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Workbook
Workbook for
for Lippincott’s
Lippincott’s Textbook
Textbook

for Nursing Assistants

Third Edition

PAMELA J. CARTER, RN, BSN, MEd, CNOR

Program Coordinator/Instructor
School of Health Professions
Davis Applied Technology College
Kaysville, Utah
LWBK743-FM_i-x.qxd 24/11/2010 04:10 AM Page ii Aptara

Acquisitions Editor: Elizabeth Nieginski

Product Manager: Eric Van Osten
Vendor Manager: Cynthia Rudy
Director of Nursing Production: Helen Ewan
Designer: Holly McLaughlin
Manufacturing Coordinator: Karin Duffield
Production Services / Compositor: Aptara, Inc.

3rd edition

Copyright © 2012 by Lippincott Williams & Wilkins, a Wolters Kluwer business.

Copyright © 2008 by Lippincott Williams & Wilkins.

Copyright © 2005 by Lippincott Williams & Wilkins. All rights reserved. This book is protected
by copyright. No part of this book may be reproduced or transmitted in any form or by any
means, including as photocopies or scanned-in or other electronic copies, or utilized by any
information storage and retrieval system without written permission from the copyright owner,
except for brief quotations embodied in critical articles and reviews. Materials appearing in this
book prepared by individuals as part of their official duties as U.S. government employees are not
covered by the above-mentioned copyright. To request permission, please contact Lippincott
Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via
email at [email protected], or via our website at lww.com (products and services).

9 8 7 6 5 4 3 2 1

ISBN-13: 978-1-60547-636-0
ISBN-10: 1-60547-636-6

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Preface

Workbook for Lippincott’s Textbook for Nursing ACTIVITIES DESIGNED TO

Assistants, developed alongside the textbook with
the aid of an instructional design team, is
APPEAL TO DIFFERENT TYPES
designed to help students internalize and apply OF LEARNERS
the important concepts and facts presented in
the textbook. Students will benefit from first This workbook uses several different types of
reading the assignment in the textbook and then activities to help students internalize and apply
completing the corresponding workbook assign- the information in the textbook. A wide variety
ment. This approach allows students to review of activities is important for appealing to
and reinforce the information that they have just students with different learning styles. Variety
read. In addition, after working on the workbook also helps to keep students engaged in the
assignment, students who are having difficulty assignment. Some of the activity types that you
understanding the information presented in the will find in this workbook include:
textbook will know what type of questions they ■ Multiple-choice questions: Select the
need to ask in class the following day. This single best answer from four choices.
ability to recognize areas of difficulty helps ■ Fill-in-the-blanks: Complete a phrase or
students to better utilize instruction time. sentence.
■ Think About It! Write a short response to a
thought-provoking “what if?” scenario.
A UNIQUE ORGANIZATION ■ True or false? Identify the true statements
and correct the false ones.
The organization of each chapter in the ■ Matching: Match the terms or pictures to
workbook follows the same organization as the their descriptions.
corresponding chapter in Lippincott’s Textbook for ■ Crossword puzzles: Decipher the clues to
Nursing Assistants. This unique organization complete the puzzle.
enhances flexibility with regard to assignments— ■ Word find puzzles: Locate key vocabulary
it is easy to assign all, or just part of, a workbook words in the grid of letters.
chapter, according to the needs of your particular ■ Word jumbles: Use the clues to rearrange
curriculum. In addition, this unique organization scrambled letters and reveal key vocabulary
allows students to identify particular areas of words.
difficulty where more clarification and review is ■ Labeling: Fill in the missing labels on a key
needed. Key Learning Points, derived from piece of artwork.
the learning objectives in the textbook, are given ■ Sequencing: Put the steps of a procedure or
for each sub-topic within the chapter and help process in the correct order.
the student to easily identify the concepts that ■ Identification: Recognize the phrases or
are being reviewed and reinforced. sentences that apply to each situation.

iii
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iv PREFACE

Many workbooks rely heavily on multiple- the course, when students are practicing the
choice questions. Although multiple-choice procedures they have just learned.
questions are important for helping students to ■ Pam’s pearls: Scattered throughout the
prepare for the certification exam, the goal of workbook, these words of advice and encour-
this workbook is to help prepare students for agement from the author serve to reinforce
what comes after the exam. We want students to key concepts and remind students of the very
develop a depth of understanding of this important role they will play in providing
material that will serve them well in their clinical patient and resident care.
practice, long after the exam is over. Our goal is
to help promote good problem-solving abilities
Preventing the complications of
and more of a “working” application of the
immobility through frequent
material. Instructors wishing to provide their
repositioning and transferring is a major
students with additional practice in answering
responsibility of the nursing assistant!
multiple-choice questions can create worksheets
and practice tests using the multiple-choice
questions provided on the Instructor’s Resource Answers to the activities in the Workbook for
CD and on thePoint, a web-based course and Lippincott’s Textbook for Nursing Assistants are
content management system provided on the Instructor’s Resource CD and on
(http://[email protected]/Carter3e). thePoint (http://[email protected]/Carter3e).
It is our sincere hope that students will find
completing assignments from the workbook to
OTHER KEY FEATURES be fun as well as educational. As always, we
welcome and appreciate feedback from our
In addition to a variety of activities designed to readers.
reinforce the information in Chapters 1 through
45 and Appendix B (“Introduction to the Pamela J. Carter
Language of Health Care”) of Lippincott’s Textbook Lippincott Williams & Wilkins
for Nursing Assistants, this workbook contains:
■ Procedure checklists. These checklists are
very useful during the laboratory portion of

*thePoint is a trademark of WKHealth.

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Acknowledgment

I’d like to thank Joellen Shumway, Elizabeth Nieginski, and Eric Van Osten for their assistance
during the development of this workbook.

v
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Contents

CHAPTER 10
UNIT I
Patient Safety and Restraint
INTRODUCTION TO HEALTH CARE Alternatives 50
CHAPTER 1 CHAPTER 11
The Health Care System 1 Positioning, Lifting, and Transferring
Patients and Residents 55
CHAPTER 2
The Nursing Assistant 5 CHAPTER 12
Basic First Aid and Emergency Care 59
CHAPTER 3
Professionalism and
Job-Seeking Skills 9
UNIT III
BASIC PATIENT and RESIDENT CARE
CHAPTER 4
Legal and Ethical Issues 15 CHAPTER 13
The Patient or Resident Environment 65
CHAPTER 5
Communication Skills 20 CHAPTER 14
CHAPTER 6 Admissions, Transfers, and Discharges 71
Those We Care For 25
CHAPTER 15
Bedmaking 74
UNIT II
SAFETY CHAPTER 16
Vital Signs, Height, and Weight 79
CHAPTER 7
Communicable Disease and Infection CHAPTER 17
Control 32 Comfort and Rest 90
CHAPTER 8 CHAPTER 18
Bloodborne and Airborne Pathogens 39 Cleanliness and Hygiene 95
CHAPTER 9 CHAPTER 19
Workplace Safety 43 Grooming 103
vii
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viii CONTENTS

CHAPTER 20 CHAPTER 32
Basic Nutrition 109 The Digestive System 185

CHAPTER 21 CHAPTER 33
Assisting With Urinary The Urinary System 192
and Bowel Elimination 117
CHAPTER 34
UNIT IV The Reproductive System 198

DEATH AND DYING

UNIT VI
CHAPTER 22 SPECIAL CARE CONCERNS
Caring for People
Who Are Terminally Ill 124 CHAPTER 35
Caring for People With
CHAPTER 23 Rehabilitation Needs 206
Caring for People Who Are Dying 127
CHAPTER 36
UNIT V Caring for People With Developmental
Disabilities 210
STRUCTURE AND FUNCTION OF THE
HUMAN BODY CHAPTER 37
CHAPTER 24 Caring for People
With Mental Illness 215
Basic Body Structure and Function 132
CHAPTER 38
CHAPTER 25
Caring for People With Dementia 220
The Integumentary System 137
CHAPTER 39
CHAPTER 26
Caring for People With Cancer 226
The Musculoskeletal System 144
CHAPTER 40
CHAPTER 27
Caring for People With HIV/AIDS 230
The Respiratory System 150

CHAPTER 28 UNIT VII

The Cardiovascular System 160 ACUTE CARE

CHAPTER 29 CHAPTER 41
The Nervous System 169 Caring for Surgical Patients 233

CHAPTER 30 CHAPTER 42
The Sensory System 174 Caring for Mothers and Newborns 239

CHAPTER 31 CHAPTER 43
The Endocrine System 180 Caring for Pediatric Patients 244
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CONTENTS ix

APPENDIX B
UNIT VIII
Introduction to the Language of
HOME HEALTH CARE Health Care 257
CHAPTER 44 Procedure Checklist 265
Introduction to Home Health Care 249

CHAPTER 45
Safety and Infection Control
in the Home Health Care Setting 253
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CHAPTER
The Health Care
System

HEALTH CARE DELIVERY, c. To train people in the field of health care

PAST AND PRESENT d. To teach people the ways to achieve and
maintain physical and mental fitness
Key Learning Points 2. Who is referred to as a “patient”?
■ The changes that have occurred in how health a. A person who receives the services of a
care is delivered long-term care facility
b. A person who receives the services of an
Activity A Mark each statement as either
assisted-living facility
“true” (T) or “false” (F). Correct the false
statements. c. A person who receives the services of a hospital
d. A person who receives the services of a
1. T F In the 18th, 19th, and early part of the
home health care agency
20th centuries, health care delivery in
the United States was focused around 3. Why are people who are cared for in a long-
care given in health care facilities. term care facility referred to as “residents”
rather than “patients”?
2. T F A holistic approach focuses on taking care
of only the emotional needs of a person. a. Because most of the people who are admit-
ted to a long-term care facility are elderly
b. Because the long-term care facility
becomes the person’s home, either
HEALTH CARE ORGANIZATIONS temporarily or permanently
Key Learning Points c. Because the long-term care facility cares for
people of all ages with any number of
■ Types of health care organizations different medical needs
■ Structure of a health care organization
d. Because the people in a long-term care
Activity B Select the single best answer for facility receive more advanced care than
each of the following questions. those in a hospital

1. Which of the following would most likely be Activity C Fill in the blanks using the words
the primary mission of a university hospital? given in brackets.
a. To use the health care industry as a
[inpatient, outpatient]
financial investment to turn a profit
b. To promote health by offering 1. A patient who stays in a hospital for one or
rehabilitation services to people more nights receives care.

1
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2 UNIT 1 INTRODUCTION TO HEALTH CARE

2. A patient with cancer who returns to the hos- 4. Long-term b. Provides limited
pital every day for a period of time to receive care facility help with
radiation therapy would be receiving medications,
5. Subacute care
care. transportation,
unit
meals, and
Activity D Observe the figure and answer the housekeeping
following question. c. Provides care for
people who are
Physical therapist unable to care for
themselves at
Lab, Housekeeping
home yet do not
pharmacy, need to be hospital-
X-ray ized
d. Provides skilled care
Social Dietary in a person’s home
services
e. Relieves pain and
provides emotional
Patient or resident and spiritual
support for both the
dying person and
the family
Physician Nursing
assistant
Activity F Look at the organization chart
Nurse below and match the job title in Column A
with its corresponding function in Column B.
1. In a health care setting, who is always the
focus of the health care team’s efforts?
Board of Trustees
a. The physician
b. The housekeeping staff
c. The patient or resident
d. Social services
Administrator CEO Medical staff

Health care is provided by a team of

people, each with different areas of
expertise and job responsibilities. As a nursing
assistant, you are a critical member of the Director of Director of Director of Director of
Nursing Ancillary Business Facility
health care team!
Services Services

Activity E Match the health care organization

in Column A with its corresponding function in RNs X-ray Admitting Housekeeping
Column B. Lab Billing Maintenance
LPNs Pharmacy Collections Security
Column A Column B Dietary Payroll Laundry
CNAs
1. Hospice a. Provides rehabilita- Human Grounds
Resources
tion and other
2. Home health
skilled care and
care
helps the person
3. Assisted-living advance from
facility hospital care to
home care

Copyright © 2012. Wolters Kluwer Health | Lippincott Williams & Wilkins. Workbook for Lippincott’s Textbook for Nursing Assistants,
A Humanistic Approach to Caregiving, 3rd edition.
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CHAPTER 1 THE HEALTH CARE SYSTEM 3

Column A Column B PAYING FOR HEALTH CARE

1. Board of a. Manages the organi-
trustees zation and is the Key Learning Points
link between the ■ How health care is paid for
2. Director of
board and the
Nursing
organization Activity H Match the insurance or plan in
3. Administrator b. Sets policies to Column A with its corresponding function in
or chief exec- ensure that the care Column B.
utive officer offered by the orga- Column A Column B
nization is safe and
of good quality 1. Group a. A federally funded
insurance insurance plan by
c. Responsible for the
Social Security,
quality of the nurs- 2. Managed care
under the adminis-
ing care provided in system
tration of the Cen-
the facility
3. Medicare ter for Medicare and
Medicaid Services
4. Medicaid
(CMMS)
OVERSIGHT OF THE b. A federally funded
HEALTH CARE SYSTEM and state-regulated
plan designed to
Key Learning Points help people with
■ Government and private agencies that provide low incomes to pay
oversight of the health care system for health care
c. Insurance that is
Activity G Match the agencies and regulations purchased at
used to protect health care recipients and group rates by an
providers in Column A with their corresponding employer or
function in Column B. corporation
Column A Column B d. Assists in delivering
health care to peo-
1. United States a. Established safety ple who need it by
Department and health standards arranging contacts
of Health and for the workplace with various health
Human Services b. Sets national care providers
2. Omnibus Budget standards for all
Reconciliation types of health care
Act (OBRA), 1987 organizations
c. Primary government
3. Occupational
agency responsible
Safety and Health
for protecting
Act, 1970
nation’s health
4. The Joint d. Improved
Commission conditions for
people in long-term
care facilities

Copyright © 2012. Wolters Kluwer Health | Lippincott Williams & Wilkins. Workbook for Lippincott’s Textbook for Nursing Assistants,
A Humanistic Approach to Caregiving, 3rd edition.
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M I S S I O N P L
SUMMARY
Activity I Use the clues to find words that are
E Q A Z W S X C G present in the grid of letters, either horizontally
from left to right or vertically from top to
D E C D F P B L R bottom.
I P L H H A H I J Down
1. A type of insurance plan that is federally
C K L O I T U E K funded by Social Security and that all people
65 years and older, and some younger
A W B L K I Q N L disabled people, are eligible to participate in
2. An adjective used to describe care of
R E S I D E N T V the whole person, physically and emotionally
3. A federally funded and state-regulated plan
E U H S Q N D Y X designed to help people with low incomes to
pay for health care
W K M T S T F H M
Across
E Q A I F A M N A 1. The officially stated purpose of a health care
facility or organization
R W Y C L I E N T 2. A person being cared for in a long-term care
facility
T B T F U H D U Q 3. A person who is receiving the services of a
home health care agency
Y I J N K M I J W

U X D W Q A C M F

I U H B T F A C S

O K M I J N I B A

P Q A X D W D X Y
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CHAPTER
The Nursing Assistant

NURSING, PAST AND PRESENT c. Omnibus Budget Revision Act

d. Omnibus Budget Reform Act
Key Learning Points 2. OBRA requires that every state maintain an
■ The history of nursing official database of the people who have
successfully completed the nursing assistant
Activity A Select the single best answer for training program. What is this record called?
each of the following questions.
a. A catalogue
1. What is Florence Nightingale credited for? b. A database
a. Demonstrating the effect of music on the sick c. A handbook
b. Establishing nursing as a profession in its d. A registry
own right
c. Founding the world’s first hospital Activity C Mark each statement as either
d. Discovering the cure for smallpox “true” (T) or “false” (F). Correct the false
statements.
2. What were early nursing assistants called?
1. T F Many long-term care facilities offer nurs-
a. Helpers
ing assistant training programs.
b. Sub-nurses
2. T F OBRA requires all nursing assistants to
c. Aides
undergo a minimum of 50 hours of
d. Caretakers training.
3. T F A student is given three opportunities to
successfully complete the competency
EDUCATION OF THE evaluation at the end of the training
NURSING ASSISTANT period.
4. T F The principle of reciprocity means that
Key Learning Points your certificate will not be valid in states
■ OBRA requirements for nursing assistant other than where you received your
training training.
■ Contents of the registry
5. T F Nursing assistants who have not worked
Activity B Select the single best answer for for 2 consecutive years need to undergo
each of the following questions. retraining and retake the competency
evaluation.
1. What does OBRA stand for?
a. Overall Budget Reconciliation Act
b. Omnibus Budget Reconciliation Act

5
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6 UNIT 1 INTRODUCTION TO HEALTH CARE

Activity D Place an “X” next to the THE NURSING TEAM

information that does NOT appear in the
registry. Key Learning Points
1. Full name ■ The members of the nursing team, and the
role of each team member
2. Home address
3. Social Security number Activity F Fill in the blanks.

