Trends Exam 2 Flashcards

Consumers are concerned with security issues related to their confidential health information being placed in an electronic health record (EHR). However, when the security of the EHR is compared with that of paper-and-pencil records, the EHR has been proven to be what?

During a search for the term informatics, what should the nurse determine about the site‘s affiliation when the domain ―.edu,ǁ is noted?

What statement accurately describes findings when paper-and-pencil medical records are compared with computer-based records?

A nurse is preparing a scholarly publication on the worldwide prevalence of hepatitis A. The most efficient and effective means of conducting an Internet search to gather information for this publication is to use what resource?

A consumer is learning about electronic health records at a local health fair and states, ―I am worried that someone can read my health information and I really don‘t understand the difference between privacy and confidentiality.ǁ The nurse provides what as an example of confidentiality?

A primary health care provider has installed a computer-based patient records system. An outside care provider who requests medical information must obtain the patient‘s signed consent and then is assigned a password to gain access to the medical information. A monthly audit is conducted to determine for whom and for what purpose patient records have been accessed. What term is used to refer to this type of protection?

A nurse walks up to a computer in the hallway and presses the index finger to the sensor, thereby gaining access to patient data. A few moments later another nurse performs the same steps and is granted access. A visitor who is watching from a room walks over and places the index finger on the sensor, only to receive an ―error and access deniedǁ message. This security feature is a result of what form of technology?

A nurse who is teaching a class to introduce telehealth to the staff would include which example?

An advanced practice nurse inputs into a computer software program the following clinical manifestations: open wound with tibia exposed, petechial hemorrhage, and temporary loss of consciousness. The computer diagnosis of fat emboli is generated by what information associated system?

A nurse is preparing a presentation using different websites to collect information. The nurse is concerned that contact information and the author‘s credentials are not listed for one of the websites reviewed. Which criterion required to establish a reputable website is missing?

A nurse is interested in locating reliable information concerning noninvasive blood glucose monitoring. Information is located, and the author is a scientist who conducted studies within the last year on the effectiveness of a noninvasive blood glucose monitor. The scientist received funding from a pharmaceutical company to support the studies. The URL indicates the pharmaceutical company site.com. The nurse is concerned about what component associated this information?

A nurse providing care at the bedside receives an ―alertǁ that a patient‘s stat potassium level is 2.5 and a dose of digoxin is scheduled. The nurse holds the medication and prevents a possible complication. This feature of the Electronic Health Record is available through which core function of EHR?

A nurse works on a unit where electronic health records (EHR) are being initiated and asks, ―What is meant by ̳meaningful use‘ standards that are in our education packet? What statement provides the best answer to the nurse‘s question?

A nurse is caring for a patient who is to receive an antibiotic drug that causes severe skin damage when infiltrated. The order reads, ―infuse over 1 hour by port-a-cath. When the nurse accesses the Personal Digital Assistant that lists the steps to access a port-a-cath, what type of computer software is being used?

The Institute of Medicine (IOM) (2003) recommends that electronic health records (EHR) systems offer eight functionalities. A patient has a severe allergy to eggs and penicillin. Which of the eight functions of the EHR would address sharing this information?

A nurse interested in quality improvement tools performed a search for cause and effect diagrams using www.ishikawa.com. A page opened that provided images and templates for performing fishbone diagrams. Which type of search did the nurse conduct?

A new nurse asks, ―Since electronic medical records (EMR) can improve quality care by having seamless data available for a patient, why doesn‘t everyone just replace paper and pencil charts? What barriers to a universal health information infrastructure exist? (Select all that apply.)

To persuade employees to bargain for another type of health insurance, a handout is circulated that describes the present employees‘ health care insurance as being insensitive, limiting choices of care providers, and providing inferior care. This reflects which aspect of Lewin‘s planned change?

What is the difference between a leader and a manager?

What is the first step in both the nursing and problem-solving processes?

An explosion just occurred at the local factory, and hundreds of employees have sustained varying degrees of injury. Which type of nursing leadership is most effective in this situation?

An RN with excellent assessment and psychomotor skills would derive power based on which source?

Managers who exhibit an authoritative behavioral style are most likely to use which source of power?

Florence Nightingale is attributed with being intelligent (she developed statistical methods to evaluate health care), dependable (she often worked long hours to care for the injured), and ambitious (she fought against society‘s perception of nursing). Those who depict her as a leader based on these qualities are practicing which leadership theory?

