Ch.3

The LPN is collecting data so that the RN may develop the plan of care for the client. What is the importance of accurate gathering of baseline data? A) The physician will be able to make a diagnosis. B) A comparison for future signs and symptoms C) The RN will be able to make the assignments based on the baseline data. D) The RN will know what type of medication the client will receive.

B) A comparison for future signs and symptoms

A new graduate nurse is assigned six clients to care for on a medical unit. Without asking anyone for help, by the end of the shift, the nurse is visibly upset and states, "I can't do this anymore." What characteristic of critical thinking has this nurse not developed? A) Show confidence B) Aware of their own limitations C) Humble D) Willing to persevere

B) Aware of their own limitations

The nurse has developed a nursing diagnosis of Risk for Complications (RC) of Thrombophlebitis for a client. This is a problem that will be monitored and managed by the nurse using physician-prescribed and nursing-prescribed interventions. What type of nursing problem is this considered? A) Syndrome diagnosis B) Collaborative problem C) Actual diagnosis D) Risk diagnosis

B) Collaborative problem

Which of the following pieces of information is included in the client database? A) Nursing care B) Diagnostic studies C) Plan of care D) Collaborative problems

B) Diagnostic studies

The nurse understands that one of the characteristics of critical thinking is flexibility. What can the nurse do to achieve this characteristic? A) Listen to new ideas and other viewpoints. B) Modify priorities and adapt to change. C) Accept that answers may not come easily. D) Foresee probable outcomes.

B) Modify priorities and adapt to change.

The RN determines the interventions for a client with pneumonia and writes them in the written plan as nursing orders. What would be an appropriate nursing order for this client? A) Force fluids. B) Offer the client 100 mL of fluid every hour while awake. C) Offer fluids prn. D) Give adequate amounts of fluid throughout the day.

B) Offer the client 100 mL of fluid every hour while awake.

The RN develops an outcome standard of "client will ambulate with an assistive device 60 feet with assistance twice a day" for a patient who had a hip replacement. What part of the nursing process is involved with this outcome statement? A) Assessment B) Planning C) Implementation D) Evaluation

B) Planning

Which of the following is involved in the implementation step of the nursing process? A. Selecting nursing interventions B. Documenting nursing care and client responses C. Documenting the plan of care D. Identifying measurable outcomes

B. Documenting nursing care and client responses

The nurse is developing a concept care map for a client with multiple medical problems. What would the nurse take as the first step in developing and using a concept care map? A) Assessment B) Assessment/Diagnosis C) Diagnosis/Planning D) Planning/Implementation

A) Assessment

The RN has developed the plan of care for a client and shares the plan with the LPN. What can the LPN provide in the implementation phase for this client? Select all that apply. A) Basic therapeutic and preventive nursing measures B) Manages client care such as delegation C) Provides client and family teaching D) Records and exchanges information with healthcare team

A) Basic therapeutic and preventive nursing measures C) Provides client and family teaching

Which type of nursing diagnosis has a goal to increase well-being and enhance specific health behaviors? A) Health promotion B) Risk C) Wellness D) Actual

A) Health promotion

Which type of nursing diagnosis statement begins with the stem readiness for enhanced and does not include related factors or supporting data? A) Health promotion B) Syndrome C) Risk D) Actual

A) Health promotion

The LPN plays a vital role in the development of a nursing diagnosis for a client. What role does the LPN have? A) Report information that suggests actual or potential health problems. B) Examine and analyze the client database to formulate nursing diagnosis. C) Inform the physician about the specific development of the nursing diagnosis. D) Evaluate the effectiveness of the nursing diagnosis and how it pertains to the data collected.

A) Report information that suggests actual or potential health problems.

A client is being admitted to the medical floor, and the RN is too busy to do the full assessment. The RN delegates the LPN to care for the patient until the RN can see the patient. What function is within the scope of practice for the LPN? A) The LPN can gather the data. B) The LPN can draw conclusions and use judgment to make a diagnosis. C) The LPN can establish priorities. D) The LPN can manage the client's care.

A) The LPN can gather the data.

In order to establish specific and realistic outcomes so that the client does not become frustrated in trying to achieve them, who should be involved in establishing these outcomes? A) The client and family B) The physician C) The certified nursing assistant (CNA) D) Case management

A) The client and family

A client is admitted to the hospital for control of diabetes mellitus. When does the LPN understand the nursing process begins? A) When the client enters the healthcare system B) Prior to the client being discharged C) After the RN initiates the plan of care D) When the physician writes the first order for care

A) When the client enters the healthcare system

Which of the following is a true statement about critical thinking in nursing? A. It involves purposeful, outcome-directed thinking. B. It shows trends and patterns in client status. C. It makes judgments based on conjecture. D. It supplies validation for reimbursement.

A. It involves purposeful, outcome-directed thinking.

The LPN states to an RN, "I don't know why we have to follow a care plan. No one even uses it, and it just means more paperwork. What's the purpose?" What is the best response by the RN? A) "I agree with you, and we should talk to the manager about eliminating them from our required paperwork." B) "I think it is something we have always done, and we have to continue to use them." C) "It helps to provide a systematic method for us to plan and implement care so that we achieve positive outcomes." D) "Physicians use our care plans in order to see what we are doing for the clients."

C) "It helps to provide a systematic method for us to plan and implement care so that we achieve positive outcomes."

