FCCA 1 #1

A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instructional?

"After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable." After assessing the client, always examine the defining characteristics in your database carefully to support or eliminate a nursing diagnosis. Although the other options are correct, they do not provide as concise an explanation as "after assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable."

Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor?

"All clients will tell you when they need pain medication." Nurses who are not familiar with how a particular culture or developmental group expresses pain can often miss the objective signs or assume there is a lack of pain when familiar signs are absent. Being culturally & developmentally aware & sensitive will improve your accuracy in making nursing diagnoses. "All clients will tell you when they need pain medication" is the correct answer.

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is the following:

"Apply two 4 × 4 dry gauze dressing pads tid." "Apply two 4 × 4 dry gauze dressing pads tid." is the most appropriate. It identifies the action, frequency, quantity, & method. "Take vital signs." fails to indicate the frequency & fails to completely indicate nursing actions (e.g., what parameters are used to notify the physician). "Refer client to a therapist." fails to completely indicate nursing interventions (e.g., what type of therapist). "Turn client as needed while in bed." fails to state an accurate frequency or precisely indicate the nursing actions.

Which of the following questions will provide the nurse with the best understanding of a terminally ill client's spiritual needs?

"Are there any spiritual needs you have that I may help with?" In asking if there are any spiritual needs that the client might need help with, you collect information about life goals, values, & religious practices; part of a client's spirituality. This option provides the client with an opportunity to discuss his needs if indeed he has any while reaffirming the nurse's wish to meet his needs. Asking simply is a client has a religious preference is a closed-ended question & provides little encouragement to discuss spiritual needs. While asking if the client has given thought to their spiritual needs provides an opportunity to discuss any client needs, it does not allow for the nurse to be of help with attending to these needs. Inquiring about a particular clergy is a closed-ended question & provides little encouragement to discuss spiritual needs.

Which of the following nursing statements is the best example of the communication tool of clarification?

"Can you give me an example?" To check whether understanding is accurate, ask the other person to rephrase it, explain further, or give an example of what the person means. By asking for an example, the nurse is best able to determine the meaning of the client's statement. The other options either simply ask the client to repeat the statement or state that the nurse needs further information.

The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain?

"Can you rate your pain using the pain scale that we've discussed?" Once you complete the assessment, you thoroughly analyze the extent & nature of the client's problem so you are able to later develop a care plan. Identifying the degree of pain the client is experiencing has priority over the other options. While this option is an appropriate pain assessment question, it is more directed towards identifying contributing factors than the characteristics (nature) of the pain. While this option is an appropriate pain assessment question regarding the nature of the pain, it does not have priority over the degree of pain because that represents an issue that requires immediate intervention. While this option is an appropriate pain assessment question, it is more directed towards identifying effective self-treatment rather than the characteristics (nature) of the pain.

Which of the following statements made by a nurse reflects a need for further instruction regarding communicating with the older adult client?

"Children & the elderly have the same communication barriers." Even though some older adults have communication barriers, you need to communicate with them on an adult level & avoid patronizing or speaking in a condescending manner. Older adults do not necessarily have the same barriers as children. The remaining options reflect interventions and/or statements that are not inappropriate & so do not require further instructions.

The client is able to ambulate without signs or symptoms of shortness of breath. Which statement by the nurse is the best example of an objective evaluation of the client's goal attainment?

"Client has no evidence of respiratory distress when ambulating." "Client has no evidence of respiratory distress when ambulating" is the best example of an objective evaluation of the client's goal attainment. It uses the same evaluative measures gathered during assessment & clearly describes objective data. "Client has no pain after ambulating" does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not pain. If the client's pain level were going to be used as an evaluative measure, it would be optimal to have the client report the pain using a pain scale to make it more measurable for comparison. "Client has no manifestations of nausea while up in hall" is not the best example of an objective evaluation of the client's goal attainment. It does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not nausea. Also, nausea is more subjective. "Client walked well & did not have any problem when up" is not the best example of an objective evaluation. It includes the nurse's interpretation rather than documentation of objective data.

The nurse writes the following goal for a client who is hypertensive: "Client will maintain a blood pressure within acceptable limits." Which of the following would be the most appropriate outcome criterion?

"Client will have a 7 AM blood pressure reading less than 140/90." "Client will have a 7 AM blood pressure reading less than 140/90" would be the most appropriate outcome criterion. It is clientcentered, singular, observable, measurable, time-limited, & realistic. "Client will request pain medication as needed" does not allow the nurse to be able to determine if change has taken place. It would be more measurable to state the client will rate pain below 4 on a scale of 0 to 10 by 24 hours. "Client will experience no headache or dizziness" is not time-limited. "Client will identify at least two things that cause stress" is not time-limited or singular.

A client is newly diagnosed with diabetes mellitus. The nurse identifies a nursing diagnosis of knowledge deficient related to new diagnosis & treatment needs. The most appropriate outcome statement based upon the established criteria is the following:

"Client will independently perform subcutaneous insulin injection by 8/31." "Client will independently perform subcutaneous insulin injection by 8/31." is the most appropriate outcome statement. It addresses the nursing diagnosis by identifying a singular outcome the client can realistically achieve, is observable, & provides a time frame. "Client will perform glucose measurements often." does not specify a time frame. "Client will appear less anxious regarding diagnosis." is not an appropriate outcome statement. There is no specific behavior observable for "will appear." "Urinary output will reach normal young adult levels." is not an appropriate outcome statement. It does not provide a standard against which to measure the client's response to nursing care, & therefore is not measurable. It is also not time-limited.

In order that they are clear & easily understood by other members of the health care team, the nurse recognizes that client goals or outcomes should be documented according to specific criterion. Of the following, the outcome statement that best meets the established criteria is:

"Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24." "Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24" is a correctly written outcome statement. It is client-centered, singular, observable, measurable, time-limited, & realistic. "Client will describe activity restrictions" is not time-limited. "Client will verbalize understanding of treatments" is not observable or time-limited. "The client will state the purpose of the breathing treatments by 4/10" would be more appropriate. "Client will be ambulated in hallway 3 times each day" is not client-centered. A correct outcome statement would be "Client will ambulate in the hall 3 times a day."

Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept mapping to client care?

"Concept maps help me see the whole client, not just individual health problems" The advantage of a concept map is its central focus on the client rather than the client's disease or health alteration.

Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept map to client care?

"Concept maps help me see the whole client, not just individual health problems." The advantage of a concept map is its central focus on the client rather than the client's disease or health alteration, thus "concept maps help me see the whole client, not just individual health problems" is the correct answer.

The nurse is conducting an interview with the client & wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication?

"Could you give me an example of how you handle stressors?" In this option, the nurse is seeking further clarification of information by asking the client to provide an example. Clarification helps the nurse to gain accurate understanding of a client's situation. This is not an example of clarifying information. This response provides information. The nurse is not using the clarifying technique of communication. In this option the nurse describes his or her observations. It does not seek clarification.

When asked to define the purpose of diagnostic reasoning, the best nursing response is:

"Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis." Diagnostic reasoning is a process of using the assessment data gathered about a client to logically explain a clinical judgment, in this case a nursing diagnosis. The remaining options do not describe purpose but rather identify outcomes of diagnostic reasoning.

The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse?

"Do you have any other gastrointestinal problems besides GERD?" The nurse should ask relevant questions & collect relevant history & physical assessment data related to the client's presenting health care needs in order to produce the most inclusive, effective nursing care plan. The questions "How long have you been dealing with GERD?" & "Are you currently taking any medications for your GERD?" as well as "Do you follow a particular diet to help manage your GERD?" are directed towards the GERD itself & not towards conditions that might be related to the presence of GERD.

Which of the following statements made by the nurse best reflects an understanding of the client's role in goal setting?

"He is best suited to determine the level of effort he is capable of providing." Unless you set goals mutually & make a clear plan for action, clients will not follow the care plan. Clients alone are not always appropriately prepared to set & plan goals without professional help. Although the other answers may be true for many clients, it is not a guarantee that the client possesses all the skills & knowledge necessary to set & plan realistic goals.

Which of the following statements made by a nurse practitioner best reflects an understanding of the availability of clinical practice guidelines?

"I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site." 4. There are clinical practice guidelines already developed by national health groups. These guidelines are readily available to any clinician or health care institution that wishes to adopt evidence-based guidelines in the care of clients with specific health problems. The best option reflects the nurse's personal experience with a published protocol.

In working with a client who is newly diagnosed with diabetes mellitus, the nurse provides feedback to the client on her progress in learning the treatment regimen. Of the following, the nurse demonstrates the use of therapeutic communication by stating:

"I believe that you have come a long way in learning how to manage your care." In stating, "I believe that you have come a long way in learning how to manage your care" the nurse is demonstrating the use of therapeutic communication by sharing hope. The nurse is pointing out that personal growth can come from illness experiences. "It didn't look like you were ever going to be able to get the injection technique" is a negative statement. The nurse should not state observations that might embarrass or anger the client. "Check your blood sugar unless you really want to come back to the hospital again" does not demonstrate the use of therapeutic communication. It implies disapproval & is an aggressive, threatening type of response. "You don't appear to have any real interest in managing your daily dietary intake" is not a therapeutic statement. It is negative & aggressive in nature. If it is a true observation, it is one the nurse should not state as it could anger the client.

The nurse will often display empathy in communication with clients. Of the following responses by the nurse, which one best conveys empathy?

"I can understand your concern about learning to inject yourself." "I can understand your concern about learning to inject yourself" is correct. Empathy is the ability to understand & accept another person's reality, to accurately perceive feelings, & to communicate this understanding to others. "Good morning. How did you sleep last night?" is asking a question. It does not convey empathy. "Do you mean you would like to talk to the new family nurse practitioner?" is asking a question to clarify the client's meaning. It does not convey empathy. "Can you describe to me what the pain in your abdomen feels like right now?" is asking a relevant question that may focus on a particular topic. It is not an example of empathy.

Which statement by the client best represents the contemplation stage of the stages of behavior change?

"I currently do not exercise 30 minutes three times a week, but I am thinking about starting to do so within the next six months." A person in this stage recognizes there is a problem, is seriously considering changing, actively gathers information, and verbalizes plans to change in the near future. Option a reflects the precontemplation stage in which the person denies there is a problem. Option b reflects the planning stage in which the person makes final plans to accomplish the change, and option d is the maintenance stage in which the person made the change and demonstrates the appropriate behavioral change.

Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurse's mentor?

"I have my nursing assistant take & document all vital signs & intake & outputs." The nurse is responsible for determining whether to perform an intervention or to delegate it to another member of the nursing team. Assessment of a client directs the decision about delegation & not the intervention alone. Vital signs are important indicators of a client's health status & the task should be delegated to ancillary personnel only when the client is in a stable condition; otherwise, the nurse should be responsible. The other options reflect responsible assignment of personnel.

Which of the following statements best reflects the nurse's correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit?

"I have some questions to ask you regarding your admission history. I'll be back once you are settled in & comfortable." Completion of the admission history is scheduled for a time when interruptions by other staff or visiting family members are minimal. The nurse should create an environment where the client feels comfortable & the client's orientation to the room is completed. While this may be appropriate if the client requires help with answering the questions, it is not the best option because family & visitors can be distracting & may represent a confidentiality problem. While the history must be taken within a specific time period, rushing to complete it before the client goes to radiology is not appropriate. The interview requires the client's attention & cooperation. Attempting to complete it immediately after a treatment or other intervention would not be the best choice of time.

The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression? (Select all that apply.)

"I just can't seem to get excited about anything anymore." "The family always thought that my father was depressed." "I just can't seem to get excited about anything anymore" & "The family always thought that my father was depressed." Remember to always have supporting cues before you make an inference. These options relate a broad lack of interest in life & a family history of depression. While mentioning "My work environment would depress anyone" as a depressing situation, this option does not infer personal depression. While mentioning "It seems like almost anything can make me cry" as a potential sign of depression, this option is not a strong inference because crying can be a result of other emotions. While mentioning "Being here away from my family makes me sad" notes sadness, this option describes a normal reaction to being separated from loved ones. While mentioning "I like winter because I can just cover up on the couch & sleep" shows withdrawal behaviors, this option is not a strong inference because winter often evokes stay-at-home tendencies in people.

In using communication skills with clients, the nurse evaluates which response as being the most therapeutic?

"I noticed that you didn't eat lunch. Is something wrong?" The nurse who is sharing an observation, "I noticed that you didn't eat lunch. Is something wrong?" is using the most therapeutic response. Sharing observations often helps the client communicate without the need for extensive questioning, focusing, or clarification. "Why don't you stick to the special diet?" is an example of a nontherapeutic response. It is asking for an explanation. "Why" questions can cause resentment, insecurity, & mistrust. "I think you need to find another physician that's better than this one." is not a therapeutic response. It is giving a personal opinion. Changing the subject, "We can't continue talking about your problems; it's time for your bath," is not therapeutic.

Which of the following statements made by a nurse most reflects the best understanding of the effect assertiveness has on interpersonal communication?

"I will need some help with that complicated dressing change." Assertiveness conveys a sense of self-assurance while also communicating respect for the other person. Assertive responses often contain "I" messages, such as "I want," "I need," "I think," or "I feel," but in a fashion that is not demeaning or demanding. The remaining options are not the best examples because some lack an explanation of the nurse's actual needs while others are not respectfully stated.

A nurse is caring for a client who experienced short-term memory loss as a result of a head injury. Which of the following statements made by the nurse regarding goal setting requires follow-up by the nurse manager?

"I will restate the goals I've created for him regularly so as to win his compliance." If a client or significant other is not able to participate in goal development, you assume responsibility until the client is able to participate. It is vital that to the degree that the client is capable, the client be included in the decision-making process. Frequent reorientation to the care plan goals may be true & so does not require follow-up. The nurse seems pessimistic about the family's ability to play a role in the client's care plan but declares that an attempt will be made to include them; so follow-up is not an immediate priority. The client seems very willing to work towards achieving his goals may be true & so does not require follow-up because there is no indication of the nurse's intention to minimize his participation.

The nurse is in the process of conducting an admission interview with the client. At one point in the discussion, the client has provided information that the nurse would like to clarify. The nurse employs the technique of clarification as indicated by the response:

"I'm not sure that I understand what you mean by that statement." "I'm not sure that I understand what you mean by that statement" is correct. Clarifying is when the nurse checks whether understanding is accurate by restating an unclear message to clarify the sender's meaning, or by asking the other person to restate the message, explain further, or give an example of what the person means. This response indicates the nurse wants to clarify what the client is saying so he or she can have an accurate understanding of what the client means. "The ECG records information about your heart's electrical activity" is an example of providing information, not clarification. "Let's look at the problem you have had with your medication when you were home" is an example of focusing, not clarification. "What's your biggest concern related to your hospitalization at the moment" is an example of sharing empathy.

Using Maslow's framework, which statement characterizes the highest level of need?

"I'm very proud of receiving the Employee of the Month award." Option a is a physiological need. Option b is a love and belonging need, and option d is a safety and security need.

The patient goal was that the patient would verbalize the side effects of theophylline & how to take the medication by the time of discharge. Which statement by the patient indicates the goal has been met?

"If I have a lot of nausea & vomiting or become restless & can't sleep, I need to call my physician." Time-release capsules must be taken whole for maximum effectiveness. The patient knows potential indications of toxicity or side effects of the medication. Although fluids are important, caffeine-containing fluids have the potential to increase the likelihood of side effects. The drug is taken long term even when the symptoms are absent.

When a patient you are admitting to the unit asks you why you are doing a history and exam since the doctor just did one, which of the following statements is your best reply?

"In addition to providing us with valuable information about your health status, the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." Though it may be true that you need to develop assessment skills (c), the chief reason you are doing a nursing history and exam is because there needs to be a documented nursing admission assessment to serve as a basis for nursing care. The fact that this is also hospital policy (b) is a secondary reason.

Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences.

"Inability to speak in complete sentences" Defining characteristics are assessment findings that support the nursing diagnosis. In this example, the inability to speak in complete sentences supports the nursing diagnosis of altered speech. "Altered speech" is the diagnostic label identifying the problem. "As evidenced by" is a connecting statement for the problem & the defining characteristics. "Recent neurological disturbances" is the etiology.

