NURSING EXAM #2 PRACTICE QUESTIONS

Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. Place your answers on the lines provided. The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (3) collects as much information as possible to understand the patient's health problems; (4) collects the patient data in an organized manner; (5) verifies that the data obtained is pertinent to the patient care plan; and (6) records the data according to facility's policy. (1) ___________________ (2) ___________________ (3) ___________________ (4) ___________________ (5) ___________________ (6) ___________________

(1) Purposeful: The nurse identifies the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. (2) Prioritized: The nurse gets the most important information first. (3) Complete: The nurse gathers as much data as possible to understand the patient health problem and develop a care plan. (4) Systematic: The nurse gathers the information in an organized manner. (5) Accurate and relevant: The nurse verifies that the information is reliable. (6) Recorded in a standard format: The nurse records the data according to the facility's policy so that all caregivers can easily access what is learned.

Read the following patient scenario and identify the step of the nursing process represented by each numbered and boldfaced nursing activity. Annie seeks the help of the nurse in the student health clinic because she suspects that her roommate, Angela, suffered date rape. She is concerned because Angela chose not to report the rape and does not seem to be coping well. (1) After talking with Annie, the nurse learns that although Angela blurted out that she had been raped when she first came home, since then she has refused verbalization about the rape ("I don't want to think or talk about it"), has stopped attending all college social activities (a marked change in behavior), and seems to be having nightmares. After analyzing the data, the nurse believes that Angela might be experiencing (2) rape-trauma syndrome: silent reaction. Fortunately, Angela trusts Annie and is willing to come to the student health center for help. A conversation with Angela confirms the nurse's suspicions, and problem identification begins. The nurse talks further with Angela (3) to develop some treatment goals and formulate outcomes. The nurse also begins to think about the types of nursing interventions most likely to yield the desired outcomes. In the initial meeting with Angela, (4) the nurse encourages her expression of feelings and helps her to identify personal coping strategies and strengths. The nurse and Angela decide to meet in 1 week (5) to assess her progress toward achieving targeted outcomes. If she is not making progress, the care plan might need to be modified. (1) _____________________ (2) _____________________ (3) _____________________ (4) _____________________ (5) _____________________

(1) is an illustration of assessing: the collection of patient data. (2) is an illustration of the identification of a nursing diagnosis: a health problem that independent nursing intervention can resolve. (3) is an illustration of planning: outcome identification and related nursing interventions. (4) is an illustration of implementing: carrying out the care plan. (5) is an illustration of evaluating: measuring the extent to which Angela has achieved targeted outcomes.

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? A) "New mothers need support." B) "The lack of a father is difficult." C) "How are you today?" D) "It is a very sad situation."

A) "New mothers need support." The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles.

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. A) Basing patient care on continuous healing relationships B) Customizing care to reflect the competencies of the staff C) Using evidence-based decision making D) Having a charge nurse as the source of control E) Using safety as a system priority F) Recognizing the need for secrecy to protect patient privacy

A) Basing patient care on continuous healing relationships C) Using evidence-based decision making E) Using safety as a system priority Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized.

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? A) Cliché B) Giving advice C) Being judgmental D) Changing the subject

A) Cliché Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition.

A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? A) Cognitive B) Psychomotor C) Affective D) Physical changes

C) Affective Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? A) After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. B) By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. C) Following physical therapy, patient will begin to gradually participate in walking/running events. D) By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.

A) After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. A) "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." B) "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" C) "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." D) "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." E) "We need to check your health status and see what kind of nursing care you may need." F) "We need to see if you require a referral to a physician or other health care professional."

A) "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." E) "We need to check your health status and see what kind of nursing care you may need." F) "We need to see if you require a referral to a physician or other health care professional." Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's BEST response to this student's diagnosis? A) "Was this diagnosis derived from a cluster of significant data or a single clue?" B) "This early diagnosis will help us manage the problem before it becomes more acute." C) "Have you determined if this is an actual or a possible diagnosis?" D) "This condition is a medical problem that should not have a nursing diagnosis."

A) "Was this diagnosis derived from a cluster of significant data or a single clue?" Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem. There may be a reason for the lack of a bowel movement for 2 days, or it might be this person's normal pattern.

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? A) "You made an inference that she is fine because she has no complaints. How did you validate this?" B) "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." C) "Sometimes everyone gets lucky. Why don't you try to help another patient?" D) "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"

A) "You made an inference that she is fine because she has no complaints. How did you validate this?" The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? A) 2, 4, 1, 3 B) 3, 1, 4, 2 C) 2, 4, 3, 1 D) 3, 2, 4, 1

A) 2, 4, 1, 3 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? A) A patient problem list B) Narrative notes describing the patient's condition C) Overall trends in patient status D) Planned interventions and patient outcomes

A) A patient problem list The SOAP format (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes of a POMR. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using CBE, not SOAP charting. Planned interventions and patient-expected outcomes are the focus of the case management model.

