Fundamentals test 2

A nurse is documenting the intensity of a client's pain. What would be the most accurate entry?

"Client states pain is a 9 on a scale of 0 to 10." Information should be documented in a complete, accurate, relevant, and factual manner. Avoid interpretations of behavior, generalizations, and words such as "good."

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his 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. Paraphrasing the client's words may lead to assumptions and misrepresentations.

Which of the following is an example of a nursing diagnosis?

Constipation Constipation is a nursing diagnosis included in the Elimination domain. Hypoglycemia, dehydration, and depression are examples of medical diagnoses or medical pathology.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

Subjective Cues may be signs (objective) or symptoms (subjective). Pain is subjectively described by the client.

A student is ambulating a client for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome?

Ask another student to help with ambulation. Unexpected outcomes do occur, such as the risk of a fall for the postoperative client who is ambulated for the first time. In anticipation, the student caregiver could ask another student to help ambulate the client, thus decreasing this risk.

Which nursing diagnosis is validated by the presence of major defining characteristics?

Actual nursing diagnosis Actual nursing diagnoses represent problems that have been validated by the presence of major defining characteristics. An actual nursing diagnosis has four components: label, definition, defining characteristics, and related factors.

A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do?

Ask the client if visitors should remain in the room. If visitors are in the client's room, check with the client to see whether she or he wants the visitors to stay during the procedure.

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would this outcome be evaluated?

Ask the client to demonstrate self-injection of insulin. Psychomotor outcomes describe the client's achievement of new skills and are evaluated by asking the client to demonstrate the new skill.

A nurse is discharging a client from the hospital. When should discharge planning be initiated?

At the time of admission to an acute health care setting

A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis?

Appendicitis Medical diagnoses identify diseases (in this case, appendicitis). Nursing diagnoses describe problems treated by the nurse within the scope of independent nursing practice.

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses.

The nurse develops long-term and short-term outcomes for a client admitted with asthma. What is an example of a long-term goal?

Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. An example of a long-term outcome is "Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack." The other three examples are short-term outcomes that focus on short-term goals related to the period of time during hospitalization.

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this?

Cognitive Cognitive goals involve increasing client knowledge. These goals may be evaluated by asking clients to repeat information or to apply new knowledge in their everyday lives.

A staff nurse has asked the nursing student to perform an intervention that the nursing student has not been trained to perform? What is the appropriate approach for the nursing student to take?

Consult with your nursing instructor before performing the procedure. Whenever you are asked by a staff nurse to perform an intervention for which you lack training, you should consult with your instructor to see if you should attempt to perform it with supervision. Under no circumstances should you attempt to perform interventions beyond your capacity without supervision, even if instructed to do so by a staff nurse. Delegating the intervention to an unlicensed assistive personnel member is not an acceptable option, as you likely are not familiar with the training of this individual.

What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation?

Critical thinking Each element of evaluation requires the nurse to use critical thinking about how best to evaluate the client's progress toward valued outcomes.

A nurse is caring for a client admitted with dehydration after completing a triathlon in a hot, dry climate. The nurse identifies an appropriate nursing diagnosis for this client as "Deficient Fluid Volume related to insufficient fluid intake as evidenced by blood pressure 84/46, heart rate 145, concentrated urine, and client stating that he drank 200 mL of water during the 4-hour event." Identify the problem statement in this nursing diagnosis.

Deficient fluid volume The problem statement is "Deficient Fluid Volume." "Insufficient fluid intake" is the etiology in this nursing diagnosis. Defining characteristics include "blood pressure 84/46, heart rate 145, concentrated urine, and client stating that he drank 200 mL of water during the 4-hour event." The phrase "hot, dry climate" is not a component of this nursing diagnosis statement.

It is acceptable for the nurse to accept a verbal order from the physician in which situation?

During a medical emergency

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. Which type of assessment would the nurse perform?

Focused assessment A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.

Which characteristic of a nurse enables nurses to be role models for clients?

Good personal health Good personal health enables nurses not only to practice more efficiently, but also to be a health model for clients and their families. Nurses can help clients to imitate good health behaviors, and eventually integrate them into their daily life through the process of identification.

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?

Human Needs (Maslow) model The nurse is following the Human Needs model based on Maslow's Hierarchy of Human Needs. The Functional Health Patterns model was developed by Gordon and is a framework that identifies 11 functional health patterns and organizes data according to these patterns. The Body System model is often used by the medical community, and it organizes data according to organ and tissue function in various body systems. The Human Response Pattern model focuses on a unitary person.

Which of the following best defines nursing diagnoses?

Identification of client problems that nurses can treat independently Nursing diagnoses are written to describe client problems that nurses can treat independently. Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Collaborative problems require that a nurse work with other health care professionals, and the treatment comes from nursing, medicine, and other disciplines. Nursing diagnoses identify actual and potential client problems.

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

Implementation Implementation refers to the action phase of the nursing process, in which nursing care is provided.

Which is a characteristic of person-centered care?

It is a framework for providing care. The model of person-centered care is a framework for providing care. The approach is not independent of other disciplines, but is interdependent with other disciplines such as medicine, physiotherapy, surgery, etc. The model can be used in all settings and is not limited to hospital settings. Person-centered care aims to provide specific care to people based on individual needs.

Which client care concern is clearly a nursing responsibility?

Monitoring health status changes Monitoring for health status changes is clearly a nursing responsibility. The other options are medical responsibilities, although in some instances an advanced practice nurse practitioner may be responsible.

