Random
The nurse would perform which activity that related to the evaluation phase of the nursing process during client care?
A) Ambulate a client 20 feet down the hallway
B) Question a client about family medical history
c) Assess a client's progress toward a desired outcome
D) Assign a nursing diagnosis to an identified need.
Ans C
The evalution step of the client's plan of care includes the assessment of the client's progress toward a previously identified desired outcome
The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process?
A. Deliver care to a client in an organized way.
B. Implement a plan that is close to the medical model.
C. Identify client needs and deliver care to meet those needs.
D. Make sure that standardized care is available to clients
Answer: C
Explanation: The purpose of the nursing process is to identify a client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.
Page Ref: 155
Unlicensed assistive personnel measure a newly admitted client's vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data?
A. Retake the vital signs.
B. Call the physician.
C. Continue with the physical assessment as soon as possible.
D. Report the findings to the charge nurse.
Answer: A
Explanation: Guidelines for validating assessment data that are out of normal range include repeating the measurements, using another piece of equipment as needed to confirm abnormalities, or asking someone else to collect the same data. In this situation, the nurse needs to be sure that the vital signs are accurate.
Page Ref: 171
While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: A
Explanation: Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.
Page Ref: 159
Prior to providing client care, the nurse reviews previous shift charting and the responses to nursing interventions. Which decision-making action is the nurse using?
A. Set the criteria
B. Examine alternatives
C. Implement
D. Evaluate the outcome
Answer: D
Explanation: In evaluating, the nurse determines the effectiveness of the plan and whether the initial purpose was achieved. In this situation, the nurse wants to determine what worked on the previous shift and what didn't. This will help with deciding on interventions for the client during the shift.
Page Ref: 150
The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems?
A. Mental status of the client
B. Chronic nature of the illness
C. Nursing care focus
D. Prognosis
Answer: C
Explanation: Nursing focus is an area that differs.
Page Ref: 176
The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing?
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Answer: C
Explanation: Implementation is that part of the nursing process in which the nurse applies knowledge to perform interventions.
Page Ref: 159
Which statement made by the nurse while taking a nursing history would elicit the greatest amount of client data?
A) "Did your pain begin recently?"
B) "You said the pain began yesterday?"
C) "Can you tell me more about how the pain began?"
D) "The pain isn't bad right now, is it?"
ANS C
Open-ended questions encourage the client to speak freely and to elaborate and clarify answers as needed.
Option A & B are closed-ended questions (where there will be a yes or no answer)
Option D is a leading question
While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time?
A. Initial assessment
B. Problem-focused assessment
C. Emergency assessment
D. Time-lapsed assessment
Answer: C
Explanation: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems.
Page Ref: 161
A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?
A. Client will ambulate without a walker by 6 weeks.
B. Client will ambulate freely in house.
C. Client will not fall.
D. Client will have freer movement in daily activities.
Answer: A
Explanation: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable.
Page Ref: 197
During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says "leave me alone." Which subjective data should the nurse document?
A. Restlessness
B. "Leave me alone"
C. Not talkative
D. Pale and diaphoretic
Answer:B
Explanation: Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the client's sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations.
Page Ref: 160
The nurse educator assigns students an activity to implement Socratic questioning in their daily lives. Which question provided by a student demonstrates this reasoning technique?
A. "What makes you think cramming for a test is an ineffective way to study?"
B. "What other ways of studying could you implement?"
C. "If you didn't study for your test, what is the probability you will fail?"
D. "If you study all the unit outcomes, what effect will that have?"
Answer: A
Explanation: Socratic questioning is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes. Questions about evidence and reason focus on just that (e.g., what evidence is there, how you know, what would change your mind).
Page Ref: 146
The nurse provides routine morning care to a client, including all the medications and scheduled treatments. What action should the nurse make next?
A. Move on to the next assignment to increase the nurse's efficiency.
B. Report this to the charge nurse.
C. Document all care in the progress notes.
D. Get supplies organized for the next client's medications and treatments.
Answer: C
Explanation: After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the progress notes.
Page Ref: 210
) A client is experiencing a productive cough, audible coarse crackles, elevated temperature of 102.3°F, chills, and body aches. What did the nurse use to determine that this patient is experiencing respiratory compromise?
A. Deductive reasoning
B. Inductive reasoning
C. Socratic questioning
D. Critical analysis
Answer: A
Explanation: Deductive reasoning is reasoning from the general to the specific. The nurse starts with a framework and makes descriptive interpretations of the client's condition in relation to the framework. Productive cough, crackles, fever, and chills all point to problems with respiratory status.
Page Ref: 147
A nurse has been assigned a new client who cannot speak English. How should the nurse facilitate communication with this client?
A. Have a member of the housekeeping staff who speaks the same language translate.
B. Use the translation services supplied by the hospital.
C. Make sure a family member who does speak English is available.
D. Conduct the interview using hand gestures.
Answer: B
Explanation: Live translation is preferred because the client can then ask questions for clarification. Many large facilities are establishing their own translator services for the languages commonly spoken in their geographical regions.
