important in clarifying the difference between his accountability and that of the community in patient care.

Answer 79

ANS: B b. Indicative that he does not clearly understand the concept of accountability. Accountability refers to the achievement of desired outcomes. If community agencies are noticing that limited or no change in patient behavior has occurred despite teaching on the unit, then the staff has not achieved accountability, and he is not holding his unit responsible for the outcomes. Martin is also demonstrating lack of accountability.

Question 80

17. Sarah determines, in partnership with her patient, that current medications are not enabling her patient, a married account executive with fibromyalgia, to continue with her employment and family responsibilities. After searching for additional information on fibromyalgia, Sarah finds nonpharmacologic interventions that are supported through credible evidence. Sarah suggests that the patient, her physician, and she meet to discuss the medications and possible options and a plan of care for the patient’s discharge. This action exemplifies which of the four historical concepts identified by Lewis and Batey? a. Authority b. Responsibility c. Communication of conflict d. Autonomy

Answer 80

ANS: A a. Authority Authority refers to the use of professional status and power to act in the patient’s best interests. In this example, Sarah is using her professional status and power to set up a conference in which her patient, the prescribing physician, and she can discuss what is not working for the patient and potential options.

Question 81

18. In looking at an organizational chart for her institution, Jennifer notes that nursing is led at the senior level by a non-nurse executive. Jennifer expresses concern that this is a reflection of how nursing is viewed within the organization. Jennifer’s comments reflect: a. A concern that resource allocation will be made on a business and not a professional model. b. The dissatisfaction that occurs when lack of autonomy is given to nurses. c. Concern with the nonadvancement of nursing practice in the institution. d. An awareness of how organizational culture is reflected in organizational structure.

Answer 81

ANS: D d. An awareness of how organizational culture is reflected in organizational structure. The organizational chart reflects the formal structure of the organization and can reflect predominant beliefs, values, and relationships in the organization. Exclusion at senior executive levels of nurse leaders may reflect institutional beliefs about how resources are allocated, the degree of autonomy given to staff, and involvement of key groups in decision making.

Question 82

19. Government and third-party payers announce reduction of compensation for the delivery of patient services. Hospital STV has a flat organizational structure. After the funding announcements, senior officials at the hospital meet and make decisions regarding cost containment of new revenue streams. This action is consistent with: a. The practice of leaving financial decisions with senior officials who understand the total context of funding. b. A tendency to concentrate decision making during economic downturns at the top administrative level. c. A need to make expedient decisions that are likely to be poorly received by staff. d. Ensuring that decisions with regard to cost are made equitably across all departments.

Answer 82

ANS: B b. A tendency to concentrate decision making during economic downturns at the top administrative level. During times of economic downturn, decisions tend to become very centralized to avoid risk. History demonstrates that increasing the breadth of input during these times is more effective than narrowing it.

Question 83

20. In Hospital STV, senior administration is strongly oriented toward fiscal and social conservatism. The nursing department is deeply concerned with the provision of quality to the community, which includes a high number of poor and unemployed. To accomplish the goals of the nursing department, resources need to be allocated that administration is not able to allocate. Nursing and administration: a. Are engaged in shared governance. b. Are involved in an irreconcilable conflict of interests. c. Represent separate subcultures in the institution. d. Represent union and nonunion conflict.

Answer 83

ANS: C c. Represent separate subcultures in the institution. Institutions can have several subcultures, which are represented by unique features and distinct ideologies. Subcultures can be congruent and can support healthy relationships in the organization, or they may be separated and characterized by tensions that may be irreconcilable and destructive. From the information given in this scenario, it is not evident that shared governance, union presence, or irreconcilable differences are present.

Question 84

21. On Unit 62, the nurses and the unit manager have been involved in shared decision making related to the model of nursing care delivery that the unit will adopt. All individuals have participated and been involved in decision making and implementation of changes. When issues arise during implementation, it is expected that: a. Accountability resides entirely with the unit manager. b. Individual expertise will be utilized to provide solutions, but that responsibility for the change is shared. c. No one really has any accountability or responsibility for the changes. d. This will contribute to widespread skepticism among the staff about the probability of success.

Answer 84

ANS: B b. Individual expertise will be utilized to provide solutions, but that responsibility for the change is shared. High-performing organizations provide for participation by all stakeholders, and each stakeholder shares responsibility and risk. This kind of environment is more satisfying for nurses and is characterized by optimism and trust.

Question 85

22. Senior executives at Hospital A determine that the hospital will engage in a strategic planning process after changes in healthcare funding and concerns expressed in the community about care that is being delivered at the hospital. The senior executives decide on a participatory process in which staff are widely consulted regarding input about the organization and the external environment and are actively invited to be part of decisions related to the mission statement, goals, and objectives. For true shared governance to be seen as part of this approach: a. It must be evident in the outcomes of the process that staff and senior executives have partnered on the decisions. b. Stakeholders must be assured of the value of their input even though final decisions rest with senior executives. c. Publications must clearly outline how staff input was solicited and obtained. d. Staff must be reassured that significant concerns will be kept in mind even if they have not been addressed in planning documents.

Answer 85

ANS: A a. It must be evident in the outcomes of the process that staff and senior executives have partnered on the decisions. Shared governance demands participation in decision making. When partnership, equity, and ownership are not involved, then shared governance has not occurred, and publication and expressions of appreciation for input will not be seen as representative of shared governance.

Question 86

23. Nurses in an Emergency Department, in an inner-city neighborhood characterized by high levels of violence, are concerned with low levels of security presence in their department. Security levels have recently been decreased and the nurses question why this has occurred. An appropriate action would be to: a. Provide nurses with information about rationale for recent changes in security staffing. b. Refer the matter to the head of security and let her deal with it. c. Provide mentors who can help nurses diffuse aggressiveness. d. Accept the security levels as a consequence of funding realities.

Answer 86

ANS: A a. Provide nurses with information about rationale for recent changes in security staffing. Workplace advocacy is an umbrella term encompassing activities within the practice setting. Workplace advocacy includes an array of activities undertaken to address the challenges faced by nurses in their practice settings. The focus of these activities is on career development, employment opportunities, terms and conditions of employment, employment rights and protections, control of practice, labor-management relations, occupational health and safety, and employee assistance. The objective of workplace advocacy is to equip nurses to practice in a rapidly changing environment. One manifestation of workplace advocacy is ensuring that relevant information is shared about decisions that affect practice so that further data gathering and decision making (in this instance about security levels and nurse safety) is informed.

Question 87

24. You are hired as a new manager. When the offer of employment is made, you agree to at-will employment. Later, you become very concerned about the policies and practices of your organization and their impact on patient care. You speak with your supervisor several times about your concerns, but no action is taken. In considering your next steps, you: a. Consider your increased vulnerability under the terms of your employment. b. Recognize that your supervisor is more vulnerable than you are because of her more senior position. c. Are more likely as a leader to take action because you are well protected from repercussions by federal and state regulations. d. Contact your union to discuss your concerns and review your options.

Answer 87

ANS: A a. Consider your increased vulnerability under the terms of your employment. Managers of at-will employees have greater latitude in selecting disciplinary measures for specific infractions. State and federal laws do provide a level of protection; however, an at-will employee may be terminated at any time for any reason except discrimination. At-will employees, in essence, work at the will of the employer. Nurses in these positions need to know their rights and accountability.

Question 88

25. Sandra, an RN on the surgery unit, is assisting with a procedure in the patient examination room. The physician orders a medication to be given through IV. Sandra questions the order, based on her knowledge of the patient’s history and of other medications that the patient has been given. The physician reiterates the order and Sandra refuses to give it. In this instance, Sandra is demonstrating: a. Autonomy. b. Accountability. c. Authority. d. Best practice.

Answer 88

ANS: A a. Autonomy. In this situation, Sandra is exemplifying autonomy, which is the act of making independent decisions in the best interests of the patient, based on her knowledge and experience. This is analogous to the example in the text where the workers on the manufacturing floor have the independence to say “Stop the line” when something is wrong. Key to the concept of autonomy is decision making and the level of independence that is given. Accountability refers to achievement of outcomes, and authority refers to the capacity to make decisions.

Question 89

1. Martin, the unit manager, receives complaints from community agencies that patients who have been discharged from his unit seem to lack understanding about their disorder and immediate strategies for managing elements of their care. Martin checks the patient teaching sheets and notes that the sheets are initialed by staff. He calls the agencies and indicates that teaching has been done. Potential outcomes of Martin’s actions include (select all that apply): a. Poor morale on the unit. b. Disruption in community relationships. c. Corruption of patient-staff relationships. d. Patient outcomes for quality care are met.

Answer 89

ANS: A, B, C a. Poor morale on the unit. b. Disruption in community relationships. c. Corruption of patient-staff relationships. Kupperschmidt (2004) points out that when accountability is not accepted, then relationships suffer, professional practice is diminished, and self-esteem suffers.

Question 90

1. A new graduate is asked to serve on the hospital’s quality improvement (QI) committee. The nurse understands that the first step in quality improvement is to: a. Collect data to determine whether standards are being met. b. Implement a plan to correct the problem. c. Identify the standard. d. Determine whether the findings warrant correction.

