Week 3 Sherpath Lessons- Nursing Fundamentals
What is the nurse's initial action when preparing a patient for a physical examination? Verify patient's identity. Provide for emotional support. Have patient change into a gown. Provide time to use the restroom.
Verify patient's identity.
Which are important components of the head-to-toe model? Select all that apply. Vital signs Values and beliefs Feelings and perceptions Health perception and management Subjective and objective patient information
Vital signs Subjective and Objective patient information
How should subjective data be documented in the patient's medical record? Within brackets Within parentheses Within quotation marks Statements should be highlighted
Within quotation marks
A nurse is performing an interview and asks the patient about allergies and medications. These questions occur during which phase of the patient interview? Orientation Transition Working Termination
Working
Which formats are commonly used for documenting the patient's health history and physical examination? Select all that apply. Functional Physiological Body system Biological Head-to-toe
Functional Body system Head-to-toe
A nurse makes preliminary observations about a patient. What is the term for this action? General survey Health history Physical assessment Review of systems
General survey
What analytical questions are asked at each step in the nursing process? Select all that apply. "Is the data collection thorough and accurate?" "Are outcomes general and hopeful?" "Have all underlying factors been addressed in the care plan?" "Are the interventions available?" "Could interventions impact the patient negatively?"
"Is the data collection thorough and accurate?" "Have all underlying factors been addressed in the care plan?" "Could interventions impact the patient negatively?"
During the general survey, the nurse notices the patient uses an assistive device. This observation should prompt the nurse to ask which important question? "How much do you currently weigh?" "Do you have any personal safety issues?" "How long have you used your walker?" "Is your walker being correctly maintained?"
"Is your walker being correctly maintained?"
A patient comes to the emergency department complaining of fever and diarrhea. What should the nurse ask the patient first? "Do you have a family history of diabetes?" "Are you taking any medications?" "Have you had any surgeries in the past?" "What is the severity and duration of your fever and diarrhea?"
"What is the severity and duration of your fever and diarrhea?" Rationale: Asking about severity and duration of the patient's fever and diarrhea gives more data to the assessment step of the nursing process that is relevant to assisting the patient with the chief complaint of fever and diarrhea. (WHY NOT THESE CHOICES) X "Do you have a family history of diabetes?"Asking the patient about a history of diabetes is additional information, but not the first thing to ask the patient. X "Are you taking any medications?"The nurse would ask about the patient's medications after finding out more data about the actual patient complaint. X "Have you had any surgeries in the past?"Surgery history is important to know, but not the first thing to ask.
As perceived by an examiner, which is an objective finding such as a fever, a rash, or the whisper heard over the chest in pleural effusion? Sign Symptom Condition Assessment
Sign
During which part of the health history will the nurse ask about environmental exposures? Medical Sensitivity Social Demographic
Social
A nurse determines the patient's goal of decreased reflux by sleeping on a pillow wedge was not totally met. How does the plan need to be revised? Add another pillow wedge at night. Add a step to avoid eating after 7 p.m. Increase grapefruit juice taken with meals. Discontinue the plan.
Add a step to avoid eating after 7 p.m.
Which assessments are completed first during an emergency? Select all that apply. Ability to urinate Airway Allergies Breathing Circulation
Airway Breathing Circulation
What is the most important reason for collecting information about the patient's smoking habits during the interview? Facilitates enrollment in educational program for smoking cessation Allows planning for potential complications after surgery Enables individualized nursing care planning Permits teaching about need to avoid smoking in patient rooms
Allows planning for potential complications after surgery
A nurse is preparing a presentation to the unit on ANA, the organization that identified the five steps of the nursing process. What does ANA stand for? American Nurses Association Active Nurses Academy American Nurses Academy Association Nurses Alive
American Nurses Association
Which statements describe the application of critical thinking to the nursing process? Select all that apply. Analyzing patient data Using baseline knowledge Considering alternative actions Recalling complex procedures
Analyzing patient data Using baseline knowledge Considering alternative actions Rationale: Analyzing... Nurses consider the implications of observed data by analyzing patient data, which requires the application of critical thinking. This occurs most frequently during the diagnosis, planning, and evaluation steps of the nursing process. Rationale: Using... Nurses draw on baseline knowledge, which requires the application of critical thinking, when interpreting and explaining patient data. This most often occurs during the assessment, diagnosis, and evaluation steps of the nursing process. Rationale: Considering... Nurses consider alternative actions, which require the application of critical thinking, to ensure the correct interventions are implemented for patients. This occurs during the planning and evaluation steps of the nursing process.