When asked to define "Nursing Diagnosis" the nurse's best response is:

"It correlates a client's problem with a condition a nurse is competent to treat." "It correlates a client's problem with a condition a nurse is competent to treat" is a statement that describes the client's actual or potential response to a health problem that the nurse is licensed & competent to treat. Although "It is the second step in the Nursing Process" is true, it does not define the term. Although "It is the process of defining a client's problems" is true, is does not address the nursing aspect of the term. Although "It focuses care a licensed nurse can provide with the identified needs of a client" is true, the focus is not primarily on care.

The faculty member is reviewing a process recording with the student nurse. The student has been working with a client who has had an amputation of the lower left leg & is emotionally fragile. The student receives positive feedback from the faculty member for the following response made to the client:

"It must be very difficult to have this happen to you." "It must be very difficult to have this happen to you" is an example of using the therapeutic communication technique of sharing empathy. "Why are you so upset today?" is an example of a nontherapeutic communication technique of asking for explanations. "I'm sure that everything will be all right" is an example of a nontherapeutic communication technique of giving false reassurance. "You shouldn't cry. The wound will heal soon" is an example of a nontherapeutic communication technique of giving disapproval.

While administering a medication to relieve a patient's pain, you wonder if there are some nonpharmacologic interventions that would enhance relief by complementing the pain medication. When you discuss this question with your instructor, which of the following responses are you most likely to hear?

"Let's talk about this . . . we often get new information that we can incorporate successfully into the plan of care. Sometimes the steps of the process interact or overlap." There may be much interaction and overlap among the steps of the nursing process. In this case, though you want to evaluate the effect of the medication you administered (options a and b), there is no reason to wait for this to happen before exploring other valid options. Answer d is incorrect because it is not possible to judge the effectiveness of nonpharmacologic methods before their use, and the instructor's response possibly indicates a prejudice toward complementary and alternative modalities.

Which of the following questions, asked by a nurse, best reflects an understanding of effective evaluation?

"May we review what we discussed earlier about your medications?" In effective evaluation, the nurse compares client behavior & responses that were assessed before delivering nursing interventions with behavior & responses that occur after administering nursing care. The answer shows direct client knowledge related to the material previously discussed, while the other options reflect close-ended questions that require only a yes or no answer.

Which of the following statements made by a client's family is the most reliable for use in the evaluation of a client's outcome?

"Mom has been eating 90% of all of her meals since she's been home." Input from the family & other caregivers can be used to evaluate client outcomes but it is best to use their observations of measurable actions, such as the amount eaten, than to rely on their subjective opinions of a client's reaction, such as pain, anxiety, or mood.

Which of the following statements made by a new nursing graduate requires immediate follow-up by the nurse's mentor?

"My client just received some bad news regarding her tests. I'll see if the chaplain can visit this evening." The nurse delivers each intervention within the context of a client's unique situation. It is an assumption that a client who has received "bad news" would want a visit from a clergy member. The other options represent statements relating to normal characteristics of a specific development stage, condition, or preference.

Which of the following assessment data provided by a client's family will have the greatest impact on the client's care while hospitalized?

"My husband doesn't like to let people know his arthritis is bothering him." Family & friends can make important observations about the client's health status, changes, & needs that can affect the way care is delivered. Being aware of the client's reluctance to discuss his pain will impact the frequency & way his pain is assessed. While this information will affect the way the staff prepares the client for sleep, it does not have priority over pain assessment. While this information will allow the staff to meet the client's morning coffee need, it does not have priority over pain assessment. While this information will affect the way the staff address the client's emotional needs, it does not have priority over pain assessment.

The nurse recognizes that client goals or outcomes should be documented according to specific criterion in order that they are clear & easily understood by other members of the health care team. Of the following, the outcome statement that best meets the established criteria is the following:

"Output will be at least 100 mL/hour of clear yellow urine within 24 hours." "Output will be at least 100 mL/hour of clear yellow urine within 24 hours." is client-centered, singular, observable, measurable, time-limited, & realistic. "Vital signs will return to within normal levels for a middle aged adult." is not measurable (i.e., guidelines for normal are not stated), & it is not time-limited (e.g., by when?). "Nursing assistant will ambulate the client in the hallway 3 times each day." is not clientcentered. "Lungs will be clear to auscultation & respiratory rate will be 20/minute." is not singular & it is not time-limited.

Which of the following nursing notes demonstrates the best evaluation of nursing interventions regarding the care provided?

"Pressure ulcer on left heel is no longer producing purulent drainage." In many clinical situations it is important to collect evaluative measures over a period of time to determine if a pattern of improvement or change exists. The absence of purulent drainage indicates successful nursing interventions while the other options either fail to provide measurable data regarding the wound or indicate no improvement.

Which of the following statements made by a nurse best reflects an understanding of the therapeutic value of perceived client control?

"Research has shown that clients are less stressed when told what to expect." Research has shown that personal control over a situation contributes to emotional comfort. By informing the client of expectations, the client's personal sense of control is increased & emotional stress should then be decreased. The remaining options show an understanding of emotional comfort but do not express an understanding of the origin of that comfort.

Which of the following statements best reflects the nurse's understanding of the function of client reassessment?

"Since the client has been ambulating to the bedroom without difficulty, I'll walk with him to the dayroom after dinner." When reassessment results in the collection of new data that identify a new client need, the care plan is modified. Modification of a plan also occurs when a client's health care need shows improvement or is resolved. The other options reflect recognition of a change in the client's condition but do not reflect an alteration of the care plan.

Which of the following statements shows the best attempt by a nurse to overcome personal biases?

"So how does that make you feel?" People often assume that others think, feel, act, react, & behave as they would in similar circumstances. They tend to distort or ignore information that goes against their expectations, preconceptions, or stereotypes. This statement clearly shows the nurse attempting to assist the client in expressing his or her personal feelings. The remaining options all make a presumption about the client's feelings or attitudes.

After visiting with the client, the nurse documents the assessment data. Both objective & subjective information have been obtained during the assessment. Which of the following is classified as subjective data?

"States feels anxious & tense" Using the functional health pattern format, the nurse clusters data that pertain to a functional health category. Fatigue upon ambulating short distances & requiring frequent periods of rest are examples of data belonging to the category of activity & exercise. "Respiratory" would be found in a systems approach of health assessment, not a functional health pattern assessment. The functional health pattern category of sleep & rest would focus more on the number of hours of sleep the client obtains, use of sleep aids, & any difficulties associated with sleep. Self-care deficit: activities of daily living would include such aspects as bathing, feeding, & dressing self. The symptoms described would be clustered more accurately under the functional health pattern category of activity & exercise.

Which of the following statements made by a nurse most reflects a poor understanding of trustworthiness regarding nurse-client communication in response to a client's report that, "I don't like the night shift nurse"?

"Tell me more about why you dislike the night shift nurse." To foster trust, the nurse communicates warmth & demonstrates consistency, reliability, honesty, competence, & respect. Sharing personal information or gossiping about others sends the message you cannot be trusted & damages interpersonal relationships. The nurse appears to be gossiping by the way the client is encouraged to discuss what the night shift nurse is doing. The remaining options show varying degrees of addressing the client's statement.

A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following statements best reflects an understanding of client-centered goals?

"The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit." A client-centered goal is a specific & measurable behavior or response that reflects a client's highest possible level of wellness & independence in function, therefore "The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit" is correct. Although "The client's A1C levels will be 7 or below at the first testing date" & "The client will experience no blood sugar readings below 60 mg/dL before first follow up visit" are appropriate, they are not the best options because they do not reflect independence in function. "The client will be visited weekly by home health nursing staff beginning 1 week after discharge" is not clientcentered because it does not reflect a client's highest possible level of wellness & independence in function.

Which of the following statements made by a new graduate nurse regarding the modification of a client's care plan requires immediate follow-up by the nurse's preceptor?

"The order reads clear liquids, but I hear good bowel sounds & she's really hungry." With the assessment data supporting advancement in diet, the new graduate should initiate a modification of the client's nursing care plan because this directly impacts the client's nutritional status. Although facilitating client independence is appropriate, this option does not have priority over the option impacting nutrition. The other options do not involve modification of the care plan.

Which of the following statements made by a new nursing graduate best reflects an understanding of expected outcomes?

"They are measurable criteria by which I can evaluation whether a goal has been achieved." "They are measurable criteria by which I can evaluation whether a goal has been achieved." It is necessary to use expected outcomes or measurable criteria to evaluate goal achievement. Although outcomes are directed at times toward the alteration of client behavior, "They are statements of how the client's behavior should change." is not the best option provided to reflect an understanding of the term. "It gives the client something positive to strive towards" & "They provide the client with suggestions on how to achieve their long & short term goals" are incorrect as outcomes are nursing-oriented, not client-oriented.

Which of the following responses best reflects an understanding of the purpose of the "related to" phrase attached to the diagnostic label deficient knowledge regarding postoperative routines?

"To provide for individualization of the nursing interventions" The inclusion of the "related to" phrase requires you to use critical thinking skills to individualize the nursing diagnosis & then select personalized nursing interventions. Although the other options are not incorrect, they do not reflect the best understanding of the purpose of the phrase, "To provide for individualization of the nursing interventions" is the correct answer.

Which of the following statements best reflects critical thinking as taught by a nurse educator to a nursing student?

"What are several interventions that you could use with this patient?" A critical thinker will use both subjective & objective data to draw inferences about a patient & his or her care. There is never only one solution to the problem. A critical thinker will use his or her own thoughts, as well as other resources, to address the situation. Considering alternatives is part of critical thinking.

Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the client's depression?

"What do you believe is the cause of your depression?" This option is an open-ended question that encourages the client to express his insight regarding his condition. This option is a closed-ended question requiring only a yes or no response & so provides minimal information regarding the client's condition. While this is an open-ended question, it is not the best option because it is not directed towards assessment of the client's current complaint. While this is an open-ended question, it is not the best option because it is directed at the client's comfort, not towards assessing his current complaint.

The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning?

"What do you think has been causing your current depression?" An open-ended question prompts the client to describe a situation in more than one or two words. This option demonstrates the open-ended question technique. This question limits the client's answers to one or two words. It is an example of a closed-ended question. The question in this option limits the client's answer to one or two words such as "yes" or "no." It is an example of a closed-ended question. This option only requires a few words to form an answer. It does not use the open-ended question technique.

An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time?

"When did your abdominal pain begin?" Subjective data are clients' perceptions about their health problems. Feeling anxious & tense is information that only the client can provide. Objective data are observations or measurements made by the data collector. In this example, the data collector is making the observation that the client appears sleepy. "No physical distress noted" is an example of objective data because it is an observation made by the data collector. "Abdomen soft & non-tender" is an example of objective data because it is an observation made by the data collector, not a client's perception.

The nurse enters a client's room & finds her crying softly. The most therapeutic statement the nurse can make at this time is to ask:

"Why are you crying?" Sounds have several interpretations: crying may communicate happiness, sadness, or anger. The nurse needs to validate such nonverbal messages with the client to interpret them accurately. Although the other options may elicit information regarding the client's tears, they make assumptions or attempt to provide generalized comfort without first establishing the cause of the tears.

You tell your instructor that your patient is fine and has "no complaints." You are likely to hear:

"You made an inference that she is fine because she has no complaints. How did you validate this?" .Your instructor is most likely to challenge your inference that the patient is "fine" simply because he is telling you that he has no problems. It is appropriate for her to ask how you validated this inference. Jumping to the conclusion that the patient does not trust you (b) is premature and is an invalidated inference. Answer c is wrong because it accepts your invalidated inference. Answer d is wrong because it is possible that the condition is resolving.

Fearful of attempting your first nursing history, you ask your instructor how anyone ever learns everything you have to ask to get good baseline data. You are most likely to hear which reply from the instructor?

"You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." Once you learn what constitutes the minimum data set, you can adapt this to any patient situation. It is not true that each assessment is the same even when you are using the same minimum data set (a), nor is it true that each assessment is uniquely different (c). Answer d is incorrect because relying solely on standard agency assessment tools does not allow for individualized patient care or critical thinking.

A new graduate nurse missed cues regarding the client's emotional state at the time of admission. The most therapeutic response to the nurse by her mentor is:

"You will be less likely to miss client cues as you acquire more experience with assessments." It is possible to miss important cues when you conduct an initial overview. However, always try to interpret cues from the client to know how in-depth to make your assessment. Remember, thinking is human & imperfect. You will acquire appropriate thinking processes in the conduct of assessment, but expect to make mistakes in missing important cues. While this may be true, it is not the most therapeutic option because it does not address the issue personally for the new graduate. While this is true, it is not the most therapeutic option because it does not offer a reason for the omission. While this may be true, it is not the most therapeutic option because it does not address the issue personally for the new graduate.

Which of the following statements made by the nurse should be included in the orientation phase of a nursing interview? (Select all that apply.)

"You're answers will be kept confidential." "My name is Susan Smith & I'm a registered nurse." "I need to ask you some questions that will help with planning your care." "Only those directly involved in your care will have access to this information." The orientation phase begins with you introducing yourself & your position & explaining the purpose of the interview. Explain to clients why you are collecting data (e.g., for a nursing history or for a focused assessment) & assure them that any information obtained will remain confidential & will be used only by health care professionals. The statements "We are here to make your hospitalization as pleasant as possible" & "I need to ask you some questions that will help with planning your care" are more appropriate for the termination phase.

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?

15mg/dL The normal blood urea nitrogen level is 8 to 25 mg/ dL. Values of 29mg/dL and 35mg/dL reflect continued dehydration. A value of 3 mg/dL reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

The nurse is caring for a client with a diagnosis of cancer who is immune-suppresscd. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value?

2000 cells/mm3 The normal white blood cell count ranges from 4500 to 11,000/mm3. The client who has a decrease in the number of circulating white blood cells is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

A client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?

3.2mEq/L The normal serum potassium level in the adult is 3.5 to 5.0mEq/L. The correct option is the onJy value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.

The nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse anticipates the client's serum amylase level to be which value?

300 units/L The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. The options of 45 units/L and 100 units/L are within normal limits. The option of 500 units/L is an extremely elevated level seen in acute pancreatitis.

An adult client with cirrhosis has been prescribed a diet with optimal amounts of protein. The nurse evaluates the client's status as being most satisfactory if the total protein is which value?

6.4g/dL The normal range for total serum protein level in the adult client is 6 to 8g/dJ,. The client with cirrhosis often has low total protein levels as a result of inadequate nutrition. Excess protein is not helpful, though, because a function of the liver is to metabolize protein. A diseased liver may not metabolize protein well. The options of 0.4g/dL and 3.7g/ dL identify low values, and 9.8g/dL identifies a high protein value

When obtaining subjective assessment data, the nurse recognizes which of the following client scenarios as being the most likely to produce accurate, credible information?

A 81-year-old receiving follow-up treatment for a hip replacement This option where the 81-year-old is receiving follow-up treatment for a hip replacement presents a client who is not necessarily experiencing pain, embarrassment, guilt, or any other emotion/factor that would inhibit the free communication of subjective symptom data. The 50-year-old client is experiencing pain; this is likely to inhibit the communication process. The 70-year-old client is febrile; this could interfere with the communication process, especially for an older adult because it may cause confusion & the 22-year-old client may be experiencing guilt &/or embarrassment; both may interfere with the communication process.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

A client receiving nasal oxygen who had difficulty breathing during the previous shift Airway is always the highest priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and three unlicensed assistive personnel (UAP) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse?

A client requiring abdominal wound irrigations and dressing changes every 3 hours When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by the unlicensed assistive personnel (UAP). The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)?

A client who requires urine specimen collections The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the UAP would be to care for the client who requires urine specimen collections. The UAP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration.

A nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

A client with a fever who is diaphoretic and restless The nurse should plan to care for the client who has a fever and is diaphoretic and restless first because this client's needs are the priority. The client who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. Waiting for pain medication to take effect before providing care to the postoperative client is best.

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a number 2 priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a number 3 priority

A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6ng/mL. The nurse determines that this result indicates which finding?

A level that indicates a myocardial infarction Troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2ng/ mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL.

