ADN140 - PrepU - Nursing Process

A staff nurse comments to the charge nurse that it is unnecessary to know how to formulate nursing diagnoses because the computerized documentation system generates them automatically. What is the most important appropriate response by the charge nurse?

"A nurse is still responsible for utilizing critical thinking to determine the validity of the nursing diagnoses generated."

The nurse has been working with a patient for several days during the patient's recovery in the hospital from a femoral head fracture. How should the nurse best evaluate whether patient education regarding fall prevention in the home has been effective?

"What changes will you make around your house to reduce the change of future falls?"

The nurse is trying to determine factors influencing a client who is not following the plan of care. Which client statement identifies a potential factor interfering with following the plan of care? Select all that apply. - "I don't drive so I was unable to fill my prescription." - "I consult the list of low sodium foods when preparing meals." _ "My social security check does not come until next week." - "I dropped the strips for my finger-stick blood glucose testing in the bath water." - "My daughter helps me with my range of motion exercises every morning and afternoon."

- "I don't drive so I was unable to fill my prescription." _ "My social security check does not come until next week." - "I dropped the strips for my finger-stick blood glucose testing in the bath water."

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which of the following factors would the nurse identify as strengths of the client? (Select all that apply). - The client states that no one should ever ask for help from others. - The client has been accompanied by family members to every appointment. - The client states a belief in a reward in heaven after death. - The client has a long history of health problems. - The client has demonstrated effective coping skills in the past.

- The client has been accompanied by family members to every appointment. - The client states a belief in a reward in heaven after death. - The client has demonstrated effective coping skills in the past.

The nurse is conducting the physical assessment of a client at the health care facility. The nurse uses the pulse oximetry technique to monitor the oxygen saturation in the client's blood. Which of the following pulse oximeter ranges indicates that the client is adequately oxygenated?

95% to 100%.

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify the nursing diagnosis as which type?

Actual.

Which outcome is therapeutic and realistic when the nurse is planning care for a female client with major depression and borderline personality disorder who is hospitalized for self-mutilation and threats of suicide?

Appropriately verbalize anger and sad feelings to the nurse.

One hour after receiving blood pressure medication, the client complains of feeling lightheaded and dizzy. What is the nurse's best first reaction?

Assess the client's blood pressure.

When the nurse prepares to discharge a client, to evaluate the effectiveness of the nursing care, the nurse should determine whether the:

Client's goals have been achieved.

The client's expected outcome is "The client will maintain skin integrity by discharge." Which of the following measures is best in evaluating the outcome?

Condition of the skin over body prominences.

The purpose of establishing a nursing diagnosis is to:

Describe a functional health problem.

An experienced obstetrical nurse is collecting data on a patient in labor. What is the best approach for the development of nursing diagnoses for this patient?

Develop nursing diagnoses from clusters of significant data.

A nurse writes the following nursing diagnosis for a patient with Alzheimer's: Disturbed Thought Process related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement?

Disturbed through processes.

On admission, a client is completely immobilized by an acute exacerbation of multiple sclerosis. Two days later, the client cries frequently and refuses to see family members. The nurse formulates a nursing diagnosis of Hopelessness. To address this diagnosis, the nurse should include which intervention in the care plan?

Encouraging the client to verbalize feelings.

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis?

Impaired urinary elimination.

When the nurse is administering Lasix 20mg to a patient in congestive heart failure, what phase of the nursing process does this represent?

Implementation.

The nurse formulated the following client outcome: "Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7." Which error has the nurse made?

Included more than one client behavior in the outcome.

The nurse ascertains that a patient is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this patient. What is the nurse's next step in correcting this problem?

Making changes in the plan of care based upon assessment data.

The nurse caring for a client formulates client outcomes based on the understanding that the outcomes should be which of the following?

Measurable.

A client has come into the clinical for a postoperative visit. The client states that the postoperative pain continues to be 6 on a 10-point rating scale. The nurse evaluates the patient and the current plan of care. Based on the information provided by the client, the nurse should do which of the following?

Modify the plan of care.

What guidelines do nurses follow to identify the patient's healthcare needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes?

Nursing Process.

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis for the client. Which of the following best reflects a nursing diagnosis?

Risk for falls.

A nurse is completing discharge teaching for the client who has left-sided hemiparesis following a stroke. When investigating the client's home environment, the nurse should focus on which nursing diagnosis?

Risk for injury.

Your older adult patient has a diagnosis of rheumatoid arthritis (RA) and has been achieving only modest relief of her symptoms with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). When creating this patient's plan of care, which nursing diagnosis would most likely be appropriate?

Self-care deficit to fatigue and joint stiffness.

A 30-year-old male patient is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this patient's care?

Teach the patient about the benefits of early mobilization and offer to assist him.

Which nursing action reflects evaluation?

The nurse assesses the client's response to pain medication.

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. What would the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath.

A nurse who believes strongly that women should make their own decisions is caring for a female client from a culture where women defer decisions to their husbands. Based on the client's insistence that her husband make all decisions for her, the nurse formulates a nursing diagnosis of "Dysfunctional family processes." What type of nursing diagnosis error has the nurse made?

The nurse has inserted her own beliefs into the interpretation of the data.

During a home health care visit, the nurse identifies a nursing diagnosis of "Caregiver role strain" for a parent who is caring for a ventilator-dependent child. What subjective assessment data would support the nurse's diagnosis?

The parent states, "I cannot allow anyone else to help because they won't do it right."

The nurse performs a comprehensive assessment of a newly admitted client. What is the primary purpose of this admission assessment?

To identify baseline data.