Answer 90

ANS: C c. Identify the standard. Before further action (data collection, decision making related to correction, and implementation of a plan) can occur, it is necessary to identify the standards against which data collection and decision making will occur. Institutions may or may not adopt standards that are already established by organizations such as the ANA.

Question 91

2. The chief executive officer asks the nurse manager of the telemetry unit to justify the disproportionately high number of registered nurses on the telemetry unit. The nurse manager explains that nursing research has validated which statement about a low nurse-to-patient ratio? It: a. Promotes teamwork among healthcare providers. b. Increases adverse events. c. Improves outcomes. d. Contributes to duplication of services.

Answer 91

ANS: C c. Improves outcomes. Studies related to staffing and patient outcomes suggest that patient outcomes are improved with a low nurse-to-patient ratio and especially with a low registered nurse-to-patient ratio.

Question 92

3. A nurse manager wants to decrease the number of medication errors that occur in her department. The manager arranges a meeting with the staff to discuss the issue. The manager conveys a total quality management philosophy by: a. Explaining to the staff that disciplinary action will be taken in cases of additional errors. b. Recommending that a multidisciplinary team should assess the root cause of errors in medication. c. Suggesting that the pharmacy department should explore its role in the problem. d. Changing the unit policy to allow a certain number of medication errors per year without penalty.

Answer 92

ANS: B b. Recommending that a multidisciplinary team should assess the root cause of errors in medication. Quality management stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.

Question 93

4. The nurse educator of the pediatric unit determines that vital signs are frequently not being documented when children return from surgery. According to quality improvement (QI), to correct the problem, the educator, in consultation with the patient care manager, would initially do which of the following? a. Talk to the staff individually to determine why this is occurring. b. Call a meeting of all staff to discuss this issue. c. Have a group of staff nurses review the established standards of care for postoperative patients. d. Document which staff members are not recording vital signs, and write them up.

Answer 93

ANS: B b. Call a meeting of all staff to discuss this issue. Leadership must identify safety shortcomings and must locate resources at patient care levels to identify and reduce risks. One method of doing this is to invite all staff into a discussion related to solutions to an identified concern. This approach encourages teamwork.

Question 94

5. A nurse is explaining the pediatric unit’s quality improvement (QI) program to a newly employed nurse. Which of the following would the nurse include as the primary purpose of QI programs? a. Evaluation of staff members’ performances b. Determination of the appropriateness of standards c. Improvement in patient outcomes d. Preparation for accreditation of the organization by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Answer 94

ANS: C c. Improvement in patient outcomes The primary purpose of QI is improvement of patient outcomes, which relates to prevention of error, quality patient care, and patient satisfaction.

Question 95

6. Before beginning a continuous quality improvement project, a nurse should determine the minimal safety level of care by referring to the: a. Procedure manual. b. Nursing care standards. c. Litigation rate of unsafe practice. d. Job descriptions of the organization.

Answer 95

ANS: B b. Nursing care standards. Standards establish the minimal safety level of care. Procedure manuals provide information about how standards are to be achieved.

Question 96

7. The nurse gives an inaccurate dose of medication to a patient. After assessment of the patient, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication understands that: a. The error will result in suspension. b. An incident report is optional for an event that does not result in injury. c. The error will be documented in her personnel file. d. Risk management programs are not designed to assign blame.

Answer 96

ANS: D d. Risk management programs are not designed to assign blame QM stresses improving the system, and the detection of staff errors is not stressed. If errors occur, reeducation of staff is emphasized rather than imposition of punitive measures such as disciplinary action or blaming.

Question 97

8. The nurse manager is concerned about the negative ratings her unit has received on patient satisfaction surveys. The first step in addressing this issue from the point of view of quality improvement is to: a. Assemble a team. b. Establish a benchmark. c. Identify a clinical activity for review. d. Establish outcomes.

Answer 97

ANS: C c. Identify a clinical activity for review. In theory, any and all aspects of clinical activity could be improved through the QI process. However, QI efforts should be concentrated on changes to patient care that will have the greatest effect.

Question 98

9. With the rise of violence in the psychiatric department, the nurse manager decides that she should work with the risk manager in violence prevention. The nurse manager should: a. Request all staff to accept new risk management practices. b. Hold staff accountable for safe practices. c. Document inappropriate behavior. d. Hire more police security.

Answer 98

ANS: B b. Hold staff accountable for safe practices. Active involvement of staff in risk management activities is key to prevention of adverse events. Nursing has a primary role in leadership in optimizing patient outcomes, preventing patient care issues, and mitigating adverse events. Accountability for safety can be one aspect of performance evaluations.

Question 99

10. A new RN staff member asks you about the difference between QA and QI. You explain the difference by giving an example of QI. a. “Last year, the management team established new outcomes that addressed issues such as medication errors.” b. “At a staff meeting last year, two of our staff commented on the number of recent falls and asked, ‘What can we do about it?’” c. “A process audit was done recently to determine how much time was being spent on patient documentation.” d. “Errors are reported on our new computerized forms, and I follow up with staff to make sure that they understand the seriousness of their error.”

Answer 99

ANS: B b. “At a staff meeting last year, two of our staff commented on the number of recent falls and asked, ‘What can we do about it?’” In QI, followers invest in the process by continually asking “What makes this indicator important to measure?” “What has been done to improve it?” “What can I do to improve it?”

Question 100

11. Healthcare organization X is committed to improving patient outcomes and, as part of the QI process, examines its executive structure and organizational design. This approach recognizes: a. The importance of decentralized structure in QA. b. That structure influences nurse burnout and participation in quality improvement initiatives. c. The need to ensure sufficient supervisory staff to respond in a corrective manner when mistakes occur. d. That a narrow hierarchy ensures accountability for errors and outcomes.

Answer 100

ANS: B b. That structure influences nurse burnout and participation in quality improvement initiatives. Common organizational characteristics of Magnet™ hospitals include structure factors (e.g., decentralized organizational structure, participative management style, andinfluential nurse executives) and process factors (e.g., professional autonomy and decision making, ongoing professional development/education, active quality improvement initiatives). ANCC Magnet™ designated hospitals and other high-reliability organizations in the United States and Europe generally have lower burnout rates, higher levels of job satisfaction, and provide higher levels of quality care resulting in greater levels of patient satisfaction (Aiken et al., 2012; Kelly, McHugh, & Aiken, 2011).

Question 101

12. Hospital ABCD is a Magnet™ hospital. This designation has been applied to Hospital ABCD because it: a. Facilitates active staff participation in decision making related to quality nursing care. b. Has implemented a graduate nurse orientation program. c. Espouses commitment to excellence in patient care. d. Is establishing career ladders for nurses.

Answer 101

ANS: A a. Facilitates active staff participation in decision making related to quality nursing care. Magnet™ hospitals are particularly successful in implementing excellence in patient care through use of standards, evidence, and participatory decision making in quality improvement. Organizations that cannot pursue Magnet™ status can implement strategies such as career ladders.

Question 102

13. A nursing-led classification system that has led to greater reliability and standardization in data utilized for QI processes is: a. NANDA. b. AHRQ. c. NIOSH. d. Nursing process.

Answer 102

ANS: A a. NANDA. NANDA has been developed by nurses and uses standardized terminology that enables study of health problems across populations, settings, and caregivers.

Question 103

14. In determining the relationship between injury-producing falls and proposed preventive measures as part of the QI process, a QI team might turn to which of the following for confirmatory evidence? a. NDNQI b. NANDA c. NIOSH d. AHRQ

Answer 103

ANS: A a. NDNQI The National Database of Nursing Quality Indicators is a national, nursing quality measurement program from the American Nurses Association that provides hospitals with unit-level performance reports with comparisons to national averages and rankings.

Question 104

15. A method commonly used in Quality Assurance to monitor adherence to established standards is: a. A Pareto chart. b. Brainstorming. c. Patient interviews. d. Chart audit.

Answer 104

ANS: D d. Chart audit. Chart audits are a common method of addressing process standards. Chart audits over time yield trend charts.

Question 105

16. Hospital Magnet™ decides against creating a separate department to lead and monitor quality activities because: a. Total organizational involvement is critical to QI. b. Data generated by a single, separate department are generally flawed. c. Monitoring and commitment to QI can come only from senior-level managers. d. Staff resent suggestions for improvement that originate outside of their unit.

Answer 105

ANS: A a. Total organizational involvement is critical to QI. Decentralized approaches are effective in developing unit-level solutions, as well as commitment to strategies and implementation of changes.

Question 106

17. As a nurse manager, you know that the satisfaction of patients is critical in making QI decisions. You propose to circulate a questionnaire to discharged patients, asking about their experiences on your unit. Your supervisor cautions you to also consider other sources of data for decisions because: a. The return rate on patient questionnaires is frequently low. b. Patients are rarely reliable sources about their own hospital experiences. c. Hospital experiences are frequently obscured by pain, analgesics, and other factors affecting awareness. d. Patients are reliable sources about their own experiences but are limited in their ability to gauge clinical competence of staff.

Answer 106

ANS: D d. Patients are reliable sources about their own experiences but are limited in their ability to gauge clinical competence of staff. Patients are reliable and motivated sources of their own experience but often do not have sufficient knowledge of clinical procedures to provide feedback about clinical competence.

