Caring exam 1-3

Which diagnosis below is NANDA-I approved? a. Sleep disorder b. Acute pain c. Sore throat d. High blood pressure

ANS: B Acute pain is the only NANDA-I-approved diagnosis listed. Sleep disorder and high blood pressure (hypertension) are medical diagnoses, and sore throat is a subjective complaint.

The nurse is attempting to prompt the patient to elaborate on her complaints of daytime fatigue. Which question should the nurse ask? a. "Is there anything that you are stressed about right now?" b. "What reasons do you think are contributing to your fatigue?" c. "What are your normal work hours?" d. "Are you sleeping 8 hours a night?"

ANS: B The question asking the patient what factors might be contributing to her fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal works hours will elicit a matter-of-fact response and does not prompt the patient to elaborate on her complaints of daytime fatigue nor ask about the contributing reasons.

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function labs are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation

ANS: A After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions. The evaluation phase involves determining whether the interventions were effective.

Which scenario best illustrates the use of data validation when making an independent nursing clinical decision? a. The nurse determines that she needs to remove a wound dressing when the patient reveals the time of the last dressing change, and she notices that the present dressing is saturated with fresh and old blood. b. The nurse administers pain medicine due at 1700 at 1600 because the patient complains of increased pain. c. The nurse removes a leg cast when the patient complains of decreased mobility. d. The nurse administers potassium when a patient complains of leg cramps.

ANS: A Changing the wound dressing is the only independent nursing action given. The nurse validates what the patient says with her own observation of the dressing. This option is the only assessment option as well that involves data validation. Administering pain medicine or potassium and removing a leg cast are examples of nursing interventions.

Which of these findings, when evaluating another nurse developing a plan of care, should the charge nurse recognize as a source of diagnostic error? a. Assigning diagnoses while completing the database b. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous antibiotics c. Completing the interview before performing the physical examination d. Documenting cultural and religious preferences

ANS: A Diagnosis should take place only after the database is completed. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview before the physical examination is appropriate. The patient's cultural background and developmental stage are important to include in a patient database.

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as a. Diagnostic reasoning. b. Defining characteristics. c. Assigning clinical criteria. d. Diagnostic labeling.

ANS: A Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Clinical criteria are objective signs or subjective symptoms. Diagnostic labeling is simply assigning the diagnosis.

The nurse is assessing a patient with a hearing deficit. Where is the best place to conduct this interview? a. The patient's room with the door closed b. The waiting area with the television turned off c. The patient's room before administration of pain medication d. The patient's room while the occupational therapist is working on leg exercises

ANS: A Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patient's room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone's ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview. Assessing a patient while another member of the health care team is working would be distracting and is not the best time for assessment to take place.

After completing a thorough assessment to formulate a patient database, the nurse should proceed to which step of the nursing process? a. Diagnosis b. Planning c. Implementation d. Evaluation

ANS: A Following assessment, analyzing the data and assigning a nursing diagnosis is the next step in the nursing process. Planning occurs after assigning the problem to establish goals. Nursing interventions are carried out in the implementation phase. The evaluation phase occurs after intervening to establish whether interventions have been effective in helping the patient meet his/her goals.

Subjective data include a. A patient's feelings, perceptions, and reported symptoms. b. A description of the patient's behavior. c. Observations of a patient's health status. d. Measurements of a patient's health status.

ANS: A Subjective data include the patient's feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition. Data sometimes reflect physiological changes, which you further explore through objective data collection. Describing the patient's behavior, observations made, and measurements of a patient's health status are all examples of objective data.

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse a. Completes a comprehensive database. b. Identifies pertinent nursing diagnoses. c. Intervenes based on patient goals and priorities of care. d. Determines whether outcomes have been achieved.

ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database. Identifying nursing diagnoses occurs during the diagnosis phase. The nurse carries out interventions during the implementation phase, and determining whether outcomes have been achieved takes place during the evaluation phase of the nursing process.

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The nursing assistant states she was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process? a. Assessment b. Diagnosis c. Planning d. Evaluation

ANS: A The diagnostic process should flow from the assessment. Without a thorough assessment, the nurse is more apt to misdiagnose a patient's responses, and the wrong interventions may be implemented. In this case, the nurse should have assessed the patient's blood pressure before giving the medication. The nurse could have prevented the patient's untoward reaction if the low blood pressure was assessed first. The nurse could have notified the physician, held the medication, or taken other steps to prevent an adverse reaction.

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a. "Do you feel like you need to use the bathroom?" b. "Are you able to walk to the bathroom by yourself?" c. "When was the last time you took your medicine?" d. "Do you have a safety rail in your bathroom at home?"

ANS: A The nurse must establish that the patient feels the urge and is unable to void. The question "Do you feel like you need to use the bathroom?" is the most appropriate to ask. This question can be answered without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis.

Which of the following are examples of subjective data? (Select all that apply.) a. Patient describing excitement about discharge b. Patient's wound appearance c. Patient's expression of fear regarding upcoming surgery d. Patient pacing the floor while awaiting test results e. Patient's temperature

ANS: A, C Subjective data include patient's feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient's health status. In this question, the appearance of the wound and the patient's temperature are objective data. Pacing is an observable patient behavior and is also considered objective data.

