Intro Exam II

The nurse is caring for a patient admitted to the intensive care unit with malnutrition. The patient is unable to walk and has developed a pressure ulcer from lying in bed constantly without changing positions. The family believes that the patient is depressed and that is why getting out of bed has stopped. When planning this patient's care, the nurse will include which key concept? a. Develop multiple nursing diagnoses. b. Develop only one nursing diagnosis to aid in focusing. c. Focus on the physical issues facing this patient. d. Deal primarily with the patient's psychological needs.

ANS: A Analysis of patient assessment data may yield several clusters of related data or cues. It is common to apply several nursing diagnostic statements to one patient. This is especially true for acutely ill patients with multiple problems related to complex physical or psychological needs.

A patient calls the nurse to report the smell of cigarette smoke in the bathroom. The nurse recognizes that this component of the communication process is identified by which term? a. Channel b. Referent c. Message d. Feedback

ANS: B The elements of the communication process include a referent (i.e., event or thought initiating the communication), a sender (i.e., person who initiates and encodes the communication), a receiver (i.e., person who receives and decodes, or interprets, the communication), the message (i.e., information that is communicated), the channel (i.e., method of communication), and feedback (i.e., response of the receiver).

The nurse is preparing to administer medications to a patient. When the patient reports new shortness of breath, which action by the nurse is most appropriate? a. Provide the patient with oxygen since it does not require a provider order. b. Complete at least three checks to ensure that the proper medication is given. c. Check the provider orders for all forms of prescription medications. d. Document that the six rights of medication administration were followed.

ANS: C All forms of prescription medication (i.e., oral, topical, and parenteral) require an order before administration, as does providing oxygen to a patient. The nurse would check for an as needed order for oxygen. Nurses must complete three checks, follow the six rights of medication administration, and document appropriately when administering medications, but those actions are not the priority due to the change in the patient's condition. The nurse must first address the patient's shortness of breath.

The nurse is admitting a patient with a foul-smelling leg wound. Which behavior by the nurse indicates an understanding of appropriate body language? a. Using hand gestures to enhance verbal communication b. Standing at the end of the bed with arms crossed c. Facial grimacing at the sight of the wound d. Gentle touching of the patient's shoulder

ANS: D Therapeutic touch, such as holding the patient's hand or touching the patient's shoulder, can provide comfort and may alleviate pain. This is especially true when a patient is undergoing a painful or stressful procedure. Making inappropriate facial expressions may be offensive and hurtful to patients or their family members. The nurse must control his or her facial expressions to avoid communicating disdain or judgmental attitudes in challenging patient care situations. Maintaining a neutral facial expression establishes an environment of caring and openness in which the patient and family members can feel safe to share their innermost concerns. The use of gestures may be challenging to nurses practicing in a multicultural environment. Although they may enhance verbal communication, gestures may be viewed as inappropriate by patients of various cultures. Standing with crossed arms may be indicating a lack of openness or acceptance.

The nurse in an outpatient clinic obtains a blood pressure of 190/88 mm Hg on a patient diagnosed with high blood pressure. The patient tells the nurse, "My blood pressure medicine is really expensive. Do you think I really need it?" The nurse assumes the patient is not taking the medication based on the blood pressure result and the patient's statement and chooses lack of knowledge as a diagnostic label. The nurse identifies the action taken is an example of what concept of nursing diagnosis formation? a. Clustering unrelated data in the diagnostic statement. b. Selecting erroneous data for use in the diagnostic statement. c. Using medical diagnoses in the diagnostic statement. d. Identifying multiple problems within one diagnostic statement.

ANS: A A variety of errors in identification, statement structure, and statement content may occur when formulating nursing diagnoses. These include clustering unrelated data, accepting erroneous data, missing the true underlying etiology of a problem, using medical diagnoses as related factors in a NANDA-I nursing diagnostic statement, and identifying multiple nursing diagnosis labels in one NANDA-I nursing diagnostic statement. Clustering unrelated data most often occurs when the nurse has not completed a thorough review of the patient's assessment information or is missing important data. The nurse assumes the patient is not taking the blood pressure medication because of the cost and chooses the diagnosis of noncompliance. The nurse fails to ask the patient if the medication is being taken as ordered. Errors in data collection (e.g., omitting key information) or an incomplete understanding or knowledge of assessment techniques or a patient's condition may lead to the inclusion of erroneous data in a nursing diagnostic statement or supporting data list. When writing nursing diagnoses, the nurse should avoid inclusion of more than one label in the statement. Regardless of the type of nursing diagnosis being written, only one label should be used in each statement. The nurse does not commit this error here. "Lack of knowledge" is not a medical diagnosis.

The nurse understands which statement about the use of electronic health records is true? a. They improve patient health status. b. They require a keyboard to enter data. c. They have not reduced medication errors. d. They require increased storage space.

ANS: A Adoption of an EHR system produces major cost savings through gains in productivity and error reduction, which ultimately improves patient health status. The most common benefits of electronic records are increased delivery of guideline-based care, better monitoring, reduced medication errors, and decreased use of care. Use of EHRs can reduce storage space, allow simultaneous access by multiple users, facilitate easy duplication for sharing or backup, and increase portability in environments using wireless systems and hand-held devices. Although data are often entered by keyboard, they can also be entered by means of dictated voice recordings, light pens, or handwriting and pattern recognition systems.

After completing a patient's initial assessment and developing a plan of care, what action by the nurse is most appropriate? a. Continuously reassess the patient. b. Restrict changes to the care interventions. c. Reassess the patient at the start of each shift. d. Evaluate patient goal attainment at intervals.

ANS: A After the nurse completes a patient's initial assessment and develops a plan of care, continual reassessment of the patient detects noticeable changes in the patient's condition, requiring adjustments to interventions outlined in the plan of care. The need for continual patient reassessment underscores the dynamic nature of the nursing process and is crucial to providing essential care.

The nurse is acting in the planning function as a manager. The nurse knows which stage should be completed first? a. Set the plan. b. Assess the situation and future trends. c. Convert plan into action statement. d. Set the goals.

ANS: D The planning function of a manager is comparable to the assessment, diagnosis, and planning portions of the nursing process. It includes four stages: (1) setting goals, (2) assessing the current situation and future trends, (3) setting the plan, and (4) converting the plan into an action statement.

