Exam #2 Prep-U

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'" (Subjective data should be recorded using the client's own words, using quotation marks as appropriate)

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

"When did you first notice the rash on your leg?" (This is an example of a direct question that can be asked to validate information or clarify information)

Four steps crucial in improving performance

1. Discover a problem 2. Plan a strategy using indicators 3. Implement a change 4. Assess the change and/or plan a new strategy if outcomes are not met

five classic elements of evaluation

1. Identifying evaluative criteria 2. Collecting data 3. Interpreting findings 4. Documenting 5. Terminating, continuing, or modifying plan

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

Actual

Which is the purpose of a focused assessment?

Adds depth to existing information

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?

Assess blood pressure with a large cuff

While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis?

Collect client subjective and objective data.

When developing nursing diagnoses, the nurse should focus on which area?

Human responses to actual or potential health problems

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

Identify measurable goals or outcomes

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next?

Notify the physician of the change and document the finding (The nurse should not wait until after rechecking the pulse to document the finding or report it to the physician)

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case?

Obtaining data regarding the amount and frequency of drinking

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature, paying close attention to technique.

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

Reporting signs and symptoms related to the client's kidney failure

T/F Evaluative criteria are measurable qualities, attributes, or characteristics that specify skills, knowledge, or health status.

T

What is the purpose of establishing a nursing diagnosis?

To describe a functional health problem

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? a. Comfort the client and family. b. Test the client's blood glucose levels. c. Provide more information about diabetes. d. Ask the client whether anyone else in the client's family also has diabetes.

a

Which action should the nurse perform during the planning phase of the nursing process? a. Identify measurable goals or outcomes. b. Identify the client's health-related problems. c. Assess the client's overall health. d. Analyze the client's response to medicines.

a

five types of nursing diagnoses

actual, risk, possible, health promotion, and syndrome

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns? a. "Take short and shallow breaths instead of deep breathing." b. "Leaning forward may help you to breathe better." c. "Running short distances can help you breathe better." d. "Do not practice pursed lip breathing, as this is a contraindication."

b

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action? a. Reassure the client that the nurse knows when to perform hand hygiene. b. Praise the client for taking an active role in the client's care. c. Tell the client that gloves are required for this procedure. d. Inform the client that it is not necessary to wash hands before vital signs.

b

Which action is appropriate when evaluating a client's responses to a plan of care? a. Terminate the plan if there are difficulties achieving the goals/outcomes. b. Continue the plan of care if more time is needed to achieve the goals/outcomes. c. Terminate the plan of care upon client discharge. d. Reinforce the plan of care when each expected outcome is achieved.

b

Which nursing action can be categorized as a surveillance or monitoring intervention? a. Use of therapeutic communication skills b. Auscultating of bilateral lung sounds c. Administering a paracetamol tablet d. Providing hygiene

b

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? a. Time-lapse b. Focused c. Emergency d. Initial

b

Avoiding information contrary to one's opinion is an example of _____, an approach that leads to potential errors in clinical decision making

bias

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? a. A plan derived from a consensus of opinions of all staff members b. A plan with problems that are easily solved c. A plan designed to support the client physically d. A plan made in conjunction with the hospital's ethics committee

c

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? a. Cost-effectiveness b. Structure c. Outcome d. Process

c

The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is: a. a protocol. b. an algorithm. c. a clinical pathway. d. an order set.

c

A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this?

client

Evaluation that is conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met is known as ___________ evaluation.

concurrent

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client? a. Adding the diagnosis "Altered Nutrition, Less Than Required" b. Obtaining written consent for the diagnostic procedure c. Posting the sign "NPO after midnight" over the bed d. Updating the diet orders in the client's plan of care

d

Identifying the kind and amount of nursing services required is a possible solution for: a. nurses who are bored. b. clients who fail to communicate their needs. c. nurses frustrated with substandard care. d. inadequate staffing.

d

The documentation of a judgment summarizing data interpretation and patient outcome achievement is an _____________ statement.

evaluative

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

focused assessment

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

What type of nursing diagnosis is Readiness for Enhanced Coping?

health promotion nursing diagnosis

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health

The nursing _____________ identifies the patient's health status, strengths, health problems, health risks, and need for nursing care

history

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality

For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

initial

clinical reasoning

interpretation of relevant data and how it applies to a situation

clinical judgment involves

knowledge, experience, intuition, clinical thinking and EBP skills

A key nursing skill when performing both the nursing history and the physical examination is ____________, the conscious and deliberate use of the five senses to gather data

observation

In the nursing process, evaluative criteria are the patient _______ developed during the planning step.

outcomes

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client?

pain

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

potential or actual nursing diagnosis

Quality assurance programs focus on three types of evaluation:

structure, process, outcome

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:

the interventions planned must be within the nurse's scope of practice

critical thinking

thought process that is systematic and logical in reviewing data to make decisions

time-lapsed assessment

to compare a client's current status to the baseline data obtained earlier.

When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind?

validate inferences with the client

The purpose of _______________ data is to keep information, an important part of assessment, free from error, bias, and misinterpretation as much as possible

validating