After setting the agenda during a patient-centered interview, what will the nurse do? a. Begin by introducing himself. b. Conduct a nursing health history. c. Explain that the interview will be over in a few more minutes. d. Tell the patient that he'll be back to administer medications in 1 hour.

ANS: B After setting the agenda, the nurse should conduct the actual interview and proceed with data collection. Setting the stage begins with introductions and takes place before an agenda is set. The termination phase includes telling the patient when the interview is nearing an end. Telling the patient medications will be given later when the nurse returns would typically take place during the termination phase of the interview.

12. Which of these selections is an etiology for Acute pain versus a defining characteristic? a. Complaint of pain as a 7 on a 0 to 10 scale b. Disruption of tissue integrity c. Dull headache d. Discomfort while changing position

ANS: B Disruption of tissue integrity is a possible cause or etiology of pain. A complaint of pain, headache, and discomfort are examples of things a patient might say (subjective data or defining characteristics) that lead a nurse to select Acute pain as a nursing diagnosis.

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. This nurse should a. Notify the physician to recommend a psychological evaluation. b. Consider cultural differences during this assessment. c. Ask the patient to make eye contact to determine her affect. d. Continue with the interview and document that the patient is depressed.

ANS: B Older women of Asian descent consider it rude to look an authority figure, such as a health care professional, in the eye. This nurse needs to practice culturally competent care and appreciate the cultural differences. Assuming that the patient is depressed or in need of a psychological evaluation is inappropriate.

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to a. Religious preferences. b. Decreased oral intake. c. Weight loss. d. Race and ethnicity.

ANS: B The cause or related to factor in this case is the patient's lack of oral intake due to lack of appropriate food choices. The patient's religious preferences, race, and ethnicity did not cause his weight loss. Ultimately, the lack of food choices and his decreased intake caused him to lose weight. Weight loss is a sign of imbalanced nutrition, not a cause. The weight loss would be noticed during the assessment and would lead to the nursing diagnosis, not in reverse order.

The charge nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic statement? a. Nursing diagnosis b. Etiology c. Patient chief complaint d. Defining characteristic

ANS: B The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. The patient's chief complaint is what the patient subjectively states is the problem. No subjective data are included in the diagnostic statement. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.

Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. "What types of foods do you think caused your upset stomach?" b. "How many bowel movements a day have you had?" c. "Are you able to get to the bathroom in time?" d. "What medications are you currently taking?"

ANS: B The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate. Asking the patient if he can make it to the bathroom will help to establish a diagnosis of incontinence, not diarrhea. The question is asking for the most appropriate statement to establish the diagnosis of Diarrhea.

While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first a. Leave the room and place the patient in isolation. b. Ask the patient to describe the type of reaction. c. Proceed to the termination phase of the interview. d. Document the latex allergy on the medication administration record.

ANS: B The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, complaints of shortness of breath when getting out of bed, and a productive cough. What are the defining characteristics for the diagnostic label of Activity intolerance? a. Decreased oral intake and decreased oxygen saturation when ambulating b. Decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed c. Complaints of shortness of breath when getting out of bed and a productive cough d. Productive cough and decreased oral intake

ANS: B The signs and symptoms, or defining characteristics, for the diagnosis Activity intolerance include decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the patient tolerates activity.

. One purpose of using standard formal nursing diagnoses in practice is to a. Form a language that can be encoded only by nurses. b. Distinguish the nurse's role from the physician's role. c. Allow for the communication of patient needs to assistive personnel. d. Help nurses focus on the scope of medical practice.

ANS: B The standard formal nursing diagnosis serves several purposes. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient's needs. Nursing diagnoses allow nurses to communicate what they do among themselves, with other health care professionals, and the public. Nursing diagnoses distinguish the nurse's role from that of the physician, and help nurses focus on the scope of nursing practice while fostering the development of nursing knowledge.

A nursing student is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which of the following actions made by the nursing student requires the nursing professor to intervene? a. The nursing student is making eye contact with the patient. b. The nursing student is speaking only to the patient's daughter. c. The nursing student nods periodically while the patient is speaking. d. The nursing student leans forward while talking with the patient.

ANS: B When assessing an older adult, nurses need to listen carefully and allow the patient to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the patient. Gathering data from family members is acceptable, but when a patient is able to interact, nurses need to include information from the older adult to complete the assessment.

Which of the following methods of data collection is utilized to establish a patient's nursing database? a. Reviewing the current literature to determine evidence-based nursing actions b. Orders for diagnostic and laboratory tests c. Physical examination d. Anticipated medications to be ordered

ANS: C A nursing database includes a physical examination. Orders are included in the order section of the patient's chart. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. Medication orders are usually written after the database is completed.

A nurse using the problem-oriented approach to data collection will first a. Complete an observational overview. b. Disregard cues and complete the database questions in chronological order. c. Focus on the patient's presenting situation. d. Make accurate interpretations of the data.