Question 107

18. An example of an effective patient outcome statement is: a. Eighty percent of all patients admitted to the Emergency Department will be seen by a nurse practitioner within 3 hours of presentation in the Emergency Department. b. Patients with cardiac diagnoses will be referred to cardiac rehabilitation programs. c. The hospital will reduce costs by 3% through the annual budget process. d. Quality is a desired element in patient transactions.

Answer 107

ANS: A a. Eighty percent of all patients admitted to the Emergency Department will be seen by a nurse practitioner within 3 hours of presentation in the Emergency Department. Patient outcomes must be measurable, specific, and patient-centered.

Question 108

19. Patient perceptions are useful in: a. Determining disciplinary actions in QI. b. Establishing the competitive advantage of QI decisions. c. Providing one source of data for QI initiatives. d. Establishing blame for poor-quality care.

Answer 108

ANS: C c. Providing one source of data for QI initiatives. Customers define quality and patient dissatisfaction as useful indicators of which areas are of greatest concern to patients and of what matters then to nurses and organizations. Patient perceptions guide areas of inquiry; however, they do not establish what disciplinary decisions will be made.

Question 109

20. Through the QI process, the need to transform and change the admissions process across administrative and patient care units is identified. In this particular situation, what method of data organization will be most effective? a. Flowchart b. Histogram c. Narrative d. Line graphs

Answer 109

ANS: A a. Flowchart Flowcharts are useful in identifying and visualizing sequential steps, such as the admissions process.

Question 110

21. A nursing unit is interested in refining its self-medication processes. In beginning this process, the team is interested in how frequently errors occur with different patients. To assist with visualizing this question, which organizational tool is most appropriate? a. Histogram b. Flowchart c. Fishbone diagram d. Pareto chart

Answer 110

ANS: A a. Histogram Histograms are bar graphs that are useful in outlining and identifying frequency.

Question 111

22. The outcome statement “Patients will experience a ten percent reduction in urinary tract infections as a result of enhanced staff training related to catheterization and prompted voiding” is: a. Physician-sensitive and nonmeasurable. b. Measurable and nursing-sensitive. c. Precise, measurable, and physician-sensitive. d. Patient care–centered and nonmeasurable.

Answer 111

ANS: B b. Measurable and nursing-sensitive. Nursing-sensitive outcomes refer to outcomes that are affected by nursing activity and are precise, measurable, and patient-centered.

Question 112

23. Your institution has identified a recent rise in postsurgical infection rates. As part of your QI analysis, you are interested in determining how your infection rates compare with those of institutions of similar size and patient demographics. This is known as: a. Quality assurance. b. Sentinel data. c. Benchmarking. d. Statistical analysis.

Answer 112

ANS: C c. Benchmarking. Benchmarking is a widespread search to identify the best performance against which to measure practices and processes.

Question 113

24. At Hospital Ajax, there has been a 20% increase in instruments and sponges being left in patients during surgery and surgeries on the wrong limbs. These are known as: a. Sentinel events. b. Medically sensitive events. c. Nurse-sensitive events. d. Never events.

Answer 113

ANS: D d. Never events. The NQF and CMS define never events as errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients and that indicate a real problem in the safety and credibility of a healthcare facility. Examples of never events include surgery on the wrong body part, foreign body left in a patient after surgery, mismatched blood transfusion, major medication error, severe pressure ulcer acquired in the hospital, and preventable postoperative deaths.

Question 114

1. Examples of sentinel events include (select all that apply): a. Forceps left in an abdominal cavity. b. Patient fall, with injury. c. Short staffing. d. Administration of morphine overdose. e. Death of patient related to postpartum hemorrhage.

Answer 114

ANS: A, B, D, E a. Forceps left in an abdominal cavity. b. Patient fall, with injury. d. Administration of morphine overdose. e. Death of patient related to postpartum hemorrhage. Sentinel events are serious, unexpected occurrences involving death or physical or psychological harm.

Question 115

1. The chief nursing officer decides to establish a client advocacy position in an oncology unit. Advocacy is best represented by: a. Establishing private and professional networking systems. b. Asking social services to handle clients’ concerns. c. Identifying community support groups. d. Empowering others by promoting self-determination.

Answer 115

ANS: D d. Empowering others by promoting self-determination. Advocacy involves empowering and promoting self-determination in others.

Question 116

2. As part of performance appraisal, the nurse manager designs strategies to acknowledge staff members. What practices by the nurse manager best acknowledge staff accountability and contribution? a. Providing new and varied learning experiences for staff members b. Fostering group cohesiveness through standardization of unit activities c. Allowing professionals greater influence over their practices d. Giving recognition for success and support for failure to staff members

Answer 116

ANS: C c. Allowing professionals greater influence over their practices Facilitating greater control over practices implies trust and acknowledges expertise and performance.

Question 117

3. The nurse manager understands that the three Ps associated with client education are philosophy, priority, and performance. Effective client education programs start with a shared philosophy that such programs are worth the investment. Evidence of a philosophic commitment to client teaching is best represented by: a. Investing time and energy in teaching clients. b. Developing teaching skills among the nursing staff. c. Assuming that clients lack the knowledge they need. d. Having a teaching checklist on clients’ charts.

Answer 117

ANS: A a. Investing time and energy in teaching clients. A philosophy that patient education is an investment with a significant positive return is one of the three Ps of a successful consumer education focus. Money invested in teaching is money well spent.

Question 118

4. The nurse manager on a pediatric intensive care unit wants to evaluate patient satisfaction. The nurse manager understands that ultimately, positive relationships with consumers of care are evaluated by the: a. Cultural sensitivity of staff. b. Cost-effectiveness of care delivery. c. Economic value of service. d. Outcomes for clients and their perceptions of care.

Answer 118

ANS: D d. Outcomes for clients and their perceptions of care. Trend-setting organizations such as MagnetTM organizations need to demonstrate excellence in outcome data such as patient satisfaction. Patient satisfaction and perception of the quality of care are affected by the quality of the nurse-patient relationship. Valid measurement of patient satisfaction is an evolving science; nurses do not always accurately gauge what factors are most important to patients. Satisfaction measures are often skewed in a positive direction with scores clustered at the top of the scale.

Question 119

5. The nurse manager has to develop a patient satisfaction survey. What is one of the critical elements in selecting a patient satisfaction instrument? a. Being able to use the same instrument for all clinical units b. Including items that are important from the patient’s perspective c. Being able to administer the instrument before a patient’s discharge from the hospital d. Being sure that the reading level is no higher than third grade

Answer 119

ANS: B b. Including items that are important from the patient’s perspective Because satisfaction is a measure of service and service is a measure of perception of what matters to the patient, to measure satisfaction, surveys must include items that reflect the perspective of the patient. The quality of human contacts becomes the measure by which the consumer forms perceptions and judgments about nursing and the health agency. Consumers may not be able to evaluate the quality of interventions, but they always can evaluate the quality of the relationship with the person delivering the service.

Question 120

6. In writing the patient satisfaction survey, the nurse manager is aware of the education levels of the families. What is the most critical element in the concept of health literacy? a. Providing instructional materials at appropriate reading levels b. Facilitating access to translators for persons with language barriers c. Obtaining, processing, and understanding basic health information so appropriate decisions can be made d. Knowing that most people have limited health literacy skills

Answer 120

ANS: C c. Obtaining, processing, and understanding basic health information so appropriate decisions can be made The definition of health literacy used by the federal government is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (U.S. Department of Health and Human Services, 2010).

Question 121

7. The nurse manager analyzes the data from the patient satisfaction surveys. What can a nurse manager do to strengthen service recovery and improve consumer relationships? a. Post comparisons of patient satisfaction scores with those of other units on a monthly basis. b. Involve the staff in resolving consumer issues quickly and effectively. c. Ensure that staff members apologize to patients when they complain about services. d. Ask that patients with complaints about services place them in a written format.

Answer 121

ANS: B b. Involve the staff in resolving consumer issues quickly and effectively. Consumers need to be treated with fairness, given explanation, and provided with information about how errors will be prevented in the future. Staff can be assisted to respond to patient concerns through scripting, support, and an atmosphere that places an emphasis on learning and solutions rather than on blaming.

Question 122

8. Based on data from the patient satisfaction survey, the nurse manager decides that a change should be made in communication with family members. What would be important for a nurse manager to consider when instituting a change to improve customer service? a. Assess the perceptions of the nursing staff regarding the particular service problem. b. Include community representatives on a planning committee to address the change. c. Involve physicians, other healthcare professionals, and ancillary staff. d. Review all patient complaints with the nursing staff.

Answer 122

ANS: A a. Assess the perceptions of the nursing staff regarding the particular service problem. Nurses are the healthcare providers who spend the most time with the consumer and are in an opportune position to understand the issues, structures, and processes that affect patients. The nurse acts as the primary person to be alert to circumstances that may prevent a successful outcome for the patient and to intervene on the patient’s behalf. As a nurse manager, it is important to support staff in their use of power to be in control and to make decisions at the consumer-staff level of interaction.

