Practice T2
A registered nurse is educating a nursing student about the importance of nursing documentation for performing risk management. What information should the nurse give? Select all that apply. 1 "A nurse's documentation is the evidence of care that a client receives." 2 "Nurses' notes should not be given to attorneys in the event of a lawsuit." 3 "The nurse should note down assessments and significant changes in the client's health." 4 "In case an occurrence report is filed, nurses should enter the information the client's charts." 5 "Nurses should always document the primary healthcare providers' responses whenever they are contacted.
1 "A nurse's documentation is the evidence of care that a client receives." 3 "The nurse should note down assessments and significant changes in the client's health." 5 "Nurses should always document the primary healthcare providers' responses whenever they are contacted. To perform risk management, nurses should always complete documentation in the appropriate manner. A nurse's documentation is considered to be an evidence of care received by a client. Documenting assessments and significant changes in the client's health are essential because this information helps to defend nurses in lawsuits. Nurses should document that the primary healthcare provider was contacted and document the provider's response to the situation at hand. Attorneys often review nurses' notes first if a lawsuit is filed. Nurses should never document that an occurrence report has been completed in a client's chart.
While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning? 1 "I will ask the client to move his or her arm towards the body." 2 "I will ask the client to bend his or her limb by decreasing the angle." 3 "I will ask the client to move his or her hand so that the ventral surface faces downward." 4 "I will ask the client to move his or her head beyond its normal resting extended position."
1 "I will ask the client to move his or her arm towards the body." Adduction is moving the arm towards the body. Assessing the range of motion by bending the limb and decreasing the angle indicates flexion. Moving the hand by facing the ventral surface downwards indicates pronation. The movement of the head beyond the normal resting extended position indicates hyperextension.
A nurse is demonstrating to a client how to manipulate the ankles through full range of motion. Which movements should the nurse use during this process? Select all that apply. 1 Eversion 2 Inversion 3 Abduction 4 Dorsiflexion 5 Plantar flexion
1 Eversion 2 Inversion 4 Dorsiflexion 5 Plantar flexion Eversion is turning the ankle inward toward the midline of the body. The ankle can evert. Inversion is turning the ankle outward away from the midline of the body. The ankle can invert. Dorsiflexion occurs when the toes and the distal part of the foot are bent upward toward the abdomen. The ankles can dorsiflex. Plantar flexion occurs when the toes and the distal part of the foot are bent downward away from the abdomen. The ankles can plantar flex. The ankle cannot be abducted; abduction is moving an extremity away from the midline of the body.
Which image shows the Trendelenburg position? 1 Head down, feet down 2. Flat faciing up 3. Head down, legs down and straight/bent, arms out straight. 4. Flat on stomach
1 Head down, feet down Image 1 shows the Trendelenburg position, in which the client is supine with the legs below the level of the heart. Image 2 shows the supine position, in which the client is on his or her back. Image 3 shows lateral position, in which the client is on his or her side. Image 4 shows prone position, in which the client is on his or her stomach.
A nurse has made a nursing diagnosis without validating the data obtained from the client. Into what category does this error fall? 1 Labeling 2 Collecting 3 Clustering 4 Interpreting
1 Labeling The nurse's error of failure to validate the data is categorized as labeling. Errors at the collecting level include inaccurate data, missing data, and disorganization. Errors at the clustering level include insufficient clusters of cues, premature or early closure, and incorrect clustering. At the interpreting level, errors include failure to consider conflicting cues and failure to consider cultural influences or developmental stage.
A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? 1 A statement that the nursing staff was not at fault because the client initiated the accident 2 A listing of facts related to the incident as witnessed by the nurse 3 The name of the nurse who was responsible for implementing the restraints 4 The potential reasons why the restraints were not in place at the time of the fall
2 A listing of facts related to the incident as witnessed by the nurse PP Table 26-1 The nurse filling out an incident or variance report needs to state only the objective facts surrounding the incident, no opinion or speculation. In an incident report, fault or blame is subjective and should not be implied. It is not necessary to include names except for those of witnesses. Speculations or opinions as to the reason why the ordered restraints were not on the client are subjective and not appropriate to include in an incident or variance report.