Page Ref: 166
According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client?
A. Make sure that he or she is able to get to the client's home.
B. Assist the client in finding an alternative plan for the achieving the therapy's outcomes.
C. Tell the client that this therapy will be impossible to receive.
D. Make arrangements to have the client moved to a long-term care facility.
Answer: B
Explanation: The nurse must consider a variety of factors when assigning priorities, including resources available to the nurse and client. Factors in this case include the distance between the client's home and the hospital and the fact that therapy is ordered on a twice-daily basis. Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered (e.g., a neighbor who might be willing to drive the client, or someone in the area who may be able to assist with the therapy).
Page Ref: 195
The nurse notes that a client has the outcome goal "Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic." Which client statement should the nurse use to evaluate this goal?
A. "I'm getting really sleepy from that medication. I think I'll take a nap."
B. "My pain is a 4."
C. "I still have some pain."
D. "Will the pain ever go away?"
Answer: B
Explanation: The nurse collects data so that conclusions can be drawn about whether goals have been met. If the goal is clearly stated, precise, and measurable, it will be easy to evaluate. If the goal was a pain level of 3, the client should be able to give a numerical rating to the pain in order for the nurse to evaluate it.
Page Ref: 211
The nurse completes collecting data from a client and determines a list of problems. Which step in the nursing process should the nurse perform next?
A. Assess
B. Diagnose
C. Plan
D. Evaluate
Answer: C
Explanation: The planning portion of the nursing process involves setting criteria, weighting the criteria, and seeking/examining alternatives when compared to the decision-making process.
Page Ref: 148
The nurse is reviewing interventions written for a client's plan of care. Which intervention should the nurse recognize as being dependent?
A. Repositioning the client every 2 hours
B. Assisting the client with transfers to the bathroom
C. Providing ongoing physical assessment, especially of the incisional sites
D. Administering medications for pain
Answer: D
Explanation: Dependent interventions are those activities carried out under the physician's orders or supervision or according to specified routines. The nurse is responsible for assessing the need for and administering medications, but the physician prescribes them.
Page Ref: 201
On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take?
A. Ask the nurse mentor to assist with the teaching after reviewing the procedure.
B. Read the policy and procedure manual before the teaching session.
C. Do the best the nurse can by remembering what was taught in nursing school.
D. Ask for a different assignment until the nurse feels comfortable with this one.
Answer: A
Explanation: When implementing some nursing interventions, the nurse may require assistance. In this case, the nurse lacks the knowledge or skills to implement a particular nursing activity (teaching).
Page Ref: 210
A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client?
A. Pain due to unknown factors
B. Pain related to unknown etiology
C. Pain caused by psychosomatic condition
D. Pain manifested by client's report
Answer: B
Explanation: The second part of the nursing diagnosis statement is the etiology (E)—the factors contributing to or probable causes–and should be joined to the first part, the problem (P), by the words "related to" rather than "due to." The phrase "related to" implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem is evident.
Page Ref: 182
The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the client's coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information?
A. Strengths can be an aid to mobilizing health and the healing process.
B. The client will be more active in the plan.
C. It will be easier for the nurse to educate the client about other interventions.
D. The nurse won't have to spend time going over the pathology of the client's disease.
Answer: A
Explanation: 1. Establishing strengths, resources, and ability to cope will help the client develop a more well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and regenerative processes.
Page Ref: 181
A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client?
A. Altered oral mucous membranes, related to dry mouth
B. Activity intolerance, related to oxygen supply imbalance
C. Knowledge deficit, related to medication regimen
D. Ineffective airway clearance, related to increased secretions
Answer: D
Explanation: Prioritizing care must begin with the basic needs, in this case, the airway.
Page Ref: 185
During a clinical conference, a staff nurse states that critical thinking is essential when providing client care. What additional statements should this nurse make to support the use of critical thinking? Select all that apply.
A. "Patient acuity is so much greater than it was even 10 years ago."
B. "Care delivery systems are only as good as the nurses delivering care."
C. "Nurses have always relied on commonsense thinking to provide quality, appropriate nursing care."
D. "With health care being so expensive, nursing has to take on responsibility to keep the costs controlled."
E. "My practice involves caring for clients who require care that didn't even exist when I went to school."
A B D E
Explanation: A. Patients are sicker, with multiple problems, and so nursing care requires a more critical form of thinking in order to meet their nursing needs.
B. Redesigning care delivery is useless if nurses don't have the thinking skills required to deal with today's world.
D. Consumers and payers demand to see evidence of benefits, efficiency, and results.
E. Today's progress often creates new problems that can't be solved by old ways of thinking.
Page Ref: 144
The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label?
A. Must contain three components
B. Describes the health problem for which nursing therapy is given
C. Helps define medical diagnoses for nursing
D. Promotes a taxonomy of nursing
Answer: D
Explanation: The purpose of the NANDA label is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. This label describes the health problem or response by the client for which nursing therapy is given.
Page Ref: 176