EXAM 2

When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply.

- Outcome setting allows for individualization of the plan of care. - Outcomes can be short- and long-term. - A plan of care should be comprehensive, including the initial, ongoing, and discharge planning.

Nurses perform assessments on clients as part of their routine care. Which statements accurately describe the unique focus of these nursing assessments? Select all that apply.

- The findings from a nursing assessment may contribute to the identification of a medical diagnosis. - An initial assessment establishes a complete database for problem solving and care planning. - Nursing assessments focus on the client's responses to health problems.

The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:

0100

A mother is bringing her infant into the the clinic for a well-baby checkup. The infant's weight gain is on target for age. A correctly written evaluative statement is:

8FEB2016. Goal met. The infant's weight gain is appropriate for age.

A nurse is reviewing the medication administration record. Which order does the nurse question?

A diuretic administered twice daily at 9am and 9pm

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 diagnosis

A client has been diagnosed with pneumonia and is experiencing chest pain when taking a deep breath. What are the two priority nursing diagnoses?

Acute Pain Ineffective Airway Clearance

A nursing student is assisting with taking health histories of all clients. The student identifies when is the best time to do a health history?

As soon as possible after a client presents for care

During the nursing examination, the nurse notices that the client, an older adult female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation?

Ask the client if it is okay to interview her husband for the answers to the interview questions.

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required.

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? (Select all that apply.)

Assess for pain control 30 minutes after administering an analgesic Consider cultural implications of the perception of pain Provide pain medication before activity that may increase pain

A client is receiving home care due to an unstable blood pressure. Which nursing intervention is a priority?

Assess the client's blood pressure

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process

Assessment

A nurse is evaluating the plan of care for a client and determines that the achievement of goals is difficult to evaluate. What will the nurse do when evaluating the plan to see that the outcomes are achievable? Select all that apply.

Be sure that the criteria for appropriate response are clearly specified. Be certain that the subject is the client or some part of the client. See if the client's expected behavior is written in observable, measurable terms, Specify time limits in the plan.

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

Both during the collection and at the end of the collection

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses.

An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective?

Client has generalized myalgia or muscle pain.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization, or:

Clustering

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?

Collaborate with other disciplines to revise the discharge plans.

A 50-year-old female client is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information?

Consult nursing and medical literature

A nurse is planning nursing interventions for clients on a busy hospital unit. Which guideline would the nurse follow when designing the plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

Diagnosis

The nurse is assessing a client who was just admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis

Diminished breath sounds in left lower lobe

The night shift RN is caring for a hospitalized adult client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client?

Disturbed sleep pattern

Which interview question would be the best choice for the nurse to use to assess for recent changes in a client's sleep-wakefulness pattern

Do you usually go to bed and wake up about the same time each day?

Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse will then make a judgment and document a statement summarizing those findings. This is called:

Evaluative statement

During the morning assessment, a client states to the nurse, " I feel hung over from the sleeping pill I took last night." The nurse reviews the Medication Administration Record and determines that which medication is most likely to cause the client's symptoms?

Flurazepam

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

Gather data from sources

The nurse that ascribes to the gate control theory of pain would be most likely to prescribe which of the following for the relief of pain? (Select all that apply.)

Heat Massage Cold

nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?

Hypothalamus

The purpose of obtaining a nursing history is to:

Identify actual and potential nursing diagnoses

The nurse formulates a nursing diagnosis for a client of: Impaired Physical Mobility related to postoperative pain as evidenced by difficulty ambulating. What descriptor does the nurse identify in this nursing diagnosis?

Impaired

During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:

Inform the client of the maintenance of confidentiality

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority?

Inform the client what to expect after the surgery.

A nurse is explaining to an insomniac client the effect of a prescribed medication and the different phases of sleep. Which statement is true for non-rapid eye movement (NREM) sleep?

It is called slow wave sleep.

Which of the following are examples of objective data?

Lab results, breath sounds, client's temperature

The student nurse is providing an education program for preschool parents. The nursing student should include which intervention to improve the child's sleep

Limit fluids after supper

The nurse is caring for a 48-year-old male client with a new colostomy. Which client goal for Mr. Conner is written correctly?

Mr. Conner will demonstrate proper care of stoma by 29MAR2015.

The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit?

Narcan (naloxone)

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nurse assistant

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

A nurse is evaluating the plan of care for the client under her care. Which problem might the nurse note that is associated with the implementation phase of the plan of care?

Nurses are not aware of client priorities and the plan of care.

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?

Nursing process

While studying methods of data collection, a nursing student learns that there are many different skills involved. Which action is a key nursing skill that uses all five senses?

Observation

A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

PC: Decreased cardiac output related to cardiac tissue damage

The nurse is conducting a client interview and notices that the client answers every questions with a "yes" or "no" response. What is most likely the cause of this action by the client?

