Care Management BSN Exam 2

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?

"I get out of breath when I walk a few steps."

A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem?

"I think fatigue is a problem for you. Do you agree?"

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment?

Focused Assessment

Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview?

Tell me more about what caused your pain.

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?

Focused

Which intervention does the nurse recognize as a collaborative intervention?

Teach the client how to walk with a three point crutch gait.

A male client is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: "After attending an educational session, client will demonstrate correct technique for applying his prosthesis." Which of this client's following statements would signal a need to amend this outcome?

"Im not interested one bit in wearing an artificial hand."

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual?

"Mr. Koeppe, tell me what you do to take care of yourself."

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?

"Unable to palpate femoral pulse in left leg."

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct?

"ineffective airway clearance r/t thick mucus".

Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning?

"what problems require my immediate attention or that of the team?"

Which of the following examples of client data needs to be validated? Select all that apply.

1. A client has trouble reading an informed consent, but states he does not need glasses. 2. An elderly client explains that the black and blue marks on his arms and legs are due to a fall.

In which of the following clients has the order of priorities for nursing diagnoses changed? Select all that apply.

1. A client in a long term care facility who had a stroke 2. A client who insists on using the bathroom instead of a bedpan 3. A client who appear confused after taking pain medication

The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply.

1. Bowel Incontinence 2. Impaired Swallowing 3. Impaired Physical Mobility

Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply.

1. Diet and Exercise 2. Developmental stage 3. Need for nursing

Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply.

1. State Nurse Practice Acts 2. The joint commission 3. The agency for health care research and quality

Which of the following is a correctly written client goal? Select all that apply.

1. The client will identify five low-sodium foods by Oct. 9 2. The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. 3.The client will eat at least 75% of all meals by May 5.

Which of the following data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply.

1. The client's chemo cause nausea and loss of appetite. 2. The pt has been experiencing fatigue in recent weeks.

Which of the following statements accurately describes the impact on nursing of using NIC/NOC standardized languages? Select all that apply.

1. They demonstrate the impact that nurses have on the system of health care delivery. 2. They standardize and define the knowledge base for nursing curricula and practice. 3. They enable researchers to examine the effectiveness and cost of nursing care.

A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply.

1. Using the nursing process to diagnose a blocked airway. 2. Interviewing privately a client suspect of being a victim of abuse. 3. Checking w the family about the data supplied by a client suffering from Dementia.

Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis?

A cluster of several significant cues of data that suggest a particular health problem.

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?

Actual Nursing Diagnosis

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention?

Administer oxygen 4L/min per nasal cavity

The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse recognizes this information is an example of what?

An inference

Which of the following groups of terms best describes a nurse-initiated intervention?

Autonomous, clinical judgement, client outcomes

After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data

Ausculation of the lungs

A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis?

Appendicitis

Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?

Assessment date about the client should be collected continuously

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using which of the following?

Assessment skills

A nurse is discharging a client from the hospital. When should discharge planning be initiated?

At the time of admission to an acute health care setting

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?

Focused Assessment

The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?

Clarify discrepancies of assessment date w the client.

The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal?

Client returns home verbalizing an understanding of contributing factors, medications, and signs & symptoms of an asthma attack.

Which of the following illustrates a common error when writing client outcomes?

Client will be less anxious and fearful before and after surgery

A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?

Client's wife

What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system?

Clinical pathways

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ...

Clustering

A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client's physiologic response. This action is known as a:

Collaborative problem.

Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client's situation?

Concept map care plan

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond?

Do you take anything to help your constipation?

A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern?

Disturbed body image

A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?

Disturbed body image r/t incision scar

A nurse writes the following nursing diagnosis for a client with Alzheimer's disease: Disturbed Thought Processes related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement?

Disturbed thought process

A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation?

Encourage the nurse to independently observe the same situation w a peer, validate the date, and discuss the situation afterward.

In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is "presence of large scar over left side of face"?

Etiology

What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?

Etiology of the problem

What common problem is related to outcome identification and planning?

Failing to involve the client in the planning process

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?

Hierarchy Human Needs (MASLOW) Model

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis?

Impaired urinary elimination

Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses?

Improving communication among nurses

The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made?

Included more than one client behavior in the outcome.

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?

Ineffective airway clearance as evidenced by inability to clear secretions.

The nurse observes the client as he walks into the room. What information will this provide the nurse?

Information regarding the client's gait

A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?

Is written as a two-part statement

Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process?

Keep an open mind and trust your intuition when formulating diagnoses.

The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?

Measure the client's oral temperature.

Which of the following client care concerns is clearly a nursing responsibility?

Monitoring health status changes

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data?

Nausea

Of the following information collected during a nursing assessment, which are subjective data?

Nausea, abdominal Pain

A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing good health habits. What conclusion did the nurse reach after interpreting and analyzing the data?

No problem.

What is the nurse accountable for, according to the state nurse practice act?

Nursing Diagnoses

A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the baby's strengths?

Nurturing is a strength for developing infants.

Which of the following is an example of a well-stated nursing intervention?

Offer client 100mL of water every 2 hours while awake

Which of the following outcomes is correctly written?

On discharge, the client will be able to list five symptoms of infection.

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs?

Physiologic

Which of the following is a correct guideline to follow when composing a nursing diagnosis statement?

Place defining characteristics after the etiology and link them by the phrase "as evidenced by".

A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?

Possible problem

A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he "can't live with this fear." Which of the following diagnoses for this client is correctly written?

Post-trauma syndrome r/t being attacked

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis?

Presuming to know the factors that contribute to the problem

The nurse is planning the care of a male client who is receiving treatment for acute renal failure and who has begun dialysis three times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of his arteriovenous fistula." This outcome is classified as which of the following?

Psychomotor

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation?

Record an evaluative statement in the client's plan of care.

Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following?

Reduction in the time spent on care planning

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?

Resolve the client's anxiety

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure?

Risk for body image disturbance

A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make?

Safety of the immediate environment

After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used?

Selecting nursing interventions to meet expected outcomes

A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself?

Sitting at a 45 degree angle to the bed

The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following?

The client is more vulnerable to certain problems than other individuals would be.

Which of the following is a correctly written client goal?

The client will ambulate 10 feet with a walker by Oct 12

Which of the following client outcomes best describes the parameters for achieving the outcome?

The client will consume a 2400 calorie diet with three meals and two snacks starting tomorrow

An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first?

The client's airway should be assessed

A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase "Disturbed Self-Esteem" identify?

The health state or problem of the client

A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority?

The need to feel good about oneself

While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing?

The nurse asking if the client is having pain.

Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes?

The nurse expresses the client outcome as a nursing intervention

Which of the following reflects the diagnosis phase?

The nurse identifies that the client does not tolerate activity.

Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client?

The nurse must decide if she is qualified to make a nursing diagnosis and will accept responsibility for treating it.

A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future?

The nurse should practice interviewing strategies

What is the focus of a diagnostic statement for a collaborative problem?

The potential complication

During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived?

The problem statement

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the SECOND assessment?

Time-Lapsed

What is the primary purpose of the outcome identification and planning step of the nursing process?

To design a plan of care for and with the client

A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?

To encourage the client and family to be involved

The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?

To establish a database to identify problems & strengths

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status?

To identify a life-threatening problem

In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?

To identify etiologies of health problems

What is the primary purpose of validation as part of an assessment?

To plan appropriate nursing care

When documenting subjective data, the nurse should do which of the following?

Use the client's own words place in quotation marks.

The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis?

Validate the nursing diagnosis

Which of the following questions or statements would be an appropriate termination of the health history interview?

can you think of anything else you would like to tell me?