How does a nurse incorporate the quality of accuracy into client documentation? 1 By providing a logical order for the communication 2 By using exact measurements for each client's activity 3 By providing complete and appropriate information in each client record 4 By recording descriptive and objective information of what the nurse sees, hears, feels and smells
2 By using exact measurements for each client's activity The use of exact measurements establishes accuracy. A nurse follows the principle of organization by communicating the information in a logical order. The nurse incorporates the guideline completion by providing a complete and appropriate record with all the essential information. A factual record contains descriptive and objective information about what a nurse sees, hears, feels, and smells.
A primary healthcare provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this prescription? 1 Asking that the prescription indicate the type of restraint 2 Recognizing that PRN prescriptions for restraints are unacceptable 3 Implementing the restraint prescription when the client begins to act out 4 Ensuring that the entire staff is aware of the prescription for the restraints
2 Recognizing that PRN prescriptions for restraints are unacceptable A new prescription must be written each time a client requires restraints. When a client is acting out, the nurse may use restraints or a seclusion room and then obtain the necessary prescription. Less restrictive interventions should be used when the client begins to act out; restraints are used as a last resort.
Which client is likely to have a health promotion nursing diagnosis? 1 The client with acute pain due to appendicitis. 2 The client who is willing to take a 30-minute walk daily. 3 The elderly client with dementia admitted to the healthcare facility. 4 The client with reduced cognitive ability while recovering from surgery.
2 The client who is willing to take a 30-minute walk daily. A health promotion nursing diagnosis is a clinical judgment of an individual's desire to increase well-being. A client who is willing to take a 30-minute walk daily is expressing a desire to improve health behavior. The nurse identifies a health promotion nursing diagnosis for this client. Acute pain due to appendicitis is an actual nursing diagnosis. The nurse selects an actual nursing diagnosis when there is sufficient assessment data to establish the nursing diagnosis. It describes the client's response to a particular health condition. A risk nursing diagnosis describes an individual's response to health conditions that may develop in a vulnerable individual. The elderly client with dementia may have a risk nursing diagnosis for confusion. The client recovering from surgery has reduced cognitive ability and may have a risk nursing diagnosis for confusion or falls
After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, what specific range-of-motion exercise should the nurse teach the client? 1 Eversion 2 Supination 3 Opposition 4 Circumduction
3 Opposition Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gliding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip
A preschool child with a spinal cord injury will be on prolonged bed rest. The nurse explains to the parents that certain foods will be restricted to prevent complications associated with immobility. What food should be noted as restricted in the teaching plan? 1 Fish 2 Fruit 3 Beef 4 Cheese
4 Cheese Cheese contains calcium, which is excreted by the kidneys and may contribute to the formation of kidney stones; it adds to the child's risk because immobility causes bone decalcification. Fish contains protein, which is needed for wound healing and growth. Fruit contains some fiber, which will help decrease the risk of constipation. Beef contains protein, which is needed for wound healing and growth.
While assessing a client's joint for mobility, the primary healthcare provider moved the client's first and fifth metacarpals anteriorly from the flattened palm. Which type of synovial joint movement is this termed? 1 Flexion 2 Extension 3 Abduction 4 Opposition
Opposition Opposition is a synovial movement that involves moving the first and fifth metacarpals anteriorly from the flattened palm (cupping position). Flexion involves bending the joint as a result of muscle contractions that result in decreasing the angle between two bones. Extension involves the straightening of the joint that increases the angle between two bones. Abduction involves the movement of a part away from the midline of the body.
syndrome diagnosis
a clinical judgment describing a specific cluster of nursing diagnoses that occur together.
health promotion nursing diagnosis
a clinical judgment of a person's, family's, or community's motivation, and readiness to increase well-being.
risk nursing diagnosis
describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community.
What is the difference between risk nursing diagnoses and actual nursing diagnoses? 1 Actual nursing diagnoses have related factors; risk nursing diagnoses do not have related factors. 2 Actual nursing diagnoses are present in NANDA-I classification; risk nursing diagnoses are absent in NANDA-I classification. 3 Actual nursing diagnoses are associated with environmental and physiological factors; risk nursing diagnoses are not associated with these factors. 4 Actual nursing diagnoses are least likely to be established in a vulnerable population; risk nursing diagnoses are established in vulnerable population.