Which actions demonstrate a nurse utilizing critical thinking when her patient complains of increased pain at the surgical site? Select all that apply. The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. The nurse verifies that no pain medications were ordered and tells patient she has no medications ordered. The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient. The nurse assesses vital signs and checks to see when patient was last medicated for pain. The nurse assesses the surgical site to determine the cause of the increased pain.
Answer: 1,3,4,5 Rationales: (1) The nursing process requires nurses to think analytically, using many aspects of critical thinking. The nurse must be able to assess patients accurately and then organize and analyze the findings to provide safe care. Calling a provider indicates the nurse is critically thinking about interventions for the patient. XXXX (2)The nurse verifies that no pain medications were ordered and tells patient she has no medications ordered.There is no intervention listed for the patient, so there are no steps that will help lower the patient's pain level. (3)The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient.The nurse must be able to assess patients accurately and then organize and analyze the findings to provide safe care. The nurse does not need a provider order to implement non-pharmaceutical interventions. (4)The nurse assesses vital signs and checks to see when patient was last medicated for pain.The nursing process requires nurses to think analytically using many aspects of critical thinking. The nurse must be able to assess patients accurately and then organize and analyze the findings to provide safe care. The nurse is assessing to see if there is new data that necessitates modification of the existing plan of care. (5)The nurse assesses the surgical site to determine the cause of the increased pain.In addition to assessing vital signs and pain level, the nurse should assess the surgical site to determine if there are new signs of poor wound healing or infection. The root cause of the pain should be considered when planning further interventions.
A nurse is caring for a patient with a UTI. Which of these interventions address the patient's short-term goals? Select all that apply. Teaching hygiene practices to prevent further UTIs. Educating the patient on the signs and symptoms of UTIs. Applying a heating pad to the low back or abdomen. Refraining from sexual intercourse. Discussing the possibility of using a different type of birth control.
Applying a heating pad to the low back or abdomen. Refraining from sexual intercourse.
During a review of systems, the patient voices concern about having heart disease because of a strong family history. What should the nurse do next? Gather more information about the patient's family history. Ask a focused question about the patient's concerns. Continue reviewing systems to identify additional health concerns. Investigate the patient's desire for diagnostic testing.
Ask a focused question about the patient's concerns.
What is the best method for avoiding erroneous assumptions about patients? Reviewing patients' records carefully and completely Observing patients' interaction with other caregivers Determining what other staff members believe Asking questions to clarify information
Asking questions to clarify information Rationale: An erroneous assumption is something which is taken for granted as true, but is not true. To avoid assuming something is true when it is not, information must be clarified by asking questions. (WHY NOT THESE CHOICES) X Reviewing patients' records carefully and completely Reviewing patients' records carefully and completely does not ensure the information will be interpreted correctly; therefore, it does not prevent incorrect assumptions from being formed. X Observing patients' interaction with other caregiversObserving the interaction of patients with other caregivers does not prevent observers, such as nurses, from forming assumptions that are not correct. X Determining what other staff members believeWhat one staff member believes about a patient may influence the beliefs of other staff members and vice versa, but it does not prevent the other staff members from forming incorrect assumptions. Each person forms his or her own beliefs and opinions, whether correct or erroneous.