A patient is found unresponsive and pulseless. The nurse begins cardiopulmonary resuscitation (CPR) and calls for help. When help arrives, the nurse should take on which role? a. Autocratic leader b. Democratic leader c. Laissez-faire leader d. Bureaucratic leader

ANS: A Although autocratic leadership is a strict form of leadership, it is useful in crisis situations. A nurse may act as an autocratic leader when taking charge after a patient is found unresponsive. In this situation, it is helpful to have a leader who takes control and directs other members of the health care team. Democratic leaders may see themselves as equals with other team members and may consult with other nurses, exhibiting a democratic form of leadership. This style of leadership can be used in unit council meetings where nurses collaborate to identify solutions to common problems. A nurse in a leadership position who uses the laissez-faire style of leadership assigns patient care and expects all team members to set goals for the day and manage their time to complete the assignment. Successful implementation of this leadership style in nursing requires a highly efficient and reliable staff, such as seen in some specialized OR nursing teams with a history of working together on a set type of cases. The bureaucratic leader relies on policies and procedures to direct goals and work processes. The nurse using bureaucratic leadership tends to relate impersonally to staff and exercises power on the basis of established rules.

The morning nurse is assigned to care for a patient admitted during the night with rectal bleeding. When making rounds, the nurse observes that the patient's face is ashen in color and the skin is cool and clammy. The nurse auscultates the patient's heart and lungs. Which category of physical assessment is the basis for the nurse's response? a. Emergency assessment b. Focused assessment c. Complete assessment d. Initial comprehensive

ANS: A Emergency assessment is a physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes. Attention is paid to the patient's airway, breathing, and circulation. Other concerns in the emergent setting are noticeable deformities such as compound fractures, contusions, abrasions, puncture wounds, burns, tenderness, lacerations, bleeding, and swelling. During an emergency, the nurse may never have time to do a complete assessment and may work to stabilize one body system at a time. A focused or clinical assessment is a brief individualized physical examination conducted at the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern. A focused assessment may be conducted when signs indicate a change in a patient's condition or the development of a new complication. A comprehensive or complete assessment includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing. A complete physical examination may be conducted on admission to a hospital, during an annual physical at the office of a physician or nurse practitioner, or on initial interaction with a specialist.

The nurse is caring for a patient with pneumonia, who is a retired soldier who served in World War II. With this information in mind, what should the nurse do in regarding this patient? a. Shake the patient's hand and allow the patient time to "warm up." b. Expect the patient to be optimistic and question everything. c. Allow the patient to multitask and talk in short "sound bites." d. Understand that the patient is probably technologically literate.

ANS: A Establishing rapport is paramount to gaining the trust of the patient. The nurse should consider the patient's generational cohort, which may influence behavior, and willingness to share personal information during the interview process. Veterans (born before 1945) respect authority; are detail oriented; communicate in a discrete, formal, respectful way; may be slow to warm up; value family and community; and accept physical touch as an effective form of therapeutic communication. Baby Boomers (born 1946 to 1964) are optimistic, relationship oriented, and communicate by using open or direct speech, using body language, and answering questions thoroughly. They expect detailed information, question everything, and value success. Generation X members (born 1965 to 1979) are informal; are technology immigrants; multitask; communicate in a blunt or direct, factual, and informal style; may talk in short sound bites; share information frequently; and value time. Millennials, also called Generation Y (born 1980 to 1994) are flexible; are technologically literate or are technology natives; multitask; communicate by using action verbs and humor; may be brief in the form of texting or e-mail exchanges; like personal attention; and value individuality. Individuals from Generation Z (born 1995 to 2015) are digitally connected, value group work, want immediate feedback, are accepting of others, value honesty and family, and are entrepreneurial.

The nurse is caring for a complex patient needing physical and emotional support. As the primary caregiver, the nurse has which responsibility? a. The nurse is ultimately responsible for assessment of patient needs and progress. b. The nurse delegates to people who know what they are doing and operate independently. c. The nurse provides total care to the patient after getting direction from other disciplines. d. The nurse understands that the patient is ultimately responsible for failure or success.

ANS: A Even though collaboration and delegation may occur, the nurse is ultimately responsible for the continued assessment of patient needs and progress. As delegator, the nurse must supervise other disciplines to make sure that the patient needs are being met. Detection of additional problems or lack of progress with the patient should prompt the nurse to reconsider the nursing process steps.

The nurse is preparing to restart a patient's intravenous line and discovers that the patient has no usable veins in either arm. When working to solve this problem, the nurse should carry out which action? a. Discuss the problem with the nurse in charge. b. Not start the intravenous line. c. Conduct an Internet search for infusion journal articles. d. Contact the provider and report the concern.

ANS: A Experienced nurses who have confidence and strong clinical judgment know when to seek help and collaborate with more experienced colleagues. It is critical for students and nurses at all stages of their education and careers to know when, and from whom, to seek guidance. Through dialog with others who have expertise or experience with the issue being faced, knowledge gaps can be filled, erroneous assumptions exposed, and unconscious biases addressed. Not starting the intravenous line is not an option at this point. A literature review to gain published information about intravenous complications may be appropriate after the patient's concern has been addressed. Initially contacting the provider without fully exploring the options for alternate insertion sites is neither wise nor recommended.

The nursing student is reviewing the components of a nursing diagnosis. Which statement made by the student indicates correct understanding of a health-promotion diagnostic statement? a. "The defining characteristics will include the patient's willingness to get better." b. "The risk factors are only psychological in nature, not physical." c. "The health-promotion diagnostic statement is composed of three parts." d. "An example of a health-promotion label is ineffective community coping."

ANS: A Health promotion nursing diagnoses are clinical judgments concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential. Health promotion nursing diagnoses are written with only two sections: (1) the diagnosis label and (2) defining characteristics. Defining characteristics are cues or clusters of related assessment data that are signs, symptoms, or indications of a problem-focused, or health promotion nursing diagnosis. Risk factors that are identified in a risk nursing diagnosis are environmental, physical, psychological, or situational concerns that increase a patient's vulnerability to a potential problem or concern. However, risk factors are not a component of a health promotion nursing diagnosis. Actual diagnoses describe the person, family, or community's response to a health condition or life process that already has occurred. "Ineffective community coping" would be an example of an actual problem.

The nurse knows that standardized care plans may be available and are utilized under which circumstance? a. They need to be individualized for each patient. b. They are implemented without adjustment. c. They remove the need for nurse involvement. d. They do not require the use of nursing diagnoses.