The client smokes two packs of cigarettes per day. The nurse works with the client, & they agree that he will smoke one cigarette less each week until he is down to one pack per day. In 3 weeks, the client is smoking two & a half packs of cigarettes per day. This is an example of:

A negative evaluation This is an example of a negative evaluation. During evaluation, the nurse is able to determine that the client has not met the expected outcome of decreasing smoking by one cigarette each week but rather has increased his smoking. This is not an example of a realistic goal. It is an example of the evaluation step of the nursing process. The client is noncompliant. The goal is measurable. During evaluation, the nurse determines if expected outcomes are met in order to judge if goals have been met.

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice?

A registered nurse leads nursing personnel in providing care to a group of clients. In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

Throughout the nursing process communication is used. During the evaluation phase, communication is specifically used by the nurse to:

Acquire both verbal & nonverbal client feedback The nurse & client determine whether the plan of care has been successful by evaluating the client communication outcomes established during planning. This process involves acquiring verbal & nonverbal feedback. Delegation is not the purpose of communication in the evaluation phase of the nursing process. Delegation is more likely to be used in the implementation phase of the nursing process. Validation of the client's needs is not why the nurse specifically uses communication in the evaluation phase of the nursing process. Validation of the client's needs is often determined when data are gathered during the assessment phase of the nursing process. Documenting expected outcomes & planned interventions is part of the planning phase of the nursing process, not the evaluation phase.

When clustering data according to functional health patterns, the nurse determines that the client is only able to ambulate short distances without becoming fatigued & requires rest periods during morning care. The health pattern that requires intervention is identified by the nurse as:

Activity & exercise In this option, the nurse is seeking further clarification of information by asking the client to provide an example. Clarification helps the nurse to gain accurate understanding of a client's situation. This is not an example of clarifying information. This response provides information. The nurse is not using the clarifying technique of communication. In this option the nurse describes his or her observations. It does not seek clarification.

A nurse is planning a workshop on health promotion for older adults. Which topic will be included?

Adequate sleep Learning about sleep will increase the older adult's well-being, which is the focus of health promotion. Prevention of falls (option a) is health protection because the focus is avoiding injury. Learning about cardiovascular risk factors (option b) relates to health protection/disease prevention. How to stop smoking (option d) focuses on health protection and avoiding illness.

Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated?

Administering a cleansing enema in preparation for radiological testing Preparing a client for a diagnostic test is an example of a physician-initiated intervention. Teaching a client to administer his or her insulin injection is an example of a nurse-initiated intervention. Assisting a new mother with breast-feeding is an example of a nurse-initiated intervention. Notifying a nutritionist of a client's dietary preferences is a collaborative intervention.

The nurse auscultates the thorax and lungs and hears coarse gurgling sounds on expiration. The nurse would describe these sounds as:

Adventitious breath sounds Adventitious breath sounds are sounds not normally heard in the lungs.

The patient is Vietnamese and does not speak English. Her son is with her and does speak English. How should you respond?

After determining that the son can translate, evaluate if he can do so objectively and if the patient wants him to serve in this capacity. This is difficult, but it is important to evaluate whether or not the son can adequately translate medical information, can be trusted to translate what is said without introducing his bias, and if the patient wants him to serve in this capacity. The choice belongs to the patient, not the son (a) and there is no policy that prohibits family members from translating (d). Answer b is incomplete.

The nurse is going to perform the admission history for a newly admitted client on the medical unit. The optimum time for completion of the history is planned for:

After the client has become comfortably oriented to the room Completion of the admission history is scheduled for a time when interruptions by other staff or visiting family members are minimal. The nurse should create an environment where the client feels comfortable. Conducting the admission history after the client's orientation to the room & completion of lunch would be optimum because the client will not be distracted by hunger, & the interview will less likely be interrupted. The admission history should be scheduled for a time when interruptions by other staff are minimal. During the physician's visit would not be an optimum time. The nurse should provide an environment private enough to allow the client to be comfortable when providing personal information. Inclusion of family members should be left up to the client to decide. Information obtained should remain confidential. Immediately before a client's testing would not be an optimum time for obtaining a nursing history. The client may feel more anxious about the upcoming test, impeding communication, & there may not be sufficient time allowed to gather all of the information.

When dealing with toddlers or preschoolers what communication technique may be used most effectively?

Allowing manipulation of equipment to be used Allowing toddlers & preschoolers to touch & examine objects that will come in contact with them is an effective communication technique. Toddlers & preschoolers are unable to understand analogies. Sudden movements can be frightening. Children often prefer to make the first move in interpersonal contacts. Focusing on what other children have done is not an effective communication technique for toddlers or preschoolers. Communication should be focused on the child.

Which of the following nursing actions is most likely a result of the nurse's clinical experience?

Always assessing a client's IV site before hanging a new bag of fluid As a nurse gains clinical experience, he or she will be able to consider which interventions have worked previously, which have not, & why. The decision to check each IV site has become a practice standard for this nurse as a result of previous experiences with IV sites. The remaining options are either standards of care or facility/unit standards.

A helping relationship is being established between nurse & client. In addressing the client, the nurse should:

Always knock & pause before entering the client's room Common courtesy is part of professional communication. To practice courtesy, the nurse says hello & goodbye, knocks on doors before entering, & uses self-introduction. Knocking on doors is important in addressing the client. Because using last names is respectful in most cultures, nurses usually use the client's last name in the initial interaction, & then use the first name if the client requests it. Touching the client right away would not be an appropriate action in establishing a helping relationship. It would more likely be interpreted as invading the client's personal space. Sitting far enough away from the client is important in that the nurse should not enter the client's personal space when establishing a helping relationship. However, leaning toward the client conveys that the nurse is involved & interested in the client. Knocking on the door before entering the client's room would be the first step in addressing the client properly.

Which of the following statements best defines quality improvement (performance improvement)?

An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the client's needs Quality improvement (QI) & performance improvement (PI) are interchangeable terms that describe an approach to the continuous study & improvement of the processes of providing health care services to meet the needs of clients & others. The remaining options reflect individual facets of QI.

Select aspects of the skin that the nurse assesses during a routine examination.

Answers include color, turgor, temperature, moisture, lesions, odor, and edema dimples, piercings & tattoos are not a normal assessment aspect.

A client expresses concern over a scheduled intravenous pyelogram by stating, "I don't know what to expect." Which of the following nursing diagnoses is most appropriate for this client need?

Anxiety related to lack of knowledge concerning intravenous pyelogram Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself. The client need, identified by the statement, is not related to the necessity for the test but concern over a lack of knowledge about what to expect before, during, & after the test. The remaining options fail to identify a client need.

When reaching over the side rails to take a client's blood pressure, he draws back. To promote effective communication, the nurse should first:

Apologize for startling the client & explain the need for touching the client Nurses often have to enter a client's personal space to provide care. The nurse should convey confidence, gentleness, & respect for privacy. This response demonstrates respect & provides information so the client can understand the need for personal contact. Telling the client that the blood pressure can be taken at a later time does not promote effective communication. Rotating the nurses who are assigned to take the client's blood pressure impedes the nurse's ability to form a therapeutic, helping relationship. Continuing to perform the procedure quickly & quietly may send a negative nonverbal message. It also does not promote effective communication.

If the client reports loss of short-term memory, the nurse would assess this using which one of the following?

Ask the client to describe how he or she arrived at this location. Recent memory includes events of the current day. Recalling a series of numbers tests immediate recall (option a). Recalling childhood events tests remote (long-term) memory (option b), and subtracting backwards from 100 tests attention span and calculation skills (option d).

The nurse can best detect that a client needs clarification of the information provided on a special diet by:

Assessing the client's nonverbal cues that suggest confusion You determine the need for clarification by watching the listener for nonverbal cues that suggest confusion or misunderstanding. The remaining options are means of reinforcing or evaluating the listener's understanding of the information.

For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention?

Assisting with activities of daily living (ADLs) A client with bilateral arm casts has a temporary need for assistance with ADLs. Counseling is a direct care method that helps the client use a problem-solving process to develop new attitudes & feelings. It does not meet the physical need for assistance with ADLs. Teaching is an implementation method used to present correct principles, procedures, & techniques of health care to clients & to inform clients about their health status. Compensating for adverse reactions means the nurse takes action to reduce or counteract the reaction, such as by administering an antihistamine when a client has an allergic reaction to a medication. Assisting with ADLs would be compensating for the client's impaired mobility.

After inspecting a patient's abdomen, which technique would the nurse do next?

Auscultation When assessing the abdomen, the sequence is inspection, auscultation, percussion, and palpation. Auscultation follows inspection because percussion and palpation stimulate bowel sounds.

A new unit nurse manager is holding her first staff meeting. The manager greets the staff and comments that she has been employed to bring about quality improvement. The manager provides a plan that she developed and a list of tasks and activities for which each staff member must volunteer to perform. In addition, she instructs staff members to report any problems directly to her. What type of leader and manager approach do the new manager's characteristics suggest?

Autocratic The autocratic leader is focused, maintains strong control, makes decisions, and addresses all problems. The autocrat dominates the group and commands, rather than seeks suggestions or input. In this situation, the manager addresses a problem (quality improvement) with the staff, designs a plan without input, and wants all problems reported directly back to her. A situational leader will use a combination of styles, depending on the needs of the group and the tasks to be achieved. The situational leader would work with the group to validate that the information that the leader gained as a new employee was accurate and that a problem existed. Then, the leader would take the time to get to know the group and determine which approach to change (if needed) would work best according to the needs of the group and the nature and substance of the change that was required. A democratic leader is participative and would likely meet with each staff person individually to determine the staff member's perception of the problem. The democratic leader would also speak with the staff about any issues and ask the staff for input with developing a plan. A laissez-faire leader is passive and nondirective. The laissez-faire leader would state what the problem was and inform the staff that the staff needed to come up with a plan to "fix it."

Which of the following is considered objective data obtained from the patient?

Blood pressure of 110/70 at 8 PM A patient's expression of a problem is subjective data. The client expressing concern about missing work is an inference based on what patient has said. "Patient nods, indicating an affirmative answer to a question" is interpretation of a movement. Objective data are measurable & observable.

A client reports to the nurse that the room is "too hot." Which of the following nursing actions best reflects the nurse's understanding of the therapeutic manipulation of the client's environment?

Bringing a portable fan into the room Although closing the blinds may manipulate the environment, it will always minimize the ambient light in the room. Cooling the room by introducing the fan will not impact any other aspect of the environment. It may not be appropriate for the client to remove clothing & leaving the room is only a temporary solution to the problem.

After auscultating the abdomen, the nurse should report which finding to the primary care provider?

Bruit over the aorta A bruit suggests abnormal turbulence in the aorta, and the primary care provider must be notified. For absence of bowel sounds to be considered abnormal, they must be silent for 3 to 5 minutes (option b). Continuous bowel sounds are normally heard over the ileocecal valve following meals (option c). Bowel sounds are more commonly irregular than they are regular (option d).

"I've never told anyone this information about my son," is an example of a parent:

Building trust This response is an example of trust. Trusting another person involves risk & vulnerability, but it also fosters open, therapeutic communication & enhances the expression of feelings, thoughts, & needs. This statement is not an example of revealing. Although the parent may have provided information that was never before revealed, in this statement the parent is indicating there is trust between himself or herself & the nurse practitioner. This statement is not clarifying roles of the nurse & client. This statement is not an example of identifying problems & goals.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which abnormal laboratory test results should the nurse report? Select all that apply.

Calcium, 7 mg/dL White blood cells, 3000 cells/mm3 Magnesium, 1 mg/dL Neutrophils, 1000 cells/mm3 The normal values include the following: calcium, 8.6 to lOmg/dL; magnesium, 1.6 to 2.6mg/dL; phosphorus, 2.7 to 4.5 mg/dL; neutrophils, 1800 to 7800 cells/mm3; serum creatinine, 0.6 to 1.3 mg/dL; and white blood cells, 4500 to 11,000 cells/mm3. The calcium level noted is low; the magnesium level noted is low; the phosphorus level noted is normal; the neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low.

Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated?

Changing a dressing 2 times each day Changing a dressing is a physician- or prescriber-initiated intervention. Taking vital signs is a nurse-initiated intervention. Providing support to a family is a nurse-initiated intervention. Measuring intake & output is a nurse-initiated intervention.

If unable to locate the client's popliteal pulse during a routine examination, what should the nurse do next?

Check for a pedal pulse. If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point (option b). Taking a thigh BP requires locating the popliteal pulse (option c). Because the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate (option d).

Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Chronic pain related to insufficient use of medication Chronic pain related to insufficient use of medication is an example of an appropriately written nursing diagnosis. It consists of a diagnostic label & the associated etiology. Nursing interventions can be directed at treating or managing the behavior of insufficient medication use. Anxiety related to cardiac monitor is written incorrectly because it identifies the equipment rather than the client's response to the equipment. It would be appropriate to state deficient knowledge regarding the need for cardiac monitoring. Pain related to difficulty ambulating is not written correctly. What could be a defining characteristic is used as an etiology. This nursing diagnosis could be rewritten more appropriately as impaired mobility related to pain as evidenced by difficulty ambulating. Or it could be an inaccurate diagnostic label & could be rewritten as anxiety related to difficulty in ambulating. Bedpan required frequently as a result of altered elimination pattern is written incorrectly because it identifies a nursing intervention, not the client's problem. It could be reworded as diarrhea related to food intolerance.

Which subjective assessment data are most supportive of a client's diagnosis of anxiety?

Claims "something is terribly wrong" Subjective data are clients' perceptions about their health problems. The statement by the client regarding his sense of impending doom is the best example of subjective data regarding his anxiety because it is his own verbalization of the problem. Cool, damp skin is an example of objective data. Objective data are observations or measurements made by the data collector. A pulse rate is an example of objective data. Objective data are observations or measurements made by the data collector. While a client statement regarding the need to leave the hospital is subjective in nature, it is not as strong an indicator of anxiety as is the verbalization of impending doom.

The primary source of information when completing an assessment of a client that is alert & oriented as he is admitted to the medical center for diagnostic testing is the:

Client A client is usually the best source of information. The client who is oriented & answers questions appropriately can provide the most accurate information about health care needs, lifestyle patterns, present & past illnesses, perception of symptoms, & changes in activities of daily living. The physician may have knowledge of the client's medical problem, but the client is the primary source of information for completing an assessment. Family members can be interviewed as primary sources of information about infants or children or critically ill, mentally handicapped, disoriented, or unconscious clients. Usually, however, they are secondary sources of information & can confirm findings provided by the client. The client in this situation is capable of being the primary source of information. An experienced nurse on the unit may offer insight into a client's health care needs & care, but is not the primary source of information when completing a client assessment.

The process of data collection should begin with the nurse performing a:

Client interview The first step in establishing the database is to collect subjective information by interviewing the client. The physical examination follows the client interview so that data can be verified. A review of medical records is not the first step the nurse should take in the process of data collection. The medical record is a valuable tool for checking the consistency & congruency of personal observations made during the client interview. Discussion with other health team members may provide additional information & be used to relay information, but is not the first step in the process of data collection.

Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process?

Client is observed grimacing when walking to bathroom. To collect complete, relevant, & correct assessment data it helps to identify assessment activities that produce specific kinds of data. When possible, the nurse should collect objective data because they are often more supportive than subjective data. Observation of the client's response to the use of the affected joint is the most supportive of the options.

Which of the following assessment findings best supports the nursing diagnosis of Pain in right knee joint related to degenerative process?

Client observed grimacing when walking to bathroom. To collect complete, relevant, & correct assessment data it helps to identify assessment activities that produce specific kinds of data. When possible, the nurse should collect objective data, because it is often more supportive than subjective data. Observation of the client's response to the use of the affected joint is the most supportive of the options.

The nurse has identified a nursing diagnosis of knowledge deficit regarding the need to monitor blood glucose levels daily. Which of the following statements best reflects the client's understanding of the need for therapy?

Client records blood glucose levels for a 3-week period. During the planning phase of the nursing process it is important for you to select an observable client state, behavior, or self-reported perception that will reflect goal achievement. The actual written result of regular blood glucose monitoring is the best indicator of the client's understanding of the importance of regular testing. The remaining options may show initial willingness or ability to perform the test but do not show consistent compliance.

Which of the following client-centered goals best rest reflects singular focus?

Client will ambulate to the bathroom for the purpose of showering daily. Each goal & outcome addresses only one behavior or response. In this case the client will walk to the shower daily. Although coughing & deep breathing are usually done as a unit, they are really two separate actions. The client being free of shoulder & elbow pain by discharge relates to two different anatomical locations. Adhering to a diet & losing 3 pounds are two different actions.