A nurse is caring for a patient who is cyanotic and has edema. The nurse is making a list of the patient's physical, psychological, emotional, environmental, cultural, and spiritual health. What stage of the nursing process is this? Assessment Diagnosis Planning Evaluation
Assessment
Which step of the nursing process does a nurse use when finding blood pressure of 180/75, a heart rate of 90, and a patient complaint of chest pain? Implementation Evaluation Diagnosis Assessment
Assessment Rationale: Assessment is always the first step when managing patient care. The nurse must analyze that data in order to create nursing diagnoses and a patient-centered care plan.
When nurses make determinations about patients needing emergent, urgent or non-urgent care, which type of assessment are they using? Comprehensive Focused Shift Triage
Triage
If the patient interview takes place in the patient's home, in what room does it generally take place? Bedroom Dining room Kitchen Living room
Bedroom
What subjective information is obtained from the patient during the initial interview? Select all that apply. Vital signs Height and weight Chief complaint Presence of pain Hemoglobin levels.
Chief complaint Presence of pain
What does the term "dynamic nature" of the nursing process refer to? Change over time in response to the patient's needs Change over time in response to the nurse's needs Change over time in response to the provider's needs Change over time in response to the family's needs
Change over time in response to the patient's needs
A nurse enters a patient room to assess the patient's blood pressure, temperature, pulse, and pain. What type of assessment is being performed? Comprehensive Emergency Focused Shift
Focused
Which common thinking error is most likely to hinder the development of a therapeutic nurse-patient relationship? Lack of knowledge Illogical thinking Closed-mindedness Erroneous reasoning
Closed-mindedness Rationale: Closed-mindedness leads to ignoring relevant information provided by others. Being close-minded hinders communication and the establishment of a therapeutic nurse-patient relationship. (WHY NOT THESE CHOICES) X Lack of knowledge. Lack of knowledge on the part of the nurse can lead to errors and affect the delivery of quality patient care. It is not, however, the thinking error most likely to hinder the development of the nurse-patient relationship. X Illogical thinking. Illogical thinking refers to failure to use a rational, systematic approach to solving a problem. Use of illogical thinking can interfere with the nurse's ability to plan and deliver care, but it is not the thinking error most likely to hinder development of the nurse-patient relationship. X Erroneous reasoning/ There is no specific thinking error known as erroneous reasoning. However, errors in reasoning could lead to errors in nursing diagnoses, planning, and evaluation.
Which is a documentable component of Gordon's functional health patterns model? Cognition Vital signs General health status Physical examination
Cognition
What is the primary purpose of the nursing diagnosis? Resolving patient confusion Communicating patient needs Meeting accreditation requirements Articulating the nursing scope of practice
Communicating patient needs Rationale: In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers.
Which statement accurately represents documentation of a patient's review of systems findings? Smokes one pack cigarettes per day. Complains of frequent headaches. Consumes a low fat, vegetarian diet. Weight within normal range for height.
Complains of frequent headaches.
Laboratory and other diagnostic tests are obtained during a patient office visit. These tests are associated with which type of patient assessment? Comprehensive Emergency Focused Shift
Comprehensive
Which assessment should be performed during the patient's initial visit to a new health care provider? Brief Comprehensive Emergency Focused
Comprehensive
What information is obtained during a patient interview? Select all that apply. Financial status Current health concerns Political and social views Medical and surgical history Culture, ethnicity, and spiritual views
Current health concerns Medical and surgical history Culture, ethnicity, and spiritual views
What is a part of the assessment process? Data collection Care plan Interventions Prioritize diagnoses
Data collection (WHY NOT THESE CHOICES) X Care Plan Developing the care plan is a part of the planning step of the nursing process. X Interventions Interventions are a part of the implementation step of the nursing process. X Prioritize diagnoses Prioritizing diagnoses is a part of the planning step of the nursing process.
Which statement accurately represents documentation of a patient's focused health history? Patient is a Hispanic male appearing stated age. Denies chest pain or rapid heart rate over the past week. Strong family history of type 2 diabetes mellitus. Reports allergies to shell fish and peanuts.
Denies chest pain or rapid heart rate over the past week.