ANS: A In most agencies and specialty units, standardized care plans that must be individualized for each patient are available to guide nurses in the planning process. There are multiple formats in which to develop individualized care plans for patients, families, and communities. Each health care agency has its own form, including electronic formats, to facilitate the documentation of patient goals and individualized patient-centered plans of care. All formats contain areas in which the nurse identifies key assessment data, nursing diagnostic statements, goals, interventions for care, and evaluation of outcomes. In many agencies and specialty units, standardized care plans that must be individualized for each patient are available to guide nurses in the planning process.

When the patient has had a fall while trying to climb out of bed, the nurse must carry out which task? a. Complete an incident report as a risk management document. b. Complete an incident report and add it to the medical record. c. Document that an incident report was completed in the medical record. d. Say nothing about the incident in the medical record.

ANS: A Incident reports are objective, nonjudgmental, factual reports of the occurrence and its consequences. The incident report is not part of a medical record but is considered a risk management or quality-improvement document. The fact that an incident report was completed is not recorded in the patient's medical record; however, the details of a patient incident are documented

The nurse knows which response to be an example of a measurable goal? a. "The patient will be able to lift 10 lb by the end of week one." b. "The patient will be able to lift weights by the end of the week." c. "The patient will be able to lift his normal weight amount." d. "The patient will be able to lift an acceptable amount of weight by week one."

ANS: A Measurable goals are specific, with numeric parameters or other concrete methods of judging whether the goal was met. When writing a goal statement with a patient, the nurse needs to clearly identify how achievement of the goal will be evaluated. When terms such as acceptable or normal are used in a goal statement, goal attainment is difficult to judge because they are not measurable terms, unless they refer to laboratory values or diagnostic test findings. The amount of weight a patient will lift at the end of the week is not specified. "Normal" and "acceptable" weight have not been defined.

The NCSBN Clinical Judgment Measurement Model (NCSBN-CJMM) contains six clearly defined steps, with each one identifying a thought process integral to making sound clinical judgments/decisions. The nurse identifies which question to be an example of the step of analyzing cues? a. "Why is a particular cue or subset of cues of concern?" b. "Which possible explanations are the most serious?" c. "What information is relevant/irrelevant?" d. "Would other interventions have been more effective?"

ANS: A Organizing and linking the recognized cues to the client's clinical presentation is analysis. The question "Why is a particular cue or subset of cues of concern?" is analyzing cues. Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.) is prioritizing hypotheses. The question "Which possible explanations are the most serious?" is an example of this step. Identifying relevant and important information from different sources (e.g., medical history, vital signs) is recognizing cues. The question "What information is relevant/irrelevant?" is an example of this step. Evaluating outcomes is comparing observed outcomes against expected outcomes. The question "Would other interventions have been more effective?" is an example of this step.

The nurse develops a list of nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" The nurse identifies which diagnosis will have the highest priority? a. Disturbed body image b. Nausea c. Maintain skin integrity d. Imbalanced nutrition: less than body requirements

ANS: A Priority of nursing diagnoses is determined by the patient's preference as well as the severity of the symptoms. The patient is concerned about the loss of hair because this will affect body image. For the patient, this is a prime focus. It is possible that the patient may experience nausea as a result of the chemotherapy drugs. The patient will not be able to eat properly if the nausea is not controlled thus decreasing nutritional intake. There is a potential for bleeding as a result of the low platelet count created by the drugs. All of these must be addressed, but the primary diagnosis, in this case, would be body image.

The nurse is formulating a plan of care for a patient. In this phase of the nursing process, the nurse should complete which actions? (Select all that apply.) a. Prioritize nursing diagnoses. b. Determine short- and long-term goals. c. Identify outcome indicators. d. List nursing interventions. e. Gather assessment data.

ANS: A, B, C, D Planning is the third step of the nursing process. During the planning phase, the professional nurse prioritizes the patient's nursing diagnoses, determines short- and long-term goals, identifies outcome indicators, and lists nursing interventions for patient-centered care. Each of these actions requires careful consideration of assessment data (collected earlier) and a thorough understanding of the relationship among nursing diagnoses, goals, and evidence-based interventions.

Clinical judgment models seek to describe the various thought and reasoning activities nurses use when making clinical judgments. The student nurse identifies which clinical judgment model has four key aspects of clinical judgment? a. Tanner Clinical Judgment Model b. Lasater Clinical Judgment Rubric c. NCSBN Clinical Judgment Measurement Model d. Intuitive-Humanistic Model

ANS: A Tanner (2006) identifies four key aspects of clinical judgment: Noticing, Interpreting, Responding, and Reflecting. Lasater's Clinical Judgment Rubric seeks to expand on Tanner's Clinical Judgment Model by identifying 11 dimensions (specific actions) involved in clinical judgment. The NCSBN-CJMM contains six clearly defined steps. Each step identifies a thought process integral to making sound clinical judgments/decisions. The six steps include: (1) recognize cues, (2) analyze cues, (3) prioritize hypotheses, (4) generate solutions, (5) take actions, and (6) evaluate outcomes. Clinical judgment models seek to describe the various thought and reasoning activities nurses use when making clinical judgments. Most contain aspects of the Information Processing Model and the Intuitive-Humanistic Model which were developed several decades ago.

According to Fayol, controlling is a function of management. The nurse understands controlling compares to what phase of the nursing process? a. Evaluation b. Diagnosis c. Assessment d. Implementation

ANS: A The act of controlling involves comparing expected results of the planned work with the actual results. In the nursing process, evaluation is comparable to controlling. The planning function of a manager is comparable to the assessment, diagnosis, and planning portions of the nursing process.

Upon entering a patient's room, the nurse notes that the patient is unresponsive. The nurse takes control and begins to direct other members of the health care team during this crisis. The nurse is demonstrating characteristics of which type of nursing leadership? a. Autocratic b. Democratic c. Laissez-faire d. Bureaucratic

ANS: A The authoritarian or autocratic leader exercises strong control over subordinates. In this scenario, the nurse takes charge and gives directions that others will follow. The participative or democratic leader believes that employees are motivated by internal means and want to participate in decision-making. The primary function of the leader in this situation is to foster communication and develop relationships with followers. Like the democratic leader, the permissive or laissez-faire leader thinks that employees are motivated by their own desire to do well. The laissez-faire leader provides little or no direction to followers, who develop their own goals and make their own. Like the autocratic leader, the bureaucratic leader assumes that employees are motivated by external forces. This type of leader relies on policies and procedures to direct goals and work processes. The nurse using bureaucratic leadership tends to relate impersonally to staff and exercises power on the basis of established rules.

