A
The nurse collects objective data and subjective data when conducting a patient assessment. Which of the following is an example of objective data?
A. The patient tells the nurse he feels anxious
B. The patient's wrists are swollen
C. The patient tells the nurse he feels nauseous
D. The patient expresses a pain score of 5 on a scale of 1-10
What is: B (The patient's wrists are swollen)
A nurse assesses a patient and conducts the following diagnosis: Impaired skin integrity, related to incontinence of bowel and bladder, as evidenced by a reddened perineum. Which phrase represents the etiology of this diagnostic statement?
A. Impaired skin integrity
B. Related to incontinence of bowel and bladder
C. As evidenced by
D. As evidenced by a reddened perineum
What is: B (Related to incontinence of bowel and bladder)
Once a nurse has collected and clustered all the data from the assessment and identified the problem, what’s the next step in the nursing process?
A. Evaluation
B. Diagnoses
C. Plan the care
D. Implementation
What is: C (Plan the care)
Question from article handout:
The ____ ____ is a systematic approach to identifying the care needs of healthy individuals (for) implementing, and evaluating nursing interventions.
What is: The nursing process
Question from the article handout:
On page 817, Third Year Student No. 5 said this…
What is: "I sometimes get confused whether I should evaluate the goal or the intervention."
A nurse is assessing a client who had been admitted to the emergency room an hour earlier. Initially, the client was complaining of mild abdominal pain and shortness of breath, but now the client states that the pain is more severe. This is an example of what type of data?
A. Primary objective data
B. Primary subjective data
C. Secondary objective data
D. Secondary subjective data
What is: B (Primary subjective data)
Question from the article handout:
Nursing students have difficulty establishing the ____ of _____ _____.
What is: The priority of nursing diagnoses
When planning nursing care for a client, objectives should be SMART. Which example best describes a correctly stated outcome goal written by the nurse?
A. The client will verbalize feelings about her diagnosis
B. The client will have improved physical mobility from the bed to the wheelchair and back within a week
C. The client will regain their former state of health by April 1
D. The client’s family will agree to the methods of treatment
What is: B (The client will have improved physical mobility from the bed to the wheelchair and back within a week)
What are some barriers that arise when implementing a plan? Select all that apply.
A. The patient is either not interested or not cooperating with the care plan
B. The patient struggles with understanding the care plan
C. The patient disagrees with the care plan
D. The client complies and cooperates with the nurses' plan of care
E. Performing actions that have positive outcomes
What is: A, B, & C
(A. The patient is either not interested or not cooperating with the care plan B. The patient struggles with understanding the care plan C. The patient disagrees with the care plan)
A nurse is getting ready to discharge a patient to home who has an impaired gas exchange. Before discontinuing the patient’s plan of care, what does the nurse need to do?
A. Establish whether the patient has a follow-up appointment
B. Ensure that patient has everything they need
C. Determine whether patient has a transportation to home
D. Evaluate whether patient goals and outcomes have been met
What is: D (Evaluate whether patient goals and outcomes have been met)
A nurse is assessing a client who has recently had coronary artery bypass surgery after being admitted for congestive heart failure. What type of assessment is the nurse conducting?
A. Initial
B. Focused
C. Time-lapsed
D. Emergency
What is: B (Focused)
An older adult client, Mr. Jones, is being cared for at a long term care facility. He had knee surgery two weeks ago related to severe arthritis. What is an appropriate nursing diagnosis for Mr. Jones?
A. Impaired skin integrity r/t limited mobility aeb knee surgery
B. Risk for falls r/t severe arthritis
C. Risk for impaired skin integrity r/t limited mobility
D. Impaired mobility r/t severe arthritis aeb not being able to ambulate
What is: C (Risk for impaired skin integrity r/t limited mobility)
A nurse is creating a care plan for a client who has a nursing diagnosis of Self Care Deficit: Dressing and Grooming. During the initial assessment, the client expressed frustration with their handicap. Which nursing intervention is MOST appropriate to be added to the care plan based on the client’s frustration?
A. Provide privacy during dressing
B. Suggest elastic shoes or shoes with Velcro rather than shoes with laces
C. Place the client in a stationary chair while dressing or grooming
D. Encourage the use of tighter clothing
What is: B (Suggest elastic shoes or shoes with Velcro rather than shoes with laces)
Which of these is an example of a nurse-initiated action during the implementation phase?
A. Diagnosing a patient with reddened sacrum with risk of impaired skin integrity
B. Administering 0.25 mg of digoxin to a patient with a heart arrhythmia
C. Adjusting the posture of a patient’s bed so they are sitting in an upright position while taking medication
D. Assessing a newly admitted patient for allergies
What is: C (Adjusting the posture of a patient’s bed so they are sitting in an upright position while taking medication)
A nurse is evaluating a patient who received a new treatment after the onset of a disease. What action should the nurse take?
A. Evaluate health problems
B. Evaluate the potential for terminating the health care relationship
C. Evaluate the success of the patient
D. Evaluate the data and health status as it relates to the goals set in the assessment
What is: D (Evaluate the data and health status as it relates to the goals set in the assessment)