The five steps that make up the nursing process allow it to be: Collaborative Analytical Outcome based Dynamic
Dynamic Rationale: The nursing process is dynamic and adaptable due to the multiple ways it changes to meet the patient needs.
A signed release form is required prior to sharing medical records in which cases? Select all that apply. Emergency Surgical Abuse Workers' compensation Home health care
Emergency Surgical Abuse Home health care
When is a focused health history obtained instead of a full health history? Select all that apply. Patient admission five years ago. Initial visit to new healthcare provider. Emergency room visit for chest pain. Clinic visit following hospitalization. New patient upon hospital admission.
Emergency room visit for chest pain. Clinic visit following hospitalization.
Which statements are correct about the critical thinking skill of self-regulation? Select all that apply. Distinguishes patterns of deductive and inductive thinking Emphasizes reflection on reasons for one's actions Enables recognition and correction of one's errors Required for all steps of the nursing process Necessitates monitoring of self-thinking
Emphasizes reflection on reasons for one's actions Enables recognition and correction of one's errors Required for all steps of the nursing process Necessitates monitoring of self-thinking
A nurse is evaluating the care plan for a pregnant patient. What is the main reason the nurse would ask the patient about support systems and eating habits? Ensure individualized care. Concern over the baby arriving prematurely. Facilitate setting patient outcomes. Determine if the patient has other children.
Ensure individualized care.
Which action is appropriate when attempting to build trust and rapport with a patient during the assessment process? Standing when the patient is sitting Ensuring patient comfort and privacy Avoiding eye contact with the patient Slightly leaning away from the patient
Ensuring patient comfort and privacy *SOLER*
Which statements are true regarding preparation of equipment? Select all that apply. Equipment should be working properly. Equipment should be open and ready to use when needed. Equipment should be sterilized per medical asepsis principles. Reusable equipment should be sent for cleaning and decontamination. Equipment should be made available in the order that it will be needed.
Equipment should be working properly. Equipment should be sterilized per medical asepsis principles. Reusable equipment should be sent for cleaning and decontamination. Equipment should be made available in the order that it will be needed.
Which critical thinking skill did the nurse use when verifying the latest revision date prior to using a website's patient education brochure? Analysis Interpretation Evaluation Explanation
Evaluation Rationale: Evaluation- Nurses use evaluation to determine the reliability, credibility, and bias of information sources used for patient care standards or patient education information. (WHY NOT THESE CHOICES) X Analysis is used when nurses consider the advantages, disadvantages, and consequences of multiple nursing actions or decisions before deciding on the course of action. X Nurses use interpretation to understand and explain the meaning of data. XNurses use explanation to provide a sound rationale for their thoughts and actions.
A patient reports that his pain level is now 6 out of 10. The patient's goal for a pain level of 3-4 out of 10 is not met. Which step of the nursing process does this statement reflect? Planning Diagnosis Implementation Evaluation
Evaluation Rationale: During evaluation, the nurse reviews patient outcomes to determine whether the patient's goals and nursing diagnoses were appropriately met or addressed. (WHY NOT THESE CHOICES) X Planning During the planning step, the nurse identifies appropriate interventions that will address the patient's goals and nursing diagnoses. X Diagnosis During the diagnosis step, the nurse analyzes assessment data and develops a nursing diagnosis to address identified health problems. X Implementation During the implementation step, the nurse carries out the interventions listed on the nursing care plan and those identified during the planning stage.
Stella Jones, RN, reassesses a patient one hour after giving morphine for the patient's pain. The patient states that she is still in horrible pain, eliciting a response of 8 out of 10. What would be the most appropriate intervention? Check blood pressure. Give additional breakthrough pain medication. Reassess pain level in two hours. Monitor heart rate every 30 minutes.