4. Date of birth 1. Every nursing team consists of at least a nurse

and a nursing assistant. A nurse
5. Date the competency evaluation was can either be a
passed , or a .
6. Educational qualifications In some states, an LPN is also referred to as a
.
7. Reported incidents of resident A nursing team could also include
abuse or neglect, or theft of resident a , whose duty
property involves supervising other nurses during a
shift, and a , who
heads a department or section. An RN who
RESPONSIBILITIES OF directs all the nursing care within a health
care organization is called a
THE NURSING ASSISTANT .
Key Learning Points Activity G Think About It! Briefly answer
■ Responsibilities of the nursing assistant the following question in the space provided.

Activity E Select the single best answer for Explain the difference between primary
each of the following questions. nursing, functional (modular) nursing, and team
nursing.
1. What important role does the nursing
assistant play?
a. Consultant
b. Medical advisor
c. Observer and communicator
d. Administrator
2. Which one of the following is NOT a basic DELEGATION
physical need?
Key Learning Points
a. Hygiene
■ The delegation process as it relates to the nurs-
b. Comfort ing assistant
c. Nutrition ■ The “five rights” of delegation
d. Entertainment
3. A nursing assistant’s duties do NOT include
taking care of the patient’s or resident’s:
a. Safety
b. Exercise
c. Financial needs
d. Emotional needs

Copyright © 2012. Wolters Kluwer Health | Lippincott Williams & Wilkins. Workbook for Lippincott’s Textbook for Nursing Assistants,
A Humanistic Approach to Caregiving, 3rd edition.
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CHAPTER 2 THE NURSING ASSISTANT 7

Activity H Mark each statement as either Activity J Select the single best answer for
“true” (T) or “false” (F). Correct the false each of the following questions.
statements.
1. Which one of the following reasons is NOT an
1. T F “Scope of practice” refers to the range of acceptable reason to refuse to perform a dele-
tasks that a nursing assistant is morally gated task?
allowed to perform. a. The directions given to you by the nurse are
2. T F By delegating a task, a nurse gives not clear.
a nursing assistant permission to b. You do not have the proper equipment to
perform the task on his or her behalf. perform the task.
3. T F Tasks such as assessment, planning, and c. You do not enjoy the task.
evaluating can be delegated to nursing d. The task is illegal or unethical.
assistants. 2. When a nurse delegates a task to a nursing
assistant, the nurse is responsible for any
Activity I The National Council of State
injury that may occur to the patient or
Boards of Nursing (NCSBN) has developed resident if:
guidelines, called the “five rights” of delegation,
to help nurses effectively delegate tasks. Match a. The nursing assistant is not qualified for the
the rights in Column A with the corresponding task
guidelines in Column B. b. The nursing assistant is suitably qualified,
but is not supervised by the nurse
Column A Column B
c. The nursing assistant is suitably qualified
1. The right task a. Will the nurse but makes a mistake while carrying out the
be available to task
2. The right
supervise or answer
circumstance d. The nursing assistant is suitably qualified
questions?
but does not perform the task as requested
3. The right b. Will the nurse be
person able to give the
nursing assistant The delegation of tasks cannot be taken
4. The right
clear directions lightly by either the nurse or the nursing
direction
regarding how to assistant. Both share responsibility for
5. The right perform the task? ensuring that the procedure is carried out
supervision without harm to the patient or resident.
c. What are the needs
Know which tasks are within your scope of
of the patient or resi-
practice and which are not, and don’t be
dent at this time?
afraid to ask for help or clarification if you
d. Can this task be need it.
delegated?
e. Does the nursing
assistant have
the right training
and experience to
safely complete the
task?

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8 UNIT 1 INTRODUCTION TO HEALTH CARE

SUMMARY
E R C R I O P T I Y C Activity K Words shown in the picture have
been jumbled. Use the clues to form correct
words using the letters given in the picture.
E G Y R R T I S
1. The principle by which one state recognizes
the validity of a license or certification granted
by another state
E T A G E L E D 2. An official record maintained by the state of
the people who have successfully completed
the nursing assistant training program
A D E H E U R N S 3. To authorize another person to perform a task
on your behalf
4. A registered nurse (RN) who is in charge of a
department or section
A E M T G I N S R U N
5. A model for organizing the nursing team’s
efforts in which a team leader (a registered
nurse) determines all of the nursing needs for
the patients or residents assigned to the team,
and assigns tasks according to each team
member’s skills and level of responsibility

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CHAPTER
Professionalism and
Job-Seeking Skills

WHAT IS A PROFESSIONAL? The health care industry relies on all

types of professionals to provide quality
Key Learning Points care to patients and residents. Professionals
■ The meaning of the terms professional and pro- have certain credentials that are earned
fessionalism through education and training, but being a
■ Characteristics of a professional health care professional also means having a professional
worker attitude and a good work ethic.

Activity A Select the single best answer for the

following question.
1. Which one of the following nursing assistants
WHAT IS A WORK ETHIC?
does NOT show the attitudes characteristic of
a professional? Key Learning Points
a. Sara is an experienced nursing assistant ■ The term work ethic and how good work habits
who is kind and caring toward the patients promote professionalism
and residents in the facility where she
works. Activity B Select the single best answer for
each of the following questions.
b. Sally is a certified nursing assistant who
works only to earn a paycheck. 1. A strong “work ethic” is one of the most
c. Sara is a certified nursing assistant who is important qualities that potential employers
committed to doing her work to the best of look for in a nursing assistant. What does this
her ability. term refer to?
d. Sally is a certified nursing assistant who takes a. A person’s ability to judge whether a nurse
pride in her work at the hospital and is has made a correct decision
always interested in learning more about b. A person’s ability to perform the work
her job. assigned to him or her
c. A person’s attitude toward his or her work
d. A person’s awareness of the rules that
should be followed in the workplace

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10 UNIT 1 INTRODUCTION TO HEALTH CARE

2. Which of the following qualities does NOT PERSONAL HEALTH AND

reflect a strong work ethic?
HYGIENE
a. Punctuality
b. Competitiveness Key Learning Points
c. Accountability ■ The importance of personal health and
d. Reliability hygiene for a health care worker

Activity C Match the words given in Activity D To maintain good physical health,
Column A with the corresponding meanings a nursing assistant must take care of himself or
in Column B. herself first. Look at the figures below and fill in
the blanks.
Column A Column B
1. Punctuality a. You can be trusted B
A
by patients and
2. Reliability
residents with
3. Accountability their private
information and
4. Conscientious-
valuables.
ness
b. You are polite and
5. Courtesy and C
do not make nega-
respectfulness tive remarks about
your coworkers. D
6. Honesty
c. Your supervisor can
7. Cooperative-
depend on you to
ness
finish your assign-
8. Empathy ment properly.
d. You offer a helping
hand when you
see that a coworker
requires help.
e. You take responsi-
bility for your
actions and their
consequences.
f. You are always on
time for work.
g. You are able to
show kindness and
tolerance by imag-
ining yourself in E
someone else’s
situation. A. You should get enough .
h. You take your
B. You should not and you
work seriously and
should limit your intake.
give your patients
or residents the C. You should regularly.
“royal treatment.”
D. You should have a routine
.
A nursing assistant with a strong work E. You should eat __________________________
ethic has qualities that make her both meals.
pleasant to work with and dependable.

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CHAPTER 3 PROFESSIONALISM AND JOB-SEEKING SKILLS 11

Activity E Select the single best answer for Activity G Match the characteristics of a
each of the following questions. nursing assistant in Column A with the health
care facility that she would be best suited for in
1. Why is it important for a nursing assistant to
Column B.
maintain good personal hygiene?
a. Good personal hygiene helps to prevent the Column A Column B
spread of infection. 1. Likes to work a. acute care unit
b. Good personal hygiene sets you apart from with elderly b. long-term care
other nursing assistants. people facility
c. Good personal hygiene makes you eligible 2. Wants to care c. home health
for a raise in salary. for people in care agency
d. Good personal hygiene sets an example for their homes
your patients and residents.
3. Likes a fast-
2. Which of the following activities is NOT a paced work
part of maintaining good personal environment
hygiene?
a. Bathing daily and using a deodorant Activity H Sally is searching for a suitable
nursing assistant job. Considering her
b. Keeping your nails short and clean
situation, help her make a decision from the
c. Wearing a clean, pressed uniform everyday given options. Select the single best answer for
d. Wearing jewelry to improve your appearance each of the following situations.
1. Sally has a child.
Activity F Mark each statement as either
“true” (T) or “false” (F). Correct the false
statements.
1. T F Physical activity relieves mental and
emotional stress.
2. T F Making time for yourself is just not that
important when you feel overwhelmed
with responsibilities.
3. T F You must never ask to be assigned to dif-
ferent work areas or to different patients
or residents.

To care for your patients or residents to

the best of your ability, you must first
care for yourself!

JOB-SEEKING SKILLS
a. She takes the child to work.
Key Learning Points b. She works whatever shift she is scheduled
■ Sources of information about employment for, not considering the childcare
opportunities in the health care industry arrangements.
■ Factors to consider when seeking employment c. She tells the employer that she is available to
■ The application process necessary for work any shift, even though this is not true.
obtaining employment d. She tells the employer what shift she is
available to work, based on her childcare
arrangements.

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12 UNIT 1 INTRODUCTION TO HEALTH CARE

2. Sally plans to take the bus to get to work. Activity I Use the clues for sources of
employment opportunities to complete the
crossword puzzle.
2nd Avenue
1

2 3

a. She applies for a job at every health care 6

facility, whether or not it is served by the
bus line nearest to her home.
b. She applies for a job at health care facilities
serviced by the bus line nearest her home.
c. She applies for a job at a health care facil-
ity serviced by the train, even though she
does not live near a train station.
d. She applies for a job at every health care
facility, even those not served by public
transportation.

Across
4. Contains classified ads listing employment
opportunities
6. Use this to check sites that help people find
jobs
Down
1. A department at your school that may have
job listings and can often help with writing a
résumé

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CHAPTER 3 PROFESSIONALISM AND JOB-SEEKING SKILLS 13

2. Check here for a list of facilities and agencies Activity L Think About It! Briefly answer the
that hire nursing assistants following question in the space provided.
3. They may know of possible job openings
5. Many schools and facilities have one of these, Amy Robinson goes on an interview for a posi-
where job opportunities may be posted tion as a nursing assistant at a long-term care fa-
cility. The interviewer asks Amy whether or not
she is married. How should Amy respond to the
Advance planning about the type of interviewer’s question?
employment you want helps to give your
job search direction.

Activity J Match the words given in

Column A with their corresponding meanings
in Column B. Activity M Select the single best answer for the
following question.
Column A Column B
1. Why is it a good idea to first ask for a person’s
1. Résumé a. A letter to introduce permission before including his name
yourself to a and contact information in your reference list?
2. Cover letter
potential employer
a. The person may not want his contact
3. Reference list b. List of three or four information given out.
people willing to
b. The person may not be able to give you a
talk to a potential
positive reference and therefore might be
employer about your
more comfortable not giving any reference
abilities
at all.
c. A brief document that
c. It is good manners to ask before including
gives general informa-
someone on a reference list.
tion about you, your
education, and work d. All of the above
experience to a poten-
tial employer Activity N Place an “X” next to the
information that should be included in a job
Activity K Place an “X” next to the application form.
information that should be included in a 1. Weight
résumé.
2. Work history
1. Full name
3. Marital status
2. Employment history
4. Education
3. Weight
5. Position applied for
4. Marital status
6. Reason you left your previous job
5. Age
7. Shifts that you can work
6. Address
8. Contact address and how can you be
7. Education history reached
8. Sexual preference 9. Sexual preference
10. Religion

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14 UNIT 1 INTRODUCTION TO HEALTH CARE

Activity O Which one of the nursing 2. A person who has credentials, obtained
assistants pictured below is most likely to make through education and training, that enable
a favorable impression on a potential employer? him or her to become licensed or certified to
practice a certain profession; also, a person
who demonstrates a professional attitude
A. B. 3. The side of ourselves that we display to the
world, communicating outwardly how we feel
about things
4. A brief document that gives a potential
employer general information about a job
candidate’s education and work
experience
Across
1. A person’s attitude toward his or her work
C. D.

I H R P E R S O N

N L I S T S D Y J

T A E N Y B G P Q

E V S E T L K I D

Activity P Fill in the blanks.

