A
The nurse who uses the nursing process will:
a. help reduce the obvious signs of discomfort.
b. help the patient adhere to the primary care provider’s treatment protocol.
c. approach the patient’s disorder in a step-by-step method.
d. make all significant nursing care decisions involving patient care.
C
The nursing process is a collaborative process used throughout the patient’s stay. It is an organized method for identifying and meeting patient needs in a step-by-step manner.
A nurse will arrive at a nursing diagnosis through the nursing process step of:
a. planning.
b. evaluation.
c. research.
d. assessment.
D
As a result of the nursing assessment, a nursing diagnosis is established.
In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is to:
a. collect data of health status.
b. select a nursing diagnosis.
c. organize data to help the RN evaluate patient progress.
d. prioritize nursing diagnoses for more effective care.
A
The LPN/LVN collects data of the patient’s health status to assist the RN in selecting a nursing diagnosis.
The participants of the planning stage of the nursing process during which the health goals are defined include:
a. the RN.
b. the health team led by the RN.
c. the health team, the patient, and the patient’s family.
d. the health team as directed by the physician.
C
The planning stage during which the health goals are defined are best shared by the entire health team, the patient, and the patient’s family for the optimum outcome.
When a resident in the nursing home complains of constipation, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an example of:
a. implementation.
b. nursing diagnosis.
c. assessment.
d. evaluation.
C
The examination to confirm and affirm the complaint of constipation is an assessment.
The nurse completing morning assessments on a patient who is sitting up in bed is told by the patient, “I’m having trouble breathing—I can’t seem to get enough air.” The best nursing response is to:
a. notify the doctor as soon as he or she comes in later in the morning.
b. finish the vital signs for the assigned patients, and then notify the charge nurse.
c. reassure the patient, if his blood pressure and pulse are normal.
d. notify the charge nurse immediately of the patient’s statement.
B
The nurse should finish the assessment in order to confirm the complaint and inform the charge nurse.
The order in which the nursing process is approached is:
a. planning, assessment, implementation, nursing diagnosis, evaluation.
b. nursing diagnosis, evaluation, assessment, implementation, planning.
c. assessment, nursing diagnosis, planning, implementation, evaluation.
d. evaluation, nursing diagnosis, planning, implementation, assessment.
C
The order of assessment nursing diagnosis, planning, implementation, and evaluation sets up a basis for an organized approach to nursing care.
Once the nursing plan has been initiated, the nursing care plan will:
a. stay in place until all nursing goals have been met.
b. change as the patient’s condition changes.
c. remain on the patient record to show progress.
d. be given to the patient for final approval.
B
The nursing care plan is always a work in progress and will change as the patient condition changes.
When a patient states, “I can’t walk very well,” the first problem-solving step would be to:
a. consider alternatives such as a wheelchair or walker.
b. find out what the problem is, such as weakness or poor balance.
c. choose the alternative with the best chance of success.
d. consider the outcomes of the choices, such as danger of falling with a walker.
B
Defining the problem clearly assists in the interventions to reduce the problem.
A student nurse can begin to develop critical thinking skills by means of:
a. working with a more experienced nurse.
b. questioning every statement made by instructors to be sure of its correctness.
c. memorizing class notes for tests and studying all night for big tests.
d. listening attentively and focusing on the speaker’s words and meaning.
D
Critical thinking involves foundation skills such as effective reading and writing and attentive listening.
When a nurse prioritizes the patient care, consideration is given to:
a. completing assessments before mid-shift.
b. considering situations that may result in an alteration of health.
c. assuming all health care activities for a group of patients.
d. identifying who can assist with the aspect of care.
B
Priority setting includes addressing health endangering situations and physiological needs first.
When the nurse checks to see whether a patient has had relief 45 minutes after administering pain medication, the nurse is performing a(n):
a. nursing diagnosis.
b. implementation.
c. assessment.
d. evaluation.
D
Evaluation is the step in which the nurse determines whether the plan and interventions are effective or need to be modified.
The activity that is an implementation in the nursing care is:
a. checking the assigned patient’s blood pressure, pulse, and respiration.
b. changing the patient’s surgical dressing.
c. asking the patient to demonstrate how to give himself medication after teaching him.
d. discussing the patient with other team members to establish a care plan.
B
Changing a dressing that is soiled is a nursing intervention performed to meet a patient’s need. Checking vital signs is assessment. Demonstrating medication administration is evaluation. Discussing the patient with other team members is planning.
Constant nursing assessments and evaluations of the patient will most likely result in:
a. the nursing care plan changing to reflect appropriate priorities.
b. small changes in the patient condition being overlooked.
c. cluttered and confusing documentation.
d. impeded problem solving.
A
Continued assessment and evaluation are necessary; reprioritizing and reorganizing activities occur in response to the patient’s changing condition.
The effect of using a scientific problem-solving approach in nursing care will cause decision making to be:
a. slowed down considerably by the multiple steps.
b. rigid and nonpatient oriented.
c. improved nursing care outcomes.
d. unrelated to the nursing process.
C
A scientific problem-solving approach is most likely to result in positive patient outcomes.
An emergency room nurse will give first priority to the patient with the most critical need, which is the patient who:
a. is bleeding from a chin laceration.
b. complains of a productive cough.
c. has a fever of 102°F.
d. complains of severe chest pain.