Which of the following goals best shows that the nurse understands the concept of a client-centered goal?

Client will consume at least 75% of each meal served. Client will consume at least 75% of each meal served is correct. Outcomes & goals reflect the client's behavior & responses expected as a result of nursing interventions. Write a goal to reflect client behavior, not to reflect your goals or interventions. The other options are nursing-centered

The expected outcome that best evaluates the presurgical goal of, "Client will understand purpose of coughing & deep breathing within 4 hours of returning to room" is:

Client will cough & deep breathe every 1 hour while awake without staff prompting An expected outcome is a criteria designed to evaluate the achievement of the stated goal. This option best represents evaluation of the client's understanding of the purpose of deep breathing & coughing because it shows appropriate compliance. Although demonstration evaluates the proper technique, it is not the best option to evaluate understanding of purpose. Although restatement evaluates understanding, it is not the best option to evaluate understanding of purpose because it does not include client compliance. The client's lungs being free of abnormal breath sounds within 1 hour is more reflective of a goal than of an expected outcome.

Which of the following outcomes, made by a nurse planning care for a client recently fitted with a hearing aid, best reflects an understanding of short-term client education goals?

Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today. Although all the options represent short-term goals, client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today is directly related to patient education because it relates to the proper care of the hearing aid. Client will properly clean the hearing aid ear piece daily with soap & water does not directly relate to client education but more to an expected client action. The goal does not include a time limit for compliance. Although client will state 3 positive effects of wearing his hearing aid at follow-up appointment may be a short-term goal (depends on time of next appointment), it is not as directly related to client education as it is compliance-oriented. Although client will wear hearing aid while awake to help improve his ability to understand instructions may be a short-term goal, although there is no time limit, it is not as related to client education as some other options.

Which of the following outcomes best reflects a nurse-sensitive client outcome?

Client will experience no falls during hospitalization. A nurse-sensitive client outcome is a measurable client or family state, behavior, or perception largely influenced by & sensitive to nursing interventions. The nurse is instrumental in the prevention of falls while the remaining options are dependent on the client.

Which of the following would be the most appropriate outcome criterion for the goal, "Client's pain will be managed to within an acceptable level within 30 minutes of receiving pain medication."

Client will rate pain at a level of 3 or less out of a possible 10. Client will rate pain at a level of 3 or less out of a possible 10 would be the most appropriate outcome criterion because it is directly related to the management of pain levels as reflected by the pain scale. Client will deny presence of any pain or discomfort does not necessarily reflect a reasonable goal. Although client will demonstrate ability to request pain medication as needed is directed towards pain management, it does not have the primary focus that evaluating the pain management intervention has. Client will identify two external factors that decrease presence of pain is not the best option because it does not directly relate to pain management but the identification of contributing factors.

Which of the following goals concerning client anxiety is the best example of measurability?

Client will report anxiety at less than 3 out of 5 by discharge. You need to be able to observe if change takes place in a client's status. Observable changes occur in physiological findings & the client's knowledge, perceptions, & behavior. You observe outcomes by directly asking clients about their condition or by using assessment skills. The client rating his anxiety is one method of observing improvement. The phrase "will be less anxious" is not observable. The phrase "will appear less anxious" is not observable. Although pulse rate & blood pressure may be affected by anxiety, there is no assurance that normal readings reflect an improvement.

Which of the following goals best reflects measurability?

Client will report being free of shoulder pain by discharge. Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely. "Pain free" relates to quantity as well as quality. Do not use vague qualifiers such as "normal," "acceptable," or "stable" in an expected outcome statement. Vague terms result in guesswork in determining a client's response to care.

Which of the following statements best reflects a goal based on a clinical standard of practice?

Client's peripheral intravenous site will be free of redness. Goals often are also based on standards of care or guidelines established for minimal safe practice. Prevention of acquired infection is a standard of practice; the remaining options reflect client-specific goals.

During an interview, the nurse needs to obtain specific information about the signs & symptoms of the client's health problem. To obtain these data most efficiently, the nurse should use:

Closed-ended questions Using closed-ended questions helps the nurse to acquire specific information about health problems such as symptoms, precipitating factors, or relief measures in an efficient manner. Channeling is where the nurse uses active listening techniques, such as "all right," "go on," or "uh-huh," to indicate the nurse has heard what the client said & encourage the client to elaborate further. Using open-ended questions prompts the client to describe a situation in more than one or two words. Because it allows the client the opportunity to tell their story & reveal what is important to them, it is not the most efficient method of obtaining specific information regarding a client's signs & symptoms of a health problem. In problem-seeking technique, the nurse takes the information provided in the client's story to more fully describe & identify the client's specific problems. Using closed-ended questions would be the most efficient method for obtaining specific information about the signs & symptoms of a client's health problem.

When assessing heart sounds, the nurse understands that the sounds heard reflect which of the following?

Closure of the heart valves Heart sounds result from closure of the heart valves.

A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors & symptoms in the database is known as:

Clustering data Clustering data means the nurse organizes the information obtained into meaningful clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When clustering data, the nurse identifies relationships between factors & symptoms. Validating data means to compare the data obtained with another source to ensure its accuracy. Peer review is the evaluation of the quality of the work effort of an individual by his or her peers. After validating data & clustering data, the nurse may formulate a problem statement, usually in the form of a nursing diagnosis.

The nurse recognizes the discharge needs of a client following a hip replacement. This is an example of which type of nursing skill?

Cognitive Cognitive skills involve the application of nursing knowledge. Being able to identify a client's discharge needs is a cognitive skill. Interactive skills are interpersonal skills such as developing a trusting relationship & communicating effectively. Psychomotor skills involve the integration of cognitive & motor skills such as with administering an injection. Effective communication is an interpersonal skill. The nurse communicates with the client & family when providing client teaching & emotional support. The nurse communicates with the health care team to achieve client outcomes.

Which of the following would be most important for a nurse to do to ensure the accuracy of inspection during assessment?

Compare bilateral body parts .With inspection, a comparison of bilateral body parts is necessary for recognizing abnormal findings. Perfect vision is unnecessary; the nurse examines all body systems and uses touch during palpation.

A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the client's weight, the nurse also considers the age & height. This is an example of:

Comparing data with normal health patterns The nurse uses scientific knowledge & experience to analyze & interpret data collected about the client. This includes comparing the data with norms. The nurse is comparing data to determine if there is a problem. A problem has not yet been identified. The nurse is not recognizing gaps in data assessment. An example of a gap in data assessment would be if the client's weight had not been measured. The nurse has not drawn a conclusion about the client's response. The nurse must first compare the data with normal health problems to be able to arrive at a conclusion.

A client is admitted for heart failure. The nurse assesses that the client's blood pressure is below normal range and the apical pulse is 110 beats/min. The nurse knows that the increase in the client's pulse illustrates which aspect of the client's homeostatic mechanism?

Compensation The compensatory mechanism of increasing the heart rate is the body's way of trying to balance an ineffective cardiac output since the BP has decreased. Decompensation (option b) occurs when the compensatory mechanism is ineffective. Self regulation (option c) refers to the homeostatic mechanisms that come into play automatically in the healthy person. Equilibrium (option d) is balance through adaptation to the environment.

The client is given an injection of an antibiotic. Shortly afterwards the client reports hives & itching. The nurse administers an antihistamine to counteract the effect of the antibiotic. The nurse is using which one of the following intervention methods?

Compensation for adverse reactions Nursing actions that control for adverse reactions reduce or counteract the reaction, such as administering an antihistamine after an allergic reaction to a medication. Preventive measures promote health & prevent illness while assisting with ADLs & preparing for special procedures are direct care measures.

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the UAP?

Confront the UAP to encourage verbalization of feelings regarding the change. Confrontation is an important strategy to meet resistance head on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance, but will not address the concern specifically.

The nurse observes a child lying rigidly in bed & taking shallow breaths. The child reports a pain score of 4 out of 5 & says, "My leg hurts." The nurse determines that the objective & subjective data are

Congruent & support that the child is in pain The statement & behaviors observed indicate that the child is experiencing pain. One can make a conclusion. The child states he is in pain & his rigid positioning & shallow breathing are behaviors found when individuals experience pain. The subjective nature of pain requires obtaining the information from the patient if at all possible. The mother's assessment may validate the data.

When a nurse tells an advanced nurse practitioner that her client is "slipping a little" in reference to hemodynamic pressures, The nurse is using:

Connotative meaning The connotative meaning is the shade or interpretation of a word's meaning influenced by the thoughts, feelings, or ideas people have about the word. "Slipping a little" in reference to hemodynamic pressures is an example of using connotative meaning. Brevity means that communication is simple, brief, & direct. This is not an example of using brevity. Relevance means the message is relevant or important to the situation at hand. This is not an example of using relevance. Pacing & control mean speaking slowly enough to enunciate clearly & not changing subjects rapidly. This is not an example of using pacing & control.

Critical thinking in nursing needs to include which of the following important variables?

Consideration of ethics & responsible decision making Critical thinking in nursing is based on ethics & standards of the profession. Critical thinking is consciously developed, complex, & purposeful, never impulsive. Critical thinking & decision making are based on patient's values & beliefs. Critical thinking is based on a decision-making model & nursing standards.

The nurse is involved in requesting a management consultation for personnel-related issues. Which of the following is true regarding the consultation process in which the nurse is involved?

Consultation is often used when the exact problem remains unclear. Consultation is appropriate when the nurse has identified a problem that cannot be solved using personal knowledge, skills, & resources, or when the exact problem remains unclear. A consultant objectively entering a situation can more clearly assess & identify the exact nature of the problem. The whole problem is not turned over to the consultant. The consultant is not there to take over the problem but is there to assist the nurse in resolving it. The person requesting the consult usually identifies the problem area. The nurse should not bias the consultant with subjective & emotional conclusions about the client & problem.

Several methods have been developed to assist nurses in organizing patient data. They include (select all that apply):

Correct "Henderson's 14 nursing problems," "Gordon's 11 functional health patterns" & "Sister Callista Roy's adaptation framework" help sort patient data into categories. Incorrect The ANA Standards of Practice do not provide any method to organize data.

Developing sound clinical judgment is a professional responsibility of the nurse. Which statements indicate behaviors that improve clinical judgment? (Select all that apply.)

Correct "I always assess before acting & make changes as needed," "I look for research findings to support my nursing actions," "I believe that every patient deserves my very best efforts" & "I have read the professional nursing standards" are behaviors that demonstrate the use of resources & the nursing process to give the patient quality care. These activities facilitate the development of clinical judgment. Incorrect The nurse is not taking opportunities to extend herself & potentially learn from other situations.

The nurse is admitting a woman for surgery. She twists a handkerchief in her hands, saying, "I'm going to have a little mole removed. I'm not worried. I will go home right after surgery. I've never been sick a day in my life, so I'll be fine." The nurse finds the following during her physical assessment: BP = 150/90; T = 98.6; P = 88; R = 20; black, brown, & red pigmented pea-sized raised area on her right shoulder. Which of the above information would be considered subjective data? (Select all that apply.)

Correct "I'm not worried. I'll be fine" & ""I will go home right after surgery" are statements made by the patient describing feelings or events. Incorrect "Pigmented mole on shoulder" is a conclusion based on objective data. "Patient is anxious" is incorrect because this is a conclusion the nurse might make based on the subjective & objective data. "Heart rate is increased" is incorrect because this is a conclusion the nurse might make based on objective data.

The nurse is admitting a woman for surgery. She twists a handkerchief in her hands while saying, "I'm going to have a little mole removed. I'm not worried. The surgery will take only an hour & then I will go home. I've never been sick a day in my life, so I'll be fine." The nurse finds the following during her physical assessment: BP = 150/90; T = 98.6; P = 88; R = 20; black, brown, & red pigmented pea-sized raised area on her right shoulder. Which of the above information would be considered objective data? (Select all that apply.)

Correct "Twisting handkerchief" & "BP 150/90"are measurable or observable data. Incorrect "Patient is worried" is subjective data & "Patient is exhibiting denial" is the patient's description of what is going to occur. ""Patient is worried" is incorrect because this is a conclusion the nurse might make based on the subjective & objective data. ""Patient is exhibiting denial" is incorrect because this is a conclusion or inference that the nurse might make based on the data.

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the UAP.

The client is receiving postural drainage from physical therapy & intermittent breathing treatments from respiratory therapy. Which type of care plan would be the ideal method to document interventions for this client?

Critical pathway Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type. The nursing Kardex is a card-filing system that allows quick reference to the particular needs of the client for certain aspects of nursing care. A computerized care plan is a standardized care plan on the computer. A standardized care plan is a prewritten plan created for a specific nursing diagnosis or clinical problem. The nurse individualizes the care plan for the client's needs.

The nurse begins to auscultate the client's lungs. While listening, the nurse notices fresh bloody drainage oozing from the abdominal dressing. The nurse stops auscultating & applies direct pressure to the wound site. This is an example of:

Critically analyzing client assessment data The nurse who stops auscultating lung sounds to take measures to stop noticeable bleeding is analyzing data presented. This is demonstrated by the nurse setting priorities & effectively implementing the safest nursing action. The nurse is doing more than performing a nursing assessment. The nurse is taking action based on new assessment data. The nurse is not reorganizing nursing diagnoses. The nurse is implementing the priority nursing action. This is not an example of setting realistic goals & implementing nursing interventions. Applying direct pressure to a wound site to stop bleeding demonstrates critical analysis of the data & implementation of the safest nursing action.

Which of the following critical thinking attitudes contributes to an effective nurse-client relationship? (Select all that apply.)

Curiosity motivates the nurse to communicate & know more about a person. Perseverance & creativity are also attitudes conducive to communication because they motivate the nurse to communicate & identify innovative solutions. A self-confident attitude is important because the nurse who conveys confidence & comfort while communicating more readily establishes an interpersonal, helping-trust relationship. Risk-taking rather than a guarded attitude is important because colleagues sometimes question the suggested nursing interventions. At the same time, an attitude of fairness goes a long way in the ability to listen to both sides of any discussion.

Which of the following is an expected finding during assessment of the older adult?

Decreased peripheral, color, and night Visual acuity often lessens with age. Facial hair is likely to become coarser, not finer (option a). The sense of smell becomes less, rather than more acute (option c). The respiratory rate and rhythm is regular at rest (option d). However, both may change quickly with activity and be slow to return to the resting level.

Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Deficient knowledge related to need for cardiac catheterization This nursing diagnosis is written correctly. It defines a problem & its etiology. In this case the problem is the client's response to a diagnostic test. A medical diagnosis should not be recorded as the etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state acute pain related to impaired skin integrity secondary to mastectomy incision. This nursing diagnosis is written incorrectly because it uses supportive data of the problem as the etiology. This nursing diagnosis does not identify the problem & etiology. It identifies the client's goal rather than the problem. It could be reworded as imbalanced nutrition: less than body requirements related to inadequate protein intake.

In the nursing process, the most complete description of the evaluation phase is a process used to determine the

Degree of outcome achievement Evaluation does not measure the value of the intervention. Evaluation does not measure the accuracy of problem identification. While it is an indicator of the effectiveness of the plan of care, evaluation is far more than that. The evaluation phase of the nursing process is used to evaluate patient progress related to goals & outcome achievement to determine whether a problem is resolved.

The primary reason for documenting discontinued portions of the care plan when a client goal has been met is to ensure:

Delivery of both timely & relevant nursing care Documentation of a discontinued plan ensures that other nurses will not unnecessarily continue interventions for that portion of the plan of care. Continuity of care assumes that care provided to clients is relevant & timely. The remaining options refer to the potential nursing outcomes related to poor documentation of care plan editing.

Which of the following statements best reflects the nurse's understanding of the primary nursing related purpose of a concept map?

Demonstrate the relationship between the client's various health problems Concept mapping is one way to graphically represent the connections between concepts & ideas that are related to a central subject (e.g., the client's health problems). While the other options are correct they do not provide the best understanding of the purpose of concept mapping in nursing practice.

Which of the following statements best reflects the client's positive feedback to the nurse's question, "Do you understand how to check your blood sugar?"