The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. A) A patient tells the nurse that she is feeling nauseous. B) A patient's ankles are swollen. C) A patient tells the nurse that she is nervous about her test results. D) A patient complains that the skin on her arms is tingling. E) A patient rates his pain as a 7 on a scale of 1 to 10. F) A patient vomits after eating supper.

A) A patient tells the nurse that she is feeling nauseous. C) A patient tells the nurse that she is nervous about her test results. D) A patient complains that the skin on her arms is tingling. E) A patient rates his pain as a 7 on a scale of 1 to 10. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: A) Clinical judgment B) Clinical reasoning C) Critical thinking D) Blended competencies

A) Clinical judgment Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients.

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? A) Cognitive B) Psychomotor C) Affective D) Physical changes

A) Cognitive Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; affective outcomes pertain to changes in patient values, beliefs, and attitudes; and physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? A) Compare this reading to standards. B) Check the taxonomy of nursing diagnoses for a pertinent label. C) Check a medical text for the signs and symptoms of high blood pressure. D) Consult with colleagues.

A) Compare this reading to standards. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.

A nurse is preparing to teach a patient with asthma how to use his inhaler. Which teaching method would be the BEST choice to teach the patient this skill? A) Demonstration B) Lecture C) Discovery D) Panel session

A) Demonstration Demonstration of techniques, procedures, exercises, and the use of special equipment is an effective patient-teaching strategy for a skill. Lecture can be used to deliver information to a large group of patients but is more effective when the session is interactive; it is rarely used for individual instruction, except in combination with other strategies. Discovery is a good method for teaching problem-solving techniques and independent thinking. Panel discussions can be used to impart factual material but are also effective for sharing experiences and emotions.

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? A) Determining the progress made in achieving established goals B) Clarifying when the patient should take medications C) Reporting the progress made in teaching to the staff D) Including all family members in the teaching session

A) Determining the progress made in achieving established goals The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coordinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care.

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. A) Group decision making B) Group leadership C) Group power D) Group identity E) Group patterns of interaction F) Group cohesiveness

A) Group decision making D) Group identity E) Group patterns of interaction F) Group cohesiveness Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes.

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? A) Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. B) or nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. C) The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! D) It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

A) Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: A) Quality assurance B) Quality improvement C) Process evaluation D) Outcome evaluation

B) Quality improvement Unlike quality assurance, quality improvement is internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than people, and has no end points. Its goal is improving quality rather than assuring quality. Process evaluation and outcome evaluation are types of quality-assurance programs.

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. A) Monitoring patient status every hour B) Using intuition to troubleshoot patient problems C) Turning a patient on bed rest every 2 hours D) Becoming a nurse mentor to a student nurse E) Administering pain medication ordered by the physician F) Becoming involved in community nursing events

A) Monitoring patient status every hour C) Turning a patient on bed rest every 2 hours E) Administering pain medication ordered by the physician Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent. Standards would include monitoring patient status every hour, turning a patient on bed rest every 2 hours, and administering pain medication ordered by the physician. Using intuition to troubleshoot patient problems, becoming a nurse mentor to a student nurse, and becoming involved in community nursing events are not patient care standards.

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? A) Pain B) Anxiety C) Depression D) Fluid volume deficit

A) Pain A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior.

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? A) Perform the focused assessment as this is an independent nurse-initiated intervention. B) Request an order from Jill's physician since this is a physician-initiated intervention. C) Request an order from Jill's physician since this is a collaborative intervention. D) Request an order from the nutritionist since this is a collaborative intervention.

A) Perform the focused assessment as this is an independent nurse-initiated intervention. Performing a focused assessment is an independent nurse-initiated intervention; thus the nurse does not need an order from the physician or the nutritionist.

A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the people responsible for these errors and see if we can replace them." This is an example of: A) Quality by inspection B) Quality by punishment C) Quality by surveillance D) Quality by opportunity

A) Quality by inspection Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by punishment and quality by surveillance are not quality-assurance methods used in the health care field.

