NACE Foundations of Nursing 2 — Questions and Answers

Question 1: Which nursing theorist developed the Self-Care Deficit Theory that emphasizes patients' ability to perform self-care activities?

Florence Nightingale
Dorothea Orem (Correct answer)
Virginia Henderson
Jean Watson

Correct answer: Dorothea Orem

Dorothea Orem developed the Self-Care Deficit Theory, which focuses on the patient's ability to perform self-care and identifies when nursing intervention is needed.

Dorothea Orem's Self-Care Deficit Theory (1971) identifies three related theories: self-care, self-care deficit, and nursing systems. The theory proposes that individuals have a natural ability for self-care and that nursing is required when the individual is unable to fulfill their biological, psychological, developmental, or social needs independently.

Question 2: A nurse is prioritizing care for multiple patients. Which framework is most appropriate for organizing tasks based on urgency?

Maslow's Hierarchy of Needs (Correct answer)
Erikson's Developmental Stages
Piaget's Cognitive Theory
Kohlberg's Moral Development

Correct answer: Maslow's Hierarchy of Needs

Maslow's Hierarchy of Needs helps nurses prioritize by addressing physiological and safety needs before higher-level needs.

Maslow's Hierarchy of Needs (1943) provides a structured approach to prioritization in nursing. Physiological needs (airway, breathing, circulation) take precedence, followed by safety, belonging, esteem, and self-actualization. This framework helps nurses determine which patient requires immediate attention when caring for multiple patients simultaneously.

Question 3: What is the primary purpose of the nursing process?

To document patient care for legal purposes
To provide a systematic framework for delivering individualized patient care (Correct answer)
To ensure nurses complete tasks in order of difficulty
To reduce the workload of healthcare providers

Correct answer: To provide a systematic framework for delivering individualized patient care

The nursing process provides a systematic, patient-centered framework with five steps: assessment, diagnosis, planning, implementation, and evaluation.

The nursing process is a critical thinking framework consisting of five interrelated steps: Assessment (collecting data), Diagnosis (identifying problems), Planning (setting goals and interventions), Implementation (carrying out the plan), and Evaluation (determining if goals were met). This systematic approach ensures comprehensive, individualized care and serves as the foundation of professional nursing practice.

Question 4: A patient refuses a blood transfusion based on religious beliefs. Which ethical principle supports the nurse's obligation to respect this decision?

Beneficence
Justice
Autonomy (Correct answer)
Nonmaleficence

Correct answer: Autonomy

Autonomy is the ethical principle that respects a patient's right to make informed decisions about their own healthcare, including the right to refuse treatment.

Autonomy, derived from the Greek words 'autos' (self) and 'nomos' (rule), is the ethical principle that upholds a competent patient's right to make informed decisions about their care. Even when healthcare providers believe a treatment is necessary, they must respect the patient's right to refuse. This principle is foundational in informed consent and is supported by the Patient Self-Determination Act of 1990.

Question 5: During a patient assessment, which technique should the nurse perform first?

Palpation
Percussion
Auscultation
Inspection (Correct answer)

Correct answer: Inspection

Inspection is always performed first in a physical assessment as it provides visual information without touching the patient and can reveal important findings.

The correct sequence of physical assessment techniques is Inspection, Palpation, Percussion, and Auscultation (IPPA). Inspection uses vision and smell to observe the patient's general appearance, symmetry, skin color, and abnormalities. The one exception to the IPPA sequence is abdominal assessment, where auscultation precedes palpation and percussion to avoid altering bowel sounds through manipulation.

Question 6: Which documentation method uses a structured format of Subjective data, Objective data, Assessment, and Plan?

Narrative charting
SOAP notes (Correct answer)
Focus charting
Charting by exception

Correct answer: SOAP notes

SOAP notes organize documentation into Subjective (patient-reported), Objective (measurable findings), Assessment (clinical judgment), and Plan (interventions) sections.

SOAP documentation was developed by Dr. Lawrence Weed in the 1960s as part of the problem-oriented medical record (POMR). Subjective data includes the patient's own words about symptoms and feelings. Objective data encompasses measurable findings like vital signs and lab results. Assessment reflects the clinician's interpretation and clinical judgment. Plan outlines the intended interventions, tests, or follow-up actions.

NACE Foundations of Nursing 2

Which nursing theorist developed the Self-Care Deficit Theory that emphasizes patients' ability to perform self-care activities?