A nurse manager is concerned with restocking the emergency cart, creating the staff schedule, requesting floor stock from pharmacy, and checking the orders on patient charts. Which type of leader accurately describes this nurse?

According to the unit‘s policy for call-ins, a nurse is suspended for 3 days because of excessive call-ins that occur within 15 minutes of shift change. The nurse states, ―You are unfair to me.ǁ Which theory would disprove the nurse‘s statement?

A nurse is reading about positive reinforcement with the goal of increasing staff motivation. Which action would demonstrate positive reinforcement?

Which action represents the key management function of strategic planning?

A hospital‘s policy requires that all nurse managers must have a minimum of a bachelor‘s degree in nursing. A BSN nurse new to the hospital has recently been hired as nurse manager for the oncology unit. An RN who has worked on this unit for many years is unable to be promoted to a nurse manager position because of his educational status and has been commenting to physicians and staff, ―The new nurse manager has book sense but no leadership abilities.ǁ What is the best approach that can be used by the new nurse manager who is attempting to gain the trust and respect of the nursing staff on the unit?

A clinical nurse leader (CNL) enters the workforce and hopes to use her interdisciplinary skills to participate on a quality improvement committee. The coordinator of the quality group invites the CNL to join the group. Which type of power is demonstrated by the coordinator of the group?

A director of nursing (DON) asks the staff to list how their nursing unit can help the organization meet its goal to ―provide quality patient care with attention to compassion and excellence.ǁ An ad hoc committee is formed to develop a timeline of identified actions. The DON coaches the committee to reach desired outcomes. This DON is demonstrating which other role of leadership and management?

A staff nurse provides care based on intuition and always seems to be in control of her personal and professional life—serving on the board of the state nurses association, serving as the nursing unit‘s representative on the ethics committee, and coaching her daughter‘s soft ball team. Many of the staff observes how she manages time and provides care. This nurse‘s power comes from which type of power?

A staff nurse states, ―I really enjoyed having dinner with the Chief of Medical Staff and the President of the hospital. We hope to meet again soon.ǁ Which source of power does this nurse possess?

A nurse manager wants his nursing unit to be a place where all nurses want to work, where patient satisfaction is high, and care is innovative and interdisciplinary. Staff are encouraged to chair taskforces to improve quality of care and he counsels staff in areas of measuring patient outcomes. Other managers want to mimic this manager‘s approach to improve their own units. This nurse is which type of leader?

A hospital recently learned that their scorecard did not meet the national benchmark for patient satisfaction and brought in a professional change agent to determine what their issues were and how they could improve their score. The agent collected data and recommended that nurses participate in interdisciplinary walking rounds and allow the patient and family to be participants. Nurses now round every shift and perform ―huddles to update the teamǁ as needed throughout the shift as part of best practices. Random visits are made to nursing units to ensure all nurses are participating and patients are interviewed for their involvement. These practices are associated with which stage of Lewin‘s change process?

A manager just finished the last annual performance review of the staff, reviews the unexpected expenditures for the month due to use of agency nurses, and shares the latest quality indicators with the staff nurses. This manager is performing which management function?

Registered nurses who are entering the workforce will have expanded leadership responsibilities that include what tasks? (Select all that apply.)

A nurse asks, ―What is meant by ̳internal‘ customers? The correct response should identify which person or persons? (Select all that apply.)

A nurse manager plans the fiscal budget to include salaries for two RNs for two 12-hour shifts with a patient census of 6 in the short-stay observation room. The nurse manager reviews the budget report 3 months later and notes that the salary expenses are higher than was budgeted because of higher-than-planned RN staff salaries. This additional RN staff is necessary to meet patient care needs because the census has remained constant at 10 patients rather than the 6 projected when the budget was developed. The difference between the planned budget and the actual cost is referred to by what term?

A nursing unit‘s census consists primarily of long-term residents with a high risk for falls. To meet new safety regulations, the nurse manager must plan to replace all 50 patient beds with new beds equipped with Fall Watch electronic sensors. The manager will be involved in which type of budgeting to replace the beds?

A nurse manager is preparing a budget that does not base annual budgets on the revenue and expenditures of the prior year and has the advantage that outdated information is not integrated into the budget. The manager is using which budget method?