1 Actual nursing diagnoses have related factors; risk nursing diagnoses do not have related factors. Actual nursing diagnoses have related factors that show a causality relationship between the diagnosis and the etiology. Risk nursing diagnoses have a risk factor which may predispose a client to a disease. Both the types of diagnoses are mentioned in the NANDA-I classification. Both types of diagnoses may have associations with environmental and physiological factors. Both types of diagnoses can be established in vulnerable population.
A client newly diagnosed with rheumatoid arthritis is admitted to the hospital with bilateral painful knee and wrist joints. The nurse identifies impaired physical mobility related to painful, swollen joints. What should the nurse teach the client to do during the acute phase of the disease? 1 Avoid exercises to the involved joints. 2 Engage in passive exercises to the involved joints. 3 Increase isometric exercises to the involved joints slowly. 4 Participate in progressive, resistive exercises to the involved joints
1 Avoid exercises to the involved joints. During the acute phase, immobilization of the joints reduces pain and inflammation. Passive exercises are contraindicated during the acute inflammatory phase; joints need to be immobilized. Isometric exercises involve muscles, not joints. Progressive, resistive exercises are contraindicated during the acute inflammatory phase because joints need to be immobilized to reduce pain and inflammation.
Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply. 1 Nursing diagnoses involve the client when possible. 2 Nursing diagnoses are based on results of diagnostic tests and procedures. 3 Nursing diagnoses are the identification of a disease condition in the client. 4 Nursing diagnoses involve the sorting of health problems within the nursing domain. 5 Nursing diagnoses involve clinical judgment about the client's response to health problems.
1 Nursing diagnoses involve the client when possible. 4 Nursing diagnoses involve the sorting of health problems within the nursing domain. 5 Nursing diagnoses involve clinical judgment about the client's response to health problems. Establishing a nursing diagnosis is the second step in the nursing process. It is unique and involves the client's participation in the process. Nursing diagnoses classify health problems to be treated primarily by nurses. The nurse reviews the client assessment, sees cues and patterns in the data, and identifies the client's specific health care problems. The nursing diagnosis is a clinical judgment about the client's actual or potential health problems that the nurse is licensed to treat. A medical diagnosis is based on results of diagnostic tests and procedures, whereas a nursing diagnosis is based on the results of the nursing assessment. A medical diagnosis identifies a disease condition in the client.
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? 1 Planning 2 Evaluation 3 Assessment 4 Implementation
1 Planning The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.
Which feature is characteristic of a risk nursing diagnosis? 1 The diagnosis does not have related factors. 2 The diagnosis can be used in any health state. 3 The defining characteristics support the diagnostic judgment. 4 The defining characteristics are supported by a client's readiness.
1 The diagnosis does not have related factors. A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures. A health promotion nursing diagnosis can be applied to any individual with a desire to enhance health behaviors in any health state. An actual diagnosis is formed when the defining characteristics support the diagnostic judgment. There must be sufficient nursing assessment data to establish an actual diagnosis. A health promotion nursing diagnosis is a clinical judgment of an individual's readiness to increase well-being.
Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? 1 Have the prescription renewed every 48 hours. 2 Assess the client's condition every hour. 3 Provide range of motion to the client's elbows every shift. 4 Document output from the tube and catheter every 2 hours
2 Assess the client's condition every hour. A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every 2 hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally does not need to be documented as frequently as every 2 hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.
A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? 1 Fatigue related to weight loss secondary to COPD 2 Imbalanced nutrition: less than body requirements, related to fatigue 3 Imbalanced nutrition: less than body requirements, related to COPD 4 Ineffective breathing pattern, related to alveolar hypoventilation
2 Imbalanced nutrition: less than body requirements, related to fatigue The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA-approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem, but does not specifically relate to the weight loss problem.