The student nurse is developing a concept care map for her client with multiple sclerosis. In what phase does the student determine the relationship among the nursing diagnoses and begin to see the client holistically? A) Assessment B) Assessment/diagnosis C) Diagnosis/Planning D) Planning/Implementation

C) Diagnosis/Planning

The nurse is developing a care plan for a client who has had a stroke and is unable to assist with care at this time. Which problem would the nurse deem a top priority? A) Risk for development of a pressure ulcer B) Risk for Injury C) Ineffective Breathing Pattern D) Social Isolation

C) Ineffective Breathing Pattern

A client has a nursing diagnosis of Risk for Impaired Skin Integrity related to prescribed bed rest and decreased sensation and mobility of the lower extremities. What type of nursing diagnosis is this classified as? A) Actual diagnosis B) Health promotion diagnosis C) Risk diagnosis D) Syndrome diagnosis

C) Risk diagnosis

Which of the following identify a diagnosis associated with a cluster of other diagnoses? A) Risk nursing diagnoses B) Actual nursing diagnoses C) Syndrome diagnoses D) Health promotion nursing diagnoses

C) Syndrome diagnoses

The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of pneumonia. The nurse devises the outcome statement to read: "The client will have clear lungs by the third postoperative day." On the third postoperative day, the patient has left lower lobe crackles and infiltrates on the chest x-ray. What conclusion does the nurse reach for this client? A) The outcome is achieved, the problem is solved, and the nursing orders are discontinued. B) The outcome is not met, but progress is being made, and the plan of care is continued or revised with minor change. C) The outcome is not achieved, and the plan requires critical reevaluation and major revision. D) The outcome will be reassessed in 2 more days.

C) The outcome is not achieved, and the plan requires critical reevaluation and major revision.

A client being cared for by the healthcare team has a large open abdominal wound after having a surgical procedure. The wound had to be reopened due to the development of infection and is left to heal with packing and dressing changes twice daily. What would be an appropriate measurable short-term outcome for this client? A. The wound will heal before the client is discharged B. The client will change his own dressing twice a day C. The client will have no fever and no purulent discharge in 3 days. Dressing changes will be done twice a day using aseptic technique

C. The client will have no fever and no purulent discharge in 3 days.

The nursing student says to the instructor, "I always hear about critical thinking and how to develop it. How will this benefit me as a nurse?" What is the best response by the instructor? A) "If you have critical thinking skills, you won't make mistakes." B) "You will never make it through nursing school without those skills." C) "Without good critical thinking skills, you won't be able to make a decision." D) "Acquiring critical thinking skills will help you become more efficient and effective at resolving problems."

D) "Acquiring critical thinking skills will help you become more efficient and effective at resolving problems."

The nurse gathers data for a client who has dehydration and formulates a nursing diagnosis of Fluid Volume Deficit related to diarrhea and vomiting as evidenced by poor skin turgor, lethargy, and altered fluid and electrolyte balance. What type of nursing diagnosis is identified with this client? A) Risk nursing diagnosis B) Syndrome diagnosis C) Health promotion nursing diagnosis D) Actual nursing diagnosis

D) Actual nursing diagnosis

The RN is obtaining a health history and performing a physical assessment for a client who is admitted to the hospital with complaints of chest pain. What part of the nursing process does the LPN understand the RN is performing? A) Planning B) Implementation C) Evaluation D) Assessment

D) Assessment

The LPN is assisting with the admission of a client scheduled for surgery the next day. What role does the LPN have in the planning phase of the nursing process? A) Gathers more extensive biopsychosocial data B) Draws conclusions, uses judgment, and makes diagnosis C) Establishes priorities, sets short- and long-term goals D) Contributes to the development of care plans

D) Contributes to the development of care plans

Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes? A) Assessment B) Planning C) Implementation D) Evaluation

D) Evaluation

Which of the following is a true statement about critical thinking according to Alfaro-LeFevre (2010)? A) It makes judgments based on conjecture. B) It is based on the medical model. C) It considers only the client's needs. D) It is guided by professional standards and codes of ethics.

D) It is guided by professional standards and codes of ethics.

Which of the following is the highest level of human need according to Maslow (1968)? A) Physiologic B) Love and belonging C) Esteem and self-esteem D) Self-actualization

D) Self-actualization

The nurse is prioritizing the care of a client who has diagnoses of uncontrolled diabetes and may have the left foot amputated related to a nonhealing ulcer. What need would the nurse place at the lowest level while prioritizing this client's care? A) Physiologic needs B) Safety and security needs C) Love and belonging needs D) Self-actualization needs

D) Self-actualization needs

A client has been admitted to the hospital with a large sacral pressure ulcer. The physician orders the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this patient? A) A 6 cm × 4 cm wound with malodorous, yellow exudate B) The client's wound will heal by 1 cm by the end of 5 days. C) The client's wound has healed by 0.5 cm on day 3 of wound care. D) Turn the client every 2 hours.

D) Turn the client every 2 hours

The RN is attempting to formulate a nursing diagnosis for a client but does not find where the problem fits into a North American Nursing Diagnosis Association (NANDA)-approved diagnosis. What is the best option for the nurse? A) Gather other data so that it will fit into a NANDA approved diagnosis. B) The nurse will have to forgo applying a nursing diagnosis. C) Pick a NANDA-approved diagnosis as long as it somewhat fits. D) Use his or her own terminology.

D) Use his or her own terminology

Which of the following is an important element of implementation? A. Client database B. Critical thinking C. Nursing orders D. Documentation

D. Documentation