R A Z W P L I V B
1. If you haven’t heard from your employer in V L M R R A E A W
week’s time, it is appropriate
to call and ask about the status of your I J Q L O V S T T
application.
2. Write a thank you note within
E T O D F O N T U
day(s) of interviewing for a position.
W O R K E T H I C

R S E Q S V R T I
SUMMARY
F A S A S A I U T
Activity Q Use the clues to find words that are
present in the grid of letters, either horizontally V D U Z I L E D R
from left to right or vertically from top to
bottom. Y Y M W O J S E U
Down
A G E S N T Z A S
1. A meeting between an employer and a poten-
tial employee, during which information is S N Q X A R M E R
exchanged regarding the organization, the
job, and the potential employee’s H F T T L Y Q Y D
qualifications for the job

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CHAPTER
Legal and Ethical Issues

INTRODUCTION TO LEGAL PATIENTS’ AND RESIDENTS’

AND ETHICAL ISSUES RIGHTS
Key Learning Points Key Learning Points
■ Factors influencing behavior in society ■ Patients’ and residents’ rights, as set forth by
■ Need for laws and ethics the American Hospital Association (AHA) and
the Omnibus Budget Reconciliation Act (OBRA)
Activity A Place an “X” next to the ■ Two major types of advance directives
factors that influence a person’s behavior ■ Why advance directives play an important role
in society. in health care
1. Society’s laws
Activity C Select the single best answer for
2. Personal ethical code each of the following questions.
3. Fear of punishment 1. Which of the following statements is NOT
listed in The Patient Care Partnership?
4. Spiritual beliefs
a. The right to information regarding diagno-
5. Values instilled by family sis, treatment, and prognosis
6. Rules established by a governing b. The right of confidentiality pertaining to all
authority communication
c. The right to use personal possessions
Activity B Mark each statement as either
d. The right to considerate and respectful care
“true” (T) or “false” (F). Correct the false
statements. 2. Where is the right to be informed of one’s
options for care stated?
1. T F Fear of punishment is what causes a
person to act according to an ethical a. The Patient Care Partnership
code. b. Patients’ Bill of Responsibilities
2. T F Laws and ethics provide guidance to c. Residents’ Rights
health care providers. d. Rights for the Health Care Organizations
3. T F Values instilled by a person’s family
influence the person’s ethical code.

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16 UNIT 1 INTRODUCTION TO HEALTH CARE

3. Which one of the following is a responsibility 4. A for

of the patient? health care transfers the responsibility for
a. The patient is responsible for the making medical decisions on the person's
consequences of refused treatment or dis- behalf to a family member, friend, or other
regarded instructions. trusted individual, in the event that the
person is no longer able to make these
b. The patient is responsible for withholding
decisions on her own behalf.
information that is confidential.
c. The patient is responsible for having his
medical records explained and interpreted.
d. The patient is responsible for participating
LAWS: A WAY OF PRESERVING
in experimental studies. PATIENTS’ AND RESIDENTS’
4. Which of the following statements is NOT
RIGHTS
listed in the “Residents’ Rights”?
Key Learning Points
a. The right to be free from physical or
■ The legal aspects of health care delivery
psychological abuse, including the
■ Common legal violations that are related to
improper use of restraints
the provision of health care
b. The right to organize and participate in ■ The awareness that health care workers must
groups organized by other residents, or the have in order to avoid legal dilemmas
families of residents ■ Types of abuse and signs that indicate abuse
c. The right to respect the property, comfort, ■ The health care worker’s obligations in the
environment, and privacy of other patients reporting of suspected abuse
d. The right to information about advocacy
groups Activity E Place an “X” next to the correct
answers for the following questions.
5. Which of the following conditions could
result in a loss of the resident’s right to remain 1. Why should laws be enforced?
in the facility? Because they preserve citizens’ basic
a. Planned changes in living arrangements human rights
b. Harrassing or threatening the safety of Because American colonies have gained
other residents independence
c. Participation in social or religious activity
Because they protect basic human rights
d. Sharing the room with a spouse for all people, regardless of race, religion,
gender, or income
Activity D Fill in the blanks using the words
given in brackets. Because they help settle disputes in a civi-
lized, orderly way
[durable power of attorney, advance directive,
living, health care agent] 2. Which of these terms relate to a violation of
civil law?
1. An is a document
that allows a person to make his wishes Litigation
regarding health care known to family Defamation
members and health care workers, in case the
time comes when he is no longer able to make False imprisonment
those wishes known himself. Battery
2. A is 3. What is the purpose of the Health Insurance
the person who is responsible for making deci- Portability and Accountability Act (HIPAA)?
sions on the person's behalf.
It regulates who has the right to view a
3. A will allows the person to give person’s medical records, data, or other
instructions about what medical treatments he private information.
would or would not want to be done in an
effort to save his life.

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CHAPTER 4 LEGAL AND ETHICAL ISSUES 17

It sets standards on how a person’s Activity G Think About It! Briefly answer
medical information is to be stored and the following question in the space provided.
transmitted from one place to another.
Janine works in a long-term care facility located
It permits a contractual agreement that in a small town. One day, Janine runs into Mrs.
exists between a nursing assistant and the Jamison at the grocery store. Janine has just
person he or she cares for. learned that Mrs. Jamison’s mother-in-law, a
It requires that health care organizations resident at the long-term care facility where she
set policies that allow a patient or resident works, has been diagnosed with cancer. Assum-
to have access to his or her medical ing that Mrs. Jamison knows about her mother-
records. in-law’s condition, Janine tells her how sorry she
was to hear the news about her mother-in-law’s
4. Which of the following may be considered cancer. . . . and is stunned when Mrs. Jamison
elder abuse? says, “What cancer?” Did Janine do anything
Larceny wrong by expressing her condolences to Mrs.
Jamison?
Sexual abuse
Involuntary confinement or seclusion
Failure to provide food, water, care, and
medications
5. Which of the following situations may result
in abuse?
A desire of one person to overpower and
dominate another
A primary caregiver becoming very tired,
frustrated, and overwhelmed by the
responsibilities of providing care
A relationship that is long term rather
than short term
A patient or resident who is “difficult” to
manage
A failure to provide medication Activity H Match the terms associated with
abuse or legal issues given in Column A with
Activity F Mark each statement as either their examples given in Column B.
“true” (T) or “false” (F). Correct the false
statements. Column A Column B

1. T F Criminal laws are concerned with the 1. Assault a. A home health aide fails
relationship between the individual and to change an incontinent
2. Fraud
society as a whole. client’s soiled sheets more
3. Neglect than once a week.
2. T F Libel is an untrue oral statement that
4. Slander b. A nursing assistant tells a
hurts another person’s reputation. potential employer that
3. T F Keeping a person in a room alone with 5. Libel he passed his certification
the door closed can be considered a form exam when in fact he
of physical abuse. has not.
c. A nursing assistant
tells Mrs. Smith that if she
can’t be nice to her room-
mate, she will slap her.

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18 UNIT 1 INTRODUCTION TO HEALTH CARE

d. A movie star sues a tabloid 3. is respecting a person’s rights

newspaper that publishes and personal preferences.
an untrue report that the
4. is acting with integrity to earn
movie star had sought
others’ trust.
and received treatment at
a certain well-known 5. is treating people fairly and
mental health clinic. equally, regardless of race,
e. A nurse who feels she has religion, culture, disability, or
been unfairly treated by a ability to pay.
doctor on staff is
overheard telling another Activity J Place an “X” next to statements
employee of the hospital that describe the term “ethics.”
that the doctor never 1. Ethics are less prescriptive than laws.
actually graduated from
medical school. 2. Ethics are moral principles or standards
that govern conduct.

Always keep in mind the legal 3. Ethics are guidelines pertaining to

responsibilities and obligations that you standards of conduct and practice.
have as a caregiver. Knowing the tasks that 5. Ethics help us to determine the difference
are part of your job description and being between right and wrong in areas where
aware of your employer’s policies are critical the law fears to tread.
to ensure that the care you give is within the
legal limits of your job. Activity K Select the single best answer for
each of the following questions.
1. Which act or association provides the
guidelines for the code of ethics for
ETHICS: GUIDELINES FOR nursing?
BEHAVIOR a. American Hospital Association (AHA)
b. Omnibus Budget Reconciliation Act (OBRA)
Key Learning Points
c. Health Insurance Portability and
■ The difference between legal and ethical
Accountability Act (HIPAA)
issues
■ The ethical standards that govern the nursing d. American Nurses Association (ANA)
profession in particular and the health care 2. Which factors influence a person’s values?
profession in general
a. His culture and heritage
Activity I Fill in the blanks using the words b. His illness or disability
given in brackets. c. His income
[Beneficence, Autonomy, Justice, Nonmaleficence, d. His gender
Fidelity]
1. is when kindness and gentleness
are used while administering care.
2. is doing good for patients and res-
idents by preventing harm and
promoting the health and welfare
of the person above all else.

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CHAPTER 4 LEGAL AND ETHICAL ISSUES 19

SUMMARY 1. A violation of civil law

2. Spoken statements that injure someone’s rep-
Words shown in the picture have been jumbled. utation; a form of defamation
Use the clues to form correct words using the 3. Negligence committed by people who hold
letters given in the picture. licenses to practice their profession, such as
doctors, nurses, lawyers, dentists, and pharma-
cists
4. The responsibility of an individual to act
within the confines of the law
R T T O
5. Threatening or attempting to touch a person
without the person’s consent
6. Written statement that injures someone’s rep-
A R E S D N L utation; a form of defamation

A T I C E C A P R M L

L B Y T I L I A I

S A S A L U T

L B I L E

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CHAPTER
Communication Skills

WHAT IS COMMUNICATION? Activity B Select the single best answer for

each of the following questions.
Key Learning Points 1. Which of the following activities is a form of
■ The definition of the word communication communication?
■ Two major forms of communication a. Telling someone something

Activity A Communication is the exchange b. Giving a gift to someone

of information. Conversation is a form of c. Accepting a gift from someone
communication. Look at the following picture d. Driving down to a friend’s house to meet him
and fill in the blanks.
2. Which of the following is an example of
verbal communication?
a. Unintentional facial expressions
b. Shaking the hand of a new patient or
Method of transmission: resident
telephone, talking, etc.
c. Sign language or writing out a question to a
deaf resident
d. Body language
3. Which of the following statements indicates
that Mrs. Smith is using a form of nonverbal
communication?
a. Mrs. Smith walks over to the room next to
hers to talk to another resident.
The is the person with information b. Mrs. Smith grimaces and groans softly
to share, and the is the person when she gets up from her bed and
for whom the information is intended. The attempts to stand.
delivers the information in the c. Mrs. Smith talks about a pain in her back to
form of a which the receiver may a nursing assistant.
or may not understand. Through , d. Mrs. Smith listens carefully to the doctor
or a return message, the lets the who is informing her about her condition.
know whether the message was
received and understood.

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CHAPTER 5 COMMUNICATION SKILLS 21

Activity C Place a “V” next to the statements c. Speak clearly and in a voice that is loud
that are examples of verbal communication, enough to be heard
and an “N” next to the statements that are d. All of the above
examples of nonverbal communication.
2. Which one of the following is an example of
1. Use of language, either spoken or written negative body language?
2. Gently touching a patient or a resident on a. Nodding encouragingly as someone speaks
the shoulder to reassure her b. Crossing your arms across your chest
3. Making a face when you put weight on a c. Making eye contact when speaking to
painful leg someone
d. Gently touching a patient or resident on
4. Using sign language to communicate with
the shoulder or holding her hand
a person who is deaf
3. Which one of the following is an open-
5. Making a telephone call
ended question?
6. Nodding as someone speaks a. “Mr. John, tell me all about a favorite meal
7. Tapping your fingers on the table because you enjoyed in your younger days.”
you are bored b. “Are you Mrs. Smith?”
8. Recording vital sign measurements in a c. “Are you feeling okay, Mrs. Broan?”
patient’s or resident’s chart d. “Don’t you like green beans, Mrs. Jones?”
4. Mr. Zimmer is a new resident at the facility
Nursing assistants are an important link where you work. You have just explained to
between the patient or resident and him how to use the call light control system.
other members of the health care team. The What would be the best thing to say to
nursing assistant is often the first member of Mr. Zimmer to verify that he understands
the health care team to become aware of a what you have just explained to him?
change in a patient’s or resident’s condition a. “Let me make sure you understand this
that could be a sign of something serious. This correctly.”
is why it is important for nursing assistants to
b. “Let me know if you have any questions.”
have good communication skills.
c. “Could you just repeat these instructions
back to me so I can make sure that I
didn’t leave anything out?”
COMMUNICATING EFFECTIVELY d. “Do you think you’ve got it now?”
5. Which of the following is a block to effective
Key Learning Points communication?
■ Techniques that promote effective communi- a. Not being an active listener
cation b. Being judgmental
■ Blocks to effective communication and meth-
c. Interrupting a person before he finishes
ods used to avoid them
speaking
■ Causes of conflict, and ways of resolving
conflicts d. All of the above
6. Conflict between people can occur when one
Activity D Select the single best answer for person:
each of the following questions. a. Is unable to understand or accept another’s
1. How will you create a verbal message as a ideas or beliefs
sender? b. Has expectations that differ from those of
a. Organize relevant facts into a clear the other person
statement c. Misunderstands another person’s words or
b. Use language that the receiver under- intentions
stands d. All of the above

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22 UNIT 1 INTRODUCTION TO HEALTH CARE

Activity E There are different effective ways to COMMUNICATION AMONG

resolve a conflict. Place “T” in front of the MEMBERS OF THE HEALTH
sentences that describe effective ways of resolving
conflict. Place an “F” next to statements that CARE TEAM
describe ineffective ways of resolving conflict.
Then, correct the statements marked “F.” Key Learning Points
■ Methods of reporting and recording informa-
1. Arrange to speak privately with the tion in a health care setting
person you have a conflict with. ■ How a patient’s or resident’s medical record
2. Ask a supervisor to mediate immediately. makes communication easier among members
of the health care team
3. During the conversation, focus on the
■ Communication technologies that are being
area of conflict.
used in the health care field today
4. Be specific about what you understand ■ Why the nursing assistant is a vital link in the
the problem to be. communication chain
■ How the nursing assistant communicates
5. Tell the person how you feel about him or
information to other members of the health
her.
care team
6. Say, “You really hurt my feelings by what ■ Steps of the nursing process and how the nurs-
you said the other day.” ing team uses the nursing process to plan the
7. Agree to disagree. patient’s or resident’s care
■ Role of effective communication in the provi-
8. Offer advice to the person. sion of quality health care

Activity G Select the single best answer for the

Listening is one of the most important
following question.
communication skills, especially in the
health care field. 1. What usually forms the basis for a subjective
observation?
a. Mrs. Smith, a patient at the hospital, com-
plains of abdominal pain immediately after
TELEPHONE COMMUNICATION a meal.
b. A nursing assistant records Mrs. Smith’s
Key Learning Points temperature.
■ Proper telephone communication skills c. A nursing assistant measures Mrs. Smith’s
urine output.
Activity F Select the single best answer for the d. A nursing assistant reports Mrs. Smith’s
following question. pulse rate to the nurse.
1. As a nursing assistant, you are responsible for
answering the telephone, either at the nurs- Activity H As a nursing assistant, you must be
ing station or in a patient’s or resident’s a good communicator. What will you use your
room. When answering the telephone, what communication skills for? Place an “X” next to
should you NOT do? the relevant statements.
a. Speak in a pleasant and unhurried voice. 1. To comfort, reassure, and teach your
b. Take a message by writing down the caller’s patient or resident
name and telephone number and 2. To achieve a greater understanding of
delivering the message to the person it is what your patients or residents are feeling
intended for. and thinking
c. Convey a kind and professional attitude.
3. To diagnose and treat medical problems
d. Provide information about a patient’s or
resident’s condition to the caller.

