Chapter #2 Nursing Process

Which is the purpose of a focused assessment?

Adds depth to existing information

The nurse is assisting with the creation of a care plan for a client experiencing pain from kidney stones. What is an appropriate intervention for this client?

Administer ketorolac 30 mg IV now and every 6 hours.

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client?

Comfort the client and family.

The nurse assigned to care for a client who has received a sedative has asked the unlicensed assistive personnel (UAP) to help the client to the toilet. The nurse demonstrates proper delegation skills by performing which actions? Select all that apply.

Confirming that the UAP has successfully passed this skill competency Giving a report on the client to the UAP and answering questions Confirming that the UAP has repeatedly completed similar tasks Being available for questions from the UAP

A client, who is scheduled for coronary angioplasty, is concerned if the procedure is safe. Which nursing diagnosis relates most directly to this client's condition?

Fear related to potential risk and surgical outcomes

Which action should the nurse perform during the planning phase of the nursing process?

Identify measurable goals or outcomes.

A client is brought to the Emergency Department in an unconscious condition, accompanied by his son. The client is having respiratory arrest and is put on a ventilator. What is the most appropriate nursing diagnosis in the client?

Impaired Spontaneous Ventilation

An older adult client suffered a stroke a short time ago and has experienced dysphagia (difficulty swallowing) consequent to neurological damage. The nurse has thus identified the nursing diagnosis of Risk for Imbalanced Nutrition: Less than Body Requirements. What action should the nurse first take after identifying this diagnosis?

Liaise with nurses and members of other health disciplines to create a plan for promoting the client's nutrition.

The nurse is obtaining data from a client newly admitted into the acute care unit with severe pain in the left upper quadrant. Which data will the nurse document as subjective data?

Reports pain of 8 on a scale of 0 to 10

A client is post-operative day six following total hip replacement. When reviewing the client's plan of care, the nurse reads the following goal: "The client will transfer from the bed to the commode with one-person assistance." However, the nurse is aware that the client has been ambulating with a walker for the past two days and is now able to climb stairs. How should the nurse follow up this observation?

Revise the plan of care in light of the client's increased mobility.

Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease?

Risk for Injury

A nurse is educating a client about care to be taken in the treatment of nephrotic syndrome. The client expresses that the teachings are of no use, because the disease is not curable. What nursing diagnosis should the nurse write with regard to the client's concern?

Risk for Powerlessness

A hospital nurse is reviewing a client's plan of care at the beginning of a shift. One of the client's problems is denoted as a collaborative problem. The nurse should recognize what unique characteristic of this problem?

The problem requires interventions by physicians as well as nurses.

A nurse has encouraged a bedridden hospital client to perform deep breathing and coughing exercises each hour to prevent respiratory complications. After performing this intervention, the nurse should

assess the client's lungs to determine the effectiveness of the intervention.

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

functional assessment

The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?

involving the client with all the steps of the process in care development

A community health nurse has been working with an older adult client who lives alone and who receives regular wound care for a chronic, diabetic foot ulcer. What action by the nurse most clearly demonstrates the implementation phase of the nursing process?

teaching the client to maintain asepsis while applying a prescribed topical ointment