When working on the ability to critically think, the nurse needs to assess for personal critical thinking indicators that includes which quality? a. Being honest b. Having rigid behavior c. Showing complete independence d. Being reactive

ANS: A To develop critical thinking, the nurse needs to assess for the personal critical thinking indicators. Included in these indicators is being honest and upright, which is looking for the truth, even if it sheds unwanted light and demonstrating integrity (adheres to moral and ethical standards; admits flaws in thinking). Rather than being rigid, an indicator is being flexible, which is changing approaches as needed to get the best results. Rather than showing complete independence, an indicator is being careful and prudent, which is seeking help as needed, suspending or revising judgment as indicated by new or incomplete data. Rather than being reactive, an indicator is being proactive, which is anticipating consequences, planning ahead, and acting on opportunities.

The nurse manager of a unit is sharing the most recent results of a patient satisfaction survey to motivate staff. This approach is a characteristic of what type of nursing leader? a. Transformational b. Transactional c. Situational d. Autocratic

ANS: A Transformational leaders use methods that inspire people to follow their lead. Transformational leaders work toward transforming an organization with the help of others. Sharing survey results may work to inspire staff. Transactional leaders use reward and punishment to gain the cooperation of followers. The authoritarian or autocratic leader exercises strong control over subordinates. Situational theories suggest that leaders change their approach depending on the situation.

Several nurses on a medical-surgical unit have been asked by the nurse manager to form a group and gather data regarding patient complaints of late meals. When the nurses meet and establish ground rules, this would be what phase of group development? a. Forming b. Storming c. Norming d. Performing

ANS: A Tuckerman's model of group performance includes forming, storming, norming, performing, and adjourning. In the forming phase, there is little agreement on team goals other than those received from the leader, and there is a high dependence on the leader for guidance and direction. Ground rules are established and trust among the members begins to develop. There is unrest in the storming phase as the individual team members struggle for power and form cliques. Decisions do not come easily at this stage. In the norming phase, the leader plays a facilitating and enabling role as the team begins to agree and engage in group decisions. Both commitment and unity are strong. The team, in the performing phase, has a shared vision and works together to achieve the goals.

The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior to surgery that "I don't think I'll be able to handle this if I get a colostomy. I wouldn't know how to manage it." The patient is complaining of severe surgical pain and has an order for morphine sulfate. The nurse is correct when addressing which nursing diagnosis first? a. Pain b. Alteration in body image c. Knowledge deficit d. Risk for falls

ANS: A Using Maslow's hierarchy of needs helps to organize the most-urgent to less-urgent needs. This framework organizes patient data according to basic human needs common to all individuals. Maslow's theory suggests that basic needs, such as physiologic needs, must be met before higher needs, such as self-esteem. The nurse also realizes that an actual problem takes priority over a potential problem. By using the nursing process appropriately, the nurse correctly chooses the actual, physiological problem first: pain. Once the patient has the morphine, the risk for falls becomes a higher priority than knowledge deficit or alteration in body image because the morphine might confuse the patient, cause dizziness or faintness, and lead to a fall.

The nurse asks the patient for permission to involve the patient's family members in the teaching plan for the patient. Which response is the best rationale to support this involvement? a. Involving the family empowers the patients and their support system. b. Teaching family members decreases the number of questions they may ask. c. Educated family members ensure the patient will comply with the treatment plan. d. The family members may be interested in the information.

ANS: A With the patient's permission, the nurse should share instructions with the people who may assist with care. Nurses empower patients and their support systems through effective teaching. When nurses provide patients and their families with opportunities to ask questions and comprehend health care information, they become an integral part of the health care process. The family members may ask fewer questions but that is not a reason to involve them. Nothing will ensure patient compliance other than the patient deciding to do so. Family members may be interested in the information, but that is not the main reason to include them.

A patient is admitted to the Emergency Department after experiencing severe chest pain and difficulty in taking deep breaths. The patient anxiously tells the nurse, "My father died suddenly of a heart attack at the age of 52. I'm so scared." Which nursing diagnoses are appropriate for this situation? (Select all that apply.) a. Acute pain b. Fear c. Risk for aspiration d. Risk for infection e. Impaired role performance

ANS: A, B One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. The patient is reporting severe chest pain with an inability to take deep breaths. The nursing diagnostic label of acute pain is appropriate. Being scared is a defining characteristic of the nursing diagnosis of fear. The patient is not at risk for aspiration or infection based on the data presented. There is no indication of the nursing diagnosis of impaired role performance.

The nurse is attempting to develop nursing diagnoses for a patient. The nurse understands that nursing diagnoses have which characteristics? (Select all that apply.) a. Nursing diagnoses identify actual or potential problems as well as responses to a problem. b. Nursing diagnoses require naming patient problems using Nursing diagnostic labels. c. Nursing diagnoses utilize objective data since subjective data are often inaccurate. d. Nursing diagnoses include unvalidated data to determine an accurate and thorough diagnosis. e. Nursing diagnoses are similar to medical diagnoses since they both are labels for diseases.

ANS: A, B The nursing diagnosis identifies an actual or potential problem or response to a problem. Accurate identification of nursing diagnoses for patients results from carefully analyzing, validating, and clustering related patient subjective (symptoms) and objective (signs) data. If data collection includes inaccurate or inadequate information or if data are not validated or clustered with related information, a patient may be misdiagnosed. Diagnosis in the nursing process requires naming patient problems using nursing diagnostic labels. Medical diagnoses are labels for diseases, whereas nursing diagnoses describe a response to an actual or potential problem or life process.

The nurse is preparing to begin a physical examination for a patient with open lesions on the lower extremities. Which would the nurse evaluate during the physical assessment? (Select all that apply.) a. Blood test results b. X-ray results c. Recent vital signs d. Patient's health history e. Subjective data

ANS: A, B, C On completion of the patient interview, health history, and review of systems, the nurse begins the physical assessment. During the physical assessment, the nurse collects objective data. If diagnostic tests, such as blood tests or x-rays, were ordered before the patient was seen, the results are reviewed by the nurse. Vital signs are taken and recorded at the beginning of the physical examination.

Patient-centered care requires the nurse to complete which actions? (Select all that apply.) a. Have an understanding of patient preferences. b. Be aware of family values. c. Recognize the patient's expectations. d. Base conclusions on the nurse's personal experiences. e. Provide care in a standardized manner.