Demonstrating a fingerstick to the nurse Feedback is the message the receiver returns. It indicates whether the receiver understood the meaning of the sender's message. Demonstrating the technique is the best way to show the nurse an understanding of the process. The other options either nonverbally or verbally indicate understanding; they are not as conclusive as showing understanding.

What would be the most important information for the nurse to obtain when a 3-year-old patient is admitted to the pediatric unit for evaluation of recurrent episodes of new-onset tonic/clonic seizures?

Description of the seizure from the mother who witnessed it Assessment of the cranial nerves is primary source data as the data are obtained from the patient but do not relate to the seizure event. Ability to move all extremities with equal strength is primary source data as the data are obtained from the patient but do not relate to the seizure event. Heart rate & blood pressure are primary source data as they are obtained from the patient but do not relate to the seizure event. As a secondary source of data the mother's description will help determine whether a seizure occurred.

The primary purpose of the nursing evaluation process is to:

Determine the effectiveness of the nursing care provided The evaluation process determines the effectiveness of nursing care. The remaining options are all examples of evaluation but do not reflect the primary purpose of nursing evaluation.

Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Diarrhea related to food intolerance Diarrhea related to food intolerance is a correctly written nursing diagnosis. It consists of a problem related to an etiology, & it is a condition that nursing interventions can treat or manage. Alteration in comfort related to pain is not written correctly because it is a circular statement. It would be appropriate to state ineffective breathing pattern related to incisional pain. Risk for impaired skin integrity related to poor hygiene habits is not written correctly because it uses a nurse's prejudicial judgment. It would be more appropriate & professional to state risk for impaired skin integrity related to knowledge about perineal care. Potential complications related to insufficient vascular access is not written appropriately because it identifies a nursing problem, not a client's problem. It would be appropriate to state risk for infection related to presence of invasive lines.

In completing an assessment on an assigned client, the nurse obtains important information for planning nursing care. Which of the following client needs should take priority?

Difficulty breathing Difficulty breathing would be the highest priority client need. In general, priorities that protect clients' basic needs of safety, adequate oxygenation, & comfort are considered high priority. Financial problems are a low-priority client need. Financial problems are not directly related to a specific illness or prognosis but may affect the client's future well-being. A nutritional deficit is an intermediate priority client need. It involves a non-life-threatening need of the client. An impending divorce is a low-priority client need. It is a need that is not directly related to a specific illness or prognosis but may affect the client's future well-being.

The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the client's anxiety regarding the procedure?

Discuss the pre- & post procedure care that will be provided. A nursing diagnosis focuses on a client's actual or potential response to a health problem rather than on the physiological event, complications, or disease. In the case of the diagnosis deficient knowledge regarding surgery, the nurse will best minimize anxiety by providing information regarding pre- & postoperative routines so as to facilitate the client in formulating realistic expectations. Although the other options are appropriate, they are limited in scope & do not have as much impact on anxiety.

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for prothrombin time (PT) and international normalized ratio (INR). The next action is to draw a sample for PI" and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.)

Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. Which of the following describes this characteristic of the nursing process?

Dynamic The term dynamic is used to describe the fact that there is much interaction and overlap among the steps of the nursing process. In some situations, all five steps may occur almost simultaneously.

Which of the following is a recognized focus area for quality improvement (performance improvement) evaluations? (Select all that apply.)

Effective care Exceeding the standard of care Delivery of care Client satisfaction Quality improvement is concerned with exceeding the standard of care, examining ways to be more efficient, improving client satisfaction, & focusing on service. Although the remaining options are pertinent, they are not major considerations of QI evaluation

After visiting with the client, the nurse documents the assessment data. Both objective & subjective information has been obtained during the assessment. Which of the following is classified as objective data?

Elevated blood pressure Objective data are observations or measurements made by the data collector, such as a blood pressure reading. Subjective data are client's perceptions about their health problems, such as pain. Fear of surgery would be subjective data because it is the client's perception & not something the data collector can measure. Subjective data are client's perceptions about their health problems, such as discomfort during breathing. A respiratory rate would be an example of objective data.

Which of the following are overarching goals of Healthy People 2020? Select all that apply.

Eliminate health disparities. Promote healthy behaviors. Increase quality and years of healthy life. The Healthy People 2020 goals are broad based. Options a and d are specific methods to promote healthy behaviors and would be seen in the objectives for a Healthy People 2020 topic area.

The nurse realizes that in order to share information from a client's medical record with another facility, the client must provide written consent. The primary reason for this requirement is to:

Ensure the client's right to have his medical information regarded as personal & confidential Educational, military, & employment records may contain significant health care information. You need written permission from the client or guardian to access or transfer the records. Any information you obtain is confidential, & you treat it as part of the client's legal medical record. This process recognizes the client's right to confidentiality. The other three options, facilitating the exchange of information, ensuring the client's rights to have his medical information regarded as personal & confidential as well as guaranteeing the sharing of information will be only when required for client care purposes are outcomes of the process but not the primary reason for the consent.

The nurse should use which guideline(s) to plan delegation and assignment-making activities? Select all that apply.

Ensuring client safety Client needs and workers' needs and abilities There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee's understanding of the directions; communicate a feeling of confidence to the delegatee, and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

Research has shown that which of the following nursing skills is best strengthened through the use of concept mapping? (Select all that apply.)

Evaluation of client outcomes in regards to nursing care Identification of patterns in the client's health assessment data Recognition of relationships among the client's various health issues Planning specialized nursing interventions to meet a client's health needs Concept mapping significantly improved students' abilities to see patterns & relationships as well as to organize, plan, & evaluate nursing care. Client teaching & assessment collecting are not markedly affected by concept mapping.

During the assessment phase of the nursing process, the nurse may uncover data that help to identify communication problems. An example of this information is:

Extreme dyspnea or shortness of breath An extremely breathless person must use oxygen to breathe rather than speak. Urinary frequency may interrupt conversation but is not a communication problem. Chronic stomach pain would not be a communication problem. The patient with chronic pain is, to some degree, used to the pain. A lack of appetite is not a communication problem.

A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve?

Facial Motor function of the facial nerve (cranial nerve VII) is assessed by asking the patient to raise the eyebrow, smile, and show the teeth.

The client tells the nurse that he understands most of the information but still has questions concerning the medication after the nurse has provided the client with information regarding the treatment plan for the diagnosis the. This response is an example of:

Feedback This response is an example of feedback. Feedback is the message returned by the receiver. The referent motivates one person to communicate with another, such as a time schedule. This is not an example of a referent. The receiver is the person who receives & decodes the message. This question is not asking about the receiver, but rather the response. Channels are means of conveying & receiving messages through visual, auditory, & tactile senses. This response is not an example of a channel.

Percussion of the thorax reveals a dull sound. The nurse interprets this to indicate which of the following?

Fluid or a solid mass A dull sound is heard when percussing over fluid or a solid mass.

Which of the following is a correctly stated nursing diagnosis?

Fluid volume deficit related to vomiting as evidenced by increased heart rate & decreased urine output "Fluid volume deficit" is incomplete; it contains only the diagnostic label. "Hypovolemia related to vomiting" is incomplete; it contains only the diagnostic label & the etiology. "Fluid volume deficit related to vomiting as evidenced by increased heart rate & decreased urine output" contains the diagnostic label, the etiology, & the defining characteristics. The etiology of "hypovolemia related to nausea as evidenced by restlessness & anxiety" is incorrect.

A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse:

Formulates a diagnosis too closely resembling a medical diagnosis A nursing diagnosis should identify the client's response, not the medical diagnosis. Because the medical diagnosis requires medical interventions, it is legally inadvisable to include it in the nursing diagnosis. A nurse should validate assessment data for accuracy & understanding. Using the NANDA International list of diagnoses as a source helps to ensure accuracy. One purpose the nursing diagnosis serves is to distinguish the nurse's role from that of the physician. Another purpose is to help nurses focus on the role of nursing in client care. Nursing diagnoses promote understanding between nurses regarding clients' health problems.

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The intervention statement "Nurse will apply warm, wet soaks to the patient's leg while awake" lacks which of the following components?

Frequency The intervention statement does not include how frequently the warm soaks should be applied. The method is applying warm, wet soaks to the patient's leg while awake. The quantity is warm, wet soaks. The qualification of the person who will perform the action is the designation of "the nurse."

A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurse's mentor?

Frequently checking the time while waiting for the client to answer Clients are less likely to fully reveal the nature of their health care problems when nurses show little interest, appear rushed, or are easily distracted by activities around them. As long as the nurse had the client's permission, this would not require follow-up. While interrupting an assessment is not recommended, a page is an example of an acceptable exception & so this would not require follow-up. If the nurse were confirming the information, it would not require follow-up. If the mentor felt the nurse was questioning the validity of client's pain rating, a followup would be appropriate because a client's pain rating should not be questioned.

The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be:

Goal partially met; client able to state three symptoms The client is showing changes but does not yet meet criteria set; therefore, the goal is partially met. The client's response, being able to state three symptoms, does not meet or exceed the outcome criteria of being able to state five symptoms. The client's response, being able to list three symptoms, demonstrates some change. If the client were showing no progress, then the goal would not be met. If the client were showing no progress, then the goal would not be met. However, this client's response does indicate some change.

The nurse has completed an assessment & found that the client has "an activity & exercise abnormality." This type of wording indicates that which of the following organizing formats has been used?

Gordon's functional health patterns Utilizing Gordon's functional health patterns format, the nurse organizes information & makes an assessment identifying functional patterns (client strengths) & dysfunctional patterns (such as an activity & exercise abnormality). The review of systems is a systematic method for collecting data on all body systems. The nurse asks the client about the normal functioning of each body system & any noted changes. A nursing health history is broader & includes information about the client's current level of wellness, a review of body systems, family & health history, sociocultural history, spiritual health, & mental & emotional reactions to illness. A biographical information database provides factual demographic data about the client, such as age, address, occupation, marital status, etc.

The nurse positions the client sitting upright during palpation of which area?

Head and neck The client should sit for examination of the head and neck. For palpation of the abdomen (option a), genitals (option b), and breast (option c), the client should be supine.

While conducting a physical assessment, the nurse Uses the bell of the stethoscope to hear which type of sounds?

Heart sounds The bell of the stethoscope is used to hear low-pitched sounds, such as those produced by the heart and vascular system.

While hospitalized, a client is very worried about business activities. The client spends a great deal of time on the phone and with colleagues instead of resting. Which principle of need therapy applies to this client?

His lower level physiological needs are being deferred while higher needs are addressed. Choices are often related to learned experiences, lifestyle, and values. The client obviously values the business more than physical health. When a person feels strongly enough, a lower level need (rest) can be postponed until a higher level need (success, safety) is met. It is very likely that no one else can meet that need for him and the lower need must still be met eventually.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time (FT) of 35 seconds. On the basis of the prothrombin time, the nurse anticipates which prescription?

Holding the next dose of warfarin The normal PT is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time. Therefore the prescriptions noted in the remaining options are incorrect.

The purpose & distinction of a concept map, which a nurse may use when implementing a plan of care, are for:

Identification of the relationship of client problems & interventions A concept map is a diagram of client problems & interventions that shows their relationship to one another. Multidisciplinary communication is enhanced with the use of critical pathways, not concept maps. The use of a concept map promotes critical thinking & helps nurses to organize complex client data, process complex relationships, & achieve a holistic view of the client's situation. The purpose is not quality assurance in the health care facility. Standardized or computerized care plans provide a standardized format for client problems, not the concept map. A concept map is highly individualized.

The nurse uses nursing diagnoses after completion of the client assessment, because they:

Identify the domain & focus of nursing After completing the client assessment, the nurse develops nursing diagnoses based on the data obtained. Nursing diagnoses distinguish the nurse's role from that of the physician, & nursing diagnoses help nurses to focus on the role of nursing in client care. Although most state nurse practice acts include nursing diagnosis as part of the domain of nursing practice, nursing diagnoses are not required for accreditation purposes. Medical problems are identified with medical diagnostic statements to treat a disease condition. Nursing diagnoses describe the client's actual or potential response to a health problem that the nurse is licensed & competent to treat. Nursing diagnoses distinguish the nurse's role from that of the physician. Nursing diagnoses may facilitate communication among health professionals, but they do not necessarily allow all client problems to become more quickly & easily resolved.

The process of analysis of patient data results in

Identifying actual or potential problems amenable to nursing intervention Analysis identifies both actual & potential problems. Analysis identifies problems. The most important interventions are determined by identifying the most important problems & the interventions related to them. Analysis will identify both actual & potential problems. These problems can be addressed through nursing interventions. The identification of patient problems that nursing can intervene with is not related only to the medical diagnosis.

The etiology of the nursing diagnosis statement is important because

If the etiology is incorrect, the nursing interventions are likely to be ineffective. On the basis of the etiology, different interventions would be selected; for example, anxiety versus fatigue. The etiology can vary although the same diagnosis is identified. For example, the etiology of the nursing diagnosis of ineffective breathing pattern could be either fatigue or anxiety. The etiology is not necessary to identify the defining characteristics that are the signs & symptoms of the nursing diagnosis. The resolution of the problem is not determined by the etiology.

The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur?

Impaired gas exchange A potential etiology for impaired gas exchange may be atelectasis. Atelectasis would not support the diagnostic label for decreased cardiac output. Atelectasis would not be an etiology for ineffective airway clearance. Increased tenacious sputum production would be a possible etiology for ineffective airway clearance. Impaired spontaneous ventilation would not be an appropriate diagnostic label for atelectasis.

Which of the following patient problems is given the highest priority by the nurse?

Impaired tissue perfusion, cerebral, related to hypoxia as manifested by decreased level of consciousness Anxiety is a psychological, not a life-threatening, problem. Impaired tissue perfusion, cerebral, is life threatening. Impaired skin integrity has a potential for harm. "Risk for fluid volume overload related to imbalance in antidiuretic hormone as manifested by peripheral edema & decreased sodium" is a potential problem.

The nurse instructs the patient about incentive spirometry as preoperative teaching. What phase of the nursing process does this illustrate?

Implementation The example in the question is an intervention, not an assessment. The example in the question is an intervention, not a plan. Implementation is the phase of the nursing process when interventions are carried out. The example of incentive spirometry is not an evaluation.

The fundamental goal for the development of a protocol for care of a client who has had a myocardial infarction client is to:

Improve the standard of care provided to the clients cared for on that unit Clinicians within a health care agency sometimes choose to review the scientific literature & their own standard of practice to develop guidelines & protocols in an effort to improve their standard of care. All the other options are potential outcomes of the implementation of a protocol.

Which of the following is an appropriate etiology for a nursing diagnosis?

Incisional pain Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a client's response to a health problem, & a condition that a nurse can treat or manage. Poor hygiene practices would not be an appropriate etiology for a nursing diagnosis because it insinuates a nurse's prejudicial judgment. Need to offer bedpan frequently is not an appropriate etiology because it identifies a nursing intervention, not an etiology. Inadequate prescription of medication by the physician is not an appropriate etiology because it identifies the nurse's problem, not the client's problem. The nursing diagnosis should center attention on client needs.

What is the most appropriate method for the nurse to communicate a client's wishes to the nurses on the next shift?

Include the client's request in the shift report. In the acute care setting, the change-of-shift report is the way for nurses from one shift to communicate information to nurses on the next shift Documenting the request in the nursing notes is not appropriate for inclusion in the nursing notes because it does not reflect information regarding the client's condition, response to treatment, or current health status. Placing the instructions regarding the client's wishes above the bed is not appropriate because there is no guarantee that staff will see the posting, but more importantly there are confidentiality issues being ignored. While verbally informing the unit clerk of the client's request may result in the client's wishes being respected, it is not the most effective option.

Which one of the following is an appropriate etiology for a nursing diagnosis?

Increased airway secretions Increased airway secretions is a condition that responds to nursing interventions & therefore would be an appropriate etiology for a nursing diagnosis. Myocardial infarction would not be an appropriate etiology for a nursing diagnosis because it is a medical diagnosis. Nursing interventions will not alter the medical diagnosis of myocardial infarction. Cardiac catheterization is a diagnostic procedure & would not be an appropriate etiology for a nursing diagnosis. Rather, the client's response to the procedure would be the area of nursing concern. Abnormal blood gas levels would not be an appropriate etiology for a nursing diagnosis because it is not a causative factor, but rather it is a defining characteristic of a problem.