Question 123

9. The chief nursing officer is pleased with the nurse manager’s strategy of improving patient satisfaction in the pediatric intensive care unit. She decides to implement these changes throughout the hospital. What would be important to consider in implementing a new program focused on improving relationships with consumers? a. Recognition of the nursing staff for excellence in promoting consumer relationships b. Holding the staff accountable for resolving patient complaints c. Selecting a staff nurse leader to implement the program d. Identifying key staff members who have already demonstrated excellence in consumer relationships

Answer 123

ANS: A a. Recognition of the nursing staff for excellence in promoting consumer relationships The nurse leader should allow professionals more influence over their practice;give staff opportunities to learn new and varied skills; give recognition and reward for success and support and consolation for lack of success; and foster motivation and belief in the importance of each individual and the value of his or her contribution.

Question 124

10. In orienting new staff nurses to a pediatric intensive care unit, the nurse manager asks the staff nurses to answer the following question: “What is an important consideration in providing information to parents of a critically ill child?” a. Making sure that they receive complete information during each encounter with a member of the nursing staff b. Assessing parents’ preferences for the amount of information desired c. Allowing parents to observe key aspects of their child’s nursing care d. Making sure that patient education brochures explaining ICU protocols are readily available

Answer 124

ANS: B b. Assessing parents’ preferences for the amount of information desired Consultation with the parents regarding the amount of information that they desire reflects a service orientation, in which preferences and needs of the consumer are placed first. The other answers reflect nurse-directed decisions in which the nurse decides what information and how much information is needed and how it is to be delivered.

Question 125

11. In designing a program for young adults regarding safe sexual practices, which of the following might reach the greatest number in your target group? a. Web-based applications b. Print-based media such as newspapers c. Television advertisements d. Brochures in kiosks in malls

Answer 125

ANS: A a. Web-based applications Mobile technology is changing the digital divide, with young adults, minorities, those with no college experience, and those with lower household incomes being more likely to indicate that phones are their main source of Internet access

Question 126

12. A nurse is admitted to a psychiatric unit. The staff expresses frustration with her because they have explained several times her medication regimen, and yet, when she goes on passes, she fails to follow it. The staff believe that, as a nurse, she should be able to understand what is expected. The nurse’s failure to follow the regimen indicates: a. Early cognitive impairment. b. Lack of motivation. c. Lack of health literacy. d. Worsening health state.

Answer 126

ANS: C c. Lack of health literacy. What is evident from the response is that she lacks health literacy or the capacity to obtain, process, and understand basic health information and services. Using a Health Literate Care Model involves weaving health literacy strategies into care by assuming that patients do not understand their health conditions or what to do about them, and then, subsequently assessing patients’ understanding (Koh, Brach, Harris, & Parchman, 2013). For example, a nurse who is an expert clinician in a specialty practice area, when diagnosed with a serious chronic illness, may not have the appropriate background to make informed healthcare decisions.

Question 127

13. John is an older adult patient who comes regularly to the multigroup practice in which you are a nurse practitioner. He says that he doesn’t understand what he is supposed to be doing about his medications, because every time he comes to the clinic, he sees someone else who has different ideas. John’s experience represents what aspect of the current consumer experience? a. Nurses are well-trusted members of the healthcare team. b. Fragmentation of care results in lack of respect and trust. c. Care providers often have conflicting ideas about care. d. The public does not trust care providers other than nurses.

Answer 127

ANS: B b. Fragmentation of care results in lack of respect and trust. When consumers visit a multigroup practice, they do not have the option of selecting a specific healthcare provider, and thus, there is less opportunity to build a trusting relationship with a provider.

Question 128

14. The complexity of the healthcare environment for consumers is increased by: a. Falling levels of education among the public. b. Increased levels of poverty. c. Complex compensatory systems and a variety of delivery systems. d. Increased numbers of uninsured or underinsured.

Answer 128

ANS: C c. Complex compensatory systems and a variety of delivery systems. The complexity of options in health care and the processes and policies involved in funding health services for patients, as well as fragmented relationships with a growing variety of healthcare providers, contribute to the complexity of the system for patients, especially for those who might need it most, such as the poor, uninsured or underinsured, and homeless.

Question 129

15. Corrine, a student nurse, often hears that nurses are gatekeepers and wonders what that term means. As a nurse leader, you explain that this is a reference to the: a. Assessment and admission of patients into care. b. Orientation of patients to services once they are admitted. c. Function of controlling which patients see the physician and which do not. d. Coordination of care, services, advocacy, and access for patients within the healthcare system.

Answer 129

ANS: D d. Coordination of care, services, advocacy, and access for patients within the healthcare system. As gatekeepers to the system, nurses advocate for and coordinate care, services, and access for patients across all providers, settings, and levels of care.

Question 130

16. A 27-year old woman is admitted to your ICU in a coma, following an accident. The family of the patient, who is a Native American, places a medicine pouch in the bed with the young woman. As the nurse in this situation, it is important to: a. Explain to the family that the medicine pouch may contain herbs that may bother other patients. b. Ask the family about the significance of the medicine pouch for them. c. Remove the pouch when the family is not present. d. Put the medicine pouch on the shelf beside the bed.

Answer 130

ANS: B b. Ask the family about the significance of the medicine pouch for them. Diversity encompasses more than differences in nationality or ethnicity and may include a variety of ways that patients are different from their healthcare providers. Nurses need to recognize the culture of their work setting, realizing that it may differ markedly from the culture of the consumer, and move beyond ethnocentrism to provide culturally competent care. This competence includes cultural knowledge, which involves actively learning about a community; cultural sensitivity, which entails valuing and respecting beliefs, norms, and practices of the people being served; and collaboration within a community (Flaskerud, 2007). In this instance, it is important to understand the meaning of the pouch for the family; removal from the bed without discussion does not demonstrate respect for the values and beliefs of this family.

Question 131

17. You are involved in designing a clinic for women in an inner-city neighborhood. A goal of this clinic might be: a. Development of services that are identified in various studies as important for this target group. b. Partnership with area city councilors and health professionals to provide services that are consistent with their vision and funding sources. c. Provision of immunization and addictions services and health screening services for women in the area. d. Development of services that have been identified by the women and neighborhood advocates as necessary for their health care.

Answer 131

ANS: D d. Development of services that have been identified by the women and neighborhood advocates as necessary for their health care. Involvement of persons in their own health care is a cornerstone of healthcare reform and is important for improving health outcomes and patient experiences. While studies and partnership with key informants are important sources of information in the design of services, engagement of the women through their neighborhood advocates may increase activation and resulting behavior. Patient activation refers to patients’ willingness and ability to take independent actions to manage their health and care.

Question 132

18. Which of the following exemplifies a service orientation? a. Staff members on the unit are encouraged to chart details about family support networks. b. Chart audit reveals that details related to assessment of family history are missing. c. The palliative care unit organizes a “tree of light” fundraiser each year to highlight the importance of palliative care. d. A children’s preoperative holding area is initiated in response to requests from families and nurses who care for them.

Answer 132

ANS: D d. A children’s preoperative holding area is initiated in response to requests from families and nurses who care for them. A service orntation needs to translate caring into appropriate, timely action that meets the needs of patients. Activities such as documentation of details or promotion of services may remain at the technical or conceptual level without a commitment to caring interactions. The institution of a holding area where families can be with children represents a caring action that arises out of interactions and knowledge of patient needs and thus, is service oriented.

Question 133

19. As a head nurse, you are concerned about the service orientation on your unit. Which of the following findings and approaches might provide useful information for you? a. Patients find nurses friendly and accessible; data are aggregated for the institution as a whole. b. Data indicate that nurses are responsive to requests for assistance; data are available for the unit and the institution. c. Specific questions related to management of comfort are included for the institution as a whole. d. The survey asks for a range of responses for the unit and the organization, with a focus on facilities, such as cleanliness and responsiveness of administrative services.

Answer 133

ANS: B b. Data indicate that nurses are responsive to requests for assistance; data are available for the unit and the institution. The National Database of Nursing Quality Indicators (NDNQI®) is a national repository for unit-based quality data that can be used by organizations to benchmark the outcomes of care against those of other institutions (ANA, n.d.). Unit-based quality indicators, including satisfaction with nursing care, are a key feature of the NDNQI®. In addition to hospitals being provided with their own and comparison data, researchers are able to access de-identified data in order to answer important questions about nursing care quality. Pain management, the discharge process, and post-discharge patient callbacks are specific areas where nurses can make significant improvement in patient satisfaction. Because patients and nurses may differ in what they see as factors that produce satisfaction, total reliance on nursing perceptions of patient satisfaction may not provide a complete picture.

Question 134

20. As a nurse manager, you see an opportunity for patients to be well serviced through the medical home concept. You recognize that the concept of medical homes: a. Currently does not include nurses in its vision of multifaceted primary care. b. Includes nurses as part of an interdisciplinary and multidisciplinary team. c. Restricts nurses to services related to direct care and procedures. d. Cannot encompass nurses within this framework.

Answer 134

ANS: A a. Currently does not include nurses in its vision of multifaceted primary care. The concept of medical homes encompasses the idea of multifaceted medical homes that provide a usual source of health care. Current discussions have focused on physician-directed care even though nurses in advanced practice are well suited to lead teams in this model.