ANS: A, B, C Patient-centered care requires the nurse to understand patient and family preferences and values. Nurses must recognize patients' expectations for care and provide care with respect for the diversity of human experience. While interpreting data, the nurse must be careful to avoid inaccurate inferences (i.e., conclusions) based on the nurse's personal preferences, past experiences, generalizations, or outdated and inaccurate health care information.

The nurse knows that the Health Insurance Portability and Accountability Act (HIPAA) allows health information to be shared in which circumstances? (Select all that apply.) a. To provide treatment for the patient b. To determine billing and payment issues c. To enhance health care operations related to the patient d. In public areas such as the cafeteria or elevator e. Over the telephone with any family member

ANS: A, B, C The Health Insurance Portability and Accountability Act (HIPAA), originally passed in 1996, created standards for the protection of personal health information, whether conveyed orally or recorded in any form or medium. The act clearly mandates that protected health information may be used only for treatment, payment, or health care operations. HIPAA privacy standards should be applied during phone, fax, e-mail, or Internet transmission of protected patient information.

The nurse is creating a care plan for a patient admitted with severe bone pain related to an infected leg wound. Which diagnosis written on the plan indicates an understanding of the components of a nursing diagnosis? (Select all that apply.) a. Acute pain b. Risk for impaired walking c. Ineffective bone tissue perfusion d. Osteomyelitis e. Infection

ANS: A, B, C Whereas medical diagnoses identify and label medical (physical and psychological) illnesses, nursing diagnoses are much broader in focus. Nursing diagnoses consider a patient's situation more holistically, including how the patient is responding to current circumstances. Nursing diagnoses take into consideration a patient's attitudes, strengths, and resources—not just the medical problems identified—which are critical for planning holistic, individualized care. Nursing diagnoses are clinical judgments or decisions made by nurses based on patient assessment data. Pain, potential inability to ambulate, and decreased blood flow to the bone are a patient's response to the medical condition of osteomyelitis. Osteomyelitis and infection are medical diagnoses defined as inflammation and an infection of the bone usually caused by bacteria.

The nursing student is writing a report on the use of nonverbal techniques to encourage therapeutic communication. Which examples would be included in the report? (Select all that apply.) a. Providing a backrub b. Remaining silent c. Refraining from distracting body movements d. Facing the patient e. Avoiding eye contact

ANS: A, B, C, D Providing a backrub is considered therapeutic touch; additional examples include holding a patient's hand and gently touching a patient's arm. Silence refers to being present with a patient without verbal communication. Facing the patient and refraining from unusual body movements are active listening techniques. Avoiding eye contact does not facilitate communication.

The nurse has requested an order to place a patient on suicide watch. Which data noted in the health assessment led the nurse to this conclusion? (Select all that apply.) a. Threats of killing oneself b. Chronic pain c. History of prior suicide attempt d. Loneliness e. Stable heart rhythm

ANS: A, B, C, D Risk factors that are identified in a risk nursing diagnosis are environmental, physical, psychological, or situational concerns that increase a patient's vulnerability to a potential problem or concern. The nurse is concerned that the patient may be at risk for suicide. Verbal statements by the patient, physical illness such as chronic pain, prior attempts to commit suicide, and a lack of social interaction are potential causes for the act of suicide. A stable heart rhythm would not be a safety concern.

Since in the planning phase, the significance of developing organized plans of care for patients is important, the nurse must take seriously which of these responsibilities? (Select all that apply.) a. Prioritizing patient needs b. Developing mutually agreed-on goals c. Determining outcome criteria d. Identifying interventions e. Implementation of the patient's plan of care

ANS: A, B, C, D The significance of developing organized plans of care for patients cannot be stressed enough. The nurse must take seriously the responsibility of prioritizing patient needs, developing mutually agreed-on goals, determining outcome criteria, and identifying interventions that can help patients to achieve positive outcomes. After these actions are completed in the planning phase of the nursing process, it is time for implementation of the patient's plan of care (implementation phase).

The nurse knows what should be included in an in-depth health history? (Select all that apply.) a. Demographic data b. Patient's allergies c. Family history of diseases d. Patient's health promotion practices e. Patient's history of illness and surgery

ANS: A, B, C, D, E An in-depth health history includes all pertinent information that can guide the development of a patient-centered plan of care. The health history includes demographic data, which are collected during the orientation phase of the interview; a patient's chief complaint or reason for seeking health care; history of current and past illnesses and surgery; allergies; medications; adverse reactions to medications; medical history; family and social history; and health promotion practices. Because a patient's health history is continuously evolving, the data collection is ongoing, progressive, and methodical.

The nurse recognizes which interventions to be prevention oriented? (Select all that apply.) a. Immunization programs b. Cleansing an incision c. Cardiac risk factor modification d. Placing infants prone when they sleep e. Teaching patients to ask their providers to wash their hands

ANS: A, B, C, D, E Some interventions prevent illness or complications and promote healthy activities or lifestyles. Interventions such as patient education and immunization programs are prevention oriented. Cleansing an incision is a nursing intervention that can help prevent infection. Educating a patient about risk-factor modification for cardiovascular disease may prevent a future myocardial infarction. Placing infants on their backs to sleep may reduce the risk of sudden infant death syndrome. Patients should be instructed to ask their care providers to wash their hands if they have not observed them doing so.

A group of nursing students is discussing the importance of accurately selecting nursing diagnoses. Which ideas offered in the students' discussion are reasons for choosing the diagnoses carefully? (Select all that apply.) a. Patient satisfaction b. Positive patient outcomes c. Quality patient care d. Help develop standardized care plans e. Determine appropriate interventions

ANS: A, B, C, E Ultimately, nurses are accountable for formulating accurate nursing diagnoses and intervening appropriately. By collecting accurate and complete assessment data and articulating concise nursing diagnoses for each patient, the professional nurse has a significant impact on patient care outcomes, the quality of patient care, and patient satisfaction. By identifying appropriate nursing diagnoses, the nurse enables accurate development of individualized patient plans of care. The nursing diagnosis step of the nursing process leads the nurse to the planning phase, which begins with prioritizing the identified nursing diagnoses.

The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP) on a busy medical-surgical unit. Which patients are appropriate for the UAP to obtain vital signs? (Select all that apply.) a. A 28-year-old patient scheduled to be discharged home today b. A 49-year-old patient with stable chronic lung disease c. A 78-year-old patient with recent onset of rectal bleeding d. A 35-year-old patient waiting for transfer to a rehabilitation center e. A 40-year-old patient being admitted from the emergency department

ANS: A, B, D Routine assessment of vital signs of a patient who is stable may be delegated to licensed practical or licensed vocational nurses (LPNs/LVNs) or qualified UAP. Initial and ongoing assessment of patients requiring critical care or who are unstable cannot be delegated to UAPs. The patient with rectal bleeding may need critical care, and a new admission needs to be assessed by an RN. Stable patients such as the patient with stable lung disease or awaiting discharge or transfer can be delegated to UAP.

