NURS 202 Chapter 13

A nurse manager is talking with a new nurse. The nurse manager determines that the new nurse is thinking critically based on which statement?

"If I give this medication the client probably will be sleepy"

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. which domain should the nurse look to for developing a nursing diagnosis based on this client's musculoskeletal health problems?

Activity/rest

The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats. What is the most appropriate intervention for this client with a nursing diagnosis of Imbalanced Nutrition: less than body requirements?

Administer 2500 calorie (10,460 kj) diet, excluding wheat, rye and oats

A nurse is educating a pregnant woman in preterm labor on the use of her home monitoring equipment and her medications. What factor could impede the client's ability to learn?

Anxiety

The nurse is performing an assessment on a client who presents with a rash on the back that is red and raised. What would be the MOST appropriate nursing action?

Assess the client's back visually

A nurse technician is assigned to take client vital signs. When making rounds, the nurse notices that one client's vital signs are very different than they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings?

Assess the client's vital signs again

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?

Assessment

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "can you give me an example?" The nurse is demonstrating which standard for judging thinking?

Clarity

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and the pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective

Which action does the nurse associate with outcome identification and planning in the nursing process?

Develops an individualized plan of nursing care

A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is MOST likely in which phase of the nursing process

Diagnosis

which step of the nursing process involves reporting or analysis of data to identify and define health problems?

Diagnosis

a nurse should have critical thinking attitudes to develop critical thinking skills. One attitude the nurse should possess is orderly thinking to do what is best. Which term BEST suits this attitude description?

Discipline

The nurse is caring for a client who states that he hears voices in his head that tell him to do bad things. When the nurse enters the client's room, he is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?

Document this assessment based on the client's behaviors

The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0-10. There is an order for IV pain medication every 4 hours PRN. The Nurse administers the prescribed pain medication to the client What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0-10?

Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect

the nurse assesses a client's blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. What action has been implemented?

Evaluation

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill?

Intellectual

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and upon evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?

Modify the plan of care and interventions to meet the client's needs

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?

Nursing Process

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30-45 minutes of receiving prescribed analgesic." The nurse has identified:

Outcome

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?

Planning

The nurse has measured from the tip of the client's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing

A nurse has developed a plan of care for an adult client. What nursing function is important when using a nursing diagnosis to guide the care of this client?

Prioritize the nursing diagnoses

What is the best example of person-centered care provided by a registered nurse?

Reassuring a client who is anxious about a procedure

Personal characteristics demonstrate that one has developed critical thinking. Characteristics of critical thinking include

Self-aware, honest, persistent, and authentic

The nursing process is based upon the process of problem-solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg. where the blood pressure is obtained. what type of problem-solving did the nurse use?

Trial-an-error problem solving

Which action is performed in the implementation step in the nursing process? a) documenting the nursing care and client responses b) documenting the plan of care?

a) documenting the nursing care and client responses

The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast fee. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the MOST appropriate action by the nurse at this time? a) contact the lactation consultant and ask if the plan of care needs to be modified b) terminate the plan of care because evaluation reveals that the outcome has been met

b) terminate the plan of care because evaluation reveals that the outcome has to respond

A client newly diagnosed with diabetes has been sent home after an in-depth education regarding the diabetes management plan. Because the client is newly diagnosed, the nurse included in the plan of care risk for unstable glucose. What is the MOST appropriate short-term outcome for this nursing diagnosis in the client? The client will:

maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L)

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client

A nurse is engaged in diagnostic reasoning to propose appropriate nursing diagnoses for a client. Place the steps in order that they would occur from first to last during this process: a) conduction a focused data collection b) organizing the existence of cues c) Validating diagnoses d) generating possible diagnoses e) comparing cues to possible diagnoses

1. b) organizing the existence of cues 2. d) generating possible diagnoses 3. e) comparing cues to possible diagnoses 4. a) conduction a focused data collection 5. c) Validating diagnoses

The nurse is teaching about the nursing processes. In which order should the nurse explain the phases to the student nurse? a) Diagnosis b) Evaluation c) Planning d) Assessment e) Implement

1. d) Assessment 2. a) Diagnosis 3. c) Planning 4. e) Implement 5. b) Evaluation

Cognitively skilled nurses are critical thinkers. What are the characteristics of a critical thinker? select all that apply. a) thinking "outside the box" b) being open to all points of view c) resisting "easy answers" to client problems

a) thinking "outside the box" b) being open to all points of view c) resisting "easy answers" to client problems

The nursing process provides a framework for the client and nurse to work together. Recording prioritized outcomes in the plan of care ensures which benefit?

Continuity of care can be provided to the client

An obese client is in the clinic to be started on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client?