A nurse on the unit is heard saying, ―I am not going to document that I used four catheters to start that IV; it doesn‘t matter anyway.ǁ What action can help the staff nurse understand the financial budget goals of the unit?

In a large health care facility, the executive administrative leaders set the budget goals to decrease full-time equivalents by 3%, eliminate the cost of agency nurses, reduce lost revenue from lost supplies by 1%, and provide a 0.5% hourly salary incentive for working on a float unit when the assigned unit has a low census. Nurse managers meet with nursing administrators to design their unit budgets to meet these established goals. This is an example of what type of budget approach?

Which component of budgeting might normally be addressed in the annual performance evaluation for a nurse manager?

A primary function of the budgeting process is to provide managers with an opportunity to do what?

Organizations measure the effectiveness of their budgets by examining actual revenues and expenditures versus what?

What is the intended action when the nurse manager conducts a qualitative analysis of budget variances?

A nurse manager is working with the financial officer to develop the budget of the nursing unit for the next fiscal year. The nurse manager tells the financial officer that which of the following pieces of information will affect budget assumptions?

The nurse manager meets with upper management to share strategic goals agreed upon by her staff for their individual nursing unit as the first step to begin budget negotiations. One strategic goal is that staff will have access to technology that will allow them to incorporate point-of-care devices for all RNs. The second goal is to improve RNs‘ ability to recognize critical indicators that a patient‘s health status is deteriorating through advanced health assessment skills. During a meeting with the upper management, the unit manager discusses strategy options and identifies the one that works for the unit. Which type of budget development is being implemented?

The nursing executive team met to review last year‘s productivity metric to strategize for the upcoming year‘s metric. The team wants to be certain the productivity metric shows productivity demonstrates what desired outcome?

The nurse manager meets with upper administration and learns that the strategic plan for nursing is to have 80% BSN staff within the next 3 years. The nurse manager then builds the unit‘s budget to meet the organization‘s strategic goal by providing tuition reimbursement and flexible work hours, which required some agency staffing. Which approach to budgeting is used?

The nurse managers of an organization are meeting with administration to plan the budget. The above graph shows last year‘s expenditures, and the team will trend the upcoming budget knowing that, with the slowdown in the economy, patient census will be lower. Which budget approach is being used?

Nurses on a unit met with the nurse manager as part of participatory budgeting. They ask, ―What exactly is the difference between fixed and variable costs? Understanding this will help us better understand the budgeting process. The manager provides a definition and asks the staff to list types of direct and indirect cost. Which example would indicate a need for further teaching?

A nurse manager has calculated that providing 75 hours of direct nursing care per day requires that 120 hours must be worked by nursing staff. The manager is involved in what activity? (Select all that apply.)

A nurse has recently been appointed to the position of nurse manager. What should the nurse manage do to become successful in managing the unit‘s budget? (Select all that apply.)

A nurse is listening to a patient‘s apical heart rate. The patient asks, ―Is everything okay?The nurse says nothing and shrugs her shoulders. The nurse is demonstrating what form of negative communication?

A teenage patient is using earphones to listen to hard rock music and is making gestures in rhythm to the music. The nurse assesses the amount of urine output in the Foley catheter and leaves the room. What communication technique is demonstrated in both situations?

In today‘s world of fast, effective communication, what is the most commonly used means of societal communication?

Which statement accurately describes communication?

A licensed practical nurse (LPN) has been practicing for 25 years on a unit where a newly graduated RN with a bachelor‘s degree is hired. Before the RN arrives on the unit, the LPN is heard saying, ―She‘ll try to tell everyone what to do because she makes more money. She‘ll sit at the desk and let us do all the work.ǁ This is an example of what communication associated process?

A new mother is experiencing pain after delivering an infant with Down syndrome. The staff nurse states, ―I don‘t think she is really hurting. Let the next shift give the pain medication.ǁ The team leader notices the staff nurse looks agitated and anxious and asks about any concerns in providing care to this new mom. The staff nurse admits having a stillborn infant with Down syndrome. This is an example of which component of communication?

A nurse gives phenytoin intravenously with lactated Ringer‘s solution containing multivitamins. The drug precipitates and obstructs the only existing line. When the team leader informs the nurse that these drugs cannot be mixed, the nurse states, ―You‘ve disliked me since I refused to switch my vacation time last month.Which type of logical fallacy has influenced the nurse?