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? A) Tell the RN that he or she lacks the technical competencies to change the dressing independently. B) Assemble the equipment for the procedure and follow the steps in the procedure manual. C) Ask another student nurse to work collaboratively with him or her to change the dressing. D) Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

A) Tell the RN that he or she lacks the technical competencies to change the dressing independently. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the care plan. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. A) The nurse carefully removes the bandages from a burn victim's arm. B) The nurse assesses a patient to check nutritional status. C) The nurse formulates a nursing diagnosis for a patient with epilepsy. D) The nurse turns a patient in bed every 2 hours to prevent pressure injuries. E) The nurse checks a patient's insurance coverage at the initial interview. F) The nurse checks for community resources for a patient with dementia.

A) The nurse carefully removes the bandages from a burn victim's arm. D) The nurse turns a patient in bed every 2 hours to prevent pressure injuries. F) The nurse checks for community resources for a patient with dementia. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

After instituting a new system for recording patient data, a nurse evaluates the "usability" of the system. Which actions by the nurse BEST reflect this goal? Select all that apply. A) The nurse checks that the screens are formatted to allow for ease of data entry. B) The nurse reorders the screen sequencing to maximize effective use of the system. C) The nurse ensures that the computers can be used by specified users effectively. D) The nurse checks that the system is intuitive, and supportive of nurses. E) The nurse improves end-user skills and satisfaction with the new system. F) The nurse ensures patient data is able to be shared across health care systems.

A) The nurse checks that the screens are formatted to allow for ease of data entry. C) The nurse ensures that the computers can be used by specified users effectively. D) The nurse checks that the system is intuitive, and supportive of nurses. Usability refers to the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use. Checking that screens are formatted to allow ease of data entry, ensuring that computers can be used by specified users effectively, and checking that the system is intuitive and supportive of nurses are all tasks related to the "usability" of the system. Reordering screen sequencing to maximize use and improving end-user skills and satisfaction with the new system refers to optimization. The ability to share patient data across health care systems is termed interoperability.

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. A) The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. B) The nurse uses a binary decision tree for stepwise assessment and intervention. C) The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. D) The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. E) The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. F) The nurse uses a decision tree that provides intense specificity and no provider flexibility.

A) The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. C) The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. A) The nurse uses critical thinking skills to plan care for a patient. B) The nurse correctly administers IV saline to a patient who is dehydrated. C) The nurse assists a patient to fill out an informed consent form. D) The nurse learns the correct dosages for patient pain medications. E) The nurse comforts a mother whose baby was born with Down syndrome. F) The nurse uses the proper procedure to catheterize a female patient.

A) The nurse uses critical thinking skills to plan care for a patient. D) The nurse learns the correct dosages for patient pain medications. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

A registered nurse assumes the role of nurse coach to provide teaching to patients who are recovering from a stroke. Which nursing intervention directly relates to this role? A) The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change. B) The nurse is the expert in providing teaching and education strategies to provide dietary and activity modifications. C) The nurse becomes a mentor to the patients and encourages them to create their own fitness programs. D) The nurse assumes an authoritative role to design the structure of the coaching session and support the achievement of patient goals.

A) The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change. A nurse coach establishes a partnership with a patient and, using discovery, facilitates the identification of the patient's personal goals and agenda to lead to change rather than using teaching and education strategies with the nurse as the expert. A nurse coach explores the patient's readiness for coaching, designs the structure of a coaching session, supports the achievement of the patient's desired goals, and with the patient determines how to evaluate the attainment of patient goals.

Population health addresses the health status and health issues of aggregate populations and addresses ways in which resources may be allocated to address these concerns. What is the driving force behind the use by health corporations of analytics and big data to support population health? A) The transition from fee-for-service models to value-based payment models B) A growing older population with more complicated health needs C) The overcrowding and understaffing of hospitals D) The shortage of health care professionals, particularly nurses

A) The transition from fee-for-service models to value-based payment models Information technology is a part of the core infrastructure on which population health can be assessed and addressed. As organizations transition from the traditional fee-for-service model to value-based payment models (including ACOs), data, information, and knowledge about populations rather than individual patients will be required. A growing older population with more complicated health needs, the overcrowding and understaffing of hospitals, and the shortage of health care professionals, particularly nurses, may be affected by population health assessment, but are not the driving force for the development of this technology.

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? A) Administer pain medication. B) Reassess the patient. C) Prepare the equipment. D) Explain the procedure to the patient.

B) Reassess the patient. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications.

A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? A) "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." B) "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." C) "Because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" D) "Why do you think Sue isn't talking about her worries?"

B) "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." The nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mentioning the real penalties linked to abuses of privacy. Finally, it is appropriate to ask about Sue and her worries, but this should be done after the nurse clarifies what he or she is able to do.

A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? A) "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." B) "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" C) "I will need to call in on the 8th of August because I have a doctor's appointment." D) "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

B) "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" Effective communication by the sender involves the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time.