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CHAPTER 5 COMMUNICATION SKILLS 23

4. To relay vital information about a patient’s Activity J Think About It! Briefly answer the
or resident’s condition to a nurse following question in the space provided.
5. To report and record information in a What legal document is used to record informa-
health care unit tion about a person’s current condition, the mea-
sures that have been taken by the medical and
Activity I Match the documents of a medical nursing staff to diagnose and treat the condition,
record given in Column A with their description and the person’s response to the treatment?
in Column B. Write the name of the document in the space
Column A Column B provided below.

1. Admission a. Document used by the

sheet doctor to communicate
to other members of
2. Medical
the health care team
history
what should be done
3. Physician’s for the patient or resi- Activity K Think About It! Briefly answer
order sheet dent the following question in the space provided.

4. Narrative b. Document where You are caring for Mrs. Wilson, who has been ad-
nurse’s information that is mitted to a hospital for the treatment of hyper-
notes gathered routinely, tension. One morning, Mrs. Wilson tells you that
such as vital signs, is she feels dizzy when she gets up from the chair.
5. Graphic recorded This is your subjective observation. What objec-
sheet tive data would you gather to support the subjec-
c. Record of previous
surgeries and medical tive data given to you by Mrs. Wilson?
conditions, current
medications, allergies,
and current medical
diagnosis
d. Provides standard
information about
the patient or resident,
such as his or her
name, address,
age, and insurance
information
e. Record of a patient’s
or resident’s com-
plaints (symptoms)
and the actions taken
by the nursing staff
to address these
complaints

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24 UNIT 1 INTRODUCTION TO HEALTH CARE

Activity L Think About It! Mrs. Chang has SUMMARY

been admitted to the long-term care facility
where you work because her Alzheimer’s disease Activity M Use the clues to complete the
has progressed to the point where she is no crossword puzzle.
longer able to manage many basic activities,
such as bathing, dressing, and using the toilet.
1 2 3
Susan, the nursing team leader, is responsible
for preparing a nursing care plan for Mrs.
Chang. Susan will use the nursing process to
prepare this plan. The nursing process is
organized into a series of steps. Fill in the
blanks using the words given in brackets. Then,
write down the correct order of the steps in the
boxes provided below.
4 5 6
[Planning, Diagnosis, Implementation,
Assessment, Evaluation]
1. The nursing team carries out the
interventions detailed in the
nursing care plan.
2. The nursing team checks the
effectiveness of the plan and
revises it as necessary.
3. The nurse describes the
problems that Mrs. Chang is
having, as well as the cause of
the problems.
4. The nurse examines Mrs. Chang
and asks questions about her
abilities, habits, and needs.
5. The nurse makes a plan for
Mrs. Chang’s care. Down
1. The spoken exchange of information between
health care team members
3. Actions that are taken by the nursing team to
help the patient or resident
The nursing assistant plays an important 5. Discord resulting from differences between
role in the nursing process by carrying people; can occur when one person is unable
out interventions and communicating to understand or accept another’s ideas or
observations to the nurse. beliefs
6. Descriptions of what nursing interventions
(nursing actions that are taken to help a
patient or resident) are meant to achieve
Across
2. Objective observations (that is, observations
based on information that is obtained directly,
through measurements or by using one of the
five senses)
4. Communicating information about a patient
or resident to other health care team members
in written form; sometimes called charting

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CHAPTER
Those We Care For

PATIENTS, RESIDENTS, AND At the most basic level, patients,

CLIENTS residents, and clients are “those we care
for.”
Key Learning Points
■ Health care is a people-focused service Activity B There are three general types of
■ Why people need health care intervention illnesses that can cause a person to need health
■ Acute, chronic, and terminal conditions care services. Fill in the blanks using the terms
■ How the health care industry classifies given in brackets.
people
■ As a nursing assistant, the types of people that [acute, chronic, terminal]
you might have the opportunity to work with
1. A illness is a condition that is
ongoing such as diabetes or high blood
Activity A As a nursing assistant you care for
pressure.
people who are sick, injured, or unable to care
for themselves. Match the types of people you 2. A illness is an illness or
care for, given in Column A, with their condition from which recovery is not
descriptions, given in Column B. expected, such as end-stage emphysema.
Column A Column B 3. An illness is a condition charac-
1. A client a. A person who is receiv- terized by a rapid onset and a relatively short
ing health care recovery time such as pneumonia, appendicitis
2. A patient or a broken bone.
in a hospital, clinic,
3. A resident or extended-care
facility. Activity C Select the single best answer for
each of the following questions.
b. A person who is living
in a long-term care 1. In order to make providing care more efficient,
facility or an assisted- the health care industry groups people accord-
living facility. ing to which of the following criteria?
c. A person who is receiv- a. Their ages
ing care in his or her b. Their illnesses or medical conditions
own home, from a
c. Their special health care needs
home health care
agency. d. All of the above

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26 UNIT 1 INTRODUCTION TO HEALTH CARE

2. Which one of the following is an example of a 2. Rehabilitation b. Person who has

chronic condition? patient undergone a heart
a. Pneumonia or brain surgery
3. Subacute
b. Asthma or is suffering from
patient
a heart attack or
c. A broken bone 4. Intensive care stroke.
d. Appendicitis patient c. Person with
impaired mental
Activity D Use the clues to complete the
health
crossword puzzle.
d. Person undergoing
therapy to restore
1 2 3 4
his highest level of
physical, emotional
or vocational
functioning

5 People you care for can be classified in

many different ways. However, those in
need of health care services are not merely
defined by their illnesses and disabilities. First
and foremost, patients, residents, and clients
are human beings.

GROWTH AND DEVELOPMENT

Key Learning Points
■ Stages of human growth and development
■ Developmental changes that are common
throughout the life span of a person

Activity F Select the single best answer for

Across each of the following questions.
5. People who are elderly 1. Throughout the course of our lives we all
pass through a series of changes that are
Down related either to our physical growth or our
1. People who are in need of surgical treatment psychological and social development. Which
2. People who are children and adolescents of the following describes a child who is more
3. People who are pregnant or have just given advanced in terms of growth than
birth development?
4. People who need medication, physical therapy a. A child begins to walk at 8 months and talk
or radiation at 12 months.
b. A child begins to walk at 12 months and
Activity E Match the terms that are often used
talk at 8 months.
to group people who are in need of health care,
given in Column A, with their descriptions given c. A 5-year-old prefers the company of older
in Column B. children but lacks the motor skills that
would allow him to ride a bike.
Column A Column B
d. A 5-year-old prefers the company of
1. Psychiatric a. Person recovering children similar to his age and often plays
patient from an acute with them.
illness or condition

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CHAPTER 6 THOSE WE CARE FOR 27

2. From the following examples of changes that 2. Assumes the role of a caretaker and begins to
can occur in the human body, which one is an show signs of aging, such as wrinkles or a few
example of “growth”? gray hairs.
a. Changes in the height and weight of a person 3. Becomes aware of gender differences and roles
and curiosity about the differences between
b. Changes in the behavior of a person
boys and girls increases.
c. Changes in the way a person thinks 4. May suffer the loss of friendship or spouse due to
d. Changes in the way a person interacts socially death. Strength diminishes, as do many senses,
such as hearing and sight.
3. Which one of the following is typical of
5. Begins to recognize parents and siblings, begins
adolescent behavior?
to say simple words and laugh.
a. An adolescent questions the moral 6. Becomes self conscious about his or her body and
teachings of his or her parents. aware of his or her own sexuality. Secondary sex
b. An adolescent’s spirituality and religious characteristics appear and the reproductive or-
beliefs take root. gans begin to function with the onset of puberty.
c. An adolescent enjoys stable, supporting 7. Becomes able to write and ability to draw im-
friendships. proves, develops logical thinking patterns and
learns to incorporate other people’s perspec-
d. An adolescent assumes the role of caretaker.
tives into his or her own thinking.
8. Enjoys sharing wisdom with younger people.
Activity G Think About It! Briefly answer
9. Enjoys stable, supportive friendships and good
the following question in the space provided.
health. Focuses on completing his or her educa-
1. A 7-year-old does NOT prefer the company of tion, starting a career, and, possibly, finding a
older children, but is certainly as skilled when partner and marrying.
playing baseball with children older than his
age. Write the reasons for such an occurrence in
the space provided below.

Activity I Match the stages of growth and

development, given in Column A, with their
characteristics, given in Column B.
2. Why is it important for a nursing assistant to be-
come familiar with the various stages of growth Column A Column B
and development of a person? 1. Infancy a. A stage of gender
identity
2. Toddlerhood
b. A stage of active
3. Preschool imagination
4. School-age c. A stage of sharing
wisdom but failing
5. Adolescence
health
Activity H The process of growth and 6. Middle d. A stage of toilet
development is divided into stages of normal adulthood training
progression. Some of the behaviors that a person
exhibits as he or she progresses through the 7. Older e. A stage of assuming
developmental milestones are listed below. Write adulthood a caretaker’s role
down the correct order of the milestones as a f. A stage of rapid
person ages in the boxes provided below. physical and
psychological
1. Development of the muscular and nervous sys-
growth
tems permits greater control of the bladder and
bowels, so this is when toilet training begins. g. A stage of question-
ing the moral teach-
ings of an authority

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28 UNIT 1 INTRODUCTION TO HEALTH CARE

D. Self actualization needs

As a person grows and ages, the physical
and psychological changes that occur E. Love and belonging needs
affect the type of care the person needs, and
the way in which we communicate with him Activity K Fill in the blanks by using the
or her. Becoming familiar with the various words given in brackets.
stages of growth and development, and the
[Bisexuals, Transsexuals, Heterosexuals, Transves-
tasks commonly associated with these stages,
tites, Homosexuals]
will help you to become a more able
caregiver. 1. are people attracted to members
of the opposite sex.
2. are people attracted to members
of the same sex.
BASIC HUMAN NEEDS
3. are people attracted to members
Key Learning Points of both sexes.
■ Maslow’s hierarchy of basic human needs 4. are people who believe that they
■ Ways that a nursing assistant helps patients should be members of the oppo-
and residents to meet their needs site sex.
■ The difference between sex and sexuality
5. are people who get excited by
■ How a person’s sexuality can be affected by
dressing as a member of the
illness
opposite sex.
Activity J Maslow’s pyramid identifies the
Activity L Select the single best answer for
hierarchy of human needs. Look at the
each of the following questions.
following picture and write down the correct
order of needs as described in Maslow’s 1. When a nursing assistant assists a patient or
hierarchy. Also, list an example of a way that a resident with toileting, which one of Maslow’s
nursing assistant may be able to help a patient needs does the nursing assistant help the per-
or resident meet each level of these needs. son to meet?
a. Love and belonging need
b. Self esteem need
c. Self actualization need
d. Physiological need
2. Which one of the following actions helps to
fulfill a patient’s or resident’s need for love
and belonging?
a. A gentle touch
b. Tucking the patient or resident into bed at
night
c. Helping the patient or resident set realistic
goals
d. Assisting the patient or resident with basic
grooming
3. Which of the following is not a physical
need?
a. Shelter
A. Self esteem needs
b. Food
B. Physiological needs c. Acceptance
C. Safety and security needs d. Air

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CHAPTER 6 THOSE WE CARE FOR 29

4. Which one of the following is NOT a basic

Clearly, all patients and residents are not
human need?
alike. The people you will care for will be
a. Safety and security in different growth and development stages,
b. Self-esteem and as such, they will have different needs.
c. Self-actualization The primary mission of a health care
professional is to administer to the physical
d. Fear
and emotional needs of those you care for.
5. A resident in a long-term care facility shows
the desire to have a sexual relationship with
you. What would you do?
a. Ignore the resident CULTURE AND RELIGION
b. Complain to the nurse
Key Learning Points
c. Giggle and tease the resident in a flirtatious
manner ■ The concept of diversity
■ Why it is important for health care workers
d. Tell the resident kindly, yet firmly, that you
to recognize their patients’ and residents’
are not going to do what he or she is asking
diversity
you to do
6. Which of the following medical conditions Activity N Place a “C” next to the statements
could affect a person’s sexuality? that are related to a person’s culture, an “RE”
a. Mrs. Robinson has to undergo surgery for next to the statements that are related to a
the removal of a cancerous breast. person’s religion, and an “RA” next to the
statements that are related to a person’s race.
b. Mr. Smith’s gangrenous right leg has to be
amputated. 1. A person of African descent has dark skin
c. Mrs. Ching is burnt from the face down to and curly, black hair.
her chest. 2. A Jewish person does not want to have his
d. All of the above. long beard shaved.
3. An Asian person has great respect for his
Activity M Think About It! Briefly answer
elders.
the following questions in the space provided.
4. A Middle Eastern woman is not allowed to
1. Mrs. Amico broke her hip when she fell while
be questioned or examined by a male
taking a load of laundry to the washing machine
health care provider unless her husband is
in her basement. She is returning home today.
present.
By achieving her goal of making a full recovery
and coming home following her injury, Mrs. 5. An Asian person has almond-shaped eyes
Amico has met her need for self-actualization. and straight black hair.
List the difficulties that Mrs. Amico has had to
6. A person from Panama believes that wear-
overcome in order to be able to return home and
ing strings on the wrist will relieve pain.
how each of those goals was met.
7. A Catholic person does not want to eat
meat on Fridays during Lent.

2. What would you do if you see that a person is

masturbating in a public room?

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30 UNIT 1 INTRODUCTION TO HEALTH CARE

Activity O Think About It! Briefly answer Activity Q Think About It! Briefly answer
the following question in the space provided. the following question in the space provided.
Write a brief essay about the beliefs and values 1. Mr. Simon is a resident at the health care facility
that you have because of your culture or religion. where you work. He has severe arthritis, and his
children live far away and rarely come to visit.
He is very critical, and rarely has anything pleas-
ant to say to you or to anyone else. Why might
Mr. Simon be acting this way?

Throughout your career, you may be

lucky enough to care for people from
many different cultural and religious
backgrounds. You will most likely encounter
situations, practices, and beliefs that no book Each of your patients and residents must
could have prepared you for! Take time to be allowed to make decisions concerning
listen to your patients or residents, and to his or her quality of life. In order to provide
learn from them. Exposure to cultures other holistic care for your patients or residents, you
than your own is enriching, both must respect their decisions related to
professionally and personally. maintaining their quality of life.

