nursing fundamentals chapter 4

The registered nurse (RN) recognizes that there are three components to the assessment of patients when he or she gathers information about their problems and needs. These three components are

. The components are interviewing, performing a focused body system assessment, and reviewing the results of laboratory and diagnostic tests.

The registered nurse (RN) is supervising the licensed practical nurse (LPN). The RN would intervene if the LPN was

A The National Federation of LPNs Nursing Practice Standards for the licensed practical nurse and licensed vocational nurse identify assessment as an RN function.

When reviewing the nursing diagnoses in a student nurse's written care plan, the nursing instructor recognizes that additional teaching is warranted when the student nurse includes a nursing diagnosis of:

A care plan is a documented plan for giving patient care and includes physician's orders, nursing diagnoses, and nursing orders. Chronic fatigue syndrome is an example of a medical diagnosis.

A nursing instructor is educating a student nurse about how to formulate an outcome statement on a care plan. The student nurse demonstrates understanding when stating (select all that apply):

ANS: A, C, E, F Feedback: An outcome statement should include a realistic, specific action to be taken by the patient, not the nurse. Outcome statements should be measurable; to be measurable, it is necessary to use action verbs that can be evaluated. An outcome statement should be an action that the patient is willing and able to perform. An outcome statement has a definite time frame for the action to have been accomplished.

The nursing instructor is educating a student nurse about indirect patient care. The student nurse demonstrates understanding when identifying an example of indirect patient care as (select all that apply):

ANS: C, E. Indirect patient care is performed when the nurse provides assistance in a setting other than with the patient. Examples of indirect care would include documenting care and talking with the health care provider.

A patient arrives to the nursing unit as a direct admit. First the nurse should

Assessment

When the nurse gathers information through signs and symptoms and obtains the patient history, he or she is performing the step in the nursing process that is called

Assessment

While caring for a newly admitted patient, the nurse interviews the patient to obtain a health history, performs a head-to-toe assessment, and reviews laboratory and diagnostic tests. This step in the nursing process is called

Assessment

When performing an initial admission assessment, the nurse listens to the patient's heart and lung sounds. This is an example of the assessment technique that is called

Auscultation

The nurse encourages the student nurse to practice using skillful reasoning and logical thought to determine the merits of a belief or action. This approach best describes

Critical thinking

The nurse has just finished completing an admission assessment of a newly admitted patient. Next the nurse should

Diagnosis

When the nurse formulates nursing diagnoses through analysis of the assessment information, he or she is performing the step in the nursing process that is called

Diagnosis

When the nurse reflects on the interventions that he or she has performed and decides if they have brought the patient closer to achieving the goals and outcomes set in the planning step, he or she is performing the step in the nursing process that is called

Evaluation

The nurse is caring for a patient with a diagnosis of asthma who is experiencing increased dyspnea. The nurse notifies the respiratory therapist who administers a nebulizer treatment. After the treatment, the patient continues to experience dyspnea. The nurse reflects on treatment to determine if the goal of relief from dyspnea has been accomplished. When the nurse determines if the goal has been met, he or she is performing the step in the nursing process that is called

Evaluation .

The nurse admits a patient and selects the priority nursing diagnosis of acute pain. The nurse plans to administer analgesics as needed. When the patient complains of pain, the nurse medicates the patient. Next the nurse should

Evaluation. The steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

The nurse is caring for a patient who has a hip spica cast. The nurse monitors the patient for pain, pallor, parasthesia, pulselessness, and paralysis. When the patient complains of pain, the nurse administers analgesics. When the nurse medicates the pain, he or she is performing the step in the nursing process that is called

Implementation

When the nurse takes actions to resolve a patient's problems, he or she is performing the step in the nursing process that is called

Implementation

When performing an initial admission assessment, the nurse visually examines the patient's body for rashes, breaks in the skin, and normal appearance of eyes, ears, nose, mouth, limbs, and genitals. This is an example of the assessment technique that is called

Inspection

The registered nurse (RN) formulates four nursing diagnoses for her patient. The nurse recognizes that the priority nursing diagnosis is

Nursing diagnoses address physical, psychosocial, and environmental needs of patients with some of them being a higher priority than others. For example, the nursing diagnosis "Ineffective airway clearance" would be considered a higher nursing priority than "chronic low self-esteem." Both diagnoses are important, but the first is critical to the patient's ability to breathe.

The nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies as objective data that

Objective data is that which can be observed through the senses of hearing, sight, smell, and touch. Subjective data is information that is known only to the patient and family members. While some clues to these symptoms may be observable, only the patient knows exactly what he or she is feeling. Option 2 is an example of objective data.

When performing an admission history on a patient, the nurse collects primary data. An example of primary data is that

Option 3 is an example of primary data.

When performing an admission history on a confused patient, the registered nurse (RN) collects secondary data, an example of which is that

Option 4 is an example of secondary data.

When performing an initial admission assessment, the nurse touches and feels the patient's pulses bilaterally. This is an example of the assessment technique that is called

Palpation

When performing an initial admission assessment, the nurse taps on the patient's abdomen to detect abnormalities. This is an example of the assessment technique that is called

Percussion

When caring for a patient who complains of abdominal pain, the nurse determines that analgesics must be given to manage the patient's pain. This step in the nursing process is called

Planning

When the nurse determines priorities and what nursing actions should be performed to help resolve or manage each patient problem, he or she is performing the step in the nursing process that is called

Planning

The nurse receives a patient who was a direct admission. The nurse initially completes an assessment on the patient and gathers a health history. The nurse determines the top-priority nursing diagnosis. Next the nurse should

Planning nurse then decides on appropriate interventions to resolve each patient problem or nursing diagnosis.

The nurse educates the student nurse that the formulation of nursing diagnoses is a function of the

Registered nurses

The registered nurse (RN) supervises the licensed practical nurse (LPN/LVN). The RN recognizes that the most appropriate task to delegate to the LPN/LVN is

The LPN/LVN participates directly in the steps of planning, intervention, and evaluation. Administering an intramuscular analgesic is an intervention.

The registered nurse (RN) is supervising the licensed practical nurse (LPN). The RN would intervene if the LPN was

The National Federation of LPNs Nursing Practice Standards for the licensed practical nurse and licensed vocational nurse identify formulating a nursing diagnosis as an RN function.

A nursing instructor is teaching a class of nursing students about performing a patient assessment and formulating nursing diagnoses. The nursing instructor states that the health care team member responsible for performing a patient assessment and formulating nursing diagnoses is

The RN

A patient is admitted to the hospital with pneumonia. The assessment reveals that he is short of breath at rest, has a weak cough, and is unable to bring up mucus that can be heard in his lungs and throat. He complains of chest discomfort and has a temperature of 101.6°F, pulse of 110, respirations 23, and blood pressure 126/82. When auscultating his lungs, the nurse hears crackles and wheezes. The patient is weak and becomes short of breath with exertion. His oxygen saturation is 96% at rest. The nurse selects as a priority nursing diagnosis

ineffective airway clearance

When educating a class of nursing students about the nursing process, the nursing instructor teaches that the nursing process is a

is a decision-making framework used by all nurses to determine the needs of their patients and to decide how to care for them

The nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies as subjective data that

is known only to the patient and family members. While some clues to these symptoms may be observable, only the patient knows exactly what he or she is feeling. Option 4 is an example of subjective data.

The nurse receives an order from the physician for an anticoagulant to be administered to a patient who has a deep vein thrombosis. The nurse recognizes that the patient has a critical international normalized ratio (INR) level. The nurse should

speak with the individual (the physician) who ordered the anticoagulant and the INR level.