Which is an example of an actual nursing diagnosis? 1 Risk for acute confusion 2 Impaired social interaction 3 Readiness for enhanced nutrition 4 Readiness for increased family coping
2 Impaired social interaction Impaired social interaction is an example of an actual nursing diagnosis. Actual nursing diagnoses are the responses of a person to a health condition. "Risk for" nursing diagnoses define human responses to conditions that have not occurred yet. Risk for acute confusion is an example of this kind of diagnosis. A health promotion nursing diagnosis is the clinical judgment of an individual's or family's willingness to improve health. Readiness for enhanced nutrition and readiness for enhanced family coping are examples of health promotion nursing diagnoses.
The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. What should the nurse be aware of when using the problem-etiology-signs and symptoms (PES) format? 1 Signs and symptoms come last in the diagnostic process. 2 Nursing interventions are derived from the etiology statement. 3 The only allowable diagnoses are nursing diagnoses. 4 Nursing diagnoses deal only with actual or potential illness problems
2 Nursing interventions are derived from the etiology statement. The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to remember that gathering the signs and symptoms, or "S" in the acronym, comes first in the diagnostic process, even though the format is described as PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses handle most commonly with other healthcare providers. A wellness diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired.
A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? 1 Supine 2 Orthopneic 3 Low-Fowler 4 Semi-Fowler
2 Orthopneic The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange; it also enables the client to press the lower chest or abdomen against the overbed table, which increases pressure on the diaphragm to help with exhalation, reducing residual volume. The supine position does not permit the diaphragm to descend by gravity, and pressure of the abdominal organs against the diaphragm limits its movement. Low-Fowler and semi-Fowler positions do not maximize lung expansion to the same degree as the orthopneic position. the position assumed by patients with orthopnea, namely sitting propped up in bed by several pillows.
Which related factor is appropriate for a nursing diagnosis? 1 Prostectomy 2 Trauma of incision 3 Acute renal failure 4 Knee replacement surgery
2 Trauma of incision The related factor or etiology of a nursing diagnosis is always within the nursing domain. The nurse must ensure that the related factor is a condition that responds to nursing interventions. Trauma of incision is an appropriate related factor for a nursing diagnosis. A prostectomy is a medical condition that cannot be influenced by nursing actions. Similarly, acute renal failure is also a medical condition. Nursing interventions should be directed towards behaviors or conditions that can be managed or treated by the nurse. Knee replacement surgery is a medical condition that cannot be managed by nursing interventions.
While performing a physical assessment of a female client, the nurse positions the client in Sims' position. Which body system will be assessed in this position? Select all that apply. 1 Heart 2 Vagina 3 Rectum 4 Female genitalia 5 Musculoskeletal system
2 Vagina 3 Rectum 4 Female genitalia Sims' position is indicated to examine vagina, rectum, and female genitalia. Lateral recumbent position will aid in detecting murmurs of the heart. Prone position is indicated while assessing the musculoskeletal system
The nurse finds that a client with bilateral oral swelling, pain, and trismus had undergone a surgical extraction of an impacted tooth five days ago. What type of nursing diagnosis does the documentation of acute pain refer to? 1 Syndrome diagnosis 2 Risk nursing diagnosis 3 Actual nursing diagnosis 4 Health promotion nursing diagnosis
3 Actual nursing diagnosis According to the given information, the pain is secondary to the surgical procedure. In this case, the nurse has sufficient assessment data to establish the nursing diagnosis. This is an example of an actual nursing diagnosis. A syndrome diagnosis is a clinical judgment describing a specific cluster of nursing diagnoses that occur together. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's motivation, and readiness to increase well-being.
Elbow restraints are prescribed for an 18-month-old toddler who just had surgery for a cleft palate. The nurse explains to the parents that the restraints are used to keep the child from doing what? 1 Playing with unsterile toys 2 Rolling to a supine position 3 Putting fingers into the mouth 4 Removing the nasogastric tube
3 Putting fingers into the mouth The suture lines in the mouth must be protected. Because the toddler uses the mouth to explore the environment, elbow restraints are needed to keep the child from placing fingers or objects in the mouth. The child should have time to play with toys, but with supervision to prevent mouthing activities that could disrupt the suture line. The supine position is acceptable; the toddler should be able to move freely when asleep. A nasogastric tube is not used.