An RN is consistently late to work, causing reassignment of patient care and the need for repeated shift reports. The nurse, who receives a warning for repeated tardiness, states, ―My husband left me, I have no car, no family close by, and the bus is always late, which makes me late. The nurse manager doesn‘t care how hard I try to get here, and I am raising a child by myself. The nurse is using which type of logical fallacy?

Which nurse is demonstrating a common, productive conflict resolution style?

A male nurse hired to work in the emergency department is observed throwing a contaminated needle into the trash can. The team leader reprimands the nurse for not appropriately disposing of sharps. The nurse states, ―You don‘t care that I threw the needle in the trash. You just want an all-female staff,ǁ putting the team leader in a defensive position. This communication technique is referred to by what term?

A nurse who was recently certified in chemotherapy administration fails to check compatibility of phenytoin before injecting into a continuous infusion of D5W leading to occlusion of the line. Which statement by the nurse demonstrates a red herring?

During a health history interview, the nurse listens to a patient relating the precipitating events that led to the onset of chest pain. She focuses her attention on the patient, makes eye contact, and acknowledges what the patient has to say. The nurse is exhibiting what communication technique?

What situation demonstrates a nurse engaging in active listening?

An older adult is unable to reach the telephone and is found dead at home several hours later. The son of the deceased person arrives at the hospital and asks, ―Can I just please stay and hold my dad‘s hand? He was so afraid of dying alone.Which response by the nurse shows empathy?

A nurse is preparing an exercise program as part of a health promotion program for older adults with osteoporosis. Which question would retrieve the most valuable information about health practices?

Which component of an e-mail shown below would be both effective and concise?

When considering online communication etiquette, which nurse demonstrates a primary rule that should be adhered to by all?

A patient‘s spouse was just diagnosed with lung cancer although there was no history of tobacco use. The spouse states, ―I am so mad. How can you get cancer without smoking?Which statement by the nurse represents empathy?

A nurse wants to apply open communication to obtain a thorough history and to determine cognitive function. Which question represents the use of open communication?

The nurse caring for a patient states, ―Your blood pressure is dangerously high. Are you taking antihypertensive medicine?ǁ The patient states, ―I can‘t afford my medicine. I have no insurance.ǁ The nurse states ―I feel really sorry for that patient. I wish it wasn‘t against policy to give her money. The nurse wants to help and places a note on Facebook that any donations would be appreciated to help a waitress who works at the cafeteria next door to the hospital buy her medications. The nurse posts that ―She was so sick last evening when she came to the ED. I can‘t believe they don‘t provide insurance. I can‘t give her money but you all can help.ǁ This nurse‘s action has what possible outcome?

A group of nurses are meeting to decide how to staff the upcoming holidays. Each of the four members freely expresses thoughts about fair staffing but is willing to listen to other thoughts and reconsider their first recommendations. The nurses are avoiding conflict and supporting professional communication through implementation of what communication technique?

A nurse is asked to ―floatǁ to another area where the patients require total care. The nurse smiles, picks up her stethoscope, and says, ―I‘ll come back and eat lunch with everyone here.When she enters the elevator she hits the wall and mutters, ―Always me. Don‘t I have any rights? The nurse is demonstrating which communication style?

A nurse is overhead saying, ―I don‘t mind working during the election and holiday. My parents are divorced, money is tight, and honestly, I don‘t trust any politicians anyway. I plan to take a few weeks off next month.ǁ She works independently to research strategies to improve patient-centered care for the large number of immigrants that arrived in the area and then works with the team to share ideas. She recommends, ―Let‘s think the suggestions over and come back together next week.ǁ This nurse‘s communication style is consistent with which generation?

How do accrediting agencies such as The Joint Commission address staffing?

What is customer satisfaction primarily based upon?

Nurses on a unit provide personal hygiene, administer medications, educate the patient and family about treatments, and provide emotional support. These nurses provide patient care based on which nursing delivery system?

A hospital converts to a system of care delivery in which RNs, LPNs, and unlicensed assistive personnel (UAP) are responsible for implementing a specific task, such as medication administration or personal hygiene, for the entire nursing unit. What term is used to describe this type of delivery system?