A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? A) "Would you prefer a bath or a shower?" B) "May I help you with a bed bath now or later this morning?" C) "I will be giving you your bath. Do you use soap or shower gel?" D) "I prefer a shower in the evening. When would you like your bath?"

B) "May I help you with a bed bath now or later this morning?" The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones.

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? A) Systematic B) Interpersonal C) Dynamic D) Universally applicable in nursing situations

B) Interpersonal Interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.

A nurse forms a contractual agreement with a morbidly obese patient to achieve optimal weight goals. Which statement best describes the nature of this agreement? A) "This agreement forms a legal bond between the two of us to achieve your weight goals." B) "This agreement will motivate the two of us to do what is necessary to meet your weight goals." C) "This agreement will help us determine what learning outcomes are necessary to achieve your weight goals." D) "This agreement will limit the scope of the teaching session and make stated weight goals more attainable."

B) "This agreement will motivate the two of us to do what is necessary to meet your weight goals." A contractual agreement is a pact two people make, setting out mutually agreed-on goals. Contracts are usually informal and not legally binding. When teaching a patient, such an agreement can help motivate both the patient and the teacher to do what is necessary to meet the patient's learning outcomes. The agreement notes the responsibilities of both the teacher and the learner, emphasizing the importance of the mutual commitment.

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? A) "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" B) "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." C) "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." D) "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

B) "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.

A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three-part nursing diagnoses? 1) Disabled Family Coping related to lack of knowledge about home care of child on ventilator 2) Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-lb weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height-weight charts 3) Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" 4) Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?" "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" 5) Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression - A) (1) and (3) - B) (2) and (4) -C) (1), (2), and (3) - D) (1), (2), (3), (4), and (5)

B) (2) and (4) (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement which blames home health aides for the patient's problem. Statements that may be interpreted as libel or that imply nursing negligence are legally hazardous to all the nurses caring for the patient. Assigning blame in the written record is problematic.

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A) A nurse sits down with a patient and prioritizes existing diagnoses. B) A nurse assesses a woman for postpartum depression during routine care. C) A nurse plans interventions for a patient who is diagnosed with epilepsy. D) A busy nurse takes time to speak to a patient who received bad news. E) A nurse reassesses a patient whose PRN pain medication is not working. F) A nurse coordinates the home care of a patient being discharged.

B) A nurse assesses a woman for postpartum depression during routine care. D) A busy nurse takes time to speak to a patient who received bad news. E) A nurse reassesses a patient whose PRN pain medication is not working. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

A nurse has taught a patient with diabetes how to administer his daily insulin. How should the nurse evaluate the teaching-learning process? A) By determining the patient's motivation to learn B) By deciding if the learning outcomes have been achieved C) By allowing the patient to practice the skill he has just learned D) By documenting the teaching session in the patient's medical record

B) By deciding if the learning outcomes have been achieved The nurse cannot assume that the patient has actually learned the content unless there is some type of proof of learning. The key to evaluation is meeting the learner outcomes stated in the teaching plan.

A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? A) Promoting health B) Preventing illness C) Restoring health D) Facilitating coping

B) Preventing illness Teaching first aid is a function of the goal to prevent illness. Promoting health involves helping patients to value health and develop specific health practices that promote wellness. Restoring health occurs once a patient is ill, and teaching focuses on developing self-care practices that promote recovery. When facilitating coping, nurses help patients come to terms with whatever lifestyle modification is needed for their recovery or to enable them to cope with permanent health alterations.

When may a health institution release a PHI for purposes other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply. A) News media are preparing a report on the condition of a patient who is a public figure. B) Data are needed for the tracking and notification of disease outbreaks. C) Protected health information is needed by a coroner. D) Child abuse and neglect are suspected. E) Protected health information is needed to facilitate organ donation. F) The sister of a patient with Alzheimer's disease wants to help provide care.

B) Data are needed for the tracking and notification of disease outbreaks. C) Protected health information is needed by a coroner. D) Child abuse and neglect are suspected. E) Protected health information is needed to facilitate organ donation. According to the HIPAA, a health institution is not required to obtain written patient authorization to release PHI for tracking disease outbreaks, infection control, statistics related to dangerous problems with drugs or medical equipment, investigation and prosecution of a crime, identification of victims of crimes or disaster, reporting incidents of child abuse, neglect or domestic violence, medical records released according to a valid subpoena, PHI needed by coroners, medical examiners, and funeral directors, PHI provided to law enforcement in the case of a death from a potential crime, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease.