Based on the following information, what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, & variable respiratory rate.

Ineffective airway clearance The defining characteristics of abnormal breath sounds, dyspnea, an intermittent cough, & variable respiratory rate cue the nurse to the nursing diagnosis of ineffective airway clearance. Risk for injury does not support the diagnostic label of risk for injury. Excess fluid volume does not support the diagnostic label of excess fluid volume. There would be other defining characteristics such as edema, weight gain, & an elevated blood pressure. Impaired spontaneous ventilation does not most accurately describe impaired spontaneous ventilation. Other characteristics, such as apnea, would better support the diagnostic label of impaired spontaneous ventilation.

Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Ineffective airway clearance related to increased secretions Ineffective airway clearance related to increased secretions is written appropriately. It identifies a problem using a NANDA International diagnostic statement & connects it to its etiology. Risk for change in body image related to cancer is written incorrectly. It uses a medical diagnosis for the etiology. Cardiac output decreased related to motor vehicle accident is written incorrectly. The etiology is not treatable. Potential for injury related to improper teaching in the use of crutches is written incorrectly. It identifies the nurse's problem, not the client's.

Which of the following patient problems is given the highest priority by the nurse using Maslow's hierarchy of needs?

Ineffective airway clearance related to retained secretions Psychological safety is a not higher level need than oxygenation. The need for oxygen is one of the most basic needs. Although fluid volume excess related to third spacing of fluid (edema) concerns a basic need, it is not as life threatening as lack of oxygen. Although ineffective thermoregulation related to fever concerns a basic need, it is not as life threatening as lack of oxygen.

The goal of the orientation phase of a nursing interview is to: (select all that apply)

Initiate the nurse-client relationship Begin identifying the client's needs Earn the trust & confidence of the client Initiating the nurse-client relationship, beginning to identify the client's needs & earning the client's trust & confidence. During the orientation phase you establish trust & confidence with a client. One important goal for the initial interview is to make the foundation for understanding the client's primary needs. Another is to begin a relationship that allows the client to become an active partner in decisions about care. As the orientation phase proceeds, the client should begin to feel more comfortable speaking with you so the necessary information can be obtained. Assuming the decision role isn't correct as the client should be involved in all care decisions; assuming this role is not appropriate. While welcoming the client to the nursing unit is an expected outcome of the orientation phase of the interview process, it is not a goal. While gathering the client's demographic information is an expected outcome of the orientation phase of the interview process, it is not a goal.

A nurse and a primary care provider inform a client that chemotherapy is recommended for a diagnosis of cancer. Which nursing action is most representative of the concept of holism?

Inquire how this will affect other aspects of the client's life. Holism implies consideration of all aspects of the client's life. Although arranging for home care (option a), facilitating spirituality (option b), and offering coping resources (option d) may be appropriate, the nurse begins a holistic approach to care by examining, with the client, in what ways the illness influences the various segments of her life. The client is the best source of information regarding personal needs. Assessment should always precede intervention.

Which of the following is a characteristic of an accomplished critical thinker?

Inquisitiveness The accomplished critical thinker needs to ask questions when things do not seem quite right. The accomplished critical thinker thinks broadly, considering all possibilities. The accomplished critical thinker considers all information & all arguments before deciding on a course of action. The accomplished critical thinker considers the facts, fits them into known patterns, considers all aspects of the problem, & makes decisions based on knowledge, not on instinct.

The nurse has determined the following outcome for a client with a skin impairment: "Erythema will be reduced in 3 days." Evaluation will specifically focus on:

Inspection of the color & condition of the area Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspection of the color of the skin, as stated in the outcome criterion. Selection of appropriate wound care is an intervention, not an evaluation of a client's behavior or response. The outcome criterion does not state anything about drainage. Noting the color & amount of drainage may be a part of reassessment of the client, but is not what the nurse is evaluating according to this outcome criterion. The outcome criterion states the erythema will be reduced, not the size of the ulceration. During the evaluation step of the nursing process, the client's behavior or response should be compared to the outcome criterion & judged for degree of agreement between the two.

Mentally reviewing the steps of a complicated nursing procedure before entering the client's room is an example of:

Interpersonal communication A type of intrapersonal communication, self-instructions, provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively. Interpersonal communication is one-to-one interaction between the nurse & another person that often occurs face to face while transpersonal communication is interaction that occurs within a person's spiritual domain. Nonverbal communication includes all five senses & everything that does not involve the spoken or written word.

The nurse is discussing discharge instructions with a client who was recently diagnosed with type 1 diabetes mellitus & is now taking insulin. The nurse recognizes this as an example of:

Interpersonal communication Interpersonal communication is one-to-one interaction between the nurse & another person that often occurs face to face. Transpersonal communication is interaction that occurs within a person's spiritual domain while intrapersonal communication, self-talk or self-instruction provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively. Nonverbal communication includes all five senses & everything that does not involve the spoken or written word.

What is the primary method of obtaining patient data?

Interview with patient Medical record is the third source, along with consultation. The presence of others, even family, can obstruct the interview process. The patient interview is the primary method of obtaining information. The examination is the second process.

When you enter the patient's room to begin your nursing history, the patient's wife is there. What should you do?

Introduce yourself and ask the patient if he would like the wife to stay. The patient has the right to indicate who he would like to be present for the nursing history and exam. You should neither presume that he wants his wife there (a), nor that he does not want her there (c). Similarly, the choice belongs to the patient, not the wife (b).

An adult female client has a hemoglobin level of 10.8g/dL. The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia The normal hemoglobin level for an adult female client is 12 to 15g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen carrying capacity.

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is:

Irrigate the nasogastric tube q2h with 30 ml normal saline Irrigate the nasogastric tube q2h with 30 ml normal saline is the most appropriate intervention statement. It includes the action, frequency, quantity, & method. Offer fluids to the client q2h lacks the component of quantity. Observe the client's respirations fails to indicate the frequency or method. Also, what is the reason for observation of the client's respirations? Change the client's dressing daily omits the method.

The nurse identifies the nursing diagnosis risk for injury for a client who is unable to verbally communicate effectively. The primary risk for injury occurs because the client:

Lacks the ability to tell the staff what he or she needs The client who cannot communicate effectively will often have difficulty expressing needs & responding appropriately to the environment. A client who is unable to speak is at risk for injury unless the nurse identifies an alternate communication method. The remaining options relate to potential outcomes of ineffective verbal communication but not to the risk for injury.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The nurse anticipates that which action is needed?

Leaving the rate of the heparin infusion as is The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. This means that the client's value should not be less than 30 seconds or greater than 90 seconds. Thus the client's aPTT is within the therapeutic range and the dose should remain unchanged.

When assessing a patient's mental status, which of the following would the nurse be least likely to include when evaluating level of awareness?

Level of consciousness Assessing consciousness is separate assessment and is not included in assessing a patient's level of awareness, which involves evaluating a patient's orientation to time, place (where the patient is), and person (who the patient is, such as his name or age).

Which technique would a nurse use to assess skin turgor?

Lightly pinch a fold of skin Skin turgor is assessed by lightly pinching a fold of skin and allowing it to return to its shape when released.

The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to prioritizing her request?

Low priority The client's request would be of low priority because it is not directly related to a specific illness or prognosis. An unmet need is not the most appropriate label for the client's request. The client's request is not an intermediate priority. An intermediate priority is one that involves the non-emergent, non-life-threatening needs of the client. The client's request is not a safety & security need; the outcome does not threaten her well-being.

The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the client's:

Lungs clear bilaterally on auscultation Auscultating lung sounds is the best way to determine if airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement. Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine if airways are free of secretions. A complaint of chest pain would be a negative outcome, & it is not the focus for determining whether airways are free of secretions as written in the outcome statement. Having the ability to perform incentive spirometry does not determine whether the airways are clear or not. It is an intervention that may help achieve clear airways.

The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is she using?

Modifying the nursing care plan The nurse is modifying the nursing care plan. Data have been updated to reflect the client's current status of an elevated PTT; nursing diagnoses & specific interventions are revised. In this case, the revised intervention is withholding the Coumadin. By gathering further assessment data & revising nursing interventions, the nurse is modifying the nursing care plan.

The nurse's initial responsibility in the management of a client's collaborative problem is to:

Monitor for changes Nurses initially monitor to detect the onset of changes in a client's status. Although advocating for the client is a nursing role, it is not reserved exclusively to collaborative problems. Implement interventions is not the initial responsibility. Evaluate client outcomes is not the initial responsibility.

In documentation of nursing care plans, critical pathways differ from traditional nursing care plans in their:

Multidisciplinary approach Critical pathways are multidisciplinary. They allow staff from all disciplines, such as medicine, nursing, pharmacy, & social work, to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type. Client outcomes are included in both critical pathways & traditional nursing care plans. Client assessment is necessary for developing & evaluating critical pathways & traditional nursing care plans. Nursing interventions are included in critical pathways & in the traditional nursing care plan.

Supporting a client by holding onto her elbow while accompanying her as she ambulates around the nursing unit is considered social touching & so would typically:

Not require the client's permission A person's hands, arms, shoulders, & back are considered social zones & typically do not cause a client emotional discomfort if touched, & so permission to do so is not generally required. Nurses frequently move into clients' personal space because of the nature of caregiving. You need to convey confidence, gentleness, & respect for privacy, especially when your actions require intimate contact or involve a client's vulnerable zone. The remaining options do not necessarily deal with a client's social touching zone.

The nurse checks the laboratory result for a serum digoxin level that was prescribed for a client earlier in the day and notes that the result is 2.4ng/mL. The nurse should take which immediate action?

Notify the health care provider (HCP). The normal therapeutic range for digoxin is 0.5 to 2mg/mL. A level of 2.4mg/mL exceeds the therapeutic range and indicates toxicity. The nurse should notify the HCP, who may give further prescriptions about holding further doses of digoxin. The option that indicates to record the normal value on the client's flow sheet is incorrect because the level is not normal. The next dose should not be administered because the serum digoxin level exceeds the therapeutic range. Checking the client's last pulse rate may have limited value in this situation. Depending on the time that has elapsed since the last assessment, a current assessment of the client's status may be more useful.

Which of the following describes the primary difference between nursing diagnoses & medical diagnoses?

Nursing diagnoses identify problems that can be treated with independent nursing actions. Nursing diagnosis is not simple versus complex problems but the human response to disease. Nursing diagnoses are identified by nurses & do not need to be verified by any other professional. Nursing diagnoses identify the human effect of disease on the person. Nursing diagnoses identify problems that nurses can treat within their scope of practice.

For a client whose assessment of the musculoskeletal system is normal, which does the nurse check on the medical record? (Select all that apply.)

Of the terms listed, only equal, symmetrical, and firm are normal findings. Atrophied, flaccid, contractured, hypertrophied, crepitation, spastic, and tremor are abnormal findings. Review the terms in the glossary to go over their meanings.

When assessing a patient's eyes, which instrument would the nurse use to visualize the retina?

Ophthalmoscope

When meeting for the first time, the home health nurse smiles warmly & shakes the client's hand. The nurse client relationship is in the:

Orientation phase When the nurse & client meet & get to know one another, they are engaged in the orientation phase of the nurse-client relationship. The remaining options are phases that occur either before or after the orientation phase.

The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the morning. Which of the following client needs should take priority?

Orientation to the nursing unit & individual room The client's admission has no acute physical needs & so the emotional need of familiarization with the environment has priority. Inventory of clothes & other personal belongings does not reflect a priority because it does not relate directly to a physical need, & there are other emotional needs of higher priority. Interview regarding medications currently being taken does not reflect a priority because it does not relate directly to a physical need, & there are emotional needs of higher priority. Although assessment of body systems for presurgery checklist reflects a needed nursing action, it is not a priority because it does not relate directly to physical need, & there are other emotional needs of higher priority.

A client interview consists of three phases. The nurse recognizes that those phases are:

Orientation, documentation, database

Which of the following is considered subjective data in information gathering from the patient?

Pain Pulse rate & blood pressure measurements are signs or objective data that can be confirmed by observation. The ECG pattern is objective data. Diaphoresis is objective data. Subjective data are the patient's perceptions, sometimes called symptoms.

Based on the following outcome criterion determined by the nurse: "Client will independently complete necessary assessments prior to administration of digoxin (cardiotonic)" the nurse will evaluate the client's ability to:

Palpate the radial pulse The nurse should compare the established outcome criteria with the client's behavior or response. In this case the client is expected to independently complete the necessary assessments before administration of digoxin. The client should be able to palpate the radial pulse as an assessment before administration of digoxin. The outcome criterion does not state anything about exercise. During evaluation, the nurse is to judge the degree of agreement between the outcome criteria & the client's behavior. The outcome criterion does not state anything about diet. Evaluating whether the client reviews dietary habits would not be comparable to necessary assessment before medication administration. The outcome criterion does not state anything about the skin. The nurse, who knows that digoxin is a cardiotonic, understands that the client should be assessing the heart rate.

Which of the following represents an interdependent nursing action?

Participating in a "code" (cardiac arrest response) "Giving the patient an ordered medication" is a dependent nursing action. "Bathing the patient" is an independent nursing action. "Inserting a Foley catheter" is a dependent nursing action. "Participating in a 'code' (cardiac arrest response)" is an example of an action that involves collaboration with other health care professionals before & during implementation. It requires a protocol.

Which of the following is considered a primary source when gathering assessment data?

Patient The patient is the only true primary source. The spouse is a secondary source. Medical record is a tertiary source. The physician is a tertiary source.

The identification of nursing diagnosis & goal setting should be a collaborative process between the nurse & which other party?

Patient The physician does not set nursing goals. The nurse manager does not set nursing goals. The family does not set goals for the patient. Nursing goals should be agreed on jointly by the nurse & the patient.

A patient is in respiratory distress & placed on oxygen. Which is the most appropriate short-term goal?

Patient maintains an oxygen saturation of 90% during the shift. "Nasal cannula remains in place" is not a patient goal & there is no time frame. "Patient completes morning care & eats breakfast" is broad & there is no time frame. Although there is a short time frame, the goal "patient verbalizes that he is breathing better after lunch" lacks specificity. "Patient maintains an oxygen saturation of 90% during the shift" involves a specific goal for the patient in a short time frame.

Which of the following statements has all of the necessary criteria for a well-written outcome?

Patient will consume 50% of meals with no nausea & vomiting by 24 hours post surgery. "Patient will consume 50% of meals with no nausea & vomiting by 24 hours post surgery." is specific, measurable, & has a specific time frame. Outcomes should be patient focused. "Patient will ambulate in halls a little today" is nonspecific & not measurable. "Patient's condition will improve before discharge" is nonspecific, is nonmeasurable, & has no time frame.

Which of the following is an appropriate long-term goal to measure diabetes control for a patient in whom diabetes has been newly diagnosed?

Patient's A 1c will be 5% at 1 year post diagnosis. Taking the insulin is important but does not indicate how well blood glucose was controlled. Although keeping appointments is important for diabetes management, this does not indicate blood glucose control. "Patient's A1c will be 5% at 1 year post diagnosis" reflects the best indicator of long-term control of blood glucose level & therefore diabetes management. "Patient's recorded blood glucose will be between 60 & 120 mg/dL each day" is a short-term measure of blood glucose control.

A client who is 46 pounds overweight tells you, "I was just born to be fat. I don't have the willpower." Although weight loss occurred while attending two previous programs that "guaranteed" weight loss, the weight returned along with extra pounds after each program. According to the Health Promotion Model, the nurse is most likely to focus on which behavior specific cognition and affect variable for this client?

Perceived self-efficacy Perceived self-efficacy is the confidence the person has for achieving the desired outcome. Option a is a person's perceptions about available time, inconvenience, expense, and difficulty performing the activity. Option c is the person's perceptions concerning the behaviors, beliefs, or attitudes of others. Option d refers to the person's perception of the environment and how it assists or detracts from the healthy behavior.

When modifying a care plan to meet a client whose status has changed significantly over the past few days, the nurse should:

Perform a complete reassessment of all client factors A complete reassessment of all client factors relating to the nursing diagnosis & etiology is necessary when modifying a plan. After reassessment the nurse will determine what components of the care plan are accurate for the situation. It may not require redoing the entire care plan. The nurse should not only focus on the nursing diagnoses & goals that have changed. Interventions may also need revising to meet new goals. Adding more nursing interventions may or may not be necessary. The nurse adjusts interventions on the basis of the client's response & previous experience with similar clients. Standards of care are used to determine whether the right interventions have been chosen or whether additional ones are required.