What title identifies a nurse who is responsible for following the patient from admission through discharge or resolution of illness while working with a broad range of health care providers?

A patient is admitted with coronary artery disease and is scheduled for coronary artery bypass grafting (CABG). According to the clinical pathway the patient should be extubated and discharged from critical care the day after surgery. During surgery the patient‘s oxygen saturation decreased drastically because of chronic tobacco abuse. Subsequently, the patient remained on the ventilator an additional 2 days postoperatively. According to the clinical practice guideline for CABG, this situation results in what type of event?

A patient is admitted with pneumonia. The case manager refers to a plan of care that specifically identifies dates when supplemental oxygen should be discontinued, positive-pressure ventilation with bronchodilators should be changed to self-administered inhalers, and antibiotics should be changed from intravenous to oral treatment, on the basis of assessment findings. This plan of care is referred to by what term?

The nurse manager determines that four RNs, five LPN/LVNs, and two unlicensed assistive personnel (UAP) are required per shift to meet the needs of the patient population on the unit, according to acuity and census. The nurse manager is concerned with what related process?

A nurse manager is mentoring a novice nurse manager in determining staffing needs. The mentor explains that the acuity level of the patient is determining by implementing what process?

The nurse manager is planning staffing levels and realizes that the first step is to focus on what activity?

A hospital is concerned with nurse retention and realizes that job satisfaction is a major influence. To best enhance employee satisfaction related to staffing, what intervention should the management team implement?

A patient is admitted for a hysterectomy, and the RN develops and implements the plan of care but also delegates to the LPN/LVN the responsibility of administering oral medications. While off duty, this RN receives a call requesting a change in the plan of care because the patient has developed deep vein thrombosis. The nurse who originally planned the care is practicing which type of nursing care delivery?

When deciding which staffing option to use on a nursing unit that will open soon, the manager recognizes what basic fact related to this issue?

A task force is considering factors that contribute to high-quality safe staffing. Which statement reflects an understanding of the American Nurses Association‘s (ANA) recommendations?

A nursing unit comparing team nursing to the partnership model would find what statement to be true?

Leadership abilities of the RN are a major determinant of effectiveness of care for both models

A nurse makes patient care assignments as follows: RN1 has rooms 200-210; RN2 has rooms 211-221; RN3 has rooms 222-232. The two unlicensed assistive personnel have half the rooms, with one assigned to 200-215 and the second to 216-232. What term is used to identify the care delivery model being used?

A patient has decided to stop hemodialysis because his renal failure progresses and he wishes to spend more time with family. Palliative care will continue, and the approach will be discussed with the patient and family as needed and at change of shift. The care delivery model in this situation is referred to by what term?

A nurse plans care knowing when specific recovery milestones are expected. The nurse is providing care via what delivery model?

An orthopedic unit is considering different types of care delivery models and staff have an opportunity to ask questions about how the models differ. The nurse manager provides an overview and uses the above visual to demonstrate which model of care delivery?

While participating in a task force to proactively plan for nursing care delivery over the next 20 years, a nurse learns that dramatic changes will occur because of what factor? (Select all that apply.)

Which factors would be considered in the first steps in developing an effective patient classification system? (Select all that apply.)

A nurse responsible for staffing a medical-surgical unit must consider what factors? (Select all that apply.)

A nurse is preparing to administer a medication by using the vastus lateralis site and is unfamiliar with the process. A step-by-step reference that shows how to complete the process is referred to by what term?

What nonprofit organization distributes knowledge related to health care for the purpose of improving health to governmental agencies, the public, business, and health care professionals?

A nurse is removing a saturated dressing from an abdominal incision and must cut the tape to remove the dressing. The nurse accidentally cuts the sutures holding the incision, and evisceration occurs. In quality improvement, this incident is best identified using what term?

A nurse is assisting with the delivery of twins. The first infant is placed on the scale to be weighed. The physician requests an instrument stat. The nurse turns to hand the instrument to the physician, and the infant falls off the scale. When evaluating the incident, the nurse and her manager list contributory factors such as the need for two nurses when multiple births are known, and the location of the scale so far from the delivery field. These nurses are engaged in what process?

Each month data on admission assessments that are based on the following standard are entered: ―All patients will be assessed by an RN within 2 hours of admission.ǁ The target goal for this standard is 97% compliance. Data are displayed on a graph that shows number and time of admission assessments and compliance variation limits. This pictorial representation is documented using what tool?