Give additional breakthrough pain medication. Rationale: Giving additional breakthrough pain medication is the most appropriate intervention for controlling pain. (WHY NOT THESE CHOICES) X Check blood pressure. Checking the patient's blood pressure does not address the patient's pain level and would be part of the assessment step of the nursing process. XReassess pain level in two hours. Reassessing the patient's pain level in two hours would add more data to the assessment step of the nursing process, but does not assist with controlling pain. XMonitor heart rate every 30 minutes.Monitoring the patient's heart rate every 30 minutes is not relevant to controlling pain. This would add more data for assessment of the nursing process.
Nutrition and metabolism is a component of which model of data organization? Medical Head-to-toe Body systems Gordon's functional health patterns
Gordon's functional health patterns
Which model takes a holistic view of the patient and may reveal patterns that might not be easily seen otherwise? Medical Head-to-toe Body systems Body systems Gordon's functional health patterns
Gordon's functional health patterns
Which actions are effective for providing emotional support for patients during a physical examination? Select all that apply. Have a chaperone available. Discourage use of distractions. Allow a support person if requested. Protect physical safety by using side rails. Be aware of past history of abuse or cultural norms.
Have a chaperone available. Allow a support person if requested. Protect physical safety by using side rails. Be aware of past history of abuse or cultural norms.
Which strategies are effective in encouraging open communication between the nurse and patient? Select all that apply. Ask "Why?" questions. Have a relaxed, open posture. Avoid negative, non-verbal cues. Avoid use of closed-ended questions. Pay attention to what patient is saying.
Have a relaxed, open posture. Avoid negative, non-verbal cues. Pay attention to what patient is saying.
In which model does the physical examination end with the lower extremities? Medical Head-to-toe Body systems Gordon's functional health patterns
Head-to-toe
What policy determines the manner in which medical data is collected and organized? State Federal The Joint Commission Health care facility
Health care facility
Which strategies can nurses use to improve critical thinking skills? Select all that apply. Holding discussions with colleagues Engaging in verbalization of thoughts Reading multiple complex documents Gaining increased knowledge Conducting literature reviews
Holding discussions with colleagues Rationale: Discussions with colleagues who have expertise may improve critical thinking by filling in knowledge gaps, or by correcting erroneous assumptions or biases. Engaging in verbalization of thoughts Rationale: This exercise improves critical thinking because it incorporates elements of reflective thinking, which is an important component of critical thinking. Conducting literature reviews Rationale: Literature reviews foster critical thinking by addressing knowledge deficits and answering clinical questions. (WHY NOT THESE CHOICES) X Reading multiple complex documents may enhance the nurse's reading ability but depending on the document, may have no influence on the nurse's ability to think critically, especially if the material is too complex to comprehend. X Gaining increased knowledge by itself does not increase the nurse's ability to think critically. Critical thinking can be improved by the intentional application of knowledge to clinical practice.
A patient has a painful jaw that clicks during chewing. The nurse developed a care plan and taught the patient how to use a bite guard. What step of the nursing process did the nurse exhibit by teaching use of the bite guard? Evaluation Implementation Assessment Planning
Implementation
A nurse is admitting a new patient who has heart failure and pitting edema. At each step of the nursing process, what is likely to happen? The plan of care follows directly from the diagnosis. Revisions will be avoided until after the evaluation phase of the care plan. Information from other steps will be used to complete the plan of care. The patient will improve during each step of the nursing process.
Information from other steps will be used to complete the plan of care.
During the initial interview, which questions should the nurse be considering while visually observing the patient? Select all that apply. Is the patient clean and well-groomed? What is the patient's affect and mood? Are family members present and supportive? What is the patient's ethnic background? Is clothing up-to-date and in newer condition?
Is the patient clean and well-groomed? What is the patient's affect and mood? What is the patient's ethnic background?
Which statement describes a defining characteristic of illogical thinking? Jumping to conclusions Intentionally overlooking alternatives Accepting things as true without proof Tendency toward partiality
Jumping to conclusions Rationale: A defining characteristic of Illogical thinking is jumping to conclusions and often making hasty generalizations without considering the evidence. (WHY NOT THESE CHOICES) X Intentionally overlooking alternatives suggested by others is a defining characteristic of closed-mindedness. X To accept things as true, without proof, is a defining characteristic of an erroneous assumption. X A tendency toward partiality is a defining characteristic of bias.