Pain

Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients?

Pain assessment may require multiple methods in order to ensure accurate pain data.

A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?

Phantom pain Explanation: The nurse should document the pain as phantom pain, a type of neuropathic pain that is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. The client perceives that the amputated limb still exists and feels burning, itching, and deep pain in tissues that have been surgically removed. The client is not experiencing referred pain, visceral pain, or cutaneous pain. Visceral pain is associated with disease or injury. Referred pain is not experienced in the exact site where an organ is located. Cutaneous pain originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. 1113

A novice nurse is using the assessment technique of auscultation. What assessment finding can the nurse obtain with this method?

Presence of peristalsis

The nurse must be familiar with the client record in order to provide care effectively. Which parts of the client record include only the findings of physicians? Select all that apply.

Progress notes, medical history, physical exam

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction.

Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

Standardized Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

Surveillance intervention

The nurse is caring for a client who is having difficulty sleeping. Which medication does the nurse anticipate will be prescribed by the healthcare provider?

Temazepam (Restoril)

A male client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that he has achieved a cognitive outcome in the management of his new health problem?

The client is able to explain when and why he needs to check his blood sugar.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

The client is blind. The client denies the need for education.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. Which goal written by the nurse requires revision?

The client will understand the effects of smoking related to heart disease.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning.

The nurse assessing a client and obtaining data from the client. However, the nurse identifies that other sources of client information can include what sources? Select all that apply.

The client's support people The client's health record Family members accompanying the client Other care professionals

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?

The dose that is delivered when the client activates the machine is preset.

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

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."

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

Time lapsed

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician.

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing:

Visceral pain

A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate

Wellness diagnosis

A nurse is performing pain assessments on clients in a physician's office. Which clients would the nurse document as having acute pain? Select all that apply.

a client who is having a myocardial infarction A client who fell and broke an ankle A client who presents with the signs and symptoms of appendicitis

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

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:

biofeedback

The nurse is aware that development of nursing diagnoses are:

both within the nursing scope of practice and are client focused.

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented

clinical reasoning

The terms "criteria" and "standards" are often used interchangeably, but they actually have distinct definitions. "Measurable qualities, attributes, or characteristics that identify knowledge or health status" are known as:

criteria

A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply.

drinks coffee with all meals smokes 1 pack of cigarettes daily history of hyperthroidism

Which of the following is considered to be the most potent neuromodulators

endorphins

A nurse is planning care for clients in a physician's office. Which actions will the nurse perform during this step of the nursing process? Select all that apply.

establishing priorities identifying expected client outcomes selecting evidence-based nursing interventions Communicating the plan of nursing care

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health.

A nurse is assessing a client's pain. The nurse notes which database finding that is indicative of acute pain?

increased blood pressure

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention. A nursing intervention is any treatment based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes.

What is the nurse accountable for, according to state nurse practice acts?

making nursing diagnoses

A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?

neuropathic pain

A nurse is caring for a 48-year-old man 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, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

outcome evaluation

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?

planning

In Stage 4 sleep, the:

pulse rate is slow

Which factor necessitates the need for more sleep in the adolescent population?

rapid growth

When caring for a client, the nurse identifies and analyzes data to identify nursing diagnoses and collaborative problems. Which action is a priority role of the nurse when caring for a client with collaborative problems?

reporting trends that suggest development of complications

A nurse is caring for a client who was administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics?

sedation

Personal characteristics demonstrate that one has developed critical thinking. Characteristics of critical thinking include:

self-aware, honest, persistent, and authentic.

The terms "criteria" and "standard" are often used interchangeably but actually have distinct, separate definitions. "The levels of performance accepted by, and expected of, nursing staff or other health team members" is known as:

standards

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

structure

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

surveillance

What is the purpose of establishing a nursing diagnosis?

to describe a functional health problem

The nurse makes the following assessment. A middle-age client reports falling asleep frequently at his job during the day, feels like he is not getting enough sleep at night (even though the number of hours of sleep are unchanged), continues to feel tired, and is not able to think clearly. Also, the client reports his wife believes he is irritable upon awakening. Nursing interventions include teaching the client to:

use caution when driving an automobile

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client.

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which of the following factors would the nurse identify as strengths of the client? Select all that apply.

• The client has been accompanied by family members to every appointment. • The client states a belief in a reward in heaven after death. • The client has demonstrated effective coping skills in the past.

Which client outcome is a cognitive outcome? Select all that apply.

• The client lists the side effects of digoxin (Lanoxin). • The client describes how to perform progressive muscle relaxation. • The client identifies signs and symptoms of hypoglycemia.

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as

"Acute pain tends to increase during the day and is called a routine pain response"

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?

"Demonstrated steps"

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."