In which positions should the nurse place a client who has just had a right pneumonectomy? 1 Right or left side-lying 2 High-Fowler or supine 3 Supine or right side-lying 4 Left side-lying or low-Fowler
3 Supine or right side-lying Supine or right side-lying permits ventilation of the remaining lung and prevents fluid from draining into the sutured bronchial stump. Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump. Although the high-Fowler position promotes ventilation, it may be tiring for a postoperative client. Lying on the unoperative side restricts left lung excursion and may allow fluid to drain into the right bronchial stump.
The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1 The nurse notes nonverbal signs of discomfort. 2 The nurse observes the client's position in bed. 3 The nurse asks the client to explain the surgery. 4 The nurse asks the client to rate the severity of pain
3 The nurse asks the client to explain the surgery. The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.
A client with a high fever, chills, and a severe body ache reports to a healthcare unit. What is the correct order for the nursing diagnosis procedure? 1. Interpreting and analyzing the data obtained 2 Defining characteristics and related factors 3. Collecting information about the client's health status 4. Identifying client needs and formulating nursing diagnoses 5. Organizing the data according to signs and symptoms
3, 1, 5, 2, 4 1. Collecting information about the client's health status 2. Interpreting and analyzing the data obtained 3. Organizing the data according to signs and symptoms 4. Defining characteristics and related factors 5. Identifying client needs and formulating nursing diagnoses For the nursing diagnosis procedure, the nurse should first assess the client's health status by collecting information from the client, family, or hospital health record. Next, the nurse should interpret and analyze the data obtained. This data should be clustered according to signs and symptoms. The nurse should also define and explain the characteristics and factors related to the illness. Finally, the nurse should identify the client's needs and compose a nursing diagnosis for the client.
According to the common scale for grading muscle strength, what rating will be given to a client who can complete range of motion with some resistance? 1 scale of 1 2 scale of 2 3 scale of 3 4 scale of 4
4 According to the common scale for grading muscle strength, a client who can complete range of motion with some resistance is given the rating 4. Rating 1 is given to a client with no joint motion and slight evidence of muscle contractility. Rating 2 is given to a client who can complete range of motion with gravity eliminated. Rating 3 is given to a client who can complete range of motion against gravity.
After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our child have to have restraints?" How should the nurse respond? 1 "They're used routinely on infants who have had lip surgery." 2 "Legally we're required to put them on infants after lip surgery." 3 "The staff can't be with your baby continuously to prevent touching of the mouth." 4 "Because we're keeping the arms straight, your baby won't be able to touch the mouth."
4 "Because we're keeping the arms straight, your baby won't be able to touch the mouth." An explanation of how the restraints work and why they are used may reassure the parents. Touching the suture line may cause a separation of the wound edges, predisposing the infant to infection and compromised wound healing. Explaining routine use of restraints does not explain why they are being used now. Restraints are not a legal requirement; applying elbow restraints is a postoperative prescription. Stating that the nurse cannot be with the infant continuously may give the parents the feeling that their baby's needs are not being met.
How does a nurse prepare a "factual" record when performing a client documentation? 1 By providing a logical order for the communication 2 By using exact measurements for each activity of the client 3 By providing complete and appropriate information in each client record 4 By recording descriptive and objective information of what the nurse sees, hears, feels, and smells
4 By recording descriptive and objective information of what the nurse sees, hears, feels, and smells A factual record contains descriptive and objective information about what a nurse sees, hears, feels, and smells.
A nurse preparing to apply restraints to a client should understand which of the following principles? 1 The law prohibits restraining clients until a written prescription is obtained. 2 A felony charge may be leveled against nurses who use restraints improperly. 3 Nurses are not obligated to report institutions that use restraints unlawfully. 4 Charges of assault and battery may be leveled against nurses who use restraints improperly
4 Charges of assault and battery may be leveled against nurses who use restraints improperly Restraint of a client, whether physical or chemical, is considered a high-risk procedure requiring a valid primary healthcare provider's prescription and intensive monitoring for safety and meeting the client's needs. A nurse who does not follow correct procedures regarding restraints can legally be charged with assault and battery. Laws regarding restraint prescriptions may differ from state to state and in different settings. A felony is a severe offense or crime such as murder, rape, or burglary and is commonly punished by imprisonment. Nurses have a professional obligation to report institutional misuse of restraints, because this may constitute false imprisonment and abuse.