A nurse is caring for a patient with a UTI. The nurse's selection of two nursing diagnoses includes acute pain and impaired urinary function. What evidence would lead the nurse to diagnose acute pain? Select all that apply. Low back aching Burning upon urination Frequency of urination Urgency of urination Incontinence of urination
Low back aching Burning upon urination
Who first pioneered the term "nursing process?" Ernestine Wiedenbach Ida Jean Orlando Lydia Hall Dorothy E. Johnson
Lydia Hall Rationale: Lydia Hall coined the term "nursing process" in 1955. (WHY NOT THESE CHOICES) XErnestine Wiedenbach was responsible for identifying four main elements of nursing: the art, philosophy, purpose, and practice XIda Jean Orlando recommended the use of interpersonal relationships to improve patient care. XDorothy E. Johnson believed in a holistic, patient focused philosophy of nursing, instead of the current disease model.
Which model focuses on the physical condition rather than the holistic view of a patient? Select all that apply. Medical Body systems Head-to-toe Gordon's functional health patterns General systems
Medical The medical model focuses on physical condition rather than the holistic view of the patient. Body systems The body systems model focuses on physical condition rather than the holistic view of the patient.
In addition to patient statements, what should the nurse be very attentive to during the interview? Family input Non-verbal cues Test results Vital signs
Non-verbal cues
Which statement illustrates the collaborative characteristic of the nursing process? The nursing process can be used to assess the needs of individuals as well as large communities. The nursing process provides a systematic method of addressing patient needs, and is understood by nurses worldwide. The nursing process allows patient care to be comprehensive and well organized. Nurses may incorporate actions by the patient or family to address patient goals.
Nurses may incorporate actions by the patient or family to address patient goals. Rationale: The fact that a nurse may incorporate patient and family actions into the plan of nursing care, in order to achieve patient outcomes, makes this a characteristic of the collaborative nature of the nursing process.
Checking the patient's previous hemoglobin and hematocrit levels is an example of collecting what type of data? Primary Secondary Subjective Objective
Objective
Which actions are part of preparing an examination table? Select all that apply. Offer a small pillow for under the head. Lower the examination table for safety. Raise the head of the bed to a 90-degree angle. Clean with bactericidal cleanser between patients. Change examination table material between patients.
Offer a small pillow for under the head. Clean with bactericidal cleanser between patients. Change examination table material between patients.
The nurse enters the patient's room and says, "Hi, my name is Barbara. I am your nurse. Let's discuss why you have been admitted to the hospital." What phase of the patient interview is taking place in this situation? Orientation Transition Working Termination
Orientation
Which subcategory of planning is recognized by professionals and educators as part of the traditional five-step nursing process? Nursing interventions classification Medical outcome identification Outcome identification Medical interventions classification
Outcome identification Rationale: Outcome identification is a part of the nursing process. Most nursing professionals and educators recognize outcome identification as part of the planning step of the traditional five-step nursing process.
Which option exemplifies a short-term goal the nurse may identify during the planning step of the nursing process? Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication. Patient verbalizes a pain level of 2 or 3, out of 10, during A.M. care within 24 hours. Patient verbalizes a pain level of 1 out of 10 at the 2-week provider follow-up appointment. Patient verbalizes a pain level of 0 out of 10 at the 1-month provider follow-up appointment.
Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication. Rationale: A time period of 2 hours is an appropriate choice for a short-term goal. This time period is the shortest of all the answer choices.