QUALITY OF LIFE A PERSON’S FAMILY

Key Learning Points Key Learning Points
■ The concept of quality of life ■ How family members may be affected by a
■ How it would feel to be a patient or resident person’s illness or disability

Activity P Think About It! Briefly answer the Activity R Think About It! Briefly answer
following question in the space provided. the following questions in the space provided.
1. Mr. Pyne was treated for heart problems a few 1. Modern families can be made up of many differ-
months ago. He continues to smoke heavily, de- ent members. Describe the different types of
spite his heart problems. He also won’t eat members that make up three families that you
anything but steak, and he rarely exercises. The know personally.
first time that he was hospitalized for his heart
problems, the health care team advised Mr. Pyne
to stop smoking and to begin eating a heart-
healthy diet and exercising, but he seems not to
have taken that advice. Now Mr. Pyne is back in
the hospital again. If you were a member of the 2. Illness, injury, or disability can have a significant
health care team who cared for Mr. Pyne the first impact on a person's family. List three particular
time, how would you feel toward him now? areas that may affect a person's family.

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CHAPTER 6 THOSE WE CARE FOR 31

C U L T U R E S Q
SUMMARY
Activity S Use the clues to find words that
H S X N Z M P D A are present in the grid of letters, either
horizontally from left to right or vertically
R D C H Y M E F S from top to bottom.
O F S B Q P R G W Down
1. An illness that is ongoing and often needs to
N E E D W U I H F be controlled through continuous medication
or treatment
I H L C E B S P R 2. The highest level in Maslow’s hierarchy of
needs
C J F X R E T H E 3. The period during which the secondary sex
characteristics appear and the reproductive
I K A Z T R A Y Q organs begin to function
4. The most basic level in Maslow’s hierarchy of
L L C O I T U S U needs such as oxygen, water, food, shelter,
elimination, rest and sleep, physical activity,
L Z T A C Y S I E and sexuality and is essential for survival
N R U N A T I O N Across
1. The beliefs (including religious or spiritual
E E A K T L S L C
beliefs), values, and traditions that are
customary to a group of people; a view of the
S T L I H B D O Y world that is handed down from generation to
generation
S F I B E T F G F 2. Something that is essential for a person’s
physical and mental health
T G Z V T W Z I B 3. Sexual intercourse
4. A general characterization that describes skin
W R A C E N C C C color, body stature, facial features, and hair
texture
D R T R R T Y U X 5. A newborn infant, 28 days or younger
C I I A S R G L E
T N O C T U R I A

H A N E O N A T E

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CHAPTER
Communicable Disease
and Infection Control

COMMUNICABLE DISEASE c. The yeast used to make beer

d. All of the above
Key Learning Points
2. When a type of bacteria, which normally
■ Definition of communicable disease lives in the digestive tract, is found in any
part of the human body other than the
Activity A Select the single best answer for the intestine it can change from being harmless
following question. to pathogenic. What are such microbes
1. What is a communicable disease? called?
a. A disease that cannot be transmitted from a. Escaped microbes
one person to another b. Opportunistic microbes
b. A disease that can be transmitted from one c. Normal (resident) flora microbes
person to another d. Nosocomial microbes
c. A physical injury like a burn or a cut
3. An infection such as strep throat is most
d. A disease that results in an inability to com- likely caused by a:
municate effectively
a. Virus
b. Bacteria
c. Parasite
WHAT IS A MICROBE?
d. Fungus
Key Learning Points 4. What are the characteristics of the microbe
■ Types of “germs” (microbes) that cause known as Staphylococcus aureus?
diseases a. A rod-shaped bacterium that arranges itself
■ The conditions that are essential for the in clusters
survival and growth of microbes b. A round bacterium that arranges itself in
■ Meaning of the terms normal flora and pathogen chains
Activity B Select the single best answer for c. A round bacterium that arranges itself in
each of the following questions. clusters
d. A rod-shaped bacterium that arranges itself
1. Which one of the following is a microbe?
in pairs
a. The virus that causes chicken pox
b. The bacterium that causes “strep throat”

32
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CHAPTER 7 COMMUNICABLE DISEASE AND INFECTION CONTROL 33

5. Which one of the following diseases is caused Activity D Place an “F” next to the diseases
by a virus? that are caused by a fungi and a “P” next to the
a. Strep throat diseases that are caused by parasites.
b. Rocky mountain spotted fever 1. Pinworms
c. Common cold 2. Thrush (a yeast infection in the mouth)
d. Malaria
3. Amebic dysentery
Activity C The diagram below shows the 4. Athlete’s foot (tinea pedis)
four major types of microbes (bacteria, viruses,
fungi, and parasites). Fill in the blanks using 5. Pediculosis (lice)
the words given in brackets, according to what 6. Candidiasis (a vaginal yeast infection)
type of microbe causes the disease.
7. Ringworm (tinea corporis)
[malaria, urinary tract infection, AIDS, Rocky
Mountain spotted fever, strep throat, common 8. Tape worms
cold, athlete’s foot, lice, ringworm, hepatitis]
Activity E Match the terms related to
microbes, given in Column A, with their
Microbes descriptions given in Column B.
Column A Column B
1. Normal flora a. Microbe that can
Bacteria change from harm-
2. Pathogen
less to pathogenic
3. Opportunistic b. Hard shell that
microbe makes it difficult to
4. Endospore kill some types of
bacteria using stan-
5. Aerobic dard infection con-
bacteria trol methods
6. Anaerobic c. Bacteria that die if
bacteria oxygen is present
Viruses d. Microbe that can
cause illness
e. Harmless microbes
that live on our skin
and in our bodies
f. Bacteria that need
oxygen to live

Fungi
DEFENSES AGAINST
COMMUNICABLE DISEASE
Key Learning Points
■ Defense mechanisms used by the body to fight
infection

Parasites

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34 UNIT 2 SAFETY

Activity F Select the single best answer for Activity H Think About It! Briefly answer
each of the following questions. the following question in the space provided.
1. What does the non-specific defense system do? 1. If a pathogen manages to get past the first lines
a. It protects us only from viruses. of defense of the human body, such as the skin
and the mucous membranes, and an infection
b. It protects us only from certain pathogens.
results, the body activates a general immune re-
c. It protects us from all pathogens. sponse that helps to fight off the infection. List
d. It protects us only from bacterial and briefly describe signs that you may observe
infections. in a person who has an infection.
2. Which one of the following is an example of a
non-specific defense mechanism?
a. Receiving a vaccination
2. Why do most of us get the “childhood diseases”
b. Taking an antibiotic
such as measles and chicken pox only once?
c. Sneezing or coughing
d. Producing antibodies

Activity G Match the terms related to bodily

defense mechanisms, given in Column A, with
their descriptions, given in Column B.
COMMUNICABLE DISEASE AND
Column A Column B THE CHAIN OF INFECTION
1. Immune a. A drug that is able
system to kill bacteria or Key Learning Points
make it difficult for ■ The term infection
2. Non-specific
them to reproduce ■ The chain of events required for infection to
defense
and grow occur
mechanism
b. Specialized proteins
3. Antibiotic that help our bodies Activity I Select the single best answer for each
to fight off specific of the following questions.
4. Antibodies
microbes 1. Which one of the following could be a fomite?
5. Methicillin-
c. A defense system that a. A patient’s wound
resistant
protects us from
Staphylo- b. Linens that have just come back from the
infection
coccus laundry
aureus d. A type of Multi-
c. A dirty spoon
(MRSA) drug-resistant
organism d. A mosquito
6. C.diff
e. Skin that is without 2. All of the following can be portals of entry for
cuts, scrapes, or a pathogen EXCEPT:
wounds a. The mouth
f. A major cause of b. Non-intact skin
healthcare-associated
c. The nose
diarrhea
d. Intact skin

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CHAPTER 7 COMMUNICABLE DISEASE AND INFECTION CONTROL 35

Activity J There are six key elements in the 5. Susceptible d. Receiving required
chain of infection that are essential for an host immunizations and
infection to spread. Complete the following maintaining general
diagram with the six key elements that must be good health
present for an infection to spread. We have e. Taking the right
filled in one to get you started. antibiotic for a
bacterial infection

Activity L Match the terms related to

Pathogen infection, given in Column A, with their
definitions, given in Column B.
Column A Column B
1. Infection a. A living creature that
transmits pathogens
2. Chain of
infection b. A communicable
disease that is easily
3. Fomite transmitted from one
4. Vector person to the next
through casual
5. Contagious contact
disease
c. Medical equipment
6. Indwelling that is inserted into
medical a person’s body;
devices catheters, intravenous
lines, and feeding
tubes are
examples
d. A non-living object
Activity K The chain of infection can be that has been soiled by
broken by removing just one of the six elements pathogens
that must be present for an infection to occur. e. The elements that
Match each link in column A with the action in must be present for
Column B that will remove it, breaking the a person to get an
chain of infection. infection
Column A Column B f. Illness caused by a
pathogen
1. Reservoir a. Covering an infected
wound with a Activity M Think About It! Briefly answer
2. Portal of
dressing the following question in the space provided.
exit
b. Washing your hands
3. Method of 1. What factors make people more susceptible
and making sure that
transmission to getting infections in the health care
linens, utensils,
setting?
4. Portal of glassware, and other
entry possible fomites are
properly cleansed
c. Wearing gloves
and keeping your
skin healthy and
intact

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36 UNIT 2 SAFETY

8. When there is a possibility that you will

Some of the people you will care for will
come in contact with body fluids or sub-
be receiving health care because they
stances
have a serious communicable disease. Others
may have a serious communicable disease and
Activity O Select the single best answer for
not even know it. In addition, many of the
each of the following questions.
people you will care for will be more at risk
for catching a communicable disease because 1. What is an infection that is gotten while in a
they are not entirely healthy to begin with. hospital or other health care setting called?
Therefore, infection control is very important a. A viral infection
in the health care setting.
b. A healthcare–associated infection (HAI)
c. A bacterial infection
d. A fungal infection
INFECTION CONTROL IN 2. What type of chemical is safe to use on the
THE HEALTH CARE SETTING skin to kill pathogens or keep them from
growing?
Key Learning Points a. Disinfectant
■ The term healthcare-associated infection (HAI) b. Antiseptic
■ Ways a person could get an infection within
c. Sterilant
the health care system
■ Techniques of medical asepsis and infection d. Bleach
control 3. Which of the following procedures best
■ Methods used in the health care setting to destroys all bacteria?
destroy microbes
a. Sterilization
■ How personal protective equipment (PPE) is
used in infection control b. Washing with bleach
■ The standard precautions that are taken with c. Soaking in alcohol
every patient or resident d. All of the above
■ How isolation (transmission-based)
precautions are used to help prevent the Activity P Mark each statement as either
spread of infection “true” (T) or “false” (F). Correct the false
■ Proper hand washing, gloving, masking, statements.
gowning, and double-bagging techniques
1. T F There are four major methods of
Activity N Place an “X” in front of those situa- infection control—medical asepsis, surgi-
tions where it would be necessary to wear gloves: cal asepsis, barrier methods, and
isolation (transmission-based)
1. When you are providing perineal care precautions.
(cleaning the area between the legs)
2. T F Medical asepsis involves removing or
2. Before and after inserting contact lenses
killing pathogens through the use of
3. When picking an object up off the floor antibiotics.
4. When you have a cut or abrasion on 3. T F Sanitization by using soap and water
your hands cleans your hands after you use the bath-
5. When you are shaving a patient or resi- room.
dent
4. T F There are two main types of microbes
6. Before obtaining clean linen from a linen found on a person’s hands. They are nor-
cart mal flora and transient flora.
7. When you are performing care on a 5. T F When caring for patients or residents,
patient or resident who has an open a nursing assistant should keep her
wound or a break in the skin fingernails short and unpolished.

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CHAPTER 7 COMMUNICABLE DISEASE AND INFECTION CONTROL 37

6. T F Alcohol-based hand rubs can be used Activity T Mark each statement as either
instead of soap and water to cleanse the “true” (T) or “false” (F). Correct the false
hands. statements.
7. T F Resident flora are easily removed from 1. T F Medical asepsis involves chemically
the hands by routine handwashing. removing or killing pathogens.

Activity Q Think About It! Briefly answer 2. T F Surgical asepsis is required when insert-
the following question in the space provided. ing an intravenous catheter.

List the three new elements that have been 3. T F Personal protective equipment (PPE)
added to existing standard precaution guidelines includes disposable gloves, masks, gowns
and give an example of steps the nursing and protective eyewear.
assistant would take to follow them. 4. T F The single most important method of
preventing the spread of infection is by
using personal protective equipment
(PPE).
5. T F When your hands are visibly soiled with
dirt, blood, or other bodily fluids you
Activity R Place an “A” next to the situations should use an alcohol-based hand rub to
where you would take airborne precautions, a disinfect your hands.
“D” next to the situations where you would
take droplet precautions, and a “C” next to Activity U Think About It! Briefly answer
the ones where you would take contact the following question in the space provided.
precautions. Also mention the precautionary
measure you will take in each situation. You have just received your shift report and will
be caring for Mrs. Wilson, who is recovering
1. You are caring for a person who is suffer- from a stroke. Her roommate, Miss Blair, is
ing from whooping cough. receiving intravenous antibiotic therapy for a
2. You have to change the soiled linens of a foot infection caused by methicillin-resistant
person with a draining wound. Staphylococcus aureus (MRSA). What types of
precautions are necessary to prevent spreading
3. You are caring for a person infected with the MRSA to Miss Blair or the other patients in
measles. the hospital? Briefly describe the infection
4. You are helping an incontinent person to control methods you would use in this situation.
change her clothes.

Activity S Some of the steps in the procedure

for removing more than one article of personal
protective equipment (PPE) are listed below.
Write down the correct order of the steps in the
boxes provided below.
1. Remove and dispose of your gloves.
2. Remove and dispose of your mask.
3. Remove your protective eyewear.
4. Untie the gown’s waist ties.
5. Wash your hands.
6. Remove and dispose of your gown.

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38 UNIT 2 SAFETY

Activity V The following picture shows four SUMMARY

techniques that make up the practice of medical
asepsis. Identify the four techniques used in the Activity X Words shown in the picture have
figures and label them. Also write down their been jumbled. Use the clues to form correct
definitions. words using the letters given in the picture.

A. B.

A T O G E N S H P

L S E I C O O N

B A R E O C I

C. D.
T E F O I M

C I R V U L E N E

S A N I P S E T I S

A. 1. Microbes that can cause illness

2. Groups of bacteria
B.
3. An adjective used to describe bacteria that
C. need oxygen in order to live
4. A non-living object that has been
D.
contaminated (soiled) by pathogens
5. The strength or disease-producing potential of
Activity W Think About It! Briefly answer
a pathogen
the following question in the space provided.
6. Practices that kill microbes or stop them from
1. Handwashing is the most important safeguard growing; one of the techniques of medical
against spread of infection and is one of the asepsis
OSHA standard precautions. List below four
other standard precautions.