Regardless of the term used to describe high-quality health care, what is the primary focus of quality?

A team of experienced nurses work together to develop algorithms that are converted into checklists to ensure standardization of commonly performed procedures. The focus of this team is primarily on which Institute of Medicine (IOM) competency?

An organization‘s emergency preparedness task force meets to discuss how it should react in case of a terrorist attack and develops a disaster evacuation plan that details how each department will assist individuals in reaching safety. This type of diagram is referred to using what term?

Patients with heart failure have extended lengths of stay and are often readmitted shortly after they have been discharged. To improve quality of care, a type of ―road mapǁ that included all elements of care for this disease and that standardized treatment by guiding daily care was implemented. This road map is referred to using what term?

The staff on a nursing unit notes that patient satisfaction varies from month to month. They plot the degree of patient satisfaction each month for 1 year to determine when the periods of greatest dissatisfaction are occurring. The staff uses which type of graph to present this information?

A group of nurses are presenting the importance of high-quality care during a system-wide meeting of medical-surgical nurses. They point out a finding of the Quality Chasm that supports what?

According to the Quality Chasm report what statement is true?

During the night, a patient fell in the bathroom and sustained a hip injury. The patient was very upset because of being unable to attend a granddaughter‘s wedding in 2 days. The team looked at the process and determined that the patient had been medicated with a narcotic, had urinary urgency so had not taken the time to put on shoes, failed to turn on the light because the door to the hall let in some light, and stumbled over a towel that had been placed to collect water leaks caused by construction that was in progress to replace damaged sinks. Which factor was a special cause variation?

The number of IV site infections has more than doubled on a nursing unit. The staff determine common causes include the site is cleaned using inconsistent methods, dressing frequently becomes wet when patient showers, IV tubing is not changed every 48 hours per protocol, and inadequate hand washing of RN prior to insertion. A bar graph demonstrates the frequency in descending order, with 80% of infections being attributed to inadequate hand washing. The quality tool used is referred to as what?

The surgical team arrives in the operating room and one-member states, Everyone stop. Let‘s identify the patient and operative site. Now does anyone have any questions or concerns?ǁ This process is referred to by what term?

Institute for Healthcare Improvement (IHI) proposed a process for quality improvement with steps known as ―PDCA.ǁ What statement should be made when explaining the steps to a group of nurses interested in improving the process of medication reconciliation for heart failure patients with high rates of recidivism?

A hospital is concerned that the number of medication errors has increased significantly in the past year. A project revealed four causes of medication errors. The above chart was used to help staff and administration know where to focus efforts to reduce errors. Which process improvement tool is used in this situation?

A nurse is asked to ―floatǁ to a telemetry floor and is to place a patient on telemetry monitor. The nurse is unfamiliar with placement of EKG leads and would consult which type of chart to learn the correct placement?

Which of the following occurrences would be classified as a sentinel event?

A patient is ordered a low-protein, low-calorie diet but the patient‘s family brings fish, lentils, and unleavened bread for a meal to observe a cultural practice. The nurse works with the dietitian to adjust the next few meals to accommodate for this variance. What term should be used to identify this situation?

Nurses, physicians, and social workers finalize the plan of care and coordinate discharge for a homeless person who will need wound care and follow up over the next 4 weeks. Each member contributes based on his or her area of expertise but also recognize other members‘ strengths. Which of the QSEN competencies are being demonstrated?

Which of the following statements concerning the Institute of Medicine (IOM) competencies is correct?

Nurses working on an orthopedic unit use personal digital assistants (PDAs) to review medications prior to administration to reduce potential drug interactions. Software is also installed that provides video clips of common procedures performed by nurses. Nurses on this unit are best demonstrating which QSEN competencies?

A patient with complicated diabetes is scheduled for a below the knee amputation at 7 AM. The surgical team adheres to the 2018 National Patient Safety Goals by implementing which protocols? (Select all that apply.)

The National Database of Nursing Quality Indicators (NDNQI) identifies what client focused events as outcome indicator? (Select all that apply.)

A nurse educator is explaining to licensed staff that health care is no longer safe and describes The Quality and Safety for Nursing (QSEN) recommended competencies for educating nursing professionals. What competency is included? (Select all that apply.)