What is the appropriate scrubbing time to ensure hand hygiene when using alcohol-based sanitizers? 5-10 seconds 15-20 seconds 30-60 seconds Until hands are dry
Until hands are dry
What information should be included in a health history? Select all that apply. Patient's social history Reason for seeking medical care Patient demographic information Medications the patient is currently taking System-by-system review of the entire body
Patient's social history Reason for seeking medical care Patient demographic information Medications the patient is currently taking
The nurse is about to conduct a focused assessment at the beginning of the work shift. Which assessments will be performed? Select all that apply. Airway Peripheral pulses Skin turgor Urinary output Wounds
Peripheral pulses Skin turgor Urinary output Wounds
What is the focus of the body systems model? Vital signs General health status Physical examination Objective and subjective patient information
Physical examination
A nurse is ready to set goals for a patient who is recovering from a hip replacement. The nurse sets goals for the first three days and for the first three weeks. What part of the nursing process is this? Planning Assessment Diagnosis Evaluation
Planning
A nurse educator is reviewing the steps of the nursing process with the class. While reviewing a case study, the educator asks the students to determine which part of the process a nurse uses when establishing short- and long-term goals with the patient. How should the students respond? Planning Diagnosis Implementation Evaluation
Planning Rationale: During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation purposes. (WHY NOT THESE CHOICES) X Diagnosis In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. X Implementation The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. X Evaluation The evaluation step includes the nurse determining whether the patient's goals are met; examining the effectiveness of interventions; and deciding whether the plan of care should be discontinued, continued, or revised.
Which term describes the nurse prioritizing the diagnoses and identifying goals that are realistic, measurable, and patient-focused with specific outcomes? Assessment Planning Diagnosis Evaluation
Planning Rationale: Planning is when the nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused, with specific outcomes.
In most cases, what type of data is best to obtain first? Primary Secondary Subjective Objective
Primary
What type of data includes the patient's medical history, feelings, and management of health and health concerns in the past? Primary Secondary Tertiary Objective
Primary
Which type of symptom is intrinsically associated with a disease? Primary Secondary Tertiary Insidious
Primary
What word does the nurse use to describe the five steps? Race Process Story Content
Process
Which patient position promotes airflow and facilitates assessment of the skin and lungs? Dorsal recumbent Fowler Prone Supine
Prone
The nurse is receiving a report on a patient recovering from a myocardial infarction with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other interdisciplinary professionals may be consulted for collaboration of this patient? Respiratory therapist, cardiologist, and nephrologist Cardiologist, urologist, and pulmonologist Rheumatologist, respiratory therapist, and cardiologist Respiratory therapist, cardiologist, and pulmonologist
Respiratory therapist, cardiologist, and pulmonologist
Which aspects of written work improve critical thinking? Select all that apply. Reviewing recent lectures Noting key facts while reading Post-lecture debriefing Rewriting study notes Identifying knowledge gaps
Reviewing recent lectures Rationale: Reviewing recent lectures is an aspect of written work that improves critical thinking skills because it refreshes memory as well as thinking. Noting key facts while reading Rationale: Noting key facts while reading is an aspect of written work that improves critical thinking. It promotes memory of important information as well as thinking. Rewriting study notes Rationale: Rewriting study notes is an aspect of written work that improves critical thinking. Writing promotes memory as well as thinking. Identifying knowledge gaps Rationale: Identifying knowledge gaps is an aspect of written work that improves critical thinking skills. It increases foundational knowledge upon which thinking is built. (WHY NOT THIS CHOICE) X Post-lecture debriefing Debriefing does not occur following lectures, although sometimes nurses or teachers do ask if there are questions following lectures. Debriefing and lectures is not the same thing.
A nurse is caring for a patient who just had a colostomy. What type of nursing diagnosis (actual, risk, or health-promotion) should the nurse select when developing the plan of care? Risk, since the patient's identified need is the diagnosis of colostomy. Risk, since the patient is at risk for infection at the site of the surgical incision. Actual, since the patient is at risk from factors indicating vulnerability. Actual, since the patient is in need of health-promotion, given the nursing diagnostic label of colostomy.
Risk, since the patient is at risk for infection at the site of the surgical incision.