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A Humanistic Approach to Caregiving, 3rd edition.
Other documents randomly have
different content
publicly in every town and hamlet: “Jesus Christ in heaven, send
thou some one to deliver us from Orleans!”
Orleans smiled no less bitterly than when he had heard the public
whisper accuse him of sorcery and devil-worship. He proclaimed that
whosoever did not pay the taxes should be cast into prison; to
prevent assassination, no man was to carry another knife than he
used for his eating; a fourth of the provisions of the royal household
was to be supplied daily, without payment, by the people of Paris.
These provisions, as the people knew very well, did not go to feed or
clothe their beloved King. He, in his palace, was as poor, as suffering
as themselves. The Dauphin was no richer: “in penury and want,”
says the Monk, “if such words may be used for so great a
personage.” The insatiable Orleans, the avid little Queen, grasped
and kept everything. “Jesus Christ in heaven,” prayed the people,
“send some one to deliver us from the Duke of Orleans.”
Orleans should have listened. The air was full of warnings to
tyrants. Richard and Wenzel had fallen miserably. The Duke of Milan
had died of the plague; in six months his vast kingdom had fallen
into ruins. Tyranny is, so often, a personal accident—a possession,
not an inheritance. Was it worth while? The King himself added to
the list of these monitions. In August, 1404, he married his eldest
son to Burgundy’s daughter, his daughter to the son of Burgundy.
In the year 1405, on Ascension Day, the people found a voice. An
Augustine monk, Jacques Legrand, preached then before the Court.
The Queen, Valentine, and Orleans were present, but not the King.
“O Queen! O Duke!” said the monk, “you are the curse and derision
of your people. Do you not believe me? Go into the streets and hear
them!
“Tua curia, Domina Venus solium occupans, thy court, O Queen!
where Lady Venus fills the throne, thy Court, by day and night, is the
scene of debauch and drunkenness. Dissolute dances do honour to
the goddess. Frequent bathing enervates your bodies. Fringes to
your sleeves, and long sleeves to your garments; yet are ye clothed
upon with the sighs and tears of the poorest of your people. Your
hearts are corrupt and your minds are all unmoved: Domina Venus
solium occupat.”
 There was a flutter of indignation in the Court. The monk’s sermon
was reported to the King, but to the surprise of all, Charles
answered that he was glad of it. On Whit-Sunday Legrand was
commanded to preach again, and in the royal presence. The monk
repeated his sermon, but with larger reference to a certain noble
duke, “once good and dear, but hated now for his oppression and his
vice.” The King left his chair and sat down face to face with the
monk, listening earnestly, who can tell with what cruel suspicions,
what resolutions for inquiry and reform, in his dim and altered mind.
When the sermon was over, the King spoke to Legrand for some
moments. He thanked him earnestly.
Charles was deeply impressed with the words of the Augustine
friar. Struggling against continual relapses, he made a brave effort to
do the best he could for his disordered kingdom. When Orleans
asked for the government of Normandy, for the first time he was
refused. Another day the poor King called the Dauphin to him. “How
long, my lad, is it since your mother kissed you?”
“Three months,” the boy replied.
The King was much affected. His children were evidently pinched,
neglected, uncared for. He called the boy’s nurse to him, and gave
her a gold cup. “Look after my son when I am ill. If God grant me
life I will reward you later.”
This was in July, 1405. Burgundy was absent on his own estates.
The King wrote to him and implored him to return to Paris.
Orleans and the Queen were at St. Germains. They paid no heed
to any warning. On the 13th of July there was a fearful storm;
torrents of rain, eddies of wind. The Queen and Orleans were riding
in the forest when they were overtaken by the tempest. The Duke
took refuge in the Queen’s litter, but the frightened horses nearly
drowned them in the Seine. The people declared that it was the
judgment of heaven upon tyrants, and Orleans himself appeared
impressed. He sent a herald to Paris, and proclaimed that whosoever
of his creditors should come on Sunday next to the Hôtel de
Behaigne should have his debt discharged in full. On Sunday the
halls and anterooms of the ducal palace were crowded with eager
burghers. Many, tired and anxious, had travelled from the provinces.
The Duke’s stewards laughed in their face and shut the doors. This
was the final touch to the exasperation of the people.
All this while Jean-sans-Peur was travelling to Paris. He came at
the head of six thousand men-at-arms. The King was mad again,
and could not support him; but none the less the Queen and Orleans
feared an insurrection in Burgundy’s favour. They decided to flee
secretly away into Luxembourg with the royal children. Valentine was
with them; and they had got as far as Pouilly when the troops of
Burgundy suddenly surrounded the litter of the Dauphin, some
hours’ journey to the rear. The boy was delighted; he embraced his
father-in-law, and was carried in triumph back to Paris. Isabel, with
Valentine and Orleans, fled to the Castle of Melun. Civil war seemed
eminent; but when the two armies were actually in the field, peace
was arranged, and on the 15th of October the Queen and Orleans
re-entered Paris.
Orleans had learned nothing by his lesson. He was more than ever
arrogant, more than ever secure in his tyranny. Early in the next
year his young son Charles was married to the King’s daughter
Isabel, the widowed Queen of England, a girl of sixteen. In the first
months of 1407 the King gave his brother the rich duchy of
Aquitaine. Orleans began to think again of the governorship of
Normandy. He was richer and stronger than the King.
And yet, if Valentine, if Orleans, had really read the future as the
people thought they did, or had they even cared to read the present,
they might well have paused. In that age the fate of tyrants was not
prosperous. The King of England was a leper. The King of France
was mad. The little Duke of Milan was mad also, with a furious
Italian hemomania. The King of Scotland was a prisoner in the hands
of his enemies. There were two Popes, things for scorn and laughter,
held in derision of all nations, and a song to the people all day long.
Already, in 1380, Miles de Dormans, Chancellor of France, had
declared “A government has no force save in the obedience of the
people, for kings only rule by the suffrage of their subjects: Nam et
si centies negent, reges regnant suffragio populorum.”
The judgment of heaven, the liberties of man, seemed to conspire
alike against the rule of tyrants.
 XI.
Notwithstanding his deceptions in the affair of Genoa, and in spite
of his supremacy in France, Orleans still cherished designs on
Lombardy; and perhaps the chief cause why his Italian enterprises
are less noticeable in the fifteenth than in the seventeenth century is
due, not so much to his engrossment with affairs at home, as to the
fact that in Benedict XIII. he found an ally infinitely less subtle and
less brilliant than he had known in Clement VII. Benedict was little
more than a captive in the hands of Orleans;[41] Clement had been
an accomplice.
A greater than Clement failed him a little later. In the autumn of
1402, in the very flush and zenith of victory, Giangaleazzo Visconti
died. A score of his captains soon were fighting for his kingdom.
That vast territory, whose coherence existed only in the brain of one
man, fell rapidly into fragments: city after city threw off the unwilling
yoke of union, and what had almost begun to be a national Italy
reverted in a few weeks to the old conditions of fragmentary
independence. His two sons ruled in a narrowed Lombardy, and with
no vista, as it seemed, on the ambitions of their father. In the very
same year that the great Visconti died, Charles VI. sent to Genoa a
small, restless, quixotic man of much ability, who to some extent
filled the empty place of the dead Giangaleazzo. But if Marshal
Boucicaut had much of the ambition, and all the audacity of the late
Duke of Milan, he possessed nothing of his slow wise mind, of the
deep and subtle duplicity that Machiavelli may have envied, or of the
powers of combination, the cool tenacity to a grand idea, which
foreshadowed the genius of another North Italian, Count Cavour.
Moreover, while such share as Visconti meant to allow the French in
Italy was destined by him for his son-in-law of Orleans, Boucicaut
worked for the King. Thus, for the second time in his experience, the
Frenchman found his greatest rival in France.
 Of the two legitimate sons of the great Duke of Milan—one was a
handsome young Nero, blood-mad, inept, given over to passion and
cruelty; the other an astute child, timid, unscrupulous, who later
should develop a trace of the genius of his father. At first their hold
on their inheritance was so slight that Orleans determined on
invading Lombardy, whether to defend or to supplant his nephews,
who shall say? In October, 1403, he started for Lombardy,
accompanied by 13 knights-banneret, 43 knights, 212 squires, 28
archers, 20 crossbow-men, and other soldiers.[43] On the way south
he passed by Beaucaire, and had an interview with his charge, the
Antipope Benedict. He took into his service the famous captain of
adventure, Bernardon de Serres. He made friends with another
mighty captain—an ancient enemy—the Count of Armagnac.[42] Vast
and serious appeared his project of invasion, but, on the very verge
of the Alps, suddenly, on January, 1404, he abandoned the
prosperous enterprise, turned right about, and faced home for Paris.
What is the meaning of this sudden change of course,
unexplained, and perhaps inexplicable? What was the object of the
Lombard invasion? What was the cause which so unexpectedly
suppressed it? Orleans believed himself to have a certain claim on
Pisa, bequeathed by the great Visconti to his bastard son Gabriello-
Maria. Gabriello Visconti was ill at ease in Pisa. A little later, in 1404,
as we know, he offered his unruly city first to France, then to
Florence. It is possible—it is even from the nature of things a
necessary hypothesis—to suppose that in 1403 Gabriello had come
to terms with Orleans, and that the rights on Pisa which Orleans
vaunted as his own through Valentine Visconti were supported by
some cession of the actual lord, her half-brother. But Orleans was
not the only Frenchman capable of adventure and practice in Italy.
By the time his army reached the frontier he found himself outwitted
by a higher bidder, nearer at hand.
Jehan le Meingre, Marshal Boucicaut, Governor of Genoa, had
intrigued with Gabriello and procured the city of Pisa for the King. A
few months later, on the 15th of April, 1404,[44] a deed was drawn
up declaring Pisa henceforth a fief of France.
 At the first word of the matter Orleans had turned his back on his
contemplated campaign and marched back to Paris, fury in his heart.
Probably behind the interference of Boucicaut he divined the
inspiration of Burgundy, his enemy;—Burgundy who, as events
should prove, had unsuspected designs of his own upon the State of
Pisa. Back in wrath marched Orleans: stalked indignant into Paris his
men at his heels: found the King in his senses, and docile as was his
wont. From him, on the 24th of May, Orleans extracted the deed
which we append,[45] a deed that repudiates the action of
Boucicaut, and transfers all the rights of France in Pisa to Orleans,
who henceforth shall meet with neither let nor hindrance in his
projects.
The deed was granted in Council, the King being then in his
senses, and assisted by Berri, Bourbon, Tancarville, and others. The
reader will remark the noteworthy absence of Burgundy. He will
remember also that Berry, in 1405, will join Orleans in a defensive
league against Jean-sans-Peur. It is possible that Burgundy knew
nothing of the deed drawn up behind his back.
But it was too late for Orleans to profit by the King’s good-will.
The Florentines were in Pisa, and an invasion against so powerful an
enemy could not be undertaken.
For a moment Orleans was obliged to pause in his Italian policy—
to pause only, not to abandon it, since in 1406[48] he still reclaimed
authority on Pisa, and in the very year of his death was taking an
active part in the affairs of Lombardy.[47] That pause was filled in a
manner disastrous, fatal, yet natural enough in a man suffocating
under a sense of bitter indignation and revolt. Burgundy had
interfered with Orleans abroad. Very well; Orleans would interfere
with Burgundy at home. Already the first steps were taken. In 1401,
Orleans had married his cousin Mary Harcourt to the Duke of
Gueldres, the enemy and the neighbour of Burgundy, with whom his
rival now concluded an alliance and a league. In 1402, Orleans
purchased from the King of the Romans the Duchy of Luxembourg.
In 1405,[46] he assembled at Melun the entire strength of his
faction, sending even to Asti for the Governor and his men. In 1405
also he allied himself with Berri and the Queen against Jean-sans-
Peur. With the Court on one hand, and on the other Gueldres, the
most reckless captain of his age;—with an army at his heels, and
(through the county of Soissons, and down the banks of the Oise
and the Marne), an uninterrupted passage through his own
possessions into his new Duchy of Luxembourg: Orleans was a
deadly enemy to Burgundy. A glance at the map will show the reader
how, like a wedge or like a rivet, Luxembourg must split apart or
hold together the domains of the Netherlands and the provinces of
Franche Comté and Burgundy. In the hands of Orleans, Luxembourg
was a wedge; and the domains of Burgundy were no longer a
compact and formidable territory, but two principalities with Brussels
for the capital of the one, and Dijon for the capital of the other.
Should Orleans march an army into Luxembourg, should Gueldres
come to his aid with an armed force, the suppression of the
Dukedom of Burgundy would fall within the range of practical
politics.
Henceforth, between these two princes the struggle for power
should take on a new character and become the very struggle for
existence. And while the people, abject, all in tears, prayed to
Heaven: “Jesu Christ, send thou some man to deliver us from
Orleans,” the hero of the people, Jean-sans-Peur the Belovèd, was
urged by every motive of self-interest, every instinct of self-
preservation, and with the assurance of popular immunity, to
interrupt for ever the fatal progress of the tyrant.
 XII.
One Wednesday evening—it was St. Clement’s day, the 23rd of
November, 1407—Orleans was supping with the Queen. Isabel was
ill and dispirited. Ten days ago her new-born baby had died at its
birth, and she sorrowed for this child and loved it as she had never
loved her other children. Isabel was away from her husband in her
new Hôtel de Montaigu, near the Porte Barbette. It was here that
Orleans came every day to see her, and here they “supped right
joyously together,” says the Monk of St. Denis. Orleans had been ill
all autumn at his Castle of Beauté, and had only recently come back
to Paris. Valentine, with her four children and the Princess Isabel,
was still in the country.
As these two persons, both ill, both weary, forgot their troubles for
a while in each other’s company, a page came to the door with a
feigned message: the King earnestly beseeched his brother to come
and see him at the palace of St. Paul. Orleans arose at once and left
the Queen. He had at least six hundred men of his own lodged that
day in Paris, as Monstrelet informs us. Orleans, however, took none
of them with him. He leapt on his mule and rode away with two
squires on horseback at his side. Two or three footmen with torches
ran after him. No gentleman could go more simply than the King’s
brother in his plain suit of black damask, riding with no more than
five attendants, quickly and gaily down the frosty street. It was the
coldest winter ever known, and muffled in their cloaks the little party
rode briskly ahead, looking neither to the right or left. Orleans was
singing softly to himself and playing with one of his gloves. He
feared no enemies. Last Sunday he had taken the Sacrament with
Burgundy, and yesterday they two had dined together.
It was eight o’clock. All was dark and silent in the Rue Vieille du
Temple, then an outlying and quiet district. Orleans and his two
squires rode along so fast that the runners with the torches were left
some way behind. At last they came to a wider place in the street
where there was a well. As the three horsemen passed the Hôtel de
l’Image de Notre-Dame, seventeen or eighteen men sprang suddenly
out of the shadow of the house. One with an axe chopped off the
bridle hand of Orleans. The King’s brother gave a cry of surprise and
pain. “I am the Duke of Orleans!” “It is he we seek.”
In another moment the Duke was beaten off his mule on to the
frozen paving-stones. Seventeen axes were aimed at him; blow after
blow fell heavily; his head was cloven, his brains gushed out into the
street. His servants had all fled and left him there, save one of his
squires who had been his page (a German, says Monstrelet; a
Fleming, says the Monk), who, more constant than Orleans’
compatriots, flung himself upon the body of his master, and was
pierced and slaughtered there. When both were murdered the
assassins dragged the body of Orleans across the street, propped it
up against a heap of mud that was standing frozen there, and
lighting a torch of straw, they looked to see if he were really dead. A
woman, a cobbler’s wife, looking from a garret window, saw it all,
and set up a shriek of “Murder, murder!” “Peace, harlot,” cried the
armed men in the street, and began to shoot their arrows at the
open casement. At that moment a man with a scarlet hood drawn
well over his face, came out of the house opposite, and struck the
dead body with his club. “Put out the light. He’s dead. Let us go.”
The eighteen assassins rode away in great merriment, sowing
caltrops after them; but before they left they set fire to the house
where, for the last fortnight, Jean-sans-Peur had kept them hidden.
The flames of the burning Hôtel de l’Image streamed up through the
darkness of the night, awakening the city, and shedding a strange
light on the murdered body of Orleans, still propped up in a sitting
posture, his wounded head hanging on one side. Just then a nephew
of Maréchal de Rieulx, whose great Hôtel stood opposite, a young
man, one of Orleans’ squires, rode up as he left his uncle’s house,
and saw his master sitting thus dead, the left hand off, the right arm
hanging by a thread. A little distance off, on the stones of the street,
lay the page, dying in his faithful youth, murmuring still in his
German language, “Ach, my master!” At his side, on the ground, was
a white hand severed from the wrist. Close by there lay a fallen
glove. The young squire gave the alarm and the dead bodies were
carried into the Hôtel de Rieulx.
There was wailing and mourning in the house of Orleans, grief
and horror in the house of the King. The deed was soon known,
though as yet it was only surmised that one Raoul d’Actonville, a
dismissed steward, had wreaked in this ghastly fashion his spite
against his master. The next day the royal princes, all in black, with a
great multitude of the people of Paris, brought the murdered Duke
to the church of St. Guillaume, close at hand. He who had ever loved
the good through all his wickedness, lay now among the watching
friars, who sang psalms and repeated vigils day and night for his
soul; there he lay until they took him to be buried in his own chapel
of the Celestines, which is called the Blancs-Manteaux to-day. The
people followed him with torches, remembering only his gay and
gracious qualities, his capricious generosity, his gentle raillery, his
rhetoric and eloquence, how he had loved learning, and that he had
often lived as a monk for days among the Celestines. All Paris wept,
those also who had prayed Jesus Christ in heaven to deliver them
from Orleans; even Burgundy went in the funeral procession, all in
black, weeping also. But when the funeral was over Jean-sans-Peur
took Berri and the King of Sicily aside: “I had it done. I slew him. It
was an inspiration of the demon’s.”
 XIII.
There were two women, who were not at the burial, to whom the
death of Orleans came nearer than to any mourner there. When
Isabel heard that Orleans was slain she went in terror of her life. Ill
as she was, she had herself carried in a litter to St. Paul’s, taking
shelter there in the arms of her mad husband, and so soon as she
was fit for travel the poor, light, beautiful, little Queen went out of
Paris, far away from Burgundy, far, too, from that maimed and
slaughtered body lying in the chapel of the Celestines. Terrified,
indifferent, she could think of nothing but her own imaginary danger.
The mistress and the wife took the matter in a very different spirit.
At first, in her transports of sorrow, Valentine could not act. She tore
out her hair and shred her garments; she sobbed so much, that for
weeks afterwards her voice was hoarse. But when the first paroxysm
was over her strong Italian character centred itself upon one fixed
idea—justice, vengeance for her murdered husband. Valentine had
no thought of her own safety. She sent her two elder sons and her
girl into Blois, and then, with the Princess Isabel and little John, her
youngest child, on either hand, the Duchess of Orleans set out from
Château-Thierry for Paris.
Travelling was slow that terrible winter. It was not till the 10th of
December that Valentine entered the capital. She, her children, her
servants, were all dressed very plainly and roughly, and, of course,
in black. The King of Sicily and the Duke of Berri came out to meet
them. When they reached the palace Valentine threw herself upon
her knees before the King, demanding justice. The poor Charles
(azzez subtil pour lors) raised her up and kissed her, while they both
wept together. He promised strict justice upon Burgundy. Again, ten
days later, he declared, “What is done to my only brother is done to
me.” Valentine and her children, satisfied of vengeance, retired to
their great hotel in the Marais.
 The King fell ill again so soon as Valentine had left him. “They
say,... but I affirm nothing,” suggests the Monk. Valentine the witch
stayed on, however, among the people who had murdered her
husband. One thing that we learn of Valentine at this moment shows
us how profound, how selfless was her love of Orleans. She sought
out his bastard—the little John, afterwards Count of Dunois, the son
of Mariette de Canny—and brought him up with her own children. It
even seemed as though she loved him more than the others.
Glancing from the poetic Charles, the delicate Philip, the child John,
to his determined and eager little face, she exclaimed, “None of your
brothers is more fit than you to avenge your father. Nature has
cheated me of you!”
To avenge your father! This had become the unique preoccupation
of Valentine. But that promised vengeance tarried long. On the 8th
of March a learned doctor of theology, the chosen advocate of
Burgundy, a certain Maître Jean Petit, excused the murder of Orleans
before the King. “Il est licite d’occire un Tyran.”
It was not only of tyranny that the Burgundians accused their
victim. The tremendous accusation of Jean Petit (which every
student of the past has read in Monstrelet) enumerates attempted
regicide, and secret poisoning, sorcery, necromancy, charms,
incantations. “Sorcery, high treason against God, and regicide, high
treason against the King. There is also tyranny,” says Maître Jean
Petit. It was of course for this third cause, treason against the
people, that Orleans’ murder was condoned in Paris.
For the people never hid their support of Jean-sans-Peur. Those
who had wept at the funeral of Orleans were ready now to cry again
the cry of Burgundy. The King, whose mind was again overcast,
although he was not actually mad, the King himself on the 9th of
April, 1408, signed letters patent granting pardon to Jean-sans-Peur.
“Our very dear and well-beloved cousin of Burgundy, who for the
public good and out of faith and loyalty to us, has caused to be put
out of this world our said brother of Orleans.” This was the last insult
to his memory. Valentine would not brook it; she rallied to the
charge. Though she herself had been seriously implicated in the
tissue of villainy which his murderers had woven about the memory
of her husband, Valentine had no thoughts to spare for her own
safety. All through July and August she kept agitating against
Burgundy. Bringing her children with her she sought the King and
cried on her knees for justice. Twenty years’ exile for Burgundy! Her
two advocates, Sérisi and Cousinet pleaded eloquently for her;
refuting the vile accusations of poison and sorcery with a candour, a
logic, a fine and modern spirit worthy of the intellect of the dead
man they defended. It was all no use. “The Parisians,” says
Monstrelet, “loved so well this Duke of Burgundy; because they
believed that if he undertook the government, he would put down
throughout the kingdom all salt taxes, imposts, dues, and subsidies
which were to the prejudice of the people.” Though nearly all the
royal Princes were openly on the side of Valentine, the King did not
dare avenge his brother. The Court was impotent against the people.
In the early autumn Valentine left Paris. Life was over for her.
“Rien ne m’est plus. Plus ne m’est rien,” ran her melancholy motto.
Anger and bereavement and hopeless sorrow had worn her to a
shadow. She took the little Dunois with her children to the Castle of
Blois. There were four of them, Charles, the Poet, who should be the
father of King Louis XII.; and little John, the grandfather of Francis
I.; Philip, Count of Vertus; and Margaret, in later years the
grandmother of Anne of Brittany. These children, three of whom
should be the grandparents or great-grandparents of Henri II.,
Valentine ceaselessly instructed. All her contemporaries bear witness
to her untiring vigilance over them. “They are marvellously good,
and well-instructed for their years,” says Monstrelet: “Moult
notablement conduits et indoctrinés.” But there was one lesson,
dearer than the others, that Valentine perpetually taught her sons.
“Avenge your father,” she continually cried.
These children, so different in character and destiny, were the
dearer to their mother that she felt she had not long to love them.
Valentine was dying of a broken heart, “of anger and mourning,”
writes Juvenal; “of anger and impotent vengeance,” says Monstrelet.
Her eyes were quite dim with useless tears, and still she resented
the very grief that drained her life; for she did not want to leave her
little children and her unaccomplished task. “It was pitiful,” says
Juvenal, “before she died to hearken to her regrets and her
complaints, so piteously she regretted her children, and a bastard,
called John, whom she could not suffer out of her sight, saying none
of her children was fitter to avenge their father.”... “Since the tragic
end of her husband,” says the Monk, “this Duchess spent her days in
tears, and many say the bitterness of her heart induced that
unhealthy languor of which she died.”
This was in November. Upon St. Clement’s day, upon that heart-
sickening anniversary of her husband’s murder, Jean-sans-Peur rode
into Paris. It was a triumph. As he passed the people, and their little
children cried, “Noel, noel au bon Duc.”
It was near a week before the news came down to Blois. When
she heard it, Valentine felt that all was over. No vengeance was
possible. On the 4th of December the unhappy woman died, with
her last breath entreating her little children never to forget their
father’s murder. But these children were only children, and they were
orphans. The death of Valentine seemed to secure the triumph of
her enemy. Jean-sans-Peur did not seek to hide his rejoicing: “Car
icelle Duchesse continuoit moult asprement et diligemment sa
poursuitte.“ But already Retribution at her grindstone was
sharpening the fatal battle-axe of Montereau.