The nurse is caring for a nonambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included in the client's plan of care? 1 Risk for pressure ulcer 2 Risk for impaired skin integrity 3 Impaired skin integrity, related to infrequent turning and repositioning 4 Impaired skin integrity, related to the effects of pressure and shearing force
4 Impaired skin integrity, related to the effects of pressure and shearing force The impaired skin integrity is physiologically a result of unrelieved pressure and shearing force. This is supported by the data provided that the client is nonambulatory and has a reddened sacrum. Risk for pressure ulcer is not an approved NANDA-I nursing diagnosis. The client's problem is not being "at risk" because the client already has an actual problem. Not enough information is provided to make the assumption that the impaired skin integrity is related to infrequent turning and repositioning.
A nurse finds that there is an inaccurate match between clinical cues and the nursing diagnosis. What is the category of the diagnostic error? 1 Labeling 2 Collecting 3 Clustering 4 Interpreting
4 Interpreting An inaccurate match between clinical cues and the nursing diagnosis is an interpreting error. Interpreting errors include failing to consider conflicting cues, using an insufficient number of cues, and using unreliable or invalid cues errors. A labeling error is a failure to validate data. Collecting errors include inaccurate data, missing data, or disorganization. Errors at the clustering level include an insufficient cluster of cues, premature or early closure, or incorrect clustering.
The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format? 1 NANDA-I label, related factor, and etiologies 2 NANDA-I label, risk factor, and nursing interventions 3 NANDA-I label, related factor, and nursing interventions 4 NANDA-I label, related factor, and defining characteristics
4 NANDA-I label, related factor, and defining characteristics The three-part nursing diagnosis label consists of the NANDA-I label, related factor, and defining characteristics. This format is also known as the problem, etiology, and symptoms (PES) format. The nurse does not document the nursing diagnosis as NANDA-I label, related factor, and etiologies. A related factor is a condition or etiology that gives a context for the defining characteristics. The nurse does not document the nursing diagnosis as NANDA-I label, risk factor, and nursing interventions. A risk for nursing diagnosis uses the risk factor instead of related factor. Nursing interventions are not included in a nursing diagnosis. Therefore, the nurse does not document the nursing diagnosis as NANDA-I label, related factor, nursing interventions
Litigation resulting from improper restraint use is a common nursing legal issue. A nursing student is listing points related to the use of restraints. Which factor needs correction? 1 Restraints can be used when less restrictive interventions are not successful. 2 Restraints can be used when all other alternatives have been tried and exhausted. 3 Restraints can be used only to ensure the physical safety of the resident or other residents. 4 Restraints can be used anytime without a written order from the healthcare provider
4 Restraints can be used anytime without a written order from the healthcare provider Restraints can be used only on the written order of a healthcare provider. Restraints can be used when less restrictive interventions are not successful. Restraints may be used after all available alternatives have been tried and exhausted. Restraints can be used only to ensure the physical safety of the resident or other residents.
A nurse is assessing a client during a regular checkup. The client complains of a moderate decrease in food intake over the past 3 weeks, a 4-kilogram weight loss, and a decrease in mobility. The client had a bout of acute bronchitis 1 month ago and has recently been diagnosed with mild dementia. The body mass index of the client is 21. What is the total score of the client according to the mini nutritional assessment (MNA)? Record your answer as a whole number. ___________
5 The mini nutritional assessment (MNA) is a tool used to identify malnutrition. It measures the nutritional status and assigns a numerical score for each of the questionnaire areas. The score for a moderate decrease of food intake over the past 3 weeks is 1. The score assigned for a weight loss of 4 kg is 0. A score of 1 is assigned for the decrease in mobility (chair or bed bound). The score for a history of acute bronchitis is 0. A score of 1 is assigned to mild dementia, and a score of 2 is assigned to a body mass index of 21. Therefore, the total score of the client according to the MNA is 5.