When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate?

Perform and document a focused assessment on skin integrity. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone (b) or corrected (a). This is not a life-threatening event; thus, there is no need for an emergency assessment (c).

The nursing diagnosis of acute pain falls under which of the following comfort domain classifications?

Physical comfort There are only three classifications for the comfort domain. Acute pain is a physiological response & so is classified as a physical comfort problem. Impaired verbal communication is considered a social comfort issue, while at risk for poisoning would be considered an environmental comfort issue.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. The nurse should take which action after seeing the laboratory results?

Place the normal report in the client's medical record. A normal platelet count ranges from 150,000 to 400,000 cells/mm3. The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 cells/mm3 is not an elevated count. The count also is not low; therefore bleeding precautions are not needed.

Which of the following is the single most negative factor affecting a nurse's credibility?

Poor nurse-client communication Breakdown in communication is a top contributor to errors in the workplace & threatens professional credibility. The remaining options affect credibility but not to the extent that poor communication does.

The nurse realizes that the primary nursing responsibility regarding a physician-initiated intervention is to:

Possess the technical skills required to implement the intervention Each physician-initiated intervention requires specific nursing responsibilities & technical nursing knowledge. Although the other options are expectations, they are not the primary consideration.

There are a number of variables that may influence the client's communication with the health care team. Which of the following is an example of an interpersonal variable?

Postoperative discomfort Interpersonal variables are factors within both the sender & receiver that influence communication. An example of an interpersonal variable is postoperative discomfort. An extremely warm room is an example of an environmental variable that may affect communication. A talkative roommate is an example of an environmental variable that may affect communication because of the lack of privacy & distraction. Noise, such as a loud television, is an example of an environmental variable that may affect communication.

A client with diabetes mellitus has a glycosylated hemoglobin A]c level of 9%. On the basis of this test result the nurse plans to teach the client about the need for which measure?

Preventing and recognizing hyperglycemia In the test result for glycosylated hemoglobin A , 7% or less indicates good control, 7% to 8°/o indicates fair control, and 8% or higher indicates poor control. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

Which of the following statements describes the purpose of the nursing process?

Process used to identify & solve patient problems Although proper documentation is part of the nursing process, it is a problem-solving process, not a documentation process. The nursing process is not used with reimbursement potential in mind. The nursing process is not a time-management strategy. The purpose of the nursing process is to identify & solve patient problems.

The primary reason for the establishment of standing orders is to:

Provide appropriate nursing autonomy in settings where client needs can change rapidly Licensed prescribing physicians or health care providers in charge of care at the time of implementation approve & sign standing orders. These orders are common in critical care settings & other specialized practice settings where clients' needs change rapidly & require immediate attention, thus providing for nursing autonomy to assess & implement appropriate care.

Nursing interventions may be categorized based upon the degree of nursing autonomy. An example of a nurse initiated intervention is:

Providing client teaching Health teaching is an example of a nurse-initiated intervention. Administering medication is a physician-initiated intervention. Ordering a CAT scan is a physician-initiated intervention. Referring a client to physical therapy is a collaborative intervention.

Which of the following is the best example of an intermediate prioritized client need for a client diagnosed with risk of injury related to poor skin integrity?

Providing sufficient quantities of an aloe-based skin lotion An intermediate priority is one that involves the non-emergent, non-life-threatening needs of the client. Having sufficient aloebased lotion is required for maintaining good skin integrity but is not required for meeting a life-threatening need. Although the other options are an intermediate need, they are not the best option because they are not directly related to the client's stated nursing diagnosis.

An enterostomal nurse shows a client's significant other how to assist with the supplies for the ostomy & how to manipulate the ostomy equipment. In demonstrating this technique to the client's significant other, the nurse is using what type of nursing skill?

Psychomotor Psychomotor skills involve the integration of cognitive & motor activities, such as in providing ostomy care. Cognitive skills involve the application of nursing knowledge. Knowing the rationale for therapeutic interventions, understanding normal & abnormal physiological & psychological responses, & being able to identify client learning & discharge needs all require cognitive skills. Interpersonal skills are used when the nurse interacts with clients, their families, & other health care team members. Effective communication is an example of an interpersonal skill. Affective means pertaining to an emotion or mental state.

The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job. Job loss best fits into which of the following categories?

Psychosocial history The psychosocial history reveals the client's support system, if there are any recent losses or stressful events, & how the individual copes with such stressors. The loss of a job would fit the psychosocial history category. Family history is used to obtain data about immediate & blood relatives to determine whether the client is at risk for illnesses of a genetic or familial nature. It also provides information about the family itself. The biographical history provides factual demographic data about the client. The environmental history provides data about the client's home & working environments.

The nurse is preparing a community outreach program on stress management. The nurse realizes that speaking in public requires some specific adaptations regarding: (Select all that apply.)

Public communication requires special adaptations in eye contact, gestures, voice inflection, & use of media materials to communicate messages effectively. Makeup & clothing need to be appropriate but do not require specific adaptations.

When palpating the breast of a woman during an assessment, the nurse would divide the breast into which of the following?

Quadrants The breast is divided into four quadrants—outer upper quadrant, outer lower quadrant, inner upper quadrant, and inner lower quadrant. Each quadrant is systematically palpated.

A "well-cultivated critical thinker" is an individual who (select all that apply):

Raises questions b. Recognizes alternative ways to see problems A critical thinker identifies clear & precise questions & is open-minded to alternative ways to see problems. Incorrect A critical thinker gathers & assesses all relevant information & will communicate with others as he or she formulates solutions.

In goal setting, the nurse is aware that the factor that is associated with available client resources & motivation is:

Realistic The nurse sets realistic goals that can be achieved. This increases the client's motivation. The nurse also takes available resources into consideration in order to set realistic goals. Being observable means the nurse must be able to determine through observation if change has taken place. Being measurable means the goal is written so the nurse has a standard against which to measure the client's response to nursing care. Being client-centered means the goal should reflect the client's behavior & responses expected as a result of nursing interventions.

Which is the best response by the nurse if a client fails to follow the information or teaching provided?

Reassess the client's importance given to the behavior and readiness to change it. Change is a complex process and a nurse should not give up or assume that the client does not want to change (option a). People often resist a tough approach because it can make them feel cornered. This approach may work for some people but not for everyone (option b). The goal of teaching is to try to help the client become the expert as well (option c).

The primary purpose of a nursing diagnosis, according to the nurses, is to:

Recognize the client's response to an illness or situation The primary purpose of a nursing diagnosis is to recognize the client's response to an illness or situation. The nurse can then use the nursing diagnosis to select appropriate nursing interventions to achieve positive client outcomes. A nursing diagnosis is based on the client, not on the medical plan of care. Although nursing diagnoses may facilitate communication, it does not mean they provide a standardized approach for all clients. Nursing diagnoses are individualized to meet the client's needs. The primary purpose of nursing diagnoses is not to offer the nurse's subjective view of the client's behaviors. Nursing diagnoses are based on subjective & objective client data & should not include the nurse's personal beliefs & values.

An example of a cognitive nursing skill is:

Recognizing the potential complications of a blood transfusion Cognitive skills involve the application of nursing knowledge. Understanding normal & abnormal physiological & psychological responses is a cognitive skill, as in recognizing the potential complications of a blood transfusion. Providing a soothing bed bath involves both interpersonal skills & psychomotor skills. The nurse who provides a soothing bed bath is expressing a level of caring that is an interpersonal skill. The nurse who provides a soothing bed bath is also using a psychomotor skill in performing the bed bath correctly. Communicating with the client & family is an example of an interpersonal skill. Giving an injection to the client is a psychomotor skill.

The nurse who is assisting a client in the action stage of change would use which strategy?

Reinforce the importance of providing rewards for positive behavior. Option b is a strategy for the contemplation stage, option c is a strategy for the preparation stage, and option d is a strategy for the maintenance stage.

The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the client's environment. This involves the nurse:

Removing clutter from the client's room Making rooms free of clutter is an example of manipulating the environment to create safe surroundings. The remaining options are examples of the organization of care & personnel.

When a client goal is unmet, which of the following nursing actions is most appropriate?

Repetition of the entire nursing process regarding the nursing diagnosis When there is failure to achieve a goal, no matter what the reason, repeat the entire nursing process sequence for that nursing diagnosis to discover changes the plan needs. The remaining options reflect individual elements within the nursing process.

The use of written plans of care in the form of standardized plans of care has

Required the nurse to individualize the plan of care to the patient Standardized plans of care are not always critical paths and/or interdisciplinary. Although plans for frequent patient problems can be easily produced, the plan of care still may need to be modified to meet the needs of the patient. The use of standardized plans of care has not eliminated the need for an individualized plan. The use of the standardized plans of care has decreased the time required of the nurse to update & document the plan of care.

Which is a normal finding on auscultation of the lungs?

Resonance over the left upper lobe Resonance is a normal sound over the lung. Tympany would be heard over the stomach (air filled) (option a), hyperresonance is never a normal finding (option c), and dullness would be heard below (not above) the 10th intercostal space (option d).

Which one of the following interventions selected by the nurse is classified as Level 2, Domain 2 (Physiological: complex)?

Restoring tissue integrity to areas damaged by friction Interventions to maintain or restore tissue integrity are classified as Level 2, Domain 2 (Physiological: Complex). Maintaining regular bowel elimination is classified as Level 2, Domain 1 (Physiological: Basic). Promoting the health of the family is classified as Level 2, Domain 5 (Family). Managing restricted body movement is classified as Level 2, Domain 1 (Physiological: Basic).

The plan of care offers a number of different types of nursing interventions that may be incorporated in. An example of a nurse implemented specific life-saving measure is:

Restraining a violent client Restraining a violent client is an example of a life-saving measure to protect the client. The purpose of a life-saving measure is to restore physiological or psychological equilibrium. Administering analgesics is an example of physical care techniques. It is not a life-saving measure. Initiating stress-reduction therapy is an example of a counseling technique. Teaching the client how to take his or her pulse rate is an example of the nursing intervention of teaching. The focus is for the client to obtain new knowledge or psychomotor skills.

A patient is admitted with the diagnosis of bronchitis, congestive heart failure, & fever. The nurse's assessment finds a temperature of 101F, peripheral edema, & rhonchi. Which of the following is the best etiology to support the nursing diagnosis of ineffective airway clearance?

Retained secretions Peripheral edema is related to the accumulation of fluid in the feet & legs but has nothing to do with the airway. The nursing diagnosis indicates that "something" may be blocking the airway. Respiratory secretions are the only choice that could block the airway. Bronchitis is a medical diagnosis. Congestive heart failure is a medical diagnosis.

Assuming that all of the following are realistic, a long-term goal for a client that is a tailor by trade & has been admitted for eye surgery should include:

Returning to sewing Long-term goals focus on prevention, rehabilitation, discharge, & health education. An appropriate long-term goal for this client would be for rehabilitation & the client's return to occupation, in this case sewing. Preventing ocular infection is a short-term goal. A short-term goal is expected to be achieved within a short time, usually in less than 1 week. In 1 weeks' time, the client's risk for infection should be greatly reduced. Administering eye drops on time in the hospital is a short-term goal. Long-term goals are usually designed for problem resolution after discharge, especially from an acute care setting. Performing independent hygienic care in the hospital is a short-term goal. Long-term goals are usually made for problem resolution after discharge, especially from an acute care setting.

While discussing a client's medication history, the client tells the nurse that she thinks she is allergic to a particular type of medication. Which of the following nursing actions has priority in this situation?

Review the client's medical record for confirmation of the allergy. The medical record is a valuable tool for checking the consistency & similarities of personal observations. Information such as a history of allergic reactions would be found in the medical record. Noting the allergy on the client's Kardex would be appropriate only after the allergy is confirmed; although if there was true concern, a notation of a possible allergy should be noted on the medication record. Informing the provider of the client's possible allergy would be appropriate after the medical record was reviewed & no mention of the allergy was confirmed or denied. While telling the client to have all medications identified before taking them is a safety measure appropriate for all clients, it is not the priority in this situation.

Which one of the following is a NANDA International nursing diagnosis label?

Risk for impaired parenting "Frequent urination" is a symptom, not a NANDA International nursing diagnosis label. "Coughing & dyspnea" are symptoms, not a NANDA International nursing diagnosis label. "Risk for impaired parenting" is a NANDA International nursing diagnosis label. "Abnormal hygienic care practices" is not a NANDA International nursing diagnosis label. It incorrectly implies a nurse's prejudicial judgment.

Care plans created by nursing students usually differ from those that are completed by nurses working on client units. An aspect of the plan that is usually included in the student's care plan but not in the client's record is:

Scientific rationales An aspect of a nursing care plan that is usually included in the student's care plan, but not in the client's record, is scientific rationales. Client outcomes are included in both student care plans & the client's record. Nursing diagnoses are included in both student care plans & the client's record. Nursing interventions are a component of both student care plans & a nursing care plan in the client's record.

The nurse notes that a narcotic is to be administered "per epidural cath." The nurse; however, does not know how to perform this procedure. Which aspect of the implementation process should be followed?

Seek assistance If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature & the agency's procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly & safely provides assistance & guidance. Reassessing the client is a partial assessment that may focus on one dimension of the client or on one system. Interpersonal skills are used to develop a trusting relationship, express a level of caring, & communicate clearly with the client, family, & health care team. Critical decision making is used when the nurse implements the care plan using the knowledge bases necessary for care planning & then completing the planned interventions most effectively.

A nurse is providing care for a client receiving normal saline when the IV infiltrates. Which of the following nursing actions represents the evaluation phase of the nursing process?

Site reinspected for presence of swelling. Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the nursing process, the client's condition or well-being improves. The remaining options represent the assessment & implementation phases.

Communication involves both active listening & body language working together. The nurse actively listens to the client and:

Sits facing the client Active listening means to be attentive to what the client is saying both verbally & nonverbally. A nonverbal skill to facilitate attentive listening is to sit facing the client. This posture gives the message that the nurse is there to listen & is interested in what the client is saying. For active listening, the arms & legs should be uncrossed. This posture suggests that the nurse is "open" to what the client says. For active listening, the nurse should lean toward the client. This posture conveys that the nurse is involved & interested in the interaction. For active listening, the nurse should establish & maintain intermittent eye contact. This conveys the nurse's involvement in & willingness to listen to what the client is saying.

The nurse realizes that the cancer support group for breast cancer clients will be most effective if the group: (Select all that apply.)

Small groups are more effective when they are a workable size & have an appropriate meeting place, suitable seating arrangements, & cohesiveness & commitment among group members. Group participants need to feel accepted, feel able to communicate openly & honestly, & actively listen to others in the group. Similarity in age & similarity in culture are not necessary criteria for a successful group interaction.

The nurse is aware of the client's zones of personal space when planning interactions. The zone of personal space & touch that extends the greatest amount from an individual is the:

Social zone The social zone extends the greatest amount from an individual in personal space & touch. It is a distance of 4 to 12 feet. Permission is not needed for touch in the social zone. The personal zone is 18 inches to 4 feet. The consent zone of touch requires permission. The vulnerable zone is in the consent zone of touch. Because the vulnerable zone implies special care is needed, permission is required.

To provide optimum care, a nursing intervention should be based on:

Sound clinical judgment & knowledge The assessment data direct the nurse in the formulation of a client-specific care plan grounded within clear, relevant nursing diagnoses & directed towards appropriate, attainable client outcomes. A nursing intervention is any treatment, based upon clinical judgment & knowledge that a nurse performs to enhance client outcomes. Ideally, the interventions a nurse uses are evidence-based, providing the most current, up-to-date, & effective approaches for client problems. Interventions include both direct & indirect care measures, aimed at individuals, families, &/or the community.

A client is admitted for a CAT scan (diagnostic test) of the cranium. As the nurse explains this diagnostic test, the client moves away from the nurse. This is an example of what influencing factor in communication?