The nurse identifies which attributes that are required for successful clinical judgment? (Select all that apply.) a. Strong knowledge base b. Proficient technical skills c. Trusting relationships with colleagues d. Previous experience e. Confidence

ANS: A, B, D, E Attributes that are required for successful clinical judgment include: strong knowledge base and proficient technical skills; early problem recognition; effective communication and trusting nurse-patient relationships; previous experience, confidence, and intuition and reflection.

each task must be delegated using which guidelines? (Select all that apply.) a. The task must be within the scope of the person to whom it is being delegated. b. The task is one that can be delegated to other health care providers. c. The task can be delegated whenever assessments are required. d. The task may be re-delegated by the person to whom it was first delegated. e. The task may require the nurse to procure resources to complete the task.

ANS: A, B, E Through quality improvement, the nurse appreciates the value of what each team member can do to improve patient care. When delegating to other health care providers, the nurse understands that the task must be within the scope and abilities of the person to whom it is being delegated. The nurse must know if the task is something that can be delegated. The RN is responsible for assessment of patients even if certain tasks are delegated to others. The person to whom the assignment was delegated cannot delegate that assignment to someone else. Adequate resources must be made available to the delegatee to complete the task.

The nurse understands that the nurse-patient relationship focuses on which areas? (Select all that apply.) a. Building trust b. Demonstrating sympathy c. Tearing down boundaries d. Developing a plan of care e. Applying cultural generalities

ANS: A, C, D A helping relationship develops through ongoing, purposeful interaction between a nurse and a patient. The focal point of the nurse-patient helping relationship is the patient and the patient's needs and concerns. Nurse-patient relationships focus on five areas: (1) building trust, (2) demonstrating empathy, (3) establishing boundaries, (4) recognizing and respecting cultural influences, and (5) developing a comprehensive plan of care.

The nurse has been practicing for several years and has demonstrated successful clinical judgment, with newer nurses asking for advice about patient care. What clinical judgment attributes does this nurse demonstrate? (Select all that apply.) a. Proficient clinical skills b. Reactionary approach c. Intuition d. Trusting relationship with patients e. Practices with total independence

ANS: A, C, D Attributes required for successful clinical judgment include proficient clinical skills, intuition and having a trusting relationship with patients. Having a reactionary approach and practicing with total independence are not clinical judgment attributes.

The nurse knows that professional nursing requires a commitment to which reasons for lifelong learning? (Select all that apply.) a. Treatment modalities and technology continue to advance. b. There are always new things to memorize and store in memory. c. Nurses are expected to update and maintain competency. d. Clinical judgment skills are essential in nursing. e. Nursing school gives the nurse all one needs to be competent.

ANS: A, C, D Nursing practice requires a commitment to lifelong learning and reflection. It is that commitment that contributes to excellent clinical decision-making. All nurses must commit to lifelong learning in order to incorporate research findings, new technology, and best practices into patient care. As nurses deal with increases in both the use of technology and patient acuity, strong clinical judgment skills help reinforce safety in practice. Expanded use of technology and the increased acuity of patients in a variety of care settings enhance nurses' need for strong clinical judgment skills. Outdated learning strategies that focus on remembering content must be replaced by a focus on understanding the rationales and outcomes. No longer is rote memorization and recall of content sufficient for the complex decisions and judgment required in professional nursing practice. Because knowledge and technology continue to expand for nursing professionals, the content learned in nursing school is not sufficient to maintain competence in nursing practice.

The nurse recognizes that by involving the patient in planning care, which patient results occur? (Select all that apply.) a. Being aware of identified needs b. Accepting that not all goals are measurable c. Embracing mutually agreed-on goals d. Feeling a sense of empowerment e. Overcoming unrealistic goals

ANS: A, C, D Patients should be included in the planning process. Involving patients in planning their care helps them to: (1) be aware of identified needs, (2) accept realistic and measurable goals, and (3) embrace interventions to best achieve the mutually agreed-on goals. Inclusion of patients in the planning process tends to improve goal attainment and patient cooperation with interventions. By accepting guidance and input from patients during the planning process, the nurse provides them with a greater sense of empowerment and control.

When charting is done using the DAR charting format, the nurse documents which components? (Select all that apply.) a. The patient problems b. Subjective data c. Any actions initiated d. Objective data e. The patient's response to interventions

ANS: A, C, E A DAR note is used to chart the data (D) collected about the patient problems, the action (A) initiated, and the patient's response (R) to the actions. A SOAP note is used to chart the subjective data (S), objective data (O), assessment (A), and plan (P).

The nurse understands that clinical judgment models attempt to describe the thought and reasoning processes nurses use when making clinical judgment. Which of the following steps would the nurse include when describing the NCSBN Clinical Judgment Measurement Model? (Select all that apply.) a. Analyzing cues b. Generate questions c. Assess cues d. Evaluate outcomes e. Prioritize hypotheses

ANS: A, D, E Clinical judgment models seek to describe the various thought and reasoning activities nurses use when making clinical judgments. The NCSBN Clinical Judgment Measurement Model (NCSBN-CJMM) was developed during the Next Generation NCLEX (NGN) initiative. The NCSBN-CJMM contains six clearly defined steps. Each step identifies a thought process integral to making sound clinical judgments/decisions. The six steps include: (1) recognize cues, (2) analyze cues, (3) prioritize hypotheses, (4) generate solutions, (5) take actions, and (6) evaluate outcomes. Generating questions and assessing cues are not components of this model.

The nurse has a question regarding scope of practice and delegation. Where should the nurse seek clarification? (Select all that apply.) a. The state's nurse practice act b. Theory X management c. Nurse's Code of Ethics d. The NCSBN website e. NCSBN journal articles

ANS: A, D, E Nurses must have knowledge of the nurse practice act in the state where they are licensed. Each state's nurse practice act defines the RN scope of practice and discusses appropriate delegation. A second resource in delegation is the use of the organization's policy and procedure manual. Employers must have job descriptions for each job class that outline the responsibilities and limitations of each position. The National Council of State Boards of Nursing (NCSBN) website and journal articles are other resources for understanding delegation. Nurses are expected to follow personal and professional ethics, as outlined in the American Nurses Association (ANA) Code of Ethics for Nurses to maintain integrity. Theory X—style managers believe that the average person dislikes work and will avoid it if given the opportunity to do so.