11. At the same time there dwelt in Milan another little Valentine
Visconti, daughter of Bernabò, in after years the widowed Queen of
Cyprus, and herself an interesting and pathetic figure.

12. Corio on different pages puts the date of the birth of

Giangaleazzo as 1352 and 1343. The first date, 1352, agrees with
the account of Galeotto del Caretto and the Deed of Majority in
Corio.

13. Tu, spectabilisque Azo, natus tuus ... auctoritate, bayliâ, nec
non Regiæ Potestatis plenitudine, tam ordinariâ quam absolutâ, &c.,
Feb., 1380. Luenig. De Ducatu Mediolanense, in the “Codex Italiæ
Diplomaticus,” No. xxvii. See also Investiture of Asti, 1383, to
Giangaleazzo (vos et heredes vestri) in the Archives Nationales, K.
53, dossier 22.

14. “L’Apparicion de Maistre Jehan de Meun,” Fr. ii., 7203. MSS.

Bib. Nat.

15. This was the estimate of Giangaleazzo. The actual revenues

proved to be a little less, and an arrangement à l’amiable was made
between him and his son-in-law (Arch. Nat., K. 554, dossier 6).

16. See Comte Albert de Circourt, “Le Duc d’Orléans, frère du roi
Charles VI.: ses entreprises au dehors du royaume.” Paris: Victor
Palmé, 1887.

17. The florin, the Venetian ducat, and the French franc were
interchangeable coins worth about nine-and-eightpence of our
money. They are the equivalent of our half-sovereign, the French
crown that of our half-guinea; the Burgundian noble being, I think,
the only coin that reached the value of the modern guinea. See the
tables for 1384-1394 in De Wailly.

18. Le Pastoralet. A Burgundian satire, in the form of a Pastoral,

written by one Burcarius in the first half of the fifteenth century, and
published of late years in the Baron Kervyn de Lettenhove’s
collection of Belgian chronicles.

19. Lamansky: “Secrets de l’Etat de Venise,” pp. 157-159. Also

“Archivio di Firenze,” Signori Legazione Commissioni, &c. Filza 28,
folio 7 t.

20. Giangaleazzo in 1395 obtained the title and investiture of the

Duchy of Milan from Wenzel, King of the Romans, for 100,000
florins.

21. Arch. Nat. (K K. 315 fos. 9-52): “Notes à compter faiz à

certaines gens d’armes et archiers retenus par Monsieur le Duc à son
service avant la venue de M. de Coucy ès parties d’Ytalie.”
 22. De Circourt, op. cit., p. 48.

23. Walsingham, “Historia Anglicana,” vol. ii. p. 201.

24. Clairambault. sceaux, vol. cxiii. p. 8821. See De Circourt, op.

cit.

25. For all this question of the kingdom of Adria, too vast for this
incidental line, see the excellent paper of M. Paul Durrieu in the
“Revue des Questions Historiques” for July, 1880; also the scarce
volume of Champollion-Figeac, “Louis et Charles, Ducs d’Orléans,”
Paris, 1844; and especially the box of Manuscripts in the Paris
National Archives labelled Carton J. 495. I may also indicate an
interesting passage in Walsingham’s “Historia Anglicana,” vol. ii. p.
201, communicated to me by Comte Albert de Circourt, “Item
Dominus Papa significat Regi per prædictum nuncio, qualiter Rex
Franciæ et Antipapa pacta inierunt hinc inde: Videlicet quod idem
Rex, per fortitudinum Ducum (Burgundiæ et Turoniæ, poni faciat
Antipapem in Sedem Petri et Antipapa promisit Regem Imperio
coronare, et Duci Burgundiæ) magnalia et investiet Ducem Turoniæ
de omnibus terris ecclesiæ in partibus Italiæ, et quendam alium
coronare Regem Tusciæ et Lombardiæ, et Ducem Andexaciæ
(Andegaviæ) firmare in Regno Siciliæ.” The passage in brackets
exists only in the Brit. Mus. MS.

26. “Arch. Nat.,” K K. 315.

27. “Arch. Nat.,” J. 497, No. 15. February, 1392, Lomellini, Flisco,
and other nobles of Genoa sign an instrument offering Genoa to the
King of France.

28. Paul Durrieu, “Le Royaume d’Adria.” See also an important

passage, “Religieux de St. Denis,” t. ii. p. 402.

29. “Arch. Nat.,” K. 54, No. 37. December 12, 1396: “Comme
depuis que nostre très-cher et très amé frère le Duc d’Orleans eut,
pour les causes et les concideracions qui le meurent, entrepriz
d’avoir la Seigneurie des cité, pays et territoire de Gennes. Et tant
fait pour venir à son entencion.... Savoir faisons que pour contenter
et deffraier nostre dit frère des trés-grans fraiz missions et
despenses par luy en plusieurs manières faiz et soustenuz ... nous
avons avec nostre dit frère traicté et accordé sur de et pour ces
choses et leurs dependances la somme de trois cents mile frans d’or
pour une foiz.”

30. August 31, 1395. Lünig Codex Italiæ Diplomaticus, i. col. 421.

31. “Religieux de St. Denis,” ii. p. 436, et. seq.

32. “Delaville Le Roulx. La France en Orient,“ vol. i. p. 290-304.

33. Vide “Jean sans Peur, Duc de Bourgogne, Lieutenant et

Procureur-général du Diable cès parties d’Occident,” par M. Paul
Durrieu, Paris, 1887.

34. For example Carlo Zeno in 1403, Gattilusio in 1399, each of

whom informed the Turks concerning the plan of campaign of a
Christian enemy.