The nurse completes which patient assessments during the general survey? Select all that apply. Safety Vital signs Allergies Speech Dietary intake
Safety Vital signs Speech
What type of symptoms is a consequence of illness and disease? Primary Secondary Tertiary Insidious
Secondary
Which information is obtained from the patient's chart, medical records, and diagnostic testing? Primary Secondary Tertiary Subjective
Secondary
During which type of assessment would the nurse be most likely to assess skin turgor and capillary refill to determine the patient's clinical status? Comprehensive Emergency Focused Shift
Shift
Which type of physical assessment is usually governed and directed by the policies of the health care facility? Comprehensive Emergency Focused Shift
Shift
Which method ensures the competency of licensed nurses? Performance review Specialty certification Personal resume Employment history
Specialty certification Rationale: Specialty certification is based on nurses meeting required criteria and passing a certification examination. There are certifications for RNs and nurses with advanced degrees. Certification ensures competency of licensed nurses. (WHY NOT THESE CHOICES) A positive performance review provides information about the nurse's job performance, but it does not always ensure the nurse's competency. A personal resume describes the nurse's educational and work experience at a minimum. It may include other information, but it does not ensure nurse competency. Employment history only includes information about the nurse's work experience. It does not ensure nurse competency.
During the nurse's assessment, the patient reports feelings of dizziness and nausea. What type of data is the patient providing? Medical Objective Secondary Subjective
Subjective
What type of data includes verbal descriptions of symptoms or feelings? Primary Secondary Subjective Objective
Subjective
A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night. When assessing the patient's pain level, is the nurse assessing subjective or objective data? Subjective data, because only the patient can experience the pain. Subjective data, because the blood pressure is an accurate measure of the patient's pain. Objective data, because the pain level can be turned into a number on a one to ten scale. Objective data, because the patient can point to the "oucher" picture indicating the experienced pain level.
Subjective data, because only the patient can experience the pain.
Which factors are known to change the appearance of skin and contribute to making patient's appear older than their stated age? Select all that apply. Skin products Sun exposure Tobacco use Excessive makeup Allergy medications
Sun exposure Tobacco use
Which patient position is most difficult for patients when they have shortness of breath, back pain, or kyphosis of the spine? Dorsal recumbent High-Fowler Low-Fowler Supine
Supine
At the end of the interview, the nurse lets the patient know the interview is complete and the doctor will be in shortly. Before leaving the room, the nurse asks the patient if there are any questions. Which phase of the patient interview is represented by this statement? Orientation Transition Working Termination
Termination
During which phase of the interview is the patient given an opportunity to ask questions and add any additional information that may have been forgotten? Orientation Transition Working Termination
Termination
Which best describes the diagnosis step of the nursing process? The nurse gathers patient data through observation, interviews, and physical assessment. The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers. The nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused with specific outcomes. The nurse initiates specific nursing interventions and treatments designed to help the patient achieve established goals and outcomes.
The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers. Rationale: The diagnosis step of the nursing process is when the nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers.
A patient with diabetes reports to the clinic for diabetes education. The nurse learns that the patient's wife prepares the family meals. Why is it important to include the patient's wife in the teaching? She can report when he is not adhering to the care plan. The wife can learn how to follow his new diet too. The main person responsible for managing the patient's diabetes may be the wife. Including a second person in teaching is protocol for the facility.
The wife can learn how to follow his new diet too.
A nurse is caring for a patient at risk for appendicitis. When considering the assessment, why should the nurse use the five-step nursing process? To set up the correct surgery time for the health care provider To carefully match what is done in other hospitals To systematically identify actual or potential patient problems To better console families who are anxious about their loved one
To systematically identify actual or potential patient problems
Which abnormal findings require further evaluation if noted during the general survey of a patient's gait? Select all that apply. Tremor Balanced Shuffling Smooth Symmetry
Tremor Shuffling
A nurse is caring for a patient with decubitus ulcers who is dehydrated and suffering from malnutrition. In the evaluation stage, what evidence about the decubitus ulcers should initiate the nurse to change the nursing care plan? new decubitus ulcers have formed there is no change in decubitus ulcer size decubitus ulcers are now smaller color of decubitus ulcers has improved
new decubitus ulcers have formed