114 Chapter 5

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the client has the opportunity for an enhanced health state: wellness diagnosis risk diagnosis actual diagnosis medical diagnosis

A

A community health nurse provides information to a client with newly diagnosed multiple sclerosis for a support group at the local hospital for clients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following? A referral A consultation Conferring Reporting

A

A client has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the client's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered? Collaborative problem Nursing problem Physician problem Problem with compliance

A

A quality control nurse is reviewing client satisfaction survey comments. The nurse is most likely to read which positive remark? "Staff nurses report at the bedside so I can hear the information." "I felt safe because staff nurses made daily rounds." "The nurses kept the room doors open at all times." "Most nurses asked me yes or no questions when seeking information."

A

Shortly after a client departs the office following a routine physical, the nurse notices in her chart that the client has gained 10 lb in the past year and is now overweight. Although the client is generally healthy, the nurse realizes that if this trend continues, the overweight will begin to affect the client's health. The nurse makes a note to discuss it with the client at the next visit. Which nursing diagnosis would be most appropriate for this client? Imbalanced nutrition: less than body requirements Risk for imbalanced nutrition: more than body requirements Readiness for enhanced nutrition Imbalanced nutrition: more than body requirements

A

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a client who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered? Actual Nursing Diagnosis Risk Nursing Diagnosis Wellness Nursing Diagnosis Rule Out Nursing Diagnosis

A

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a client who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered? Actual Nursing Diagnosis Risk Nursing Diagnosis Wellness Nursing Diagnosis Rule Out Nursing Diagnosis

A

The nurse has clustered assessment data on a client with cirrhosis of the liver that has altered mental status due to the accumulation of ammonia toxins. What type of priority nursing diagnosis would be indicated for this client? Actual nursing diagnosis. A wellness nursing diagnosis. A risk nursing diagnosis. A stated nursing diagnosis.

A

The nurse has completed an assessment on a new client. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to discuss the plan with the client get physician orders to implement the plan set goals for the client document the plan on the cardex for all to utilize

A

The nurse is caring for an adult client who tells the nurse "For weeks now, I've been so tired. I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is fatigue related to excessive noise levels as manifested by the client's statements of chronic fatigue. sleep deprivation related to noisy neighborhoods and inability to sleep. chronic fatigue syndrome related to excessive levels of noise in the neighborhood. readiness for enhanced sleep related to control of noise level in the home.

A

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client? Weight gain of 3 pounds (1.5 kilograms) over 1-2 days Ineffective health maintenance related to having last mammogram 2 years ago Knowledge deficit related to lack of information regarding low-sodium diet Anxiety related to ineffective coping during hospitalization

A

The nurse is developing goals after completing the assessment of a newly admitted medical client. The nurse would document the goals under which part of the nursing process? planning diagnosis implementation Evaluation

A

The nurse is developing goals after completing the assessment of a newly admitted medical client. The nurse would document the goals under which part of the nursing process? planning diagnosis implementation Evaluation

A

The nursing student demonstrates a need for further teaching when she states which of the following? Patients do not need to understand their problems. If a client is incoherent, a family member can help validate the problem. The client's diagnosis needs to be verified with the client and other health care workers caring for the client. Validation is also important for a client who has a collaborative problem.

A

What can the nurse use to learn new information and add to their knowledge base? Clinical experience. Past experience of other nurses. Reading a medical-surgical textbook. Doing several written care plans

A

What is pivotal to determining how to move from each client problem to its goals? Clinical reasoning process Positive interpretation of the client's history Process in collecting physical data Evaluation as an accurate historian of the client

A

When formulating a nursing diagnosis, the format that is most useful to clearly document the client's problem is NANDA label (for problem) + related to + etiology + AMB (as manifested by) + defining characteristics. NANDA label + defining characteristics + AMB (as manifested by) the etiology. NANDA label + definition + defining characteristics + AMB (as manifested by) etiology. NANDA label + definition + etiology + AMB (as manifested by) + defining characteristics.

A

What should the nurse do prior to analyzing data collected on a client with Addison's disease? (Select all that apply) Collect and organize assessment data. Develop outcome criteria in order to meet the goals of the client. Validate data. Document data. Determine what steps will be taken in implementing outcomes.

A, C, D,

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.) Be nonjudgmental and keep an open mind. Only validate data that you see, not what the client tells you. Use rationale to support opinions or decisions. Do not reflect on your thoughts, just make a decision. Acquire an adequate knowledge base that continues to build.

A, C, E

A client comes to the clinic for a yearly physical examination. The assessment reveals multiple lesions on the face, neck, arms, and legs. The client appears upset, starts to cry when questioned about the skin abnormalities, and asks the nurse if the problem is skin cancer. What would be the best nursing diagnosis for this client? Risk for anxiety related to lesions on body Anxiety related to lesions on body Readiness for enhanced emotional well-being Readiness for enhanced anxiety

B

A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process? assessment implementation evaluation Diagnosis

B

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission? SBAR communication Medication reconciliation High-alert labeling Client teaching of side effects

B

A client with diabetes is admitted to the medical unit for the fifth time in 6 months because of elevated blood glucose level. The nurse caring for the client immediately states, "I knew she would be back. It was just a matter of time. She is so noncompliant." This is an example of which of the following? clustering unrelated clues not hypothesizing several diagnoses taking too much time to process data learning what is going on with the client

B

A hospitalized client reports pain 10/10 one hour after receiving a dose of intravenous morphine sulfate. The next dose is not due for over an hour. What is the nurse's best action? Administer another dose of morphine early. Notify the healthcare provider. Tell the client he/she can not have anymore pain medication. Document the pain assessment findings and reassess in 30 minutes.