A home health care nurse is using the steps of the SDLC, to design a new system for home health care documentation. The nurse analyzes the old system and develops plans for the new system. What is the next step of the nurse in this process? A) Test B) Design C) Implement D) Evaluate

B) Design The SDLC requires focus in the areas of Analyze and Plan, Design and Build, Test, Train, Implement, Maintain, and Evaluate. After analyzing and planning the new system, the nurse would move on to the design step in which the basic design of the new system is developed. The nurse would then test the system, train employees, and implement, maintain, and evaluate the new system in that order.

A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? A) Offer the patient 60-mL fluid every 2 hours while awake. B) During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. C) Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. D) At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.

B) During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60-mL fluid every 2 hours while awake." Correct: "The patient will drink 60-mL fluid every 2 hours while awake, beginning 1/3/20." The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include "know," "understand," "learn," and "become aware."

Nurses incorporate telecare in patient care plans. Which services are MOST representative of this technologic advance? Select all that apply. A) Diagnostic testing B) Easy access to specialists C) Health and fitness apps D) Early warning and detection technologies E) Digital medication reminder systems F) Monitoring of progress following treatment

B) Easy access to specialists C) Health and fitness apps D) Early warning and detection technologies Telecare generally refers to technology that allows consumers to stay safe and independent in their own homes. It may include consumer-oriented health and fitness apps, sensors and tools that connect consumers with family members or other caregivers, exercise tracking tools, digital medication reminder systems, and early warning and detection technologies. Telemedicine involves the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners. Examples include conducting diagnostic tests, monitoring a patient's progress after treatment or therapy, and facilitating access to specialists that are not located in the same place as the patient.

A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? A) Maslow's human needs B) Gordon's functional health patterns C) Human response patterns D) Body system model

B) Gordon's functional health patterns Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. A) Bronchial pneumonia B) Impaired gas exchange C) Ineffective airway clearance D) Potential complication: sepsis E) Infection related to pneumonia F) Risk for septic shock

B) Impaired gas exchange C) Ineffective airway clearance F) Risk for septic shock Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? A) A closed-ended answer B) Information clarification C) The nurse to give advice D) Assertive behavior

B) Information clarification The patient's question allows the nurse to clarify information that is new to the patient or that requires further explanation.

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. A) It functions independently of nursing standards, ethics, and state practice acts. B) It is based on the principles of the nursing process, problem solving, and the scientific method. C) It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. D) It is not designed to compensate for problems created by human nature, such as medication errors. E) It is constantly re-evaluating, self-correcting, and striving for improvement. F) It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

B) It is based on the principles of the nursing process, problem solving, and the scientific method. C) It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. E) It is constantly re-evaluating, self-correcting, and striving for improvement. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve (Alfaro-LeFevre, 2014).

An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. A) Performing the initial patient assessments B) Making patient beds C) Giving patients bed baths D) Administering patient medications E) Ambulating patients F) Assisting patients with meals

B) Making patient beds C) Giving patients bed baths E) Ambulating patients F) Assisting patients with meals Performing the initial patient assessment and administering medications are the responsibility of the RN. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? A) Erase or use correcting fluid to completely delete the error. B) Mark the entry "mistaken entry"; add correct information; date and initial. C) Use a permanent marker to block out the mistaken entry and rewrite it. D) Remove the page with the error and rewrite the data on that page correctly.

B) Mark the entry "mistaken entry"; add correct information; date and initial. The nurse should not use dittos, erasures, or correcting fluids when correcting documentation; block out a mistake with a permanent marker; or remove a page with an error and rewrite the data on a new page. To correct an error after it has been entered, the nurse should mark the entry "mistaken entry," add the correct information, and date and initial the entry. If the nurse records information in the wrong chart, the nurse should write "mistaken entry—wrong chart" and sign off. The nurse should follow similar guidelines in electronic records.

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure? A) Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions B) Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings C) A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention D) A complete list of reimbursable charges for each nursing intervention

B) Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings The NIC Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges

A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? A) Actual B) Possible C) Risk D) Collaborative

B) Possible An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? A) No problem B) Possible problem C) Actual nursing diagnosis D) Clinical problem other than nursing diagnosis

B) Possible problem When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

A nurse is using informatics technology to decide which patients may be at risk for readmission. What is the term for this type of analytic? A) Data visualization B) Predictive analytics C) Big data D) Data recall

B) Predictive analytics Predictive analytics encompasses a variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events. In health care, this is used by organizations to attempt to identify patients who are at risk for readmission so case managers can intervene. Data visualization is the presentation of data in a pictorial or graphical format for analysis. Big data comprises the accumulation of health care-related data from various sources, combined with new technologies that allow for the transformation of data to information, to knowledge, and ultimately to wisdom. Data recall is not a technical term for analytics.

