NURS 210 CHAPTER 2

A community health nurse provides information to a patient with newly diagnosed multiple sclerosis and their families. Providing this information is an example of what?

A referral

A nurse interacts with four different clients one afternoon at the health clinic. The nurse is able to directly assist three of them and makes a referral for the fourth. what type of patient should the nurse refer to another professional?

An elderly woman who needs daily therapy sessions to help her walk again after a hip fracture

OLD CART is a mnemonic that will help the nurse remember the steps in the nursing process, T/F?

False

A nursing instructor is describing why data analysis is considered a very difficult step in the nursing process. Why?

It requires diagnostic reasoning skills

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the iV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?

Review the client's prescribed medication orders

The emergency department has collected extensive data from a client who has presented with a new onset of severe abdominal pain. What nursing action should the nurse perform before proceeding with data analysis?

Validate the collected data

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

analyze the data

When documenting clinical data after an assessment of the patient's neck, what might you write in the physical assessment?

thyroid isthmus barely palpable, lobes not felt

A nurse's data analysis has led to the formulation of a risk nursing diagnosis. What is an example of a diagnosis that demonstrates an accurate risk nursing diagnosis?

Risk for violence related to history of overt, aggressive acts

Your patient has been directly admitted from the doctor's office. The only paperwork he has brought with him is his admission orders. You are gathering your admission data when ordered lab work is collected. When documenting your history, physical examination, assessment, and plan, what would you write under the heading "Laboratory Dat"?

"None currently"

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data? -anxious appearance -worried about appearance

Anxious appearance

A client present to the clinic with reports of an itchy rash all over the body. The nurse observes lesions on the client's arms and legs as well as the presence of a dry, tacky cough and sneezing. Which data collected from the client can be classifies as a subjective abnormal finding?

Itchy feeling

The nurse assesses a heart rate go 110 ppm, cool clammy skin, and blood pressure 88/85 mm Hg. Which heading should the nurse use to cluster this data?

Low fluid volume

Which of the following would be most important for a nurse when developing critical thinking skills?

Maintenance of an open mind

The nursing student demonstrates a need for further teaching when she states what?

Patients do not need to understand their problems

The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following? a. reliability b. validity c. too many or too few data

Too many or too few data

the nurse is working with a 14-year-old girl who has told the nurse that she would like to try getting to bed a little sooner to get a full night's sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to client's expressed desire to go to bed earlier. Which type of nursing diagnosis is this?

Wellness

An experienced medical-surgical nurse has identifies critical thinking as an integral component of diagnostic reasoning. How can the relationship between these two concepts be best described?

critical thinking is the foundation of the process of diagnostic reasoning

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

implementation