Question 135

21. Technology is integral to a cardiac ICU. Sue, the nurse manager, implements a patient-centered approach that focuses on the meaning of the experience for the patient and family, primary nursing, and a health literacy approach. Sue is: a. Using high-tech–low-touch approaches. b. Using high-tech–high-touch approaches. c. Providing products. d. Providing tangible products of satisfaction.

Answer 135

ANS: B b. Using high-tech–high-touch approaches. The provision of humanistic care within a high-tech environment is characteristic of high tech–high touch approaches and reflects the idea that the more that high-tech is used, the more patients also desire high-touch.

Question 136

22. Which of the following actions best exemplifies advocacy? a. Developing a list of agencies that will provide free services for the homeless b. Working in a needle exchange program for individuals in an inner-city environment c. Acting on behalf of a patient to promote end-of-life wishes to an ethics committee d. Working in a free clinic for immigrant workers

Answer 136

ANS: C c. Acting on behalf of a patient to promote end-of-life wishes to an ethics committee Advocacy means making known and defending and protecting the rights and interests of others, as well as ensuring the dignity and respect due to others. Simply being employed in an environment where this might be a focus of practice does not necessarily ensure that advocacy is actually occurring.

Question 137

23. During review of a patient’s progress, the healthcare team determines that a patient requires treatment that is generally accepted at that time in the usual illness trajectory of a patient. The patient is unable to pay. As the head nurse, you persist in ensuring that this patient receives the treatment. You are: a. Empowering the patient. b. Avoiding litigation. c. Advocating for the patient. d. Supporting the clinical pathway.

Answer 137

ANS: C c. Advocating for the patient. Advocacy means defending the rights and interests of others and, in this situation, the right of a patient to receive care, as determined by standards utilized in a critical pathway.

Question 138

24. A nurse makes a medication error that is not serious and does not cause harm to the patient. As the head nurse, your best action would be to: a. Call attention to it by posting the critical incidents report at the nursing station. b. Include the mistake on the nurse’s performance appraisal. c. Apologize to the patient for the error, and indicate that discipline has occurred. d. Educate the nurse on how to provide an apology to the patient.

Answer 138

ANS: D d. Educate the nurse on how to provide an apology to the patient. Service recovery ensures responsiveness to the patient, and as part of service recovery, it is important to address an error in the most productive way, which also includes the nurse who made the error offering an apology to the patient.

Question 139

25. An example of a factor that would impede a patient’s learning is: a. Poverty. b. Limited health insurance. c. Being an older adult. d. Heavy sedation.

Answer 139

ANS: D d. Heavy sedation. Nurses need to be sensitive to the teaching needs of those at risk for disparities in health care: persons of a different race or ethnic group, women, children, older adults, rural residents, and those with limited or no health insurance, low health literacy, and/or low socioeconomic status. It is important that lower expectations for persons who are disadvantaged, have a low literacy level, or have limited English proficiency are not unintentionally communicated.

Question 140

1. Which of the following activities would represent a customer-friendly approach in a healthcare setting? (Select all that apply.) a. Using a local anesthetic before inserting a needle into a child’s arm b. Repeating patient history information to the admitting clerk, the admitting nurse, and the ultrasound technician c. Ensuring that birthing preferences are on file and available when a laboring mother comes in d. Providing support to families when a family member is brought into trauma

Answer 140

ANS: A, C, D a. Using a local anesthetic before inserting a needle into a child’s arm c. Ensuring that birthing preferences are on file and available when a laboring mother comes in d. Providing support to families when a family member is brought into trauma A service orientation means delivering services in a manner that is least disruptive. When possible, services should come to the patient and should be as easy, comfortable, pleasant, and effective as possible. Meeting the emotional, psychosocial, and spiritual needs of the patient is important.

Question 141

1. A group of staff nurses is dissatisfied with the new ideas presented by the newly hired nurse manager. The staff wants to keep their old procedures, and they resist the changes. Conflict arises from: a. Group decision-making options. b. Perceptions of incompatibility. c. Increases in group cohesiveness. d. Debates, negotiations, and compromises.

Answer 141

ANS: B b. Perceptions of incompatibility. Conflict involves disagreement in values or beliefs within oneself or between people that causes harm or has the potential to cause harm. Folger, Poole, and Stutman (2012) add that conflict results from the interaction of interdependent people who perceive incompatibility and the potential for interference.

Question 142

2. Two staff nurses are arguing about whose turn it is to work on the upcoming holiday. In trying to resolve this conflict, the nurse manager understands that interpersonal conflict arises when: a. Risk taking seems to be unavoidable. b. People see events differently. c. Personal and professional priorities do not match. d. The ways in which people should act do not match the ways in which they do act.

Answer 142

ANS: B b. People see events differently. By definition, conflict involves a difference in perception between two or more individuals.

Question 143

3. The nurse manager is aware that conflict is occurring on her unit; however, she is focused on preparing for a state health department visit, so she ignores the problem. A factor that can increase stress and escalate conflict is: a. The use of avoidance. b. An enhanced nursing workforce. c. Accepting that some conflict is normal. d. Managing the effects of fatigue and error.

Answer 143

ANS: A a. The use of avoidance. Avoidance as a conflict-management style prolongs conflict and has a tendency to escalate conflict.

Question 144

4. The nurse manager decides to use a mediator to help resolve the staff’s conflict. A basic strategy for truly addressing this conflict is to: a. Identify the conflicting facts. b. Be determined to resolve the conflict. c. Schedule a meeting time for resolution. d. Have a clear understanding of the differences between the parties in conflict.

Answer 144

ANS: D d. Have a clear understanding of the differences between the parties in conflict. It is important for each person in the conflict to clarify the conflict as “I see it” and how “it makes me respond” before all the persons involved in the conflict can define the conflict, develop a shared conceptualization, and resolve their differences.

Question 145

5. Sarah, a staff nurse on your unit, witnesses another nurse striking a patient. Sarah wants to remain friends with her colleague and worries that confrontation with her colleague or reporting her colleague will destroy their relationship. Sarah is experiencing which type of conflict? a. Intrapersonal b. Interpersonal c. Organizational d. Professional

Answer 145

ANS: A a. Intrapersonal Intrapersonal conflict occurs within a person when confronted with the need to think or act in a way that seems at odds with that person’s sense of self. Questions often arise that create a conflict over priorities, ethical standards, and values. Some issues present a conflict over comfortably maintaining the status quo and taking risks to confront people when needed, which can lead to interpersonal conflict.

Question 146

6. The chief nursing officer plans a series of staff development workshops for the nurse managers to help them deal with conflicts. The first workshop introduces the four stages of conflict, which are: a. Frustration, competition, negotiation, and action. b. Frustration, conceptualization, action, and outcomes. c. Frustration, cooperation, collaboration, and action outcomes. d. Frustration, conceptualization, negotiation, and action outcomes.

Answer 146

ANS: B b. Frustration, conceptualization, action, and outcomes. Thomas (1992) determined that conflict proceeds through these four stages in this particular order.

Question 147

7. After using a mediator to resolve a conflict between the nurse manager and two staff nurses, the chief nursing officer decides to: a. Observe to make sure the conflict has been resolved. b. Fire both staff nurses. c. Reassign both staff nurses. d. Reassign the nurse manager.

Answer 147

ANS: A a. Observe to make sure the conflict has been resolved. The nurse leader should follow up to determine if the conflict has been resolved because, in professional practice environments, unresolved conflict among nurses is a significant issue that results in job dissatisfaction, absenteeism, and turnover, as well as in decreased patient satisfaction and poorer quality in patient care.

Question 148

8. A nursing instructor is teaching a class on conflict and conflict resolution. She relates to the class that conflict in an organization is important, and that an optimal level of conflict will generate: a. Creativity, a problem-solving atmosphere, a weak team spirit, and motivation of its workers. b. Creativity, a staid atmosphere, a weak team spirit, and motivation of its workers. c. Creativity, a problem-solving atmosphere, a strong team spirit, and motivation for its workers. d. A bureaucratic atmosphere, a strong team spirit, and motivation for its workers.

Answer 148

ANS: C c. Creativity, a problem-solving atmosphere, a strong team spirit, and motivation for its workers. Differences in ideas, perceptions, and approaches, when managed well, can lead to creative solutions and deepened human relationships. Work on conflict suggests that complete resolution of conflict is counterproductive to the achievement of organizational goals, organizational change, and cohesiveness of employees.

Question 149

9. Jane has transferred from the ICU to the CCU. She is very set in the way she makes assignments and encourages her new peers to adopt this method without sharing the rationale for why it is better. This is a good example of a process and procedure that creates which type of conflict? a. Organizational b. Intrapersonal c. Interpersonal d. Disruptive

Answer 149

ANS: C c. Interpersonal Interpersonal conflict transpires between and among nurses, physicians, members of other departments, and patients.

Question 150

10. Two nurses on a psychiatric unit come from different backgrounds and have graduated from different universities. They are given a set of new orders from the unit manager. Each nurse displays different emotions in response to the orders. Nurse A indicates that the new orders include too many changes; Nurse B disagrees and verbally indicates why. This step in the process is which of the following in Thomas’ Stages of Conflict? a. Frustration b. Conceptualization c. Action d. Outcomes

Answer 150

ANS: B b. Conceptualization Thomas’ Stages of Conflict include conceptualization, which involves different ideas and emphasis on what is important or not or about what should occur.