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? A) Risk for Impaired Skin Integrity B) Related to prescribed bed rest C) As evidenced by D) As evidenced by reddened areas of skin on the heels and back

B) Related to prescribed bed rest "Related to prescribed bed rest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a White man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis? a) Actual B) Risk C) Possible D) Wellness

B) Risk A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.

A nurse is caring for a patient who is admitted to the hospital with injuries sustained in a motor vehicle accident. While he is in the hospital, his wife tells him that the bottom level of their house flooded, damaging their belongings. When the nurse enters his room, she notes that the patient is visibly upset. The nurse is aware that the patient will most likely be in need of which type of counseling? A) Long-term developmental B) Short-term situational C) Short-term motivational D) Long-term motivational

B) Short-term situational Short-term counseling might be used during a situational crisis, which occurs when a patient faces an event or situation that causes a disruption in life, such as a flood. Long-term counseling extends over a prolonged period; a patient experiencing a developmental crisis, for example, might need long-term counseling. Motivational interviewing is an evidence-based counseling approach that involves discussing feelings and incentives with the patient. A caring nurse can motivate patients to become interested in promoting their own health.

A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. A) The nurse uses the nursing interview to collect patient data. B) The nurse analyzes data collected in the nursing assessment. C) The nurse develops a care plan for the patient. D) The nurse points out the patient's strengths. E) The nurse assesses the patient's mental status. F) The nurse identifies community resources to help his family cope.

B) The nurse analyzes data collected in the nursing assessment. D) The nurse points out the patient's strengths. F) The nurse identifies community resources to help his family cope. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

A nurse is planning teaching strategies based on the affective domain of learning for patients addicted to alcohol. What are examples of teaching methods and learning activities promoting behaviors in this domain? Select all that apply. A) The nurse prepares a lecture on the harmful long-term effects of alcohol on the body. B) The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. C) The nurse asks patients for a return demonstration for using relaxation exercises to relieve stress. D) The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. E) The nurse uses a pamphlet to discuss the tenants of the Alcoholics Anonymous program to patients. F) The nurse reinforces the mental benefits of gaining self-control over an addiction.

B) The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. D) The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. F) The nurse reinforces the mental benefits of gaining self-control over an addiction. Affective learning includes changes in attitudes, values, and feelings (e.g., the patient expresses renewed self-confidence to be able to give up drinking). Cognitive learning involves the storing and recalling of new knowledge in the brain, such as the learning that occurs during a lecture or by using a pamphlet for teaching. Learning a physical skill involving the integration of mental and muscular activity is called psychomotor learning, which may involve a return demonstration of a skill.

A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. A) The nurse formulates nursing diagnoses. B) The nurse identifies expected patient outcomes. C) The nurse selects evidence-based nursing interventions. D) The nurse explains the nursing care plan to the patient. E) The nurse assesses the patient's mental status. F) The nurse evaluates the patient's outcome achievement.

B) The nurse identifies expected patient outcomes. C) The nurse selects evidence-based nursing interventions. D) The nurse explains the nursing care plan to the patient. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diagnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? A) "You know your personal situation better than I do, so I will respect your wishes." B) "If you don't accept these services, your baby's health will suffer." C) "Let's take a look at the plan again and see if we can adjust it to fit your needs." D) "I'm going to assign your case to a social worker who can explain the services better."

C) "Let's take a look at the plan again and see if we can adjust it to fit your needs." When a patient does not follow the care plan despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the care plan is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

A nurse uses the classic elements of evaluation when caring for patients: (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting your judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes) Which item below places them in their correct sequence? A) 1, 2, 3, 4, 5 B) 3, 2, 1, 4, 5 C) 5, 2, 1, 3, 4 D) 2, 3, 1, 4, 5

C) 5, 2, 1, 3, 4 The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes); (2) collecting data to determine whether these criteria and standards are met; (3) interpreting and summarizing findings; (4) documenting your judgment; and (5) terminating, continuing, or modifying the plan.

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply. A) 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN B) 6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN C) 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN D) 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN E) 6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN F) 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

C) 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN D) 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN F) 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "patient's response to pain appears to be exaggerated" or "seems to be comfortable." The nurse should never document an intervention before carrying it out.

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. A) A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. B) A nurse consults with a psychiatrist for a patient who abuses pain killers. C) A nurse checks the skin of bedridden patients for skin breakdown. D) A nurse orders a kosher meal for an orthodox Jewish patient. E) A nurse records the I&O of a patient as prescribed by his health care provider. F) A nurse prepares a patient for minor surgery according to facility protocol.