Create an exercise plan that is realistic and valued

The nurse is caring for an obese client who needs to be turned every 2 hours. Which nursing action is an example of reflection for action

During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. After the shift is over, the nurse wonders if all health care providers are using the appropriate resources when turning this client. The next day, the nurse institutes, as part of the client's plan of care, assistance with turning so that the client gets optimal care without injury to the caregivers

A nurse has identified a nursing diagnosis of "imbalanced nutrition: less than body requirements related to continued weight loss despite adequate intake." During the implementation phase of the nursing process, which activities would be appropriate? select all that apply a) administer 100mL of a nutritional supplement as ordered at bedtime b) contact dietician to perform calorie count c) ask family to bring in a home-cooked meal

a) administer 100mL of a nutritional supplement as ordered at bedtime b) contact dietician to perform calorie count c) ask the family to bring in a home-cooked meal

The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What does the nurse determine this phase will include? select all that apply a) evaluation is the last part of the nursing process b) the evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care c) evaluations should be documented daily in the client record

a) evaluation is the last part of the nursing process b) the evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care c) evaluations should be documented daily in the client record

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

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? select all that apply a) imbalanced nutrition b)impaired mobility c)ineffective coping

a) imbalanced nutrition b)impaired mobility c)ineffective coping

Which statements are true about the implementation phase of the nursing process? select all that apply a) implementation is the process of carrying out the plan of care b) care provided during implementation should be documented in the client's chart c) this phase promotes wellness and restores health

a) implementation is the process of carrying out the plan of care b) care provided during implementation should be documented in the client's chart c) this phase promotes wellness and restores health

A nurse is using the nursing process to provide care to a client admitted to the facility. During the assessment phase, which activities would the nurse likely perform? select all that apply a) obtain a baseline oxygen saturation level b) obtain a weight c) perform passive range of motion exercises d) check results of the client's blood work

a) obtain a baseline oxygen saturation level b) obtain a weight d) check results of the client's blood work

The nurse is using the nursing process when caring for the needs of a client. What is the most beneficial use of the nursing process in addressing the needs of the client? a) provides a universally applicable framework for nursing activities b) targets desired outcomes for particular illnesses, procedures, or conditions

a) provides a universally applicable framework for nursing activities

A nursing student is shadowing a registered nurse for a day in the clinical area as part of the student's orientation for clinical rotation. The student asks the nurse, "Do you really use the nursing process when caring for your clients?" Which responses by the nurse would be appropriate? select all that apply a) "Yes, it's important for providing individualized care to each client." b) "Yes, it helps to emphasize the client's active role in making decisions." c) "Yes, the nursing process is essential for identifying medical diagnoses." d) "Yes, the nursing process is an orderly way of solving client problems

a) "Yes, it's important for providing individualized care to each client." b) "Yes, it helps to emphasize the client's active role in making decisions." d) "Yes, the nursing process is an orderly way of solving client problems

Which statements are true about informatics in nursing practice? select all that apply a) utilization of information services helps to support decision making b) the use of informatics can help manage knowledge and mitigate error c) nurses should value technologies that support error prevention and care coordination

a) utilization of information services helps to support decision making b) the use of informatics can help manage knowledge and mitigate error c) nurses should value technologies that support error prevention and care coordination

The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds: a) "You can expect your body temperature to drop about 3 degrees during your time at the bus stop." b) "We are warm-blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time." c) "Everyone is different so I cannot say how your body might react." d) "When exposed to extreme cold, the body works hard to stay warm and may warm itself 1-2 degrees above normal during exposure."

b) "We are warm-blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time."

Which is the MOST appropriate example of the assessment phase of the nursing process a) Evaluating the temperature of a client given medication for a fever b) Palpating a mass in the right lower quadrant of the abdomen

b) Palpating a mass in the right lower quadrant of the abdomen

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? a) Hypertensive b) Risk for falls c) Congestive heart failure d) Pneumonia

b) Risk for falls

A nurse is caring for a post-operative client 1 day after a total abdominal hysterectomy. Which intervention demonstrates caring? a) assessing the abdominal incision b) assisting the client to sit up in a chair

b) assisting the client to sit up in a chair

The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as: a) surveillance b) supervisory

b) supervisory

Which statement is true of the nursing process? a) It is more appropriate in medical-surgical settings than community health care. b) It is a valid alternative to using intuition to respond to nursing situations. c) Trial-and-error problem solving is incongruent with the nursing process. d) Scientific problem solving can occur within the nursing process

d) Scientific problem solving can occur within the nursing process

Which is an important element of implementation?

documentation

In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse MOST likely be engaged?

reevaluating experience in light of ideas

Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. this process is referred to as

reflective practice

Which statement is true of the nursing process?

scientific problem solving can occur within the nursing process