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA-International (NANDA-I) NANDA-International (NANDA-I) conferences are held every 2 years, and much progress continues to be made in defining, classifying, and describing nursing diagnoses.

The nursing staff on a hospital unit uses peer review to improve professional performance. Who performs the review?

Nurses Peer review is the evaluation of one staff member by another staff member on the same level of the hierarchy of the organization. Peer review is not done by the unit manager, clients, or visitors.

At the end of the shift, the nurse documents that the client has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Objective Measurable and observable urine output is an example of objective data. Objective data are also called signs or overt data. Subjective data are information perceived only by the affected person. Subjective data are also called symptoms or covert data.

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

Ongoing planning Ongoing planning is carried out by any nurse who interacts with the client, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting.

The researchers developing classifications for interventions are also committed to developing a classification of which of the following?

Outcomes The researchers involved in the development of NICs are also committed to developing a classification of client outcomes for nursing interventions, called Nursing Outcomes Classifications (NOCs). This research aims to identify, label, validate, and classify nursing-sensitive client outcomes and indicators, evaluate the validity and usefulness of the classification in clinical field-testing, and define and test measurement procedures for the outcomes and indicators.

Which group of terms best describes the nursing process?

Patient-centered, systematic, outcome-oriented The nursing process is a patient-centered, systematic, outcome-oriented method of caring that provides a framework for nursing practice. It is nursing practice in action.

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs?

Physiologic Because basic human needs must be met before a person can focus on higher-level needs, client needs may be prioritized according to Maslow's hierarchy. Physiologic needs, including the need for oxygen, are the most basic and have the highest priority.

What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations?

Reflection Reflection is defined as those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations.

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which action would be most appropriate for the nurse to do?

Strike out the entry with a single line, place initials next to it, and write the correct entry. The nurse should strike out the erroneous entry with a single line and place initials over it. When an error occurs, erasure or use of correction fluid is not permissible. Use of highlighters is not allowed and can draw attention to the erroneous documentation.

Which of the following best summarizes the evaluation step of the nursing process?

The nurse and client measure achievement of planned outcomes of care. In evaluation, which is the fifth step of the nursing process, the nurse and client together measure how well the client has achieved the outcomes specified in the plan of care.

Which example may illustrate a breach of confidentiality and security of client information?

The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether or not the client wants that family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach of confidentiality, but providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

While performing an assessment, the nurse recognizes that his own personal biases may be interfering with the collection of data. What step should the nurse take to assure the information is factual and accurate?

The nurse should consult with another nurse for that colleague's description of the assessment or observations.

A nurse delegates a specific intervention to an unlicensed assistive personnel (UAP). What implications does this have for the nurse?

The nurse transfers responsibility but is accountable for the outcome. UAPs are trained to function in an assistive role to the RN in client activities as delegated and supervised by the RN. Delegation is the transfer of responsibility of an activity to another individual while retaining accountability for the outcome.

The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment?

The nurse's physical assessment will focus on the client's functional abilities Unlike the physical assessment performed by the physician to identify pathologic conditions and their causes, the nursing physical assessment focuses primarily on the client's functional abilities. .

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which information?

The physician's assessment and treatment The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment.

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care. Quality-assurance (QA) programs enable nursing to be accountable to society for the quality of nursing care. They are a response to the public mandate for professional accountability. QA programs do not facilitate increased enrollment, specify how resources are to be used, or increase retention of nurses.

Members of the staff on a hospital unit are critical of a client's family, who has different cultural beliefs about health and illness. A student assigned to the client does not agree, based on her care of the client and family. What critical thinking attitude is the student demonstrating?

Thinking independently Although all the attitudes listed are components of critical thinking, the student is thinking independently. Nurses who are independent thinkers are careful not to let the status quo or a persuasive individual control their thinking.

A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean?

Written plans are developed that specify nursing activities for this skill. Protocols (written plans that detail the nursing activities to be executed in specific situations) are nurse-initiated interventions. They expand the scope of nursing practice in certain clearly defined situations.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

A client who has limited finances and limited capacity for education requires home health care for a chronic illness. For the nurse to provide a high level of care to this client, she must first:

implement critical-thinking skills. Critical thinking requires nurses to choose solutions or identify options for client care situations.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family. One of the most important considerations in writing outcomes is to encourage clients and families to be as involved in goal development as their abilities and interests permit. The more involved they are, the greater the probability that the goals will be achieved.

The focus of a hospital's current quality assurance program is a comparison between the health status of clients upon admission and at the time of discharge. This form of quality assurance is characteristic of:

outcome evaluation. Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care. Whereas the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in client health status. Process evaluation addresses performance expectations during the various stages of the nursing process. Structure evaluation addresses the environment of care. A nursing audit focuses on the review of records.

Which interpersonal skill is essential to the practice of nursing?

promoting the dignity and respect of clients as people Characteristics of interpersonal caring that are essential to the practice of nursing include promoting the dignity and respect of clients as people, the centrality of the caring relationship, and a mutual enrichment of both participants in the nurse-client relationship.

Implementation of the plan of care is most successful when:

the nurse includes family members and other health care professional Family members and support people, as well as other health care professionals, may be involved in the implementation of the plan of care. The plan of care is best implemented when clients who are able and willing to participate have the maximum opportunity to provide self-care. Clients and their support systems should be involved in decision making. The nurse will continue to collect data and modify the plan of care during the implementation phase. All activities should be documented during the implementation phase. s.

When documenting subjective data, the nurse should:

use the client's own words placed in quotation marks.