Space & territoriality Territoriality is the need to gain, maintain, & defend one's right to space. The client who moves away from the nurse during a conversation is demonstrating the influence of space & territoriality on communication. This not an example of gender influencing communication. This is not an example of environment influencing communication. Noise, temperature extremes, distractions, & lack of privacy are examples of environmental factors that may influence communication. Although people do maintain varying distances between each other depending on their culture, this is not an example of sociocultural background influencing communication, as cultural orientation is not mentioned in this situation.

A patient complains about feeling nauseated after lunch. This is an example of what type of data?

Subjective A patient report of "feeling nauseated" cannot be perceived or validated by the nurse, and this is subjective data, not objective (b) or overt (d), which are observable and measurable. Answer c is wrong because signs are examples of objective data.

A client shares with the nurse that they have, "almost reached the goal of smoking only one-half pack of cigarettes a day." The best example of a nursing intervention to correct this unmet outcome is:

Suggest that the strength of the prescribed nicotine patches be increased to 21 mg An unmet outcome reveals the client has not responded to interventions as planned. As a result, the nurse changes the plan of care by trying different therapies or changing the frequency or approach of existing therapies. The best option is one that adds to the existing therapy. The remaining options should have been explored as a part of the goal-setting process or exercised if the current therapy proves ineffective.

Which of the following interventions best reflects the nurse's understanding of direct care interventions regarding a cognitively impaired client's need for social interaction?

Talking about the client's favorite sport's team while redressing his or her wound Direct care interventions are treatments performed through interactions with clients. Actively engaging in a conversation with the client is the best direct care intervention & so demonstrates the best understanding of the concept. Facilitating interaction does not have as much impact as being actively involved. Turning on the TV is an example of an indirect care intervention.

Which of the following is an independent nursing intervention?

Teaching a patient with congestive heart failure to weigh himself daily Teaching requires no supervision, & nurses can carry out teaching interventions independently. Prescribing medication is not a nursing intervention. "Changing the first surgical dressing on a patient after surgery" is a dependent nursing action. "Transferring a patient out of the intensive care unit 2 days after vascular surgery" is a dependent nursing intervention.

A close, effective nurse-client relationship impacts interpersonal communication most by facilitating:

The accurate interpretation of shared information The more the sender & receiver have in common & the closer the relationship, the more likely they will accurately perceive one another's meaning & respond accordingly. The remaining options are outcomes of an effective nurse-client relationship but they do not impact communication as directly.

When following up on a client's report of hip pain during an admission assessment, the most nursing conclusive observation would be:

The client observed grimacing when positioning self in the bed This option where the client was observed grimacing describes nonverbal actions that are associated with pain when the client is unaware of being observed & so represents the most conclusive follow-up evidence of pain. The options where the client is tearing when ambulated to the chair, the ancillary staff's report of the client's pain as well as overhearing the client discuss hip pain may well be an observation of pain, but they are not the most conclusive of the options because the client is aware of being observed.

Which of the following would be the best example of a short-term safety goal for a client who recently experienced abdominal surgery?

The client will consistently use the call bell to notify the staff of a need for assistance to the bathroom upon return to the nursing unit. Although all the options represent short-term goals, this option (consistently use the call bell to notify the staff) is directly related to client safety because it deals with fall prevention. Although this is short-term goal (by time of discharge), it is not as directly related to safety as some other options. Although this is short-term goal (time is inferred by nature of pain needs), it is not as directly related to safety as some other options. Although this is short-term goal (2 hours), it is not as directly related to safety as some other options.

The primary function of a care plan is to provide:

The client with continuity of care The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care. Although the rest are functions, they are not the primary function.

The nurse caring for an immobile client with a pressure ulcer implements an intervention that requires repositioning the client every 2 hours. Which of the following represents the best evaluation method for this intervention?

The client's pressure ulcer shows a decrease in size over a 1-week period. You conduct evaluation measures to determine if you met expected outcomes, not if nursing interventions were completed. The decrease in size of the pressure ulcer best evaluates the effectiveness of this intervention while the remaining options reflect client opinion, further skin breakdown, or implementation of the intervention.

An older client who appears confused after discussing his new diagnosis of Parkinson's disease shares with the nurse that, "I didn't understand much of what you said." The nurse determines that the most likely cause of the client's failure to understand is that:

The conversation included unfamiliar medical terminology Medical jargon (technical terminology used by health care providers) sounds like a foreign language to clients unfamiliar with the health care setting. Limiting use of medical jargon to conversations with other health team members will improve communication. The remaining options may have contributed to the problem, but the more common problem deals with inappropriate use of jargon.

The nurse shares with a client diagnosed with bipolar disorder who is in the manic phase that, "The CNA will be in 20 minutes to complete your ADLs." This nurse-initiated communication will likely result in client confusion or noncompliance because:

The conversation relied on terms familiar only to health care providers Medical jargon (technical terminology used by health care providers) sounds like a foreign language to clients unfamiliar with the health care setting. Limiting use of medical jargon to conversations with other health team members will improve communication. The remaining options may contribute to client confusion and/or noncompliance, but the heavy reliance on unfamiliar terms is the most likely primary cause in this situation.

The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses?

The diagnosis should include the problem & the related contributing conditions. The diagnosis should include the problem & the related contributing conditions is a true statement. Related factors are causative or other contributing conditions that have influenced the client's actual or potential response to the health problem & can be changed by nursing interventions. The nursing diagnosis does not identify a "cause & effect" relationship; rather, it indicates that the etiology contributes to or is associated with the client's problem. The nursing diagnosis does not have to remain constant during the client's hospitalization. It should change according to changes in the patient. The etiology or cause of the nursing diagnosis must be within the domain of nursing practice & a condition that responds to nursing interventions, not those of the entire health care team.

The nurse recognizes that a client's sense of personal control is most therapeutically impacted when:

The nurse provides instructions on a patient-controlled analgesic (PCA) pump Personal control over the situation contributes to emotional comfort. Pain control is a very basic need, & by providing the client with the power to control that pain, the need has been therapeutic. The remaining options contribute to personal control but not on the same elemental level as pain control.

The nurse realizes that goals should be singular in focus primarily because:

The nurse will find it difficult to modify the plan of care if the goals are not met. The nurse finding it difficult to modify the plan of care if the goals are not met is correct. Singularity allows you to decide if there is a need to modify the plan of care because only one response is considered. Although the other answers may be true, they are not the primary reason for having only one focus per goal.

The nurse sits on a chair alongside a client's bed to discuss the postoperative nursing care the client will receive. The therapeutic outcome of sitting beside the client is that:

The nurse-client relationship will be strengthened Looking down on a person establishes authority, whereas interacting at the same eye level indicates equality in the relationship. While the remaining options may be correct in some situations, the primary benefit of the nurse sitting is to convey to the client that both are equal contributors to the conversation.

During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem oriented database, the nurse should first question the client about:

The onset & duration of his present breathing problem A client's database originates with the client's perception of a symptom or health problem. If an illness is present, the nurse gathers essential & relevant data about the nature & onset of symptoms. The problem-seeking technique takes the information provided in the client's story to more fully describe & identify the client's specific problems. Habits & lifestyle patterns such as smoking, alcohol use, & exercise may be assessed in an admission history. However, it is not the first question the nurse should ask when obtaining data for a problem-oriented database after the client reports having a health problem. Information regarding family history, such as members who had heart disease, may be obtained in an admission history. However, if a client reports a problem, the nurse should first follow-up with questions relevant to the nature & onset of symptoms. The nurse may inquire about changes in other body systems during an admission history; however, if the client reports a problem, the nurse should first follow-up using a problem-oriented approach. This would include asking specific questions about the client's health problem, such as the nature & onset of symptoms.

The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about:

The onset, severity, & duration of the chest pain If a client comes to the emergency department with chest pain, the nurse should first ask the client about the onset, severity, & duration of the chest pain. In an emergency situation, the client's current health problem becomes the priority assessment. Initially, the nurse should not ask questions regarding family history. Gathering data about the problem currently affecting the client has greater priority. Asking the client about medications taken at home is appropriate, but not at this time. The priority is to assess the symptoms the client is experiencing. Asking the client about concerns regarding hospitalization is not the priority.

A nurse provides a brief but concise orientation to the use of the room's telephone & television to a newly admitted older client experiencing abdominal pain. The client's daughter later reports that her father attempted to call her but was never shown how to use the telephone. The most likely cause for the client's apparent lack of knowledge retention is:

The pain was distracting him from focusing on the information when it was provided Timing is critical in communication. Even though a message is clear, poor timing prevents it from being effective. Do not begin routine teaching when a client is in severe pain or emotional distress. Although the other options may affect client retention of information, the scenario did not provide reason to believe that any of the options rather than poor timing was the primary factor.

A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as which of the following?

The patient has less than normal vision Normal vision is 20/20. A finding of 20/40 would mean that a patient has less than normal vision.

Which of the following are reasons for communication during the assessment phase of the nursing process? (Select all that apply.)

The reasons for communication include information exchange, goal achievement, problem resolution, & expression of feelings. The initiation of the nurse-client relationship is not considered a facet of assessment communication.

When developing appropriate nurse-initiated interventions for a client admitted to an acute care facility for abdominal pain, the nurse must first consider:

The state's defined scope of nursing practice Each state within the United States has developed a Nurse Practice Act that defines the legal scope of nursing practice (see Chapter 22). According to the Nurse Practice Act in a majority of states, independent nursing interventions pertain to activities of daily living, health education & promotion, & counseling. Although the other answers must be considered, they are not the first consideration.

The client recently became febrile & stated he "felt hot." The nurse takes the client's temperature & finds it to be 38.2° C. In addition, the pulse rate is 88 beats pe r minute, & his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data?

The statement regarding his feeling hot Subjective data are client's perceptions about their health problems. The statement by the client regarding his feeling hot is an example of subjective data. A pulse rate of 88 beats per minute is an example of objective data. Objective data are observations or measurements made by the data collector. A blood pressure of 168/80 mm Hg is something that can be measured, & therefore is an example of objective data. Becoming febrile can be determined by measurement, & therefore is an example of objective data.

Which of the following characteristics are considered guidelines for the writing of appropriate goals & outcomes? (Select all that apply.)

There are seven guidelines for writing goals & expected outcomes. The guidelines are client-centered, singular, observable, measurable, time-limited, mutual, & realistic. Practical & meaningful are not recognized characteristics

The best communicator is the nurse who:

Thinks critically Nurses who develop good critical thinking skills make the best communicators. The remaining options identify components of good communication.

A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, "what the diagnosis means." Which of the following rationales best supports the nurse's determination that the client has knowledge deficit rather than a readiness for enhanced knowledge?

This is a new diagnosis for the client. Although all the options are accurate, "this is a new diagnosis for the client" best reflects the need for knowledge because the client had no previous experience with the condition & so had a true knowledge deficit.

Discussing the client's follow-up dietary needs immediately after the surgery when the client is experiencing discomfort is an error in:

Timing & relevance Discussing follow-up dietary needs immediately after surgery when the client is experiencing discomfort is an error in timing & relevance. The client is less likely to be able to pay attention & comprehend instruction when in pain, & immediately after surgery, discussing follow-up dietary needs would seem irrelevant. Pacing has to do with the speed of conversation. This is not an example of an error in pacing. Intonation is the tone of voice used. This is not an example of an error in intonation. Denotative meaning is when a single word can have several meanings. This is not an example of an error in denotative meaning.

Which of the following statements best reflects the nurse's understanding of the primary nursing-related purpose of a concept map?

To demonstrate the relationship between the client's various health problems Concept mapping is one way to graphically represent the connections between concepts & ideas that are related to a central subject (e.g., the client's health problems). Although the other options are correct, they do not provide the best understanding of the purpose of concept mapping in nursing practice as well as "to demonstrate the relationship between the client's various health problems."

The nurse has diagnosed the client's problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except:

Total hip replacement Total hip replacement because the medical diagnosis requires medical interventions, it is legally inadvisable to use it in the nursing diagnosis. Rather, the nurse should identify the client's response, such as decreased mobility. The nurse should be able to provide nursing interventions that will treat the etiology. Poor fiber intake would be an appropriate etiology for the problem of altered elimination. Limited fluid intake would be an appropriate etiology for the nursing diagnosis of altered elimination. Lower abdominal discomfort is an appropriate etiology for the nursing diagnosis of altered elimination.

When palpating body structures, the nurse uses which sense?

Touch Palpation is the technique that uses the sense of touch.

The nurse observes a client with head bowed & hands folded seemingly in prayer. The nurse recognizes this as an example of:

Transpersonal communication Transpersonal communication is interaction that occurs within a person's spiritual domain. Many persons use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their "higher power." Intrapersonal communication, self-talk or self-instruction provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively. Interpersonal communication is one-to-one interaction between the nurse & another person that often occurs face to face while nonverbal communication includes all five senses & everything that does not involve the spoken or written word.

Which of the following interventions is the best example of an indirect intervention directed towards client safety?

Turning on a night light to illuminate the path to the bathroom Indirect care interventions are treatments performed away from the client but on behalf of the client. For example, indirect care measures include actions for managing the client's environment (e.g., safety & infection control), documentation, & interdisciplinary collaboration. Directly impacting the light level in a client's room to minimize the risk for falls is the best example of a safety-oriented indirect care intervention. Including a nursing diagnosis regarding falls would also be an example of an indirect care intervention but it is not as actively affecting the client's safety. Checking a restrained client is a direct care intervention because it involves actual client contact, while performing hand hygiene is directed more towards infection control than safety.

Percussion over the stomach reveals a loud, drum-like sound. The nurse would document this finding as which of the following?

Tympany Tympany is a loud, drum-like sound, heard over an air-filled organ.

When using an otoscope to assess the tympanic membrane of an adult, the nurse straightens the ear canal by gently pulling the pinna in which direction?

Up and back The ear canal of an adult is straightened by gently pulling the pinna of the ear up and back. In children younger than 3 years of age, the ear canal is straightened by pulling the pinna gently down and back.

To palpate lymph nodes, the nurse uses which technique?

Use the pads of two fingers in a circular motion. Use the pads of two fingers and a gentle rotating motion over the nodes. None of the other options is proper palpation of lymph nodes.

The nurse recognizes that a client's hearing deficits impact the development of the nurse-client relationship. Which of the following has the greatest impact on minimizing this obstacle?

Using various forms of nonverbal communication When a client has limited hearing or visual deficits, it becomes more important for a nurse to use nonverbal communication when establishing nurse-client relationships. Speaking slowly, clearly & in a normal tone may make verbal communication more effective, but it will not have the greatest positive impact of the offered options. Relying heavily on touch is only one form of nonverbal communication that can positively impact the development of the relationship. While involving family in discussions may help in the identification of client needs, it does not necessarily have positive impact on developing a healthy nurse-client relationship.

When working with a client with aphasia, the nurse may attempt to enhance communication by:

Using visual cues The nurse may enhance communication for a client with aphasia by using visual cues (e.g., words, pictures, & objects) when possible. The nurse should not shout or speak too loudly to enhance communication with a person who has aphasia. The nurse should ask simple questions that require "yes" or "no" answers to enhance communication with the client who has aphasia. Using a speech therapist is not the primary way to enhance communication with a client who has aphasia. The nurse can use communication techniques to facilitate communication & to develop a helping relationship with the client. The speech therapist may help the client to learn new ways or to relearn how to communicate.

You are surprised to detect an elevated temperature (102 o F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing you do?

Validate your finding You should first validate your finding if it is unusual, deviates from normal, and is unsupported by other data. Should your initial recording prove to be in error, it would have been premature to notify the charge nurse (a) or the surgeon (b). You want to be sure that all data you record is accurate, so it should be validated before documentation if you have doubts (d).

An adult patient is admitted with the diagnosis of asthma. The nurse's assessment finds a temperature of 99 F, wheezing, speaking in three-word phrases, & respiratory rate of 16. Which of the following are the best defining characteristics to support the diagnosis of ineffective airway clearance related to inflammation & constriction of the bronchial tree?

Wheezing & speaking in three-word phrases Neither the temperature nor the respiratory rate is outside of the norms of an adult. The medical diagnosis is not a defining characteristic. The constriction causes wheezing & difficulty vocalizing. There is no fever.

Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: "Client will lose 10 pounds in 3 months?"

Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: "Client will lose 10 pounds in 3 months?" When goals are not met, the nurse should identify the factors that interfere with goal achievement. The remaining options reflect actions to be taken after the interview to further determine how the care plan will be modified.