Question 151

11. Mrs. Hill, aged 68, was hospitalized after a stroke. The speech therapist recommended that oral feeding be stopped because of her dysplasia. During visiting hours, Mr. Hill fed his wife some noodles. The nurse noticed this and stopped Mr. Hill from feeding his wife, telling him it was the doctor’s decision. An hour later, the nurse returned and found Mr. Hill feeding his wife again. The nurse tried to stop him again. Mr. Hill refused and claimed that the clinical staff was trying to starve his wife; he also threatened to get violent with the nurse. The nurse decided to walk away and documented the event in Mrs. Hill’s chart. According to Thomas’ Four Stages of Conflict, in which stage could the nurse have been more effective? a. Frustration b. Conceptualizing c. Action d. Outcomes

Answer 151

ANS: C c. Action By walking away, the nurse is engaged in an action or a behavioral response, which is the action stage of conflict that is outlined in the four stages of conflict (Thomas, 1992). In this stage, the nurse might have used more effective strategies, such as clarifying Mr. Hill’s views on feeding his wife and engaging in dialogue with Mr. Hill to clarify his concerns and attempt to reach a common goal.

Question 152

12. Mrs. Hill, aged 68, was hospitalized after a stroke. The speech therapist recommended that oral feeding be stopped because of her dysplasia. During visiting hours, Mr. Hill fed his wife some noodles. The nurse noticed this and stopped Mr. Hill from feeding his wife, telling him it was the doctor’s decision. An hour later, the nurse returned and found Mr. Hill feeding his wife again. The nurse tried to stop him again. Mr. Hill refused and claimed that the clinical staff was trying to starve his wife; he also threatened to get violent with the nurse. The nurse decided to walk away and documented the event in Mrs. Hill’s chart. The outcome as depicted by Thomas’ conflict stages can be considered to be: a. Compromising. b. Confronting. c. Constructive. d. Destructive.

Answer 152

ANS: D d. Destructive. Resolution was absent because the nurse did not have time to effectively deal with the issues in the conflict. This can lead to negativity, increased frustration, and further distancing between individuals or groups, including between patients and nurses

Question 153

13. Jill is the head nurse on a unit in a large hospital. Two of the staff nurses are constantly arguing and blaming each other, and a resolution has not occurred in months. To solve the existing conflict, which is the most creative conflict resolution? a. Avoiding b. Competing c. Compromising d. Collaborating

Answer 153

ANS: D d. Collaborating Collaboration, although time-consuming, is the most creative stance. The collaboration technique involves both sides in the conflict working together to develop an optimal outcome. This results in a win-win solution.

Question 154

14. A nurse educator is giving a workshop on conflict. During the sessions, he makes various statements regarding conflict. All of the statements are true except: a. Conflict can decrease creativity, thus acting as a deterrent for the development of new ideas. b. Horizontal violence involves those with similar status but little power in the larger context. c. Interprofessional collaboration reduces unresolved conflicts. d. All conflicts involve some level of disagreement.

Answer 154

ANS: A a. Conflict can decrease creativity, thus acting as a deterrent for the development of new ideas. The opposite is true because research has shown that conflict, like change, increases creativity and allows for the development of new ideas.

Question 155

15. Sarah is a nurse manager in a surgical unit. She is concerned about a conflict between Lucy (a staff nurse) and one of the maintenance personnel. Sarah explains to Lucy that unsatisfactory resolution of the conflict is typically destructive and will result in: a. Decreased frustration between the maintenance worker and her. b. A good relationship with the maintenance department. c. Eventual resolution of the problem without further intervention. d. Decreased productivity on her part.

Answer 155

ANS: D d. Decreased productivity on her part. Research by Saltman et al. (2006) determined that productivity decreases with destructive conflict, whereas constructive conflict strengthens relationships.

Question 156

16. Staff at Valley Hospital are concerned that recent staffing cuts will affect their ability to provide quality patient care, and they express their concerns to senior management. The CEO of Valley Hospital makes the following statement: “We need to contain costs because our funding has been decreased.” This is a good example of which of the following conditions that propel a situation toward conflict? a. Incompatible goals b. Role conflicts c. Structural conflict d. Competition for resources

Answer 156

ANS: A a. Incompatible goals Conflicts arise in four areas: goals, facts, approaches, and values. Conflicts among goals arise from competing priorities such as the provision of quality patient care and containment of costs.

Question 157

17. Kala, a unit manager, in discussing a role the CEO would like her to perform, makes the following statement, “I will sit on the hospital taskforce on improving morale if you send me to the hospital’s leadership training classes next week, so I can further develop my skills and thus be more effective.” Which of the following conflict management styles is Kala using? a. Collaborating b. Avoiding c. Negotiating d. Accommodating

Answer 157

ANS: C c. Negotiating Negotiation involves an exchange of concessions (membership on a committee in return for attendance at a workshop) or trading. This strategy supports a balance of power.

Question 158

18. John is a circulating nurse in the operating room. He is usually assigned to general surgery, but on this day he is assigned to the orthopedic room. He is unfamiliar with the routines and studies the doctor’s preference cards before each patient. The fourth patient comes into the room and John prepares a site for a biopsy using a Betadine solution. The surgeon prefers another solution. He notices what John has done and immediately corrects him by rudely insulting John. Which of the following is the most appropriate approach to conflict resolution in this example? a. Collaboration b. Compromising c. Avoiding d. Withdraw

Answer 158

ANS: B b. Compromising Compromise involves negotiation or an exchange of concessions and supports a balance of power.

Question 159

19. Factors that influence the ease with which conflict is resolved include all except which of the following? a. Level of interdependence of the parties b. Interprofessional collaboration. c. Expression of one’s own needs and ideas. d. Avoidance of the issue or concern.

Answer 159

ANS: D d. Avoidance of the issue or concern. Conflict involves a level of interdependence and is a condition for conflict but not necessarily for continuance of the conflict. Expression of one’s ideas and concerns is considered assertive and effective in resolving conflict if the concerns and needs of the other are also considered. Interprofessional collaboration has been shown to be effective in resolving conflict. Avoidance tends to prolong and sometimes escalate conflict.

Question 160

20. The head nurse and a staff nurse are having a conflict over how to use and apply a new procedure for dressings in the medical/surgical unit. The staff nurse wishes to use the new procedure based on newly released nursing research. The head nurse wishes to use a protocol that has been used in the department for a number of years. The head nurse later makes comments to other staff on her unit about the credibility of the staff nurse. This behavior is associated with: a. Lateral violence. b. Horizontal violence. c. Confrontation. d. Bullying.

Answer 160

ANS: D d. Bullying. Bullying involves aggressive or destructive behavior or psychological harassment of a recipient who is in a position of power differential with the perpetrator (the head nurse). Bullying is closely related to lateral or horizontal violence and involves such behaviors as incivility or intimidation.

Question 161

21. Which of the following exemplifies the predominant conflict management style of nurse managers? a. Elizabeth, the head nurse on neurology, finds that Tom, the RN nurse on nights, is irritable in relation to any suggestions or new ideas, and so she comes in to work after Tom leaves the unit. b. The technology committee has recommended a clinical system for implementation on the nursing unit. Staff is anxious about the change. Tim, the head nurse, asks staff for ideas on how to meet the technology goals and to meet staff needs. c. During management meetings, George, the head nurse on nephrology, dominates meetings and decisions. Lee, the head nurse on the cardiac step-down unit, begins to miss the management meetings. d. Ann, RN, asks her head nurse if she can go on the permanent evening shift. The head nurse, Rajib, agrees, as long as Ann agrees to be involved in assisting to mentor evening staff in the use of the new clinical information system.

Answer 161

ANS: D d. Ann, RN, asks her head nurse if she can go on the permanent evening shift. The head nurse, Rajib, agrees, as long as Ann agrees to be involved in assisting to mentor evening staff in the use of the new clinical information system. Compromise involves trading and negotiation and is the predominant conflict management style of managers.

Question 162

22. Lee, the head nurse in ER, has attempted to meet Jillian, one of her staff RNs, for several days to discuss concerns about Jillian’s relationships with her team members. Lee hopes to offer Jillian coaching so that Jillian’s relationships can be more satisfying for Jillian and her team members. Each time Lee and Jillian set a time to meet, Jillian phones in sick. In this situation, Lee and Jillian are demonstrating: a. Similar conflict management strategies. b. Escalation of conflict. c. Avoidance and compromise strategies. d. Competing and compromise strategies.

Answer 162

ANS: C c. Avoidance and compromise strategies. Jillian is demonstrating avoidance by staying away from meetings to discuss her team relationships, and Lee is demonstrating compromise by offering coaching in return for Jillian’s being able to engage in more satisfying relationships.

Question 163

23. Which of the following best exemplifies the predominant style of conflict management for staff nurses? a. Sarah and Jonas, two RNs, disagree about the best approach to assisting a family that has complex needs. They decide that they will consult with family and together will decide what is best. b. Jennifer needs to switch a shift to attend a family function. She arranges to trade with Nancy, who wants a day off next to a 3-day break. c. Lindsay asks Melody to stay late for the third day in a row. Melody refuses, stating that she has already helped out for two days by staying late for Lindsay. d. Lara asks Stacey to switch shifts with her because Lara wants to attend a concert. Stacey would prefer not to but does to enable Lara, who is new in town, to be with her friends.