B

A nurse assesses an older adult client with confusion. When collecting clinical information from the client, which factor is the most important for the nurse to consider? The client will have a long problems list. The quality of the data may be low. Clinical information can be interpreted subjectively. The client will have multi-system problems.

B

A nurse is working with a client who has a history of chronic obstructive pulmonary disease (COPD). While bathing the client, the nurse senses that something is not quite right and takes the client's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following? scientific rationale intuition knowledge prior history

B

The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis? history of illness status of breath sounds rash on face List of present medications

B

The nurse has learned that after completing the assessment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do? Collect the data Analyze the data Validate the data Organize the data

B

The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following? reliable data too many or too few data valid data cues available to support the diagnosis

B

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response? "Call the healthcare provider to change the admitting diagnosis." "Tell the client that insurance will not pay for observation." "It's acceptable for a client to be admitted for observation." "Refuse to admit the client without a proper medical diagnosis."

C

A client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse? Collect client's health history. Reconcile current medications. Place on cardiac monitor. Record the client's allergies.

C

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information? Collaborative problem Risk diagnosis Wellness diagnosis Referral to dietitian

C

A nurse interacts with four different clients one afternoon at the health clinic. The nurse is able to directly assist three of them and makes a referral for the fourth. Which of the following clients should the nurse refer to another professional? A 12-year-old boy who is having trouble self-injecting insulin A young pregnant woman who needs to know what prenatal vitamins she should be taking An elderly woman who needs daily therapy sessions to help her walk again after a hip fracture A preschooler who needs a flu vaccine

C

A nursing student demonstrates understanding of the different types of nursing diagnoses when choosing which of the following to be an actual diagnosis? risk for impaired skin integrity readiness for enhanced skin integrity impaired skin integrity risk for infection

C

After collecting subjective and objective data for the admission database, what is the nurse's next action? Set nurse-driven goals for the client. Evaluate effectiveness of nursing actions. Validate the client's identified problems. Discuss the action plan with the client.

C

After collecting subjective and objective data for the admission database, what is the nurse's next action? Set nurse-driven goals for the client. Evaluate effectiveness of nursing actions. Validate the client's identified problems. Discuss the action plan with the client.

C

After collecting subjective and objective data for the admission database, what is the nurse's next action? Set nurse-driven goals for the client. Evaluate effectiveness of nursing actions. Validate the client's identified problems. Discuss the action plan with the client.

C

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action? Hang the IV solution the client's assigned nurse left on the pole. Obtain an IV bag of the current solution and hang it. Review the client's prescribed medication orders. Discontinue the current solution and disconnect it from the client.

C

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action? Hang the IV solution the client's assigned nurse left on the pole. Obtain an IV bag of the current solution and hang it. Review the client's prescribed medication orders. Discontinue the current solution and disconnect it from the client.

C

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan? Discuss the plan of care with all of the health care providers involved. Share the assessment and plan with the client's primary health care provider. Ask the client for opinions and willingness to proceed with the interventions. Identify the needs of the client's family in relation to the priority problem.

C

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step? The nurse must be an expert in her field in order to interpret data accurately. Final opinions or judgements must be made rapidly. Diagnostic reasoning skills are required to interpret data accurately. Opinions and comments are not relevant in making accurate interpretations of data.

C

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following? nursing intervention nursing rationale nursing diagnosis data organization

C

client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse? Collect client's health history. Reconcile current medications. Place on cardiac monitor. Record the client's allergies.

C

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse? Give the client a printed diet. Inform the client that they can look up a diabetic diet on the internet. Call the physician and ask them to come and talk with the client about their diet. Make a referral to the dietician.

D

A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to formulate too many nursing diagnoses for the client and family. include too much data about the client in the history. obtain an insufficient number of cues and cluster patterns. quickly make a diagnosis without hypothesizing several diagnoses.

D

Shortly after a client departs the office following a routine physical, the nurse notices in her chart that the client has gained 10 lb in the past year and is now overweight. Although the client is generally healthy, the nurse realizes that if this trend continues, the overweight will begin to affect the client's health. The nurse makes a note to discuss it with the client at the next visit. Which nursing diagnosis would be most appropriate for this client? Imbalanced nutrition: less than body requirements Risk for imbalanced nutrition: more than body requirements Readiness for enhanced nutrition Imbalanced nutrition: more than body requirements

D

The RN working on a surgical unit should be prepared to question which of these orders? Check intracranial pressure. Change a central line dressing. Administer a narcotic infusion. Reapply a staple in an incision.

D

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning. knowledge experience time practice seeing things as only right or wrong

E