35. “L’Apparicion de Maistre Jehan de Meun.” Bib. Nat. Fr. 811, No.
7203. This is an illuminated manuscript in defence of Valentine of
Orleans, and dedicated to her.

36. “Delaville Le Roulx. La France en Orient,” Paris, 1886, vol. i. p.

291.

37. “Ordonnances des rois de France,” t. vii. p. 535. The Duke of

Orleans was never Regent, despite the line of the Monk of St. Denis
which assures us that in 1402 the King made his brother Lieutenant-
General of the Kingdom. During the frequent relapses of Charles VI.
the kingdom was governed by a Council. There was no Regency
before the year 1415.

38. Arch. Nat. K. 55, No. 16, June 14, 1401.

 39. Arch. Nat. K. 55, No. 39, Aug. 21, 1405.

40. Arch. Nat. K. 55, No. 36, Dec. 1, 1405.

41. “Arch. Nat.” Carton K. 55, No. 10: “Lettres par les-quelles le
Roi commect la garde du Pape Bénoist 13 au Duc d’Orléans, au-quel
il donne cent hommes de sa garde. No 14 bis: Lettres du Roy
Charles VI. déclaratrices que loin de tenir le Pape Bénoist XIII.
prisonnier, il l’a pris sur sa sauve garde et que pour plus grande
sûreté de sa personne et de ses biens il a établi son frère le Duc
d’Orléans pour en avoir garde.”

42. Communicated by Comte Albert de Circourt from transcripts in

his possession.

43. See M. Paul Durrieu, “Les Gascons en Italie,” p. 214.

44. Dumont, Corps Diplomatique. II. ccxvii. and ccxxxi.

45. Avd Nat. K. 55, No. 11, bis July 26, 1404. À tous ceulx qui ces
présentes lettres verront, Guilles, Seigneur de Tignonville, chevalier,
conseiller, chamberlain du Roy nostre seigneur et garde de la
prévosté de Paris, Salut! Savoir faisons que nous l’an de grace 1404,
ce Mercredi 26 jour du mois de Juillet, vismes une lettre du Roy
nostre seigneur scellée de son grant scel sur double couronne, des
quelles la teneur s’ensuit:
Charles par la grace de Dieu Roy de France, à tous ceulx qui ces
lettres verront, Salut! Savoir faisons que après la supplication et
requeste à nous faictes par nostre très-cher et très-amé frère Loys
Duc d’Orléans, contenant que comme à cause de nostre très chère
et très amée soeur, sa femme, fille du feu nostre oncle le Duc de
Milan, plusieurs villes terres et seigneuries situées es parties d’Italie
et de Lombardie, entre lesquelles est et doit estre la ville et cité de
Pise avec toutes ses appartenances, la seigneurie de laquelle nostre
dit frère dit estre et appartenir au dit feu Duc de Milan auparavant
qu’il alla de vie à tres-passement appartiennent et doivent appartenir
à iceluy nostre très-cher frère. Il nous a exposé et il ait entendu de
nouvel que la dicte ville et cité de Pise et aucuns chasteaulx
appartenant d’icelle, par certains moyens sont à nous acquis et
venues en nostre main. Et ont été bailliz pour nous par nostre très-
féal Chevalier Chambellan et conseiller Jehan le Meingre dit
Boucicaut, Maréschal de France, et Gouverneur pour nous de nostre
cité et seigneurie de Jennes, pour quoy il nous a requis en tout le
droit que nous avons et pouvons avoir de la dicte ville et cité de Pise
et ès aultres cités et appartenances qui furent au dit Seigneur de
Milan, nous veuillons bailler et délaisser. Et tout empeschement mis
de par nous en la dicte ville et cité de Pise et ès dictes chateaulx et
aultres appartenances d’icelles, veuillons faire oster et cesser, sans y
plus procéder, ny faire procéder, en sa préjudice. Nous voulons
toujours condescendre au justes requestes de nostre-dit frère,
comme raison est. Qui avons baillie et délaissié de une certaine
science par ces présentes tout le droit et seigneurie par nous acquis
de nouvel et que nous avons et pouvons avoir en dicte ville et cité
de Pise et ès aultres chasteaulx et appartenances d’iceulx. Et
voulons et ordonnons par ces présentes que l’empeschement mis
par et en nostre nom en la dicte ville, cité et Seigneurie de Pise et ès
chateaulx et aultres appartenances d’icelles, soit osté. Si donnons en
mandement par ces présentes et envoyons très-expressement au dit
gouverneur de nostre dicte cité de Jeunes et à tous nos aultres
justiciers et conseillers ou à leurs lieutenants et à chaseur d’eulx, si
que di luy appendra, que de nostre bailli et délaissements dessus
ditz faient, sueffrent et laissent jouer et user paisiblement nostre diet
frère. En mectant au délivrement de luy ou à ses ditz gens officiers
commis et députés de par lui tous les ditz droit et seigneurie par
nous acquis de nouvel ès ditz ville cité et chasteaul dessus ditz. Et
en ostant tout l’empeschement qui en iceulx a esté mis de nostre
part. En tesmoing de ce nous avons fait mettre à ces lettres nostre
scel. Donné a Paris le 24 jour de May l’an de grace mil quatre ans et
quatre et le 24 de nostre règne. Aussi signées par le Roy en son
rayson. Messigneurs les Ducs de Berry et de Bourbon, le
Connestable, le Comte de Tancarville, le grand maistre d’ostel et
aultres.
 Et nous a ce présent transcript in tesmoing de ce que usismes le
scel de la dicte prévosté de Paris l’an et jour dessus promis et dietz.
Manessier.

46. A strange document in the Carton K. 55 Arch. Nat., under date

July 27, 1406, in the form of a letter from the King in Council
(Tancarville “et autres” being present), notifies that that day the
King has received conjointly the Dukes of Burgundy and Orleans,
who have made him their united homage for Pisa. In 1407 the
Signory of Florence, having taken Pisa (a French fief), sent to the
King, Orleans, and Burgundy to justify their conduct. Orleans seized
the Florentine ambassadors and cast them into prison—a high-
handed proceeding which he probably considered warranted by his
position as suzerain of the captive city. In so doing Orleans probably
meant to underline the fact that he, not the King or Burgundy, was
lord of Pisa, though all had claims to suzerainty. There is a long
correspondence on this subject (Archives of Florence, filza xviii. della
Signoria. Cancelleria 27).

47. It is in 1407 that the Italian projects of Orleans appear in

vigorous renascence. On the 6th of October he proclaimed himself
Protector of his nephews, Giovanni Maria, Duke of Milan, and Filippo
Maria, Count of Pavia, “frères de Dame Valentine épouse du Duc”
(Arch. Nat. K. 56, No. 16). He made the Governor of Asti their
guardian, and appeared to meditate an armed intervention. Was this
conduct purely and merely disinterested? Did Orleans in October at
Beauté-sur-Marne contemplate a great French protectorate in
Lombardy of which he should be the soul and centre? A month later
a tragic silence suddenly interrupted any answer to these questions.
 48. See “Arch. Nat.” K K. 267 fo. 97. Also the chapter on
Bernardon de Serres in M. Paul Durrieu’s valuable work, “Les
Gascons en Italie.”
 The Claim of the House of Orleans
to Milan.

Let us recapitulate.
When, on September 16, 1380, Charles V. of France expired, he
left behind him two young sons. One was twelve years old, tall,
stalwart, healthy, amiable; the other was a lad of nine, less regularly
handsome than his brother, slighter, darker, more agile, more acute,
and more engaging.
Charles V. had left his younger son no more than the pension of a
private gentleman; the elder was the king of France. The dying
monarch, a man of many brothers, had seen the dangers that arise
when royal princes are too rich. But he had died before his time; and
of his two heirs the king was gentle, dull, and generous; the
gentleman, brilliant, grasping, and ambitious. The result was
calculable. Twenty years later the younger son was king in all but
name; he was rich, puissant, terrible, and hated; while his brother,
impoverished and neglected, starved on the throne, the best-beloved
man in France. Circumstances had made the rise of the younger son
singularly easy. In his twenty-fourth year King Charles VI. became
violently mad, and henceforward till his death there were long
regencies (the subject of angry contests between his uncle and his
brother) interrupted by periods of lax and kindly government. His
younger brother, Louis, Duke of Orleans, became, as first prince of
the blood, more powerful than the king. He was too powerful; and
his arrogance and his extortions raised many enemies against him.
On November 23, 1407, he was cruelly murdered as he was riding by
night through the streets of Paris. He had made himself so terrible
that even the brother who loved him did not seek to avenge him,
but praised the murderer “who, for the public good and out of faith
and loyalty to us, has caused to be put out of this world our said
brother of Orleans.” No one mourned the murdered man absolutely
and completely except his devoted widow and his orphaned children.
A year and a week later the duchess died. Her three sons, her one
daughter, with Dunois, the natural son of Orleans, whom his widow
had adopted, were left fatherless and motherless in a kingdom full of
enemies, where their father’s murderers triumphed. They entered
the world as a battlefield; but, though so young, they entered armed
and mounted. From their father they inherited the duchies of
Orleans, Luxembourg, and Aquitaine, the counties of Valois,
Beaumont, Soissons, Blois, Dreux, Périgord, and Angoulême, with
the seigneuries of Coucy and Savona. Through their mother they
acquired the county of Vertus in Champagne, the county of Asti in
Lombardy, and certain pretensions to the ducal crown of Milan.
 I.
In the year 1387 their father, Louis of France, not yet the Duke of
Orleans, had been contracted to the Duke of Milan’s only daughter,
Valentine Visconti, whom two years later he espoused. In relation to
the established monarchs of his time, the father of Valentine stood in
much the same situation as afterwards the great Napoleon, in the
first years of his empire, towards the kings of Germany. He was rich,
too powerful to be safely opposed, a conqueror of whom the end
was still beyond prediction; hence a man to conciliate and appease.
Yet in their hearts they despised him as a parvenu and an
adventurer, and deplored and deprecated the moral flaws that
marred the beauty of his prosperity.
Giangaleazzo, first Duke of Milan, was the only son of Galeazzo
Visconti, who, in conjunction with Bernabò, his brother, swayed the
city of Milan and the greater part of Lombardy. They had murdered
their own brother, and divided his inheritance between them—
Bernabò, the elder, holding his state in Milan, Galeazzo in the city of
Pavia.
Bernabò had no less than nine-and-twenty children. Galeazzo had
but two, but for these he was ambitious. He married his daughter to
the son of the King of England; his son he married to the daughter
of the King of France. This was in 1360. The bride and bridegroom
were still of childish age. Six years later their eldest child was born.
It was a girl, Valentine. The three brothers who followed her died in
their minority; but Valentine flourished, grew to womanhood, and
brought into the house of Orleans the tangled question of the
Milanese succession.
At her birth and during her childhood her father was but one of
several rulers in Milan. The Visconti ruled as a clan rather than as an
organized dynasty. They were the descendants of a certain Captain
Eriprando, who, in the year 1037, defended Milan against the
Emperor Conrad. Notwithstanding this beginning the Visconti were
eminently Ghibelline, and depended for all their subsequent fortunes
on the emperor. In 1277 they chased the Guelfs from Milan, and
made themselves masters of the state. They became lords or domini
in Milan, lords of an imperial fief, but with no pretence to an imperial
investiture. The emperor recognized them only as his captains, his
viscounts, or his imperial vicars.
In 1372 the Emperor Charles IV., alarmed at the pretensions of the
Visconti clan, deprived them of their office. The rich tyrants, not
afraid of a distant emperor beyond the Alps, paid little heed to this
punishment. The emperor died, and his son succeeded—the
dissolute Wenzel, who was to do so much for Milan. Almost his first
act was to create the youthful father of Valentine Imperial Vicar of
the Milanese.
This taste of power whetted the ambition of the young man, left
fatherless now to confront the faction of his uncle Bernabò and his
numerous children. Lax and irregular forms of government favour a
violent ambition. By one bold stratagem Giangaleazzo took his uncle
prisoner, dispossessed his cousins, and established himself as lord of
Milan.
Milan was not enough. Fire and sword cleared the way before him,
and his territory stretched to the Apennine ridges. Florence, on the
other side, trembled for her independence. The Lombard kingdom
was alive again, and, though the Pope refused the indomitable
conqueror the title of King of Italy, in 1395 the Emperor Wenzel
invested him with the duchy of Milan.
Meanwhile, in 1389, Valentine Visconti had gone to her husband in
France. When she left Milan she was no longer her father’s only
child. A few months before, her stepmother, Caterina Visconti, had
given birth to a son. A little later a second son was born. The
greatest conqueror of his age could now divide his possessions
between two sons born in wedlock, a bastard boy named Gabriello,
and his only daughter Valentine, the child of his first wife, the
Princess Isabelle of France. The first question that confronts us is
this: What provision did Giangaleazzo Visconti make for his daughter
Valentine of Orleans?
 For many centuries there has been much debate concerning the
claim of Orleans to Milan. Much argument and little evidence has
confused the question; it is only the evidence that we shall examine
here. In the National Archives of Paris[50] there exists the original
marriage-contract of Valentine Visconti. A copy of this document is
contained in a brown leather folio, stamped with the Visconti
serpent, existing in the British Museum.[49] It is an instrument
granted by the Antipope, Clement of Avignon, on January 27, 1387,
in favour of Louis of Orleans and Bertrand de Guasche, Governor of
Vertus, as representing the father of Valentine. To the marriage
contract are appended a dispensation (Louis and Valentine were
cousins), a deed of transfer for the bride’s dowry of Asti and its
dependencies, and a declaration of her right to succeed her father in
Milan, in case his direct male line should become extinct. The clause
which chiefly concerns us runs as follows: “Item est actum et in
pactum solempni stipulatione vallatum et expresse deductum quod
in casu quo præfatus dominus Johannes Galeas vicecomes, comes
Virtutum, dominus Mediolanensis, decedat sine filiis masculis de suo
proprio corpore ex legitimo matrimonio procreatis, dicta domina
Valentina, nata sua, succedat et succedere debeat in solidum in toto
dominio suo presente et futuro quocumque, absque eo quod per
viam testamenti, codicillorum, seu alicujus alterius ultimæ voluntatis,
aut donatione inter vivos, ipsa aliquid faciat seu facere possit in
contrarium quovis modo.”
The husband of Valentine was for many years the tool with which
the astute Visconti hoped to assure his own supremacy in Italy. In
1393 and in 1394 Visconti had no dearer scheme than that Clement,
the Antipope at Avignon, should make the Duke of Orleans king of
Adria. With Clement at Rome, Anjou at Naples, Orleans ruling the
centre from Spoleto to Ferrara, Visconti beheld the annihilation of
Venice and the Tuscan republics—a united Italy north of Rome.
Doubtless he intended the kingdom of Adria and the kingdom of
Lombardy to lose themselves in one monarchy: but whether that
result was to be attained by the subsequent spoliation of Orleans or
by his adoption as heir to Milan, was a question which probably
depended on the living or dying of the sons of Giangaleazzo.
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