Answer 163

ANS: D d. Lara asks Stacey to switch shifts with her because Lara wants to attend a concert. Stacey would prefer not to but does to enable Lara, who is new in town, to be with her friends. Avoidance and accommodation are the predominant conflict management styles of nurses. Accommodating involves neglecting one’s own needs while trying to satisfy the needs of another.

Question 164

24. In trying to achieve Magnet™ status, the chief nursing officer establishes a shared governance model to help nurses experience job satisfaction. However, some nurses who have enjoyed working with less autonomy resist this change and begin to criticize and make rude comments about managers who embrace this model, as well as colleagues who support it. The comments are largely ignored because those who are making them are well established nurses who are often vocal about their displeasure with the organization. Organizational conflict is arising from which of the following? a. Staffing practices b. Increased participation in decision making c. Allocation of resources d. Tolerance of incivility

Answer 164

ANS: D d. Tolerance of incivility Organizational conflict arises from discord related to policies and procedures (such as staffing policies and practices and allocation of resources), personnel codes or conduct or accepted norms of behavior (such as incivility), and patterns of communication. A major source conflict in organizations stems from strategies that promote more participation and autonomy of staff nurses.

Question 165

1. Nurses entering into the workforce today are faced with which of the following relationships that could create organizational conflict? (Select all that apply.) a. Nurse-physician relationship b. Nurse-nurse relationship c. Nurse-patient relationship d. Nurse-chief nursing officer relationship e. Nurse-auxiliary personnel relationships

Answer 165

ANS: A, B, C, D, E a. Nurse-physician relationship b. Nurse-nurse relationship c. Nurse-patient relationship d. Nurse-chief nursing officer relationship e. Nurse-auxiliary personnel relationships By nature, conflict is potentially present in all interpersonal situations. The nurse manager should create an environment that recognizes and values differences in staff, physicians, patients, and communities.

Question 166

1. The most important approach that a nurse manager can take with an emotionally troubled employee is to: a. Act as a therapist for the employee. b. Adjust the standard of care to assist the employee. c. Assist the employee in obtaining professional help. d. Adjust the employee’s work schedule to decrease stress.

Answer 166

ANS: C c. Assist the employee in obtaining professional help. Emotional difficulties are usually beyond the scope of skills that a nurse manager would normally employ. A referral needs to be made to a professional who is specifically prepared to deal with this kind of difficulty.

Question 167

2. The nurse manager knows that the most serious effect that absenteeism has on the nursing unit is that: a. Using replacement personnel with new ideas may be beneficial. b. Salary costs are lower because personnel are fewer, and outcome is favorable. c. Absence on the part of the rest of the staff is decreased. d. Unacceptable patient care may result.

Answer 167

ANS: D d. Unacceptable patient care may result. Reduced staffing adversely affects patient care. Employee morale suffers, care standards may be lowered, and additional stress is placed on working staff.

Question 168

3. In keeping with guidelines of the organization, the nurse manager documents staff problems. Documentation of disciplinary problems should: a. Include a plan to correct them and to prevent future occurrences. b. State a detailed history of past problems that are related to the current one. c. Be written at the convenience of the manager. d. Not be discussed until the formal performance evaluation.

Answer 168

ANS: A a. Include a plan to correct them and to prevent future occurrences. In documenting staff problems, it is important to identify the incident with an objective statement of facts and record actions taken to correct/prevent future problems.

Question 169

4. Before terminating an employee, a nurse manager must: a. Be an expert in all legal aspects of termination and discipline practices. b. Follow the organization’s specific policies for addressing disciplinary problems and termination. c. Function as a counselor for problem employees. d. Do everything to assist and protect the employee by adjusting standards and policies.

Answer 169

ANS: B b. Follow the organization’s specific policies for addressing disciplinary problems and termination. It is important to know the policies of the organization to address disciplinary issues fairly and equitably, as well as to know the model that is employed to address employee problems. Human resource departments and legal departments are important sources for consultation, advice, and support.

Question 170

5. A nurse manager understands that the typical first step in handling an employee with a disciplinary problem is a: a. Verbal reprimand. b. Written reprimand. c. Reminder of employment standards. d. Day off without pay.

Answer 170

ANS: C c. Reminder of employment standards. The progressive model of discipline advocates that the first step of the disciplinary process is the informal reprimand or verbal admonishment. The nonpunitive discipline model advocates reminding the employee of the employment policies and procedures of the agency.

Question 171

6. The chief nursing officer understands that clinical incompetence is best prevented by a(n): a. Flexible protocol for evaluating competency skills. b. Standardized clinical skills checklist. c. Administration of personality tests and competency assessments at point of hire. d. Formalized competency program with established standards for practice.

Answer 171

ANS: D d. Formalized competency program with established standards for practice. The competency program with established standards of practice outlines what the nurse must do to achieve desired competencies in her current position. Competency assessment and goal-setting should help the nurse identify how to excel and which competencies the nurse wants to achieve in the future.

Question 172

7. A nurse manager understands that the second step in handling an employee with a disciplinary problem is to document the incident. Which of the following is best for documentation of personnel problems? a. Use of the performance appraisal on an annual basis b. Notes made immediately after an incident that include a description of the incident, actions taken, plans, and follow-up c. A tally sheet of medication errors and other specific problems that will be used at annual review d. Copies of reports, placed in his or her file, of all unusual occurrences involving the employee

Answer 172

ANS: B b. Notes made immediately after an incident that include a description of the incident, actions taken, plans, and follow-up In documenting staff problems, it is important to specifically indicate what rules were broken or violated, consequences if behavior is not altered, employee’s explanation of the incidents, and the plan of action to achieve and to reach new goals

Question 173

8. The nurse manager places a staff member on probation because of reports of chemical dependency. The nurse manager should be aware that which of the following statements is true regarding chemical dependency? a. The chemically dependent employee usually hides any changes in behavior. b. When confronted with the issue, the affected employee is usually relieved to have someone to talk to about the problem. c. The chemically impaired nurse affects the entire healthcare organization. d. Hospital policy, state laws, and nurse practice acts address procedures for the chemically dependent employee in the most general terms.

Answer 173

ANS: C c. The chemically impaired nurse affects the entire healthcare organization. A chemically impaired nurse jeopardizes patient care through impaired skills and judgment. She or he also compromises teamwork and continuity as peers attempt to cover deficiencies in work performance for their impaired team member.

Question 174

9. The chief nursing officer reviews the policy about “progressive discipline process.” The progressive discipline process includes which of the following? The manager: a. Is a counselor and friend to the employee. b. Should reprimand and suspend the employee as a last resort. c. Should rehire the employee after a reasonable length of time. d. Should terminate the employee if the problem persists.

Answer 174

ANS: D d. Should terminate the employee if the problem persists. Termination can be defined as the discharge of an employee who is performing at an unsatisfactory level or who is not a good match for the organization. Termination is always considered the last resort when dealing with poor performance.

Question 175

10. A nurse manager must be familiar with the agency’s policies regarding termination. Termination procedures include which of the following? a. Following specific procedures from other organizations b. Having an attorney present at the termination meeting c. Having adequate written documentation to support the action d. Having a friend present during the termination meeting

Answer 175

ANS: C c. Having adequate written documentation to support the action All steps should be followed, including full appropriate detailed documentation and following the procedures of the organization.

Question 176

11. Nathan has been on the cardiac unit for 6 months and has found it difficult to adjust to the expectations of his team. Which of the following behaviors would most likely signal that Nathan is intending to resign from his position on the unit? a. Increased absenteeism over the past month b. Increased attempts to discuss his concerns with his colleagues c. Testing of workplace guidelines d. Frequent defensiveness

Answer 176

ANS: A a. Increased absenteeism over the past month Many employees increase their absenteeism just before submitting their resignation. If the healthcare worker is experiencing some form of role stress, it might be manifested through absenteeism. Role strain may be reflected by (1) withdrawal from interaction; (2) reduced involvement with colleagues and the organization; (3) decreased commitment to the mission and the team; and (4) job dissatisfaction. Testing of workplace guidelines and defensiveness are associated with immaturity.

Question 177

12. All of the following are grounds for immediate dismissal except: a. Failing to pursue further medical help for a patient; patient dies. b. Selling narcotics obtained from the unit supply of narcotics. c. Restraining a patient in bed for 7 hours, unsupervised, as punishment for hitting a staff member. d. Grabbing the unit manager and threatening further physical harm after a poor performance appraisal.

Answer 177

ANS: A a. Failing to pursue further medical help for a patient; patient dies. Situations that may warrant immediate dismissal include theft, violence in the workplace, willful abuse of the patient, harassment, and chemical abuse.

Question 178

13. The unit manager on 4E is concerned about the performance of Jean, a staff nurse. She is not involved directly with Jean, so she has not been able to determine whether the problem is one of motivation, ability, or both. If Jean lacks ability, which of the following strategies might the head nurse use? a. Dismiss or transfer Jean. b. Document all problem areas and then discuss them with Jean. c. Develop appropriate solutions and make recommendations to Human Resources. d. Smooth over the problems if they are minor in nature.