The nurse is performing her initial assessment of the day when she notices that the patient has a facial droop that was not present yesterday and that was not reported in the hand-off report from the night nurse. The nurse proceeds to assess the neurologic status of the patient and knows this to be which type of assessment? a. Emergency assessment b. Focused assessment c. Complete physical examination d. Comprehensive assessment

ANS: B A focused or clinical assessment is a brief individualized physical examination conducted at the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern. A focused assessment may be conducted when signs indicate a change in a patient's condition or the development of a new complication. Emergency assessment is a physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes. Attention is paid to the patient's airway, breathing, and circulation. Other concerns in the emergent setting are noticeable deformities such as compound fractures, contusions, abrasions, puncture wounds, burns, tenderness, lacerations, bleeding, and swelling. A comprehensive or complete assessment includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing. A complete physical examination may be conducted on admission to a hospital, during an annual physical at the office of a physician or nurse practitioner, or on initial interaction with a specialist.

The nurse knows while leadership behaviors and management skills often complement each other they differ in which way? a. Managers focus on relationships. b. A manager may not possess leadership traits. c. Leadership focuses on coordinating and directing others. d. A manager is a visionary who sets the direction for a group.

ANS: B A manager may not possess leadership traits, and a leader may lack management skills. Management is the process of coordinating others and directing them toward a common goal. Leadership is the ability to influence, guide, or direct others. Leadership focuses on relationships, using interpersonal skills to persuade others to work toward a common goal. Leaders are visionaries who set the overall direction for a group or organization.

The nurse writes a short-term goal for a patient scheduled for surgery in the morning and identifies which goal that contains all the necessary elements? a. The patient will walk to the bathroom within 48 hours after surgery. b. The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery. c. The patient will walk to the bathroom without experiencing shortness of breath. d. The patient will walk to the bathroom without experiencing shortness of breath after surgery.

ANS: B All short- and long-term goals must be: (1) patient focused, (2) realistic, and (3) measurable. For example, a patient-focused, realistic, and measurable short-term goal may be written for a patient with the nursing diagnosis of Activity intolerance: The patient walks to the bathroom without experiencing shortness of breath within 48 hours after surgery.

The nursing student has been assigned to help feed patients at lunch time. Which nursing intervention would be most effective when assisting a blind patient to eat a meal? a. Speak loudly to ensure that the patient understands. b. Describe the food arrangement using the numbers on a clock. c. Tell the patient what is on the plate since he has lost the sense of smell. d. Encourage the patient to eat faster so that the task will be done.

ANS: B An important factor to remember when caring for visually impaired or blind patients is that they are rarely hearing impaired. Typically, blind patients have heightened auditory and olfactory senses. Communication with blind patients can be characterized as anticipatory in nature, meaning that the nurse should alert visually impaired patients of potential hazards or object locations to provide necessary information and safe care. For example, the nurse may inform the visually impaired patient that the meat entrée is in the 6 o'clock position and the coffee cup is at 2 o'clock on the tray. This system may be helpful in orienting blind patients to their hospital rooms or informing them of where their food is on a plate or tray.

The nurse understands that discharge planning begins at what point in the patient's hospitalization? a. The day before discharge b. Upon admission c. Prior to admission d. Day of discharge

ANS: B Discharge planning plays an important role in the success of a patient's transition to the home setting after hospitalization. Because most patients are in the hospital for only a short time, nurses must begin discharge planning on admission and continue until a patient is dismissed.

If a verbal or phone order is necessary in an emergency, the nurse knows what action needs to be completed? a. The order must be taken by an RN or LPN. b. The order must be repeated verbatim to confirm accuracy. c. The order is documented as a written order. d. The order does not need further verification by the provider.

ANS: B If a verbal or phone order is necessary in an emergency, the order must be taken by a registered nurse (RN) who repeats the order verbatim to confirm accuracy and then enters the order into the paper or electronic system, documenting it as a verbal or phone order and including the date, time, physician's name, and RN's signature. Most facility policies require the physician to co-sign a verbal or telephone order within a defined period.

The nurse correctly defines leadership when making which statement? a. "Leadership is coordinating others toward a common goal." b. "Leadership is the ability to influence others." c. "Leadership focuses on the task at hand." d. "Leadership is based in formal authority."

ANS: B Leaders have the ability to influence and motivate others while maintaining relationships to accomplish a goal. Management is the process of coordinating others and directing them toward a common goal. Management is focused on the task at hand. A manager holds a formal position of authority in an organization; that position includes accountability and responsibility for accomplishing the tasks within the work environment. Managers demonstrate accountability when they are answerable for their own actions and the actions of those under their direction.

What fact is the nurse aware of when charting using electronic documentation? a. Errors can be corrected and totally removed from the record in the screen view. b. Log-on access to the electronic record identifies the person charting. c. Each entry requires the nurse to sign her/his name and credentials. d. Documenting significant changes in the electronic record ends the nurse's responsibility.

ANS: B Log-on access to the electronic record identifies the person charting or making a change. If an error is made in electronic documentation, it can be corrected on the screen view or as an addendum depending on the EHR program used, but the error and correction process remain in the permanent electronic record. Any correction in documentation that indicates a significant change in patient status should include notification of the primary care provider.

After the patient's data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. What is the framework that provides the most holistic view of the patient's condition? a. Head-to-toe pattern b. Functional Health Patterns c. Cephalic-caudal pattern d. Body systems model

ANS: B Marjory Gordon developed the Functional Health Patterns to help nurses focus on patient strengths and related but sometimes overlooked data relationships. This method of organizing patient data is a more holistic approach than the others because it includes data such as values, beliefs, and roles in addition to physical data. Organizing assessment data in a head-to-toe (cephalic-caudal) pattern ensures that all areas of concern are addressed as the nurse performs an assessment covering the entire body. The body systems model organizes data on the basis of each system of the body: integumentary, respiratory, cardiovascular, nervous, reproductive, musculoskeletal, gastrointestinal, genitourinary, and immune systems. It follows a sequence similar to the medical model for physical examination. The body systems model for data organization tends to focus on the physical aspects of a patient's condition rather than a more holistic view.