D
Because the chance of a bad outcome is highest for the patient with chest pain, it is most appropriate to assess this patient first.
Before beginning to teach a patient to give himself insulin, the nurse asks, “Have you ever known anyone who gave himself insulin injections?” This question is primarily designed to:
a. assess the patient’s learning needs.
b. stimulate the patient to focus on the patient education goal.
c. reduce the patient’s anxiety relative to insulin injection.
d. reduce the amount of information the nurse has to provide.
A
Assessing a patient’s previous experience (as well as education, learning mode, and motivation) gives the nurse valuable information in developing a patient education plan tailored to the individual. It may reduce the amount of information needed, or it may increase it if some of what the patient “knows” is erroneous.
The nurse uses a syringe and vial of insulin to show how to draw up the correct dose while she explains the procedure to the patient. To best promote learning, her next step should be to:
a. give the patient written materials to study and learn the procedure.
b. have the patient explain the procedure to the nurse to assess understanding.
c. give the patient a day to allow him to process and absorb the information.
d. have the patient practice the procedure with the nurse helping.
D
Kinesthetic, or hands-on, learning reinforces the visual demonstration. Immediate handling of the materials reduces anxiety. Giving the patient reading materials or asking the patient to explain verbally will not be as effective as the kinesthetic application.
Patient education for an 82-year-old patient to perform a dressing change to be done at home after discharge, the nurse would adjust the teaching session to:
a. include another person in the instruction because an 82-year-old person will be unable to master the technique.
b. slow the pace and frequently ask questions to assess comprehension.
c. speed through the details because age and experience will shorten learning time.
d. provide written material and diagrams alone.
B
The older patient needs to have the pace slowed and have time to ask questions to confirm comprehension. The inclusion of written materials to reinforce patient education is also good, but should not be the only method of instruction.
An 80-year-old patient is to be taught the process of colostomy irrigation and reattachment of the colostomy bag. The nurse’s initial assessment prior to instruction should address the patient’s:
a. understanding of the process of irrigation.
b. familiarity with the irrigation materials.
c. manual dexterity.
d. motivation to learn.
D
The patient’s motivation to learn a new skill is essential to the success of the instruction. Some patients need to see the advantage of independence to motivate them to learn. Manual dexterity and basic understanding of materials and process are important, but initially the motivation needs to be assessed.
The nurse can assess her patient’s ability to read and comprehend written instructions by doing which of the following?
a. Asking the patient, “Did you graduate from high school?”
b. Giving the patient a printed instruction sheet and saying, “Some people have difficulty with written instructions. Others find them helpful. Would these be helpful to you?”
c. Asking the patient, “Are you able to read?”
d. Giving the patient some printed materials and saying, “After you have read this, I’ll ask you some questions about what’s in them, to see if you’ve learned it.”
B
Graduation from high school does not guarantee reading comprehension. Actually, reading allows the nurse to know if the patient can read as well as comprehend.
A patient being assessed for preoperative learning needs says his mother had the same surgery by the same surgeon 3 years ago. The nurse should design the patient education plan to:
a. do a brief review of the preoperative patient education, because the patient is already familiar with the procedure.
b. teach thoroughly as the procedure may have changed.
c. simply give the patient a written list of preoperative instructions.
d. explore with the patient what he knows about the proposed surgery and add or correct where necessary.
D
Assessing a patient’s experience and knowledge allows the nurse to tailor patient education to the individual. The nurse should never assume that a patient “knows” what he is supposed to know and that teaching again what the patient already knows is a waste of time or insults the patient’s intelligence and experience. Giving a list of preoperative instructions is simply impossible.
The nurse is aware that the knowledge deficit of a postpartum patient with her first child that can be safely addressed by the community nurse after discharge is:
a. weaning the child from breastfeeding.
b. care of the patient’s surgical incision.
c. feeding the baby by breast or bottle.
d. recognizing signs or symptoms of infection.
A
Priority patient education needs prior to discharge are those that have to do with physiological or safety needs. Thus feeding the baby, care of the incision (prevent infection), and recognition of signs that affect safety must be addressed before discharge. Weaning will not occur until much later and can be addressed safely by the home health nurse.
The nurse evaluates the effectiveness of patient education relative to how to use an eye shield after eye surgery is to:
a. have the patient tell the nurse what he is going to do.
b. have the patient demonstrate that he can secure the eye shield.
c. ask the patient if he has any questions related to the use of the shield.
d. call the patient at home in 3 days and ask if he has been wearing the shield.
B
A return demonstration and explanation by the patient will evaluate whether the patient’s learning needs are met. Having the patient describe the process and ask questions might be helpful but does not show that the patient can place the shield correctly (a psychomotor skill). Evaluation of patient education should be done to allow time to revise the education plan if the patient is unable to meet the behavioral objectives. Calling after discharge is too late to correct problems.
The nurse will choose the best time to continue postoperative education regarding wound care and dressings, which would be:
a. immediately after the patient has been medicated for pain.
b. just before the patient is discharged, so the information is current.
c. when the patient is comfortable and receptive to the patient education.
d. the last thing in the evening, after visitors have left, before bedtime.
C
A patient who is in pain, sedated from pain medication, or fatigued at the end of the day after visitors leave will not be receptive to patient education. Patient education should begin before discharge to improve learning.