IMMOBILITY
A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:
WHAT IS
A nurse assesses a patient who comes to the pulmonary clinic. “I see that it’s been over 6 months since you’ve been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you’ve been in following his plan?” The nurse’s assessment covers which of Gordon’s functional health patterns?
WHAT IS
Health perception–health management pattern
The nursing diagnosis Impaired Parenting related to mother’s developmental delay is an example of a(n):
WHAT IS
Problem-focused nursing diagnosis.
The nurse administers a tube feeding via a patient’s nasogastric tube. This is an example of which of the following?
WHAT IS
Physical care technique
A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient’s nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, “This is so unfair.” An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first?
WHAT IS
A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient?
WHAT IS
The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient’s legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of:
WHAT IS
Clinical inference.
A nurse is reviewing a patient’s list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement?
WHAT IS
Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?
WHAT IS
Individualizing how to apply the clinical guideline for a patient
A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient?
WHAT IS
An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply.)
WHAT IS
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse’s cultural competence in assessing the patient’s health care problems?
WHAT IS
You have four children; do you have any concerns about going home and caring for them?”
A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient’s report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format?
WHAT IS
Before consulting with a physician about a female patient’s need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill?
WHAT IS
Cognitive
The nurse writes an expected outcome statement in measurable terms. An example is:
WHAT IS
A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken:
WHAT IS
A nurse is checking a patient’s intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing:
WHAT IS
Patient’s level of function.
A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons?
WHAT IS
Wrong diagnostic label
The nurse enters a patient’s room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse’s actions? (Select all that apply.)
WHAT IS
A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient’s colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply.)
WHAT IS
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply.)
WHAT IS
Which of the following examples are steps of nursing assessment? (Select all that apply.)
Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
WHAT IS
A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient’s bed and adjusts the room lighting to illuminate the work area. A patient care technician comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit?
WHAT IS
PATIENT
Which of the following factors does a nurse consider in setting priorities for a patient’s nursing diagnoses? (Select all that apply.)
WHAT IS