Answer 178

ANS: B b. Document all problem areas and then discuss them with Jean. For the employee to change and grow, specific corrective measures need to be taken. Consultation with the employee is necessary, and documentation is key to determining the issues.

Question 179

14. Nurses generally experience difficulty in identifying behaviors and actions that could signal chemical dependency in a co-worker. Which of the following is not a behavioral change that occurs with chemical dependency? a. Personality and behavioral changes b. Job performance changes c. Changes in educational involvement and pursuit d. Absenteeism

Answer 179

ANS: C c. Changes in educational involvement and pursuit A manager needs to be alerted when suspicions of chemical dependency are raised by behavioral changes in the employee. These include mood swings, changes in hygiene and appearance, heightened interest in the pain control of patients, frequent changes in shifts, increases in absenteeism, and increases in tardiness.

Question 180

15. Nurse Stacey is a self-admitted drug addict and has been a heavy abuser of codeine. Stacey and the unit manager decide that changes have to occur. Stacey enrolls in an addiction program, and the manager has her transferred to a drug-free area. What other strategies might be appropriate? a. The manager could refer Stacey to the Human Resources Department. b. The manager could assist in monitoring Stacey’s progress. c. The manager could counsel Stacey if Stacey has formed a trusting relationship with her. d. Stacey needs to be asked not to involve her family in the recovery program because this is a work-related situation.

Answer 180

ANS: B b. The manager could assist in monitoring Stacey’s progress. Effective management demands that the organization take an active role in helping employees with special needs. Humanistic strategies that counsel and assist employees are cost-effective and necessary.

Question 181

16. Incivility is a disruptive behavior or communication that creates a negative environment and interferes with quality patient care and safety. The manager can implement steps that help to alleviate uncivil behavior on a unit. Which of the following would not be an appropriate first step? a. Suspending the staff member from work b. Providing written admonishment that is discussed and placed in the employee’s file c. Providing verbal admonishment d. Terminating the staff member

Answer 181

ANS: D d. Terminating the staff member Dismissal does not enable the present organization to attempt remediation of the behavior and is not consistent with first steps in progressive discipline.

Question 182

17. Incivility is a disruptive behavior or communication that creates a negative environment and interferes with quality patient care and safety. The manager can implement the following steps that help to alleviate uncivil behavior on a unit. A) Suspending the staff member from work, B) Providing written admonishment that is discussed and placed in the employee’s file, C) Providing verbal admonishment, D) Terminating the staff member a. A, B, C, D b. B, A, C, D c. C, B, A, D d. C, A, B, D

Answer 182

ANS: C c. C, B, A, D C) Providing verbal admonishment, B) Providing written admonishment that is discussed and placed in the employee’s file, A) Suspending the staff member from work, D) Terminating the staff member The steps in progressive discipline are followed from the least severe (counseling the employee) to the most severe (termination). Studies have shown that following this sequence provides a fair and effective plan for discipline and remediation.

Question 183

18. When progressive discipline is used, the steps are followed progressively only for repeated infractions of the same rule. On some occasions, rules that are broken are so serious that the employee is: a. Transferred to another unit. b. Suspended indefinitely. c. Asked to attend a union grievance meeting. d. Terminated after the first infraction.

Answer 183

ANS: D d. Terminated after the first infraction. Behaviors that include violence, theft, and purposeful abuse of a client are sufficiently serious to warrant immediate dismissal with the first incident.

Question 184

19. During unit staff meetings, you observe that Marg rolls her eyes and snorts whenever Julia makes a comment. Your first response as a unit manager is to: a. Discuss what you have observed with Marg. b. File immediate documentation in Marg’s personnel file. c. Ask Julie to monitor Marg’s behavior during meetings. d. Ignore the behavior, as Marg is one of your strongest nurses.

Answer 184

ANS: A a. Discuss what you have observed with Marg. Incivility must be addressed. The initial step in addressing it is discussion with Marg, and if the behavior continues, then written documentation should be filed in Marg’s personnel file. Monitoring and follow-up are your responsibility as the unit manager.

Question 185

20. Ellen is a novice nurse on your unit. Even though she has come to you highly recommended, as her supervisor, you have noticed some knowledge and skill deficiencies. These deficiencies have been noticed by her peers as well, who cover for her because she is new and they like her. Which of the following is likely to be the greatest asset to Ellen in improving her performance? a. Ignore Ellen’s errors until she has more experience. b. Instruct staff to avoid working with Ellen until she learns to how do things herself. c. Ask Ellen to complete a self-assessment, using a standard skills checklist. d. Encourage staff to report every behavior of Ellen’s that is different from theirs.

Answer 185

ANS: D d. Encourage staff to report every behavior of Ellen’s that is different from theirs. When other employees are engaged in enabling behavior by covering for the mistakes of one of their peers, the nurse leader may be surprised to discover that the employee does not know or cannot do what is expected of him or her. The nurse leader must remind employees that part of professional responsibility is to maintain quality care and thus they are obligated to report instances of clinical incompetence, even when it means reporting a co-worker. Ignoring violations of a safety rule or poor practice is unprofessional and cannot be tolerated. The employee may be asked to do a self-assessment of the listed skills or competencies and then have performance of the skills validated by a peer or co-worker. This is a very effective method for the leader to assess the skill level of employees and to determine whether additional education and training may be necessary.

Question 186

21. Susan, a new graduate, is upset that so many staff have been absent lately from the unit. She declares to you that all absenteeism could be eliminated with proper management. Your response is based on understanding that: a. Not all absenteeism is voluntary. b. High personal control contributes to absenteeism. c. Direct discussions with employees who have high levels of absenteeism are not recommended. d. All absenteeism is related to personal issues and needs.

Answer 186

ANS: A a. Not all absenteeism is voluntary. Not all absenteeism is voluntary or preventable, which means that absenteeism can never be fully eliminated. Absenteeism can result from personal issues and needs, work dissatisfaction, and involuntary reasons such as jury duty.

Question 187

22. The nursing director calls a meeting with one of the new unit managers. She is very concerned about a report of substance abuse on the manager’s unit, and she reviews the procedures involved in dealing with chemically dependent staff. Which of the following statements would NOT be included in the discussion? “As a manager, you: a. Need to be aware of ADA issues.” b. Should check with Human Resources regarding chemically dependent employees and employment practices.” c. Check the nurse practice acts for the state in which the nurse resides.” d. Should realize that the nurse is a professional embarrassment and should be kept out of sight of other staff.”

Answer 187

ANS: D d. Should realize that the nurse is a professional embarrassment and should be kept out of sight of other staff.” As a manager, you need to be familiar with state and professional regulatory and reporting requirements regarding chemical use and abuse, as well with Human Resource practices and guidelines.

Question 188

23. The education consultant for the hospital is presenting a workshop titled “Documentation: A Manager’s Responsibility.” Which of the following points would she not include in her PowerPoint presentation? Documentation: a. Cannot be left to memory. A notation must be placed in the personnel file. b. Should avoid discussion of the problem. c. Should include what was done about the problem when it occurred. d. Needs to include date, time, and place.

Answer 188

ANS: B b. Should avoid discussion of the problem. Documentation of personnel problems is one of the most important aspects of the nursing manager’s role. Through carefully detailed and timely documentation of the problem and plan, the manager decreases the burdensome problems that can ensue from improper or inadequate documentation.

Question 189

1. The unit manager discusses absenteeism with the unit clerk. She indicates that it is a serious problem on the unit. Which of the following points would they have likely discussed? (Select all that apply.) a. Employee morale is at a high level. b. Care will suffer and standards will be lowered. c. Existing staff have experienced little effect from the absenteeism. d. Replacement staff usually needs little supervision. e. Unit costs have increased because of staff replacements and overtime.

Answer 189

ANS: B, E b. Care will suffer and standards will be lowered. e. Unit costs have increased because of staff replacements and overtime. Absenteeism puts a strain on staff, produces morale problems, can jeopardize patient safety, and increases unit costs.

Question 190

2. Clinical incompetence is one of the more serious problems facing a nurse manager. Joyce, the nurse manager, is not aware of the problems of Sarah, a novice nurse. After she investigates, it is obvious that Sarah’s peers are covering for her. Which of the following might Joyce include in her meeting with the nurses? (Select all that apply.) a. “It is a nurse’s professional responsibility to maintain quality control.” b. “All instances of clinical incompetence are to be reported.” c. “It is not considered being disloyal when one nurse reports another for poor care.” d. “Patient care is the number one concern. Meeting standards is mandatory and necessary.”

Answer 190

ANS: A, B, C, D a. “It is a nurse’s professional responsibility to maintain quality control.” b. “All instances of clinical incompetence are to be reported.” c. “It is not considered being disloyal when one nurse reports another for poor care.” d. “Patient care is the number one concern. Meeting standards is mandatory and necessary.” The nurse leader must remind employees that professional responsibility is to maintain quality care, and thus they are obligated to report instances of clinical incompetence, even when it means reporting a co-worker. Ignoring safety violations or poor practice is unprofessional and jeopardizes patient care.