C) A nurse checks the skin of bedridden patients for skin breakdown. D) A nurse orders a kosher meal for an orthodox Jewish patient. F) A nurse prepares a patient for minor surgery according to facility protocol. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. A) Fill the silence with lighter conversation directed at the patient. B) Use the time to perform the care that is needed uninterrupted. C) Discuss the silence with the patient to ascertain its meaning. D) Allow the patient time to think and explore inner thoughts. E) Determine if the patient's culture requires pauses between conversation. F) Arrange for a counselor to help the patient cope with emotional issues.

C) Discuss the silence with the patient to ascertain its meaning. D) Allow the patient time to think and explore inner thoughts. E) Determine if the patient's culture requires pauses between conversation. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor.

A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? A) Determining the established goals of the institution B) Ensuring that verbal and nonverbal communication is congruent C) Engaging in self-talk to plan the day and decrease fear D) Speaking with fellow colleagues about how they feel

C) Engaging in self-talk to plan the day and decrease fear By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety.

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: A) Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice B) Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice C) Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice D) Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

C) Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? A) Initial planning B) Standardized planning C) Ongoing planning D) Discharge planning

C) Ongoing planning Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? A) Patient-centered care B) Evidence-based practice C) Quality improvement D) Informatics

C) Quality improvement Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provider's order sheet. What is the nurse's BEST response? A) State: "Thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet." B) Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it. C) State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." D) Try calling another resident for the order or wait until the next shift.

C) State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." In most facilities, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician or nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. Trying to call another resident for the order or waiting until the next shift would be inappropriate; the patient should not have to wait for the pain medication, and a resident is available who can immediately write the order.

A nurse is teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information?A) Ask Me 3 B) Newest Vital Sign (NVS) C) Teach-back method D) TEACH acronym

C) Teach-back method The teach-back tool is a method of assessing literacy and confirming that the learner understands health information received from a health professional. The Ask Me 3 is a brief tool intended to promote understanding and improve communication between patients and their providers. The NVS is a reliable screening tool to assess low health literacy, developed to improve communications between patients and providers. The TEACH acronym is used to maximize the effectiveness of patient teaching by tuning into the patient, editing patient information,

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? A) Allow the UAPs to do the admission assessment and report the findings to the RN. B) Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. C) Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. D) Contact his or her labor representative to report this practice to the state board of nursing.

C) Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. A) The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. B) The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. C) The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. D) The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. E) The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. F) The nurse continues a teaching session on STIs for a sexually active male adolescent despite his protest that "I've heard enough already!"

C) The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. D) The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. E) The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. Successful teaching plans for older adults incorporate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities or information. School-aged children are capable of logical reasoning and should be included in the teaching-learning process whenever possible; they are also open to new learning experiences but need learning to be reinforced by either a parent or health care provider as they become more involved with their friends and school activities. Teaching strategies designed for an adolescent patient should recognize the adolescent's need for independence, as well as the need to establish a trusting relationship that demonstrates respect for the adolescent's opinions.

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? A) The nurse judges whether the patient database is adequate to address the problem. B) The nurse considers whether or not to suggest a counseling session for the patient. C) The nurse reassesses the patient and decides how best to intervene in her care. D) The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

C) The nurse reassesses the patient and decides how best to intervene in her care. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? A) Protocols for treating the patient problem B) Standardized treatment guidelines C) The nurse's ideas about the patient problem and treatment D) Clinical pathways for the treatment of sickle cell anemia

C) The nurse's ideas about the patient problem and treatment A concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.

The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? A) Inform the charge nurse. B) Inform the surgeon. C) Validate the finding. D) Document the finding.

C) Validate the finding. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.

A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? A) "Do you take two injections of insulin to decrease the complications?" B) "Most health care providers recommend diet and exercise to regulate blood sugar." C )"Most complications of diabetes are related to neuropathy." D) "What specific complications have you experienced?"

D) "What specific complications have you experienced?" Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques.

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? A) "I'm just the IV therapist checking your IV." B) "I've been transferred to this division and will be caring for you." C) "I'm sorry, my name is John Smith and I am your nurse." D) "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

D) "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM." The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient.

A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly? A) "Outcome not met." B) "1/21/20—Patient reports no change in diet." C) "Outcome not met. Patient reports no change in diet or activity level." D) "1/21/20—Outcome not met. Patient reports no change in diet or activity level."

D) "1/21/20—Outcome not met. Patient reports no change in diet or activity level." The evaluative statement must contain a date; the words "outcome met," "outcome partially met," or "outcome not met"; and the patient data or behaviors that support this decision. The other answer choices are incomplete statements.

