Model 1A Quiz 1

A nurse is developing a plan of care for a client to meet the client's self-actualization needs. The nurse would focus on which area as most important? a.)Emphasizing the client's strengths b.)Promoting socialization c.)Addressing the client's problems d.)Reducing fear

a.) Emphasizing the client's strengths

The nurse is aware that basic client needs must be met before a client can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a client after physiologic needs have been met? a.)Grab bars are installed in a client bathroom to facilitate safe showering. b.)A nurse identifies strengths in a client who is scheduled for a mastectomy. c.)A nurse arranges for a teenage client to have visits from school friends. d.)A client enrolls in art class after recovering from major surgery.

a.) Grab bars are installed in a client bathroom to facilitate safe showering.

A nurse is caring for an adolescent who has just lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address? a.)Self-esteem needs b.)Self-actualization needs c.)Love and belonging needs d.)Safety and security needs

a.) Self-esteem needs

The nurse recognizes that identifying outcomes/goals must include: a.)involvement of the client and family. b.)involvement of the nurse manager and other staff nurses. c.)input from the multidisciplinary team. d.)input from the physician.

a.) involvement of the client and family.

When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply. a.)A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. b.)Outcome setting allows for individualization of the plan of care. c.)Only the client is involved in outcome setting, not the family. d.)Outcomes can be short- and long-term. e.)All plans of care are the same for clients with certain medical diagnoses.

a.)A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. b.)Outcome setting allows for individualization of the plan of care. d.)Outcomes can be short- and long-term.

Which activity is the clearest example of the evaluation step in the nursing process? a.)Taking a client's blood pressure on both arms at the beginning of a shift b.)Checking the client's blood pressure 30 minutes after administering captopril c.)Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading d.)Recognizing that the client's blood pressure of 172/101 is an abnormal finding

b.) Checking the client's blood pressure 30 minutes after administering captopril

What is the best way for a nurse to obtain a full set of data when performing an assessment of a client? a.)Make interpretations based on client behaviors. b.)Complete a systematic nursing history and nursing examination. c.)Have a nursing student perform the assessment and report it back to the nurse. d.)Make educated generalizations about the client's health to determine focused client problems.

b.) Complete a systematic nursing history and nursing examination.

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care? a.)It creates a teaching log for family. b.)It helps deliver holistic, goal-oriented, individualized care. c.)It verifies staffing. d.)It provides the client with information about treatments.

b.) It helps deliver holistic, goal-oriented, individualized care.

During the nurse's admission interview the client says, "I don't get too much rest because I am in nursing school and work full time to support myself and my kids." The nurse classifies this statement as an issue at which level of Maslow's basic needs? a.)Self-esteem b.)Physiologic c.)Safety and security d.)Love and belonging

b.) Physiologic

Which intervention performed by the nurse is most appropriate for assisting a client in meeting safety and security needs based on Maslow's hierarchy of needs? a.)Seeking input from the client regarding preferences for a snack b.)Providing the mother the phone number for the poison control center c.)Cutting up food and opening drink containers for the client d.)Assisting the client to validate feelings regarding treatment options

b.) Providing the mother the phone number for the poison control center

The nurse in the pediatric unit is caring for a 10-year-old client admitted with dehydration and diarrhea after eating chicken contaminated with Salmonella bacteria. What action taken by the nurse would be the most effective in preventing the spread of the infectious microorganism? a.) Bagging soiled pajamas in a labeled paper bag for the parents to take home b.)Washing hands before and after providing the client care c.)Removing the chicken from the client's meal tray d.)Wearing gloves when taking the client's blood pressure and pulse

b.) Washing hands before and after providing the client care

Which stage of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes? a.)Implementation b.)Assessment c.)Evaluation d.)Planning

c.) Evaluation

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? a.)Identify the appropriate nursing diagnoses. b.)Include the rationale for the interventions. c.)Individualize the plan to the client. d.)Expect to modify the plan significantly.

c.) Individualize the plan to the client.

The nurse provides the mother of a toddler with the phone number for the poison control center. Which level of Maslow's hierarchy of needs is the nurse addressing? a.)Physiologic needs b.)Self-actualization needs c.)Safety and security needs d.)Loving and belonging needs

c.) Safety and security needs

Which provides the best framework for prioritizing client problems? a.)Availability of hospital resources b.)Family member statements c.)Nursing skill d.)Maslow's hierarchy of needs

d.) Maslow's hierarchy of needs

Which step of the nursing process involves setting long-term goals and short-term expectations? a.)Evaluation b.)Assessment c.)Implementation d.)Planning

d.) Planning

A nurse is implementing interventions that focus on protecting a client from physical and emotional harm. Which category of needs is the nurse addressing? a.)Self-esteem b.)Love and belonging c.)Physiologic d.)Safety and security

d.) Safety and security

A nurse takes the vital signs of a new hospital client admitted for severe abdominal pain. Which step of the nursing process is this nurse performing? a.)Assessment b.)Diagnosis c.)Evaluation d.)Implementation

a.) Assessment