Chapter 2: Prep U (p2)

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

"Client will identify one coping strategy to try by end of week."

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

listen to the new nurse's suggestion & evaluate its usefulness

Which nursing action would be most effective in helping a client learn self-care behaviors?

model self care behaviors for the client

An older adult client has lost significant muscle mass during recovery from a systemic infection. As a result, the client has made no progress toward meeting any of the outcomes for mobility and activities of daily living that are specified in the nursing plan of care. How should the nurse bestrespond to this situation?

modify the plan of care to better reflect the client's current functional ability

What phrase best describes nurse-initiated interventions?

nurse-prescribed interventions

Which nursing assessment guideline is most accurate?

"Collect assessment data about the client continuously."

On admission, a health care provider diagnoses a client with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nurse diagnosing?

the response of the client to the illness

The nurse has completed a head-to-toe assessment of a client and has identified several nursing diagnoses. These diagnoses will primarily serve what function?

to describe a functional health problem

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?

updating the diet orders in the client's plan of care

The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process?

Diagnosis

Etiology

cause of disease

A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected client outcomes), what must the nurse do next?

collect data about client responses

The nurse is admitting a new client to the unit. To obtain the most thorough database possible, the nurse will perform which action?

combine assessment data w/ all existing information

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate?

"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes."

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client?

"It seems like you are having difficulty with your care regimen."

The nurse is admitting a client who is unable to identify person, place, or time. To properly analyze these data, what action must the nurse take?

interview the client's family to assess the client's usual level of cognition

these are derived from the nursing diagnosis

Nurse-initiated interventions

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 client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective?

client will use chin tuck & double swallow for each bite

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?

actual nursing diagnosis

While caring for a client admitted to the hospital for a fractured tibia, the nurse notes the client's blood pressure readings are consistently higher the expected range for the client's age. How would the nurse most appropriately plan to care for this client?

address the collaborative problem PC: Hypertension

A nurse develops the nursing diagnoses "Appendicitis" and "Acute Pain" for a client. Which of the diagnoses is a medical diagnosis?

appendicitis

The nurse should evaluate client outcomes at which time?

as early as possible

A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the mostappropriate way for the nurse to determine the significance of the client's heart rate?f

ask the client whether the heart rate is normal for the client

When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?

assess the client's interactions w/ the newborn

The nurse is caring for Isabel, a 45-year-old ventilator-dependent quadriplegic. The nurse is in the process of placing IV access when the ventilator alarms occlusion. The nurse assesses Isabel, and she appears mildly uncomfortable but is not in acute distress. What is the nurse's priority in the nursing outcome planning?

assess tracheostomy for patency

- the nurse asks the client, "How would you rate your pain?" - the client's abdomen is firm & distended w/ hypoactive bowel sounds - the client states, "I rarely sleep more than 6 hours."

assessment phase of the nursing process

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

bathing self-care related to lack of access to bathing facilities as evidenced by a strong body odor

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client?

comfort the client & family

A client comes into the clinic for a routine postoperative visit. While the nurse is assessing the level of pain, the client states that there is occasional discomfort but that pain levels have improved daily since returning home from the hospital. What should the nurse's response be regarding the client's plan of care?

continue the plan of care

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs?

cutting up food & opening drink containers for the client

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by the client refusing to look at the surgical site and stating, "I'm ugly. My husband will no longer find me desirable." What is the etiology identified in this nursing diagnosis?

decreased ability to cope w/ surgical removal of right breast

While caring for a client admitted with a Clostridioides difficile infection, the nurse notes that the client has had three loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem?

diarrhea related to infectious process as evidenced by 3 loose bowel movements in 3 hours

A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?

disturbed body image related to loss of hair

A nurse writes the following nursing diagnosis for a client with Alzheimer disease: Disturbed Thought Processes related to Alzheimer disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement?

disturbed thought processes

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management?

effectiveness of intervention including current pain scale, time frame, & client self-report

What should the nurse do to make outcomes more achievable?

encourage the client & family to be involved in the development of outcomes

What common problem is related to outcome identification and planning?

failing to involve the client in the planning process

The primary purpose of nursing diagnoses is to:

guide selection of nursing interventions to meet expected outcomes

Which best describes the purpose of nursing diagnoses?

identification of client problems that nurses can treat independently

A male client's poorly controlled type 1 diabetes has resulted in a recent below-the-knee amputation. The home health care nurse that performs the client's follow-up dressing changes has noted that the client's apartment is in an increasing state of disarray in recent weeks. The client attributes this to the fact that he has "an awful time just getting around." Which nursing diagnosis statement is most appropriate?

impaired home maintenance related to mobility alterations

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

impaired physical mobility related to pain

An adolescent on life support after a diving accident has no brain wave activity. The parents tell the nurse they are sure their child will wake up soon. Which nursing diagnosis would the nurse identify to assist the parents of the child?

interrupted family processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon

Which statement best describes the relationship between nursing diagnosis and medical diagnosis?

the nursing diagnosis is based on client response to the medical diagnosis

The nurse is assessing the client's behavioral response to a nursing intervention. This type of evaluation is known as:

outcome evaluation

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

reporting signs & symptoms related to the client's kidney failure

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement?

return the client to bed & provide pain relief measures

After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first?

review the client's recent food & fluid intake

An older adult client's venous ulcer has become foul-smelling after the client began using strips of a sheet to dress the wound due to running out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances?

risk for infection related to knowledge deficit

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal?

suggest the client use elastic shoe laces & pull clothes over leg w/ a grip extender

Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will:

terminate the plan of care

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

The nurse caring for a morbidly obese client formulates the possible nursing diagnosis, "Imbalanced Nutrition: More than Body Requirements related to excessive food intake as evidenced by morbid obesity." In order to assure the accuracy of the diagnosis, which further step must the nurse take?

validate w/ the client that excessive food intake is the cause of the client's obesity