A nurse is counseling a 19-year-old athlete who had his right leg amputated below the knee following a motorcycle accident. During the rehabilitation process, the patient refuses to eat or get up to ambulate on his own. He says to the nurse, "What's the point. My life is over now and I'll never be the football player I dreamed of becoming." What is the nurse counselor's best response to this patient? A) "You're young and have your whole life ahead of you. You should focus on your rehabilitation and make something of your life." B) "I understand how you must feel. I wanted to be a famous singer, but I wasn't born with the talent to be successful at it." C) "You should concentrate on other sports that you could play even with prosthesis." D) "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?"

D) "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?" This answer communicates respect and sensitivity to the patient's needs and offers an opportunity to discuss his feelings with the nurse or another health care professional. The other answers do not allow the patient to express his feelings and receive the counseling he needs.

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? A) "I'm sorry, but patients are not allowed to copy their medical records." B) "I can make a copy of your record for you right now." C) "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." D) "I will need to check with our records department to get you a copy."

D) "I will need to check with our records department to get you a copy." According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of facility policies regarding the patient's right to access and copy records.

During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? A) "You need to speak to the patient quietly so you don't disturb the other patients." B) "Let me help you with your transfer technique." C) "When you are finished, be sure to apologize for your rough demeanor." D) "When your patient is safe and comfortable, meet me at the desk."

D) "When your patient is safe and comfortable, meet me at the desk." The charge nurse should direct the patient care technician to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic communication.

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? 1) Ineffective Coping related to inability to maintain marriage 2) Defensive Coping related to loss of job and economic security 3) Altered Thought Processes related to panic state 4) Decisional Conflict related to placement of parent in a long-term care facility -A) (1) and (2) -B) (3) and (4) -C) (1), (2), and (3) -D) (1), (2), (3), and (4)

D) (1), (2), (3), and (4) Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? A) Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. B) Schedule the testing and meal planning first and complete hygiene as time permits. C) Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. D) Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

D) Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? A) Every 3 hours B) Every 4 hours C) Daily D) As needed

D) As needed PRN means "as needed"—not every 3 hours, every 4 hours, or once daily.

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? A) Thank the wife for being present. B) Ask the wife if she wants to remain. C) Ask the wife to leave. D) Ask the patient if he would like the wife to stay.

D) Ask the patient if he would like the wife to stay. The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? A) Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. B) By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. C) By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). D) By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

D) By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills; and (c) is an outcome describing a physical change in the patient.

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? A) Admission sheet B) Admission nursing assessment C) Flow sheet D) Graphic record

D) Graphic record While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the flow sheet.

A student health nurse is counseling a college student who wants to lose 20 lb. The nurse develops a plan to increase the student's activity level and decrease her consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 lb, the student has lost only 1 lb. Which is the BEST nursing response? A) Congratulate the student and continue the care plan. B) Terminate the care plan since it is not working. C) Try giving the student more time to reach the targeted outcome. D) Modify the care plan after discussing possible reasons for the student's partial success.

D) Modify the care plan after discussing possible reasons for the student's partial success. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the care plan. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the care plan since the student has not met her targeted outcome. The student may need more than just additional time to reach her outcome.

A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? A) Collaborative problem B) Interdisciplinary problem C) Medical problem D) Nursing problem

D) Nursing problem Altered Health Maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? A) Correct the initial assessment form. B) Redo the initial assessment and document current findings. C) Conduct and document an emergency assessment. D) Perform and document a focused assessment of skin integrity.

D) Perform and document a focused assessment of skin integrity. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? A) Comprehensive B) Initial C) Time-lapsed D) Quick priority

D) Quick priority Quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? A) Travelbee's B) Watson's C) Benner's D) Swanson's

D) Swanson's Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility." Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? A) The nurse collects data to identify health problems. B) The nurse collects data to identify patient strengths. C) The nurse collects data to justify terminating the care plan. D) The nurse collects data to measure outcome achievement.

D) The nurse collects data to measure outcome achievement. The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the care plan, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? A) The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." B) The nurse places a hand on the patient's arm and states, "You feel so alone." C) The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." D) The nurse holds the patient's hand and asks, "What makes you feel so alone?"

D) The nurse holds the patient's hand and asks, "What makes you feel so alone?" The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? A) The use of reflective questions B) The use of closed questions C) The use of assertive questions D) The use of clarifying questions

D) The use of clarifying questions The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication.

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order. A) "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." B) "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." C) "You want me to discontinue the PCA pump until you see him tonight at patient rounds." D) "I am Rosa Clark, an RN working on the second floor of South Street Hospital." E) "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." F) "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d, a, e, b, f, c. The order for ISBARR is: Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read-back.