ANS: C A problem-oriented approach focuses on the patient's current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

To gather information about a patient's home and work surroundings, the nurse will need to utilize which method of data collection? a. Carefully review lab results. b. Conduct the physical assessment before collecting subjective information. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview

ANS: C A thorough nursing history includes information about the patient's home and work surroundings. Neither lab results nor the physical assessment will reveal much about the home and work surroundings. Collecting data is part of the working phase of the interview.

Identify the defining characteristics in the nursing diagnosis statement: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and complaints of abdominal pain. a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention d. Constipation

ANS: C Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation is the identified problem derived from the defining characteristics.

A patient expresses fear of going home and being alone. Her vital signs are stable and her incision is nearly completely healed. The nurse can infer from the subjective data that a. The patient can now perform the dressing changes herself. b. The patient can begin retaking all her previous medications. c. The patient is apprehensive about discharge. d. Surgery was not successful.

ANS: C Subjective data include expressions of fear of going home and being alone. These data indicate that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make? a. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c. Ask the nursing assistant to record the patient's vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress.

ANS: C The nurse should ask the nursing assistant to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia? a. Risk for infection related to lower lobe infiltrate b. Risk for deficient fluid volume related to dehydration c. Impaired gas exchange related to alveolar-capillary membrane changes d. Ineffective breathing pattern related to pneumonia

ANS: C The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factors lower lobe infiltrate, dehydration, and pneumonia are all medical diagnoses that the nurse cannot change. Lower lobe infiltrate is simply another term for pneumonia, a medical diagnosis. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address.

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. After analyzing these data, the nurse assigns which of the following nursing diagnoses? a. Adult failure to thrive b. Hypothermia c. Deficient fluid volume d. Nausea

ANS: C The signs the patient is exhibiting are consistent with dehydration. Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses.

A nurse comparing data validation and data interpretation correctly explains the difference with which statement? a. "Validation involves looking for patterns in professional standards." b. "Data interpretation involves discovering patterns in professional standards." c. "Validation involves comparing data with other sources for accuracy." d. "Data interpretation occurs before data validation."

ANS: C Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards.

A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and complains only of moderate discomfort. What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided? a. Posttrauma syndrome b. Constipation c. Urinary retention d. Acute pain

ANS: D Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is "Complains of moderate discomfort," which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in the provided information.

Components of a nursing health history include a. Current treatment orders. b. Nurse's concerns. c. Nurse's goals for the patient. d. Patient expectations.

ANS: D Components of a nursing health history include physical examination findings, patient expectations, environmental history, and diagnostic data. Current treatment orders are located under the Orders section in the patient's chart and are not a part of the nursing health history. Patient concerns, not nurse's concerns, are included in the database. Goals that are mutually established, not nurse's goals, are part of the nursing care plan.

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). The nurse is performing what type of assessment approach in this situation? a. Comprehensive assessment using Gordon's Functional Health Patterns b. General to specific assessment c. Activity-exercise pattern assessment d. Problem-oriented assessment

ANS: D The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand and performs a problem-oriented assessment. Utilizing Gordon's Functional Health Patterns is an example of a structured database-type assessment technique. The nurse in this question is performing a specific problem-oriented assessment approach. The nurse is not performing an activity-exercise pattern assessment in this question.

While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this complaint, thinking that no correlation has been noted between having a leg cast and developing restless sleep. A more theoretically sound approach would be to first a. Document the sleep patterns and complaint in the patient's chart. b. Tell the patient you are just focused on the leg right now. c. Explain that a more thorough assessment will be needed next shift. d. Ask the patient about his usual sleep patterns and the onset of having difficulty resting.

ANS: D The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient's complaints.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's best action in response to her observation? a. Proceed to the next patient's room while making rounds. b. Offer a massage because the patient does not want any more pain medicine. c. Administer the pain medication ordered for moderate to severe pain. d. Ask the patient about the facial grimacing with movement.

ANS: D The nurse needs to clarify what she observes with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he rates his pain level at 2 out of 10. The nurse should not administer medication for moderate to severe pain if it is not necessary.

A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis? a. Actual b. Risk c. Health promotion d. Wellness

ANS: D The patient's desire is to increase his specific level of wellness to a higher level of wellness. An actual diagnosis describes human responses to health conditions or life processes that exist. A risk diagnosis describes human responses to health conditions/life processes that will possibly develop. A health promotion diagnosis is a clinical judgment of a patient's motivation and desire to enhance well-being and does not require a current level of wellness.

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient. To avoid diagnostic error, what should the nurse do? a. Assign the nursing diagnosis of Decreased cardiac output. b. Ask the patient if he has a history of cardiac problems before assigning the diagnosis ofDecisional conflict. c. Check the previous shift's assessment and document what was noted on the last shift. d. Ask a more experienced nurse to listen also.

ANS: D The potential diagnostic error here is an error in data collection. If a new nurse is not comfortable with his/her assessment technique, he or she should ask another nurse to validate the findings. Diagnosing before validating assessment findings leads to the potential for error. Assessment data are not sufficient to assign the diagnoses Decreased cardiac output and Decisional conflict. Every nurse needs to perform his or her own assessment. A patient's status can change very rapidly. A nurse who copies the previous shift's assessment is not practicing according to standards of practice and is violating the code of ethics.