Family Dynamics and Nursing Assessment
Which factor is recognized as a significant influence on family forms and their impact on health?
B. Domestic violence is listed as a critical factor influencing family forms and health.
B. NANDA-I categorizes diagnoses into these three types.
B. Developmental stages create specific safety risks.
Which factor can cause a variation in a patient's blood pressure?
B. Stress, smoking, and activity are known factors influencing BP.
The nurse has implemented a new evidence-based dressing change protocol on the unit. Which step of the EBP process should the nurse perform next?
B. After integrating/implementing a change, the nurse must evaluate the outcomes to determine effectiveness.
B. Resiliency is the ability of a family to cope with both expected and unexpected stressors
B. A risk diagnosis identifies a vulnerability to developing a problem
A 79-year-old resident wanders at night and has fallen before. What is the most appropriate intervention?
B. Assigning a room near the nursing station allows for closer observation.
What is the correct way to describe a pulse that is difficult to palpate?
C. A pulse that is hard to feel is described as weak.
A hospital committee is reviewing local work processes to improve patient outcomes and health system efficiency. This process is known as:
C. Performance improvement focuses on improving local work processes and outcomes; results are usually not generalizable.
B. Subjective data is what the patient says or feels, such as their description of pain.
B. Clustering involves finding patterns in assessment data to formulate a diagnosis.
B. Hand hygiene is a primary implementation to control the transmission of infection.
Where is the "Point of Maximal Impact" (PMI) of the heart located?
B. Fifth intercostal space, left midclavicular line.
A nurse uses a visual tool to link a patient’s various health problems and nursing interventions together. This tool is called:
B. Concept mapping is used to organize and link information about a patient’s condition.
C. The orientation phase includes setting the agenda and starting the relationship.
If a patient's goal was not achieved, what is the nurse's next step?
B. If goals are not achieved, the nurse must determine what further steps are needed.
When should a nurse use soap and water instead of alcohol-based hand rub?
B. Soap and water are mandatory for visible soil or C. diff.
When assessing an older adult, what should the nurse offer to ensure their comfort?
B. Nurses should offer rest periods, especially for those who are older or ill.
A nurse is caring for a patient who reports sudden chest pain. The nurse immediately checks the patient’s vital signs and calls for an EKG. This is an example of which specific critical thinking competency?
A. Diagnostic reasoning involves analyzing cues to make a clinical judgment about a patient's health status.
What are the two essential steps of the nursing assessment process?
B. Assessment involves collecting information and then interpreting and validating that data.
Which element is essential for the nurse to apply during evaluation?
B. Evaluation requires applying critical thinking attitudes and intellectual standards.
Which of the following is a symptom of a systemic infection rather than a localized one?
B. Fever and generalized symptoms indicate a systemic infection.
When assessing an older adult, what should the nurse offer to ensure their comfort?
B. Nurses should offer rest periods, especially for those who are older or ill.
A new graduate nurse follows the hospital’s procedure manual step-by-step without deviation when performing a dressing change. At which level of critical thinking is this nurse operating?
A. Basic critical thinking involves following rules or procedures concretely.