CH. 2: Nursing Process PREPU Qs

The charge nurse overhears two nurses talking about nursing interventions. Which statement by one of the nurses indicates that further education is required?

"Nursing interventions must be approved by other members of the health care team."

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which statement represents objective data the nurse is likely to gather and document during this assessment?

"Unable to palpate femoral pulse in left leg."

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

Which is the purpose of a focused assessment?

Adds depth to existing information

Which authoritative statements guide current professional nursing practice?

American Nurses Association Standards of Nursing Practice

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain.

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation.

Put the phases of the nursing process in the correct order.

Assessment Diagnosis Planning Implementation Evaluation

What must the nurse do to identify actual or potential health problems?

Gather data from sources

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?

Go to the client and assess the client's pain.

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data?

Hierarchy of Human Needs

The client is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8/37.1, P. 88, Resp. 28. Which is the patient care priority?

Maintain an open airway.

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA-International (NANDA-I)

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?

Reassess the client to determine the effectiveness of the interventions.

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." Which nursing action is the priority?

Resolve the client's anxiety.

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan?

Risk for Allergy Response related to latex allergy

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of Congestive Heart Failure?

Risk for Body Image Disturbance

At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25 kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 lb (0.45 kg). Which statement(s) would help the nurse most appropriately interpret these data?

The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight.

The nurse has been providing care to a client during a divorce. The client is now divorced from the spouse, effective 2 weeks ago. The nurse identified a nursing diagnosis of "Readiness for Enhanced Coping." What statement by the client would support this nursing diagnosis?

The client states, "I feel like I can finally get along with my life now that the divorce is final."

Which of the following reflects the diagnosis phase?

The nurse identifies that the client does not tolerate activity.

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal

A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as:

completely unmet.

The nurse formulates client outcomes based on the understanding that the outcomes should be:

measurable

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?

At the completion of each meal

While caring for a client recovering from a cerebrovascular accident, the nurse determines that the client would benefit from the services of physical therapy. How should the nurse plan to involve physical therapy in the client's care?

By formulating a collaborative problem

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis?

The parent states, "I cannot allow anyone else to help because they won't do it right."