PrepU Health Assess Ch. 5 Assignment 5

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client?

Weight gain of 3 pounds (1.5 kilograms) over 1-2 days

A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement?

"All patients have the same defining characteristics."

A client asks why a nurse measured the blood pressure after the nursing assistant completed the measurement a few minutes ago. What should the nurse respond to the client?

"It was done to validate the reading."

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response?

"It's acceptable for a client to admitted for observation."

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.)

-Be nonjudgmental and keep an open mind. -Use rationale to support opinions or decisions. -Acquire an adequate knowledge base that continues to build.

The nurse places a hospitalized client at risk for complications when performing which procedures? (Select all that apply.)

-Preparation for surgery -Medication administration -Assisting with a cast application -Monitoring intracranial pressure

A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following?

A referral

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a patient who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered?

Actual Nursing Diagnosis

The nurse has learned that after completing the assesment 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

A patient comes to the clinic for a yearly physical examination. The assessment reveals multiple lesions on the face, neck, arms, and legs. The patient appears upset, starts to cry when questioned about the skin abnormalities, and asks the nurse if the problem is skin cancer. What would be the best nursing diagnosis for this patient?

Anxiety related to lesions on body

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

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan?

Ask the client for opinions and willingness to proceed with the interventions.

What can the nurse use to learn new information and add to their knowledge base?

Clinical experience.

A patient has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the patient's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered?

Collaborative problem

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the patient has the opportunity for an enhanced health state:

wellness diagnosis

A nurse is performing a self-assessment of ability to think critically, making a list of characteristic behaviors. Which of the following behaviors would indicate critical thinking?

Exploring many alternatives before making a decision

In the diagnostic process, what should immediately precede the step of identifying a list of possible nursing diagnoses?

Grouping assessment findings to identify commonalities

A nurse is working with a patient who has a history of chronic obstructive pulmonary disease (COPD). While bathing the patient, the nurse senses that something is not quite right and takes the patient's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following?

intuition

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?

Medication reconciliation

A hospitalized client complains of pain 10/10 one hour after receiving a dose of intravenous Morphine sulfate intravenously. The next dose is not due for over an hour. What is the nurse's best action?

Notify the healthcare provider.

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case?

Overlooking consideration of the clients cultural background

A client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse?

Place on cardiac monitor.

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?

Reassess blood pressure

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.

Which of the following is a collaborative problem?

Risk for osteoporosis

A nurse is teaching a patient newly diagnosed with diabetes about diet and the exchange list. After several teaching sessions, the patient continues to be confused and not sure about what to eat. The nurse's next best action is which of the following?

Schedule a dietary consult.

The nurse has confirmed a diagnosis of Body Image Distrubance related to changes in physical appearance. What would the next step in the diagnostic reasoning process be?

Step Seven--Document Conclusions

A nurse assesses an older adult client with confusion. When collecting clinical information from the client, which factor is the most important for the nurse to consider?

The quality of the data may be low.

A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client?

Unable to feel his leg

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

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information?

Wellness diagnosis

The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to

discuss the plan with the patient

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 doing which step of the nursing process?

implementation

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?

nursing diagnosis

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.

seeing things as only right or wrong

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?

too many or too few data

One characteristic of a nurse who is a critical thinker is the ability to

validate information and judgments.

A nurse understands that the identified strengths found during the assessment of a patient are used for which of the following nursing diagnoses?

wellness diagnosis