NUR 3065 - Prep U Chapter 2

OLD CART is a mnemonic that will help the nurse remember the steps in the nursing process.

False. Explanation: OLD CART is a mnemonic that can help the nurse ask specific questions when performing an assessment.

During the assessment interview, the client made numerous statements that suggested his life generally exists in a state of harmony and balance. The nurse would document this as which type of nursing diagnosis?

Health promotion diagnosis Explanation: A health promotion diagnosis indicates that the client has the opportunity for enhancement of a health state. The client is in a state of harmony and balance. An actual diagnosis would be used for a stated health problem. A risk diagnosis is used when a client does not currently have a problem but is at high risk for developing it. A collaborative problem is one that requires both medical and nursing interventions.

A nurse has completed data analysis. Which of the following would the nurse identify first as the result?

Nursing diagnosis Explanation: The end result of data analysis is the identification of a nursing diagnosis, collaborative problem, or need for referral to another health care professional. After nursing diagnoses are identified, then outcomes, planning, implementation, and evaluation occur.

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 Explanation: Health promotion diagnoses represent those situations in which the client does not have a problem but is at a point at which a higher level of health can be attained. In other words, this client has the desire to increase her well-being and actualize her human potential. This type of diagnosis is often worded readiness for enhanced. It indicates an opportunity to make greater, to increase quality of, or to attain the most desired level of function in the area of the diagnostic category. The other answers clearly do not describe this diagnosis.

The nurse has completed an assessment on a new client. 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 client Explanation: Sharing the assessment and plan with the client will allow the client to offer his or her opinion, concerns, and willingness to proceed with the interventions. This makes the client an active participant in his or her plan of care.

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 Explanation: Data analysis is referred to as the diagnostic phase of the nursing process because the end result is the identification of a nursing diagnosis. A nursing intervention is done during the implementation phase, nursing rationale is identified when choosing the interventions, and data organization must be done during the collection of the data while still in the assessment phase.

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 be admitted for observation." Explanation: Assessment is one of the primary reasons a client is hospitalized. It is not uncommon that a client is hospitalized entirely for observation. The healthcare provider does not need to change the diagnosis. Telling the client that insurance will not pay for observation is not a true statement for all insurance companies.

For each client problem identified the nurse develops and records a plan. What must the plan do? (Select all that apply.) - Begin discharge planning - Flow logically from identified diagnoses - Specify which steps are needed next - Include referral to dietician - Identify timing of family involvement

- Flow logically from identified diagnoses - Specify which steps are needed next Explanation: Identify and record a plan for each client problem. The plan flows logically from the problems or diagnoses the nurse has identified. Specify which steps are needed next. These steps range from monitoring daily weights, to consultations for evaluations, to timing of dressings or IVs, to arranging a family meeting.

The nurse is attempting to cluster the data collected during the initial assessment of an older adult client. The nurse notes that the client had a swollen left knee and complained of "a bit of soreness" in the joint, but the nurse does not have enough data to support a nursing diagnosis of Impaired Physical Mobility. What should the nurse do next?

Assess the client further for evidence of reduced mobility and decreased range of motion. Explanation: When data do not fully support a nursing diagnosis, further assessment is usually warranted. Suspected nursing diagnoses do not exist; interventions and referrals would be premature.

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?

Diagnostic reasoning skills are required to interpret data accurately. Explanation: As the second step or phase of the nursing process, data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately.

A nursing instructor is describing why data analysis is considered a very difficult step in the nursing process. Which of the following would the instructor identify?

It requires diagnostic reasoning skills. Explanation: Data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately. Although abnormal data must be identified, nursing diagnoses developed, and conclusions documented, these are not the reasons for why data analysis is a difficult step.

A client presents to the clinic with reports of an itchy rash all over the body. The nurse observes lesions on the client's arms and legs as well as the presence of a dry, hacky cough and sneezing. Which data collected from the client can be classified as a subjective abnormal finding?

Itchy feeling Explanation: Based on the data gathered from the client, the nurse can classify the clients report of an itchy feeling all over the body as a subjective abnormal finding, as this information has been provided by the client about what the client feels and experiences. The presence of rash, cough, and continuous sneezing are data that the nurse observes during the examination and are therefore objective data.

Which of the following would be most important for a nurse when developing critical thinking skills?

Maintenance of an open mind Explanation: To think critically, a nurse needs to keep an open mind, explore alternatives, use sound rationales, and avoid hurried decisions. The critical thinker also uses each clinical experience to learn new information and to add to the knowledge base.

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?

Make a referral to the dietician. Explanation: Referring can be defined as connecting clients with other professionals and resources. This client would receive the greatest benefit from the professional that is able to give them the education required to manage their disease process.

The nursing student demonstrates a need for further teaching when she states which of the following?

Patients do not need to understand their problems. Explanation: It is essential for the client to understand the problem so that treatment can be properly implemented. If the client is not coherent, it is proper to consult with the family or significant other or even other health care workers. Validation is also important with the client who has a collaborative problem or who requires a referral.

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. Explanation: The nurse should review the client's current orders to confirm which IV solution should be infused. Hanging the IV bag that was left on the pole is assuming that the assigned nurse hung the correct IV solution. Nurses should always verify orders themselves. Obtaining a bag of the current IV solution to hang is assuming, rather than verifying, as well. Discontinuing the solution is not necessary while verifying the orders.

When documenting clinical data after an assessment of the client's neck, what might you write in the physical assessment?

Thyroid isthmus barely palpable, lobes not felt Explanation: An example of documentation from the assessment of a client's neck is: Neck supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.

The nurse notes the diagnosis "Readiness for enhanced coping" written on a client's care plan. What type of diagnosis has been identified for the client?

Wellness Explanation: A wellness diagnosis begins with "Readiness for enhanced..." A risk diagnosis begins with the word "risk." An actual diagnosis begins with the NANDA label. A syndrome diagnosis is a clinical judgment that describes a specific cluster of nursing diagnoses that occur together and have similar nursing interventions to resolve the situation.

A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?

implementation Explanation: This step is implementation, because the nurse is taking appropriate action by giving oral medication. Assessment is the first step of the nursing process when the nurse collects data. Diagnosis is determining the problem. Evaluation is the final step to see if client has achieved established goals.

The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis?

status of breath sounds Explanation: Certain cues are pointing toward a respiratory problem for this client; however, no data have been gathered on breath sounds, which needs to be done before formulating an appropriate nursing diagnosis. The rash on face, present medications, and previous illnesses do not support cues to help in formulating a diagnosis for the breathing problem.