The nurse recognizes which topic is appropriate teaching content for the patient who is returning from surgery? a. Signs and symptoms of infection b. Use of patient-controlled analgesia c. Activity limitations upon discharge d. Physical therapy

ANS: B Readiness to learn is an important consideration. For example, when a patient returns from surgery, it is essential that some information be reviewed (e.g., how to use the patient-controlled analgesia pump and incentive spirometer) but completing all discharge teaching at this time would not be effective. At other times, teaching is more formalized, such as discharge teaching, signs of infection, and physical therapy.

The nurse administers an ordered intravenous pain medication that is expected to decrease a patient's pain level within 5 minutes, but the patient cries out in pain and reports a pain level of 10 at the end of that time frame. What type of refection is it when should the nurse looks for interventions that could be initiated to reduce the patient's severe pain? a. Reflect-on-action b. Reflect-in-action c. Negative reflecting d. Positive reflection

ANS: B Reflection, which is thinking about actions and outcomes, is an integral part of professional development. Practice experiences and negative and positive patient outcomes can trigger the need for reflection. Research studies have found that reflection is a key attribute to improving a nurse's clinical judgment. Reflection-in-action refers to nurses' ability to "read" the patient—how he or she is responding to the nursing intervention—and adjust the interventions based on assessment. Reflection-in-action may take place more frequently in situations when expected outcomes for patients are not achieved. Reflection-on-action takes place retrospectively. Negative reflecting and positive reflection are not types of reflection

The nurse is taking an advanced cardiac life support (ACLS) recertification class. As part of that class, the nurse and other nurses in the group rotate responsibilities during multiple mock code exercises simulating cardiac arrest scenarios. The nurse recognizes what process is assigning the nurses to these different responsibilities? a. Concept mapping b. Simulation c. Collaborative group work d. Literature review

ANS: B Simulated experiences enable the student to apply previously learned content in a safe and realistic environment that allows time for questioning, clarifying, and feedback. Students develop confidence in providing direct nursing care. The concept map is a way to organize and visualize data to identify relationships and solve problems. Collaborative group work combines the knowledge, ideas, and experiences of each group member to guide the decision-making process. Adding collaboration with an expert role model such as an experienced nurse, faculty member, or mentor can further increase the learning that takes place. Because critical thinking cannot occur about subjects that are unknown, a review of literature may foster this type of thinking by addressing knowledge deficits.

The nurse is preparing to teach indwelling urinary catheter insertion techniques to a group of graduate nurses. Which teaching-learning strategy would the nurse find most useful in teaching this skill? a. Concept mapping b. Simulation c. Collaborative group work d. Literature review

ANS: B Simulated experiences enable the student to apply previously learned content in a safe and realistic environment that allows time for questioning, clarifying, and feedback. The opportunity to experience and act in a variety of complex clinical situations through simulation enables health care students to rehearse and refine the skills and holistic practices of their discipline. Concept mapping promotes active learning. It requires reading assigned textbook content, conducting literature reviews, and collaborating with peers and faculty. Collaborative group work combines the knowledge, ideas, and experiences of each group member to guide the decision-making process. Because critical thinking cannot occur about subjects that are unknown, a review of literature may foster this type of thinking by addressing knowledge deficits

The nursing student is caring for a patient admitted with severe anemia. The patient receives two units of packed red blood cells and tells the student, "I am feeling so much better. I'm not so tired anymore and can bathe myself." The student reviews the patient goal "report an increase in activity tolerance" and concludes that the patient's goal has been met and adjusts the patient's plan of care. The nurse knows this is applying which characteristic of the nursing process? a. Organization b. Dynamics c. Adaptability d. Collaboration

ANS: B The nursing process is dynamic, reflecting changing conditions and needs of patients. Adjusting the plan of care after an outcome has been met is an example of this. Care plans should be organized. Care plans are adaptable, in that they are useful in multiple settings and with either individual or groups as the patient. Collaboration is a key component of meeting patient outcomes.

The triage nurse in a hospital emergency department is determining the order of care for several patients. Which patient would the nurse consider as having the highest priority? a. A 68-year-old patient suffering from dehydration and disorientation b. A 14-year-old patient having respiratory distress and increasing anxiety c. A 46-year-old patient with multiple cuts and abrasions to the upper extremities d. A 38-year-old patient with a broken right hip and in severe pain

ANS: B Triage, a form of emergency assessment, is the classification of patients according to treatment priority. Patients are categorized by the urgency of their condition. Most emergency departments use a five-tier triage system. The five-tier system classifies patients by levels numbered 1 through 5. Level 1 is considered critical: life-threatening conditions such as severe trauma, cardiac arrest, respiratory distress, seizure, or shock. Level 2 emergencies are high risk imminently life-threatening conditions such as chest pain possible stroke, subarachnoid hemorrhage, suicidal or homicidal Level 3 is considered urgent: moderate risk potentially life-threatening conditions such as abdominal pain (without indication of abdominal aortic aneurysm), hip fracture, R/O appendicitis, R/O venous thromboembolism. Level 4 is considered semi-urgent: low risk, stable health conditions such as a twisted ankle or R/O urinary tract infection. Level 5 conditions are non-urgent and lower risk such as cold symptoms, poison ivy, minor aches, and pains.

The nurse identifies which goal is written correctly for the nursing diagnosis of activity intolerance related to imbalance between oxygen supply and demand? a. Patient will walk 1 mile without shortness of breath. b. Patient will ambulate 100 feet with no shortness of breath on third day after treatment. c. Patient will climb stairs without shortness of breath by day 2 of hospital stay. d. Patient will tolerate activity.

ANS: B Useful and effective goals have certain characteristics. They are appropriate in terms of nursing and medical diagnoses and therapy. The goals are realistic in terms of the patient's capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the patient and other nurses. They can be measured to facilitate evaluation. In option A, there is no time frame to gauge expectations, so the diagnosis is not measurable. In option C, the number of stairs is not specified and so is not measurable. In option D, the type of activity is not mentioned, so it is not specific and there is no measurable criterion.

The nurse is admitting a patient for uncontrolled diabetes mellitus. The nurse suspects that the patient could benefit from diabetic teaching. What actions by the nurse will assist in validating this suspicion? (Select all that apply.) a. Determine the patient's cognitive ability and potential language barriers. b. Gather information about what the patient already knows about diabetes. c. Have the patient demonstrate checking a blood glucose level. d. Formulate the patient's plan of care using a standard protocol. e. Prepare to teach the patient using materials written at a third-grade level.

ANS: B, C Data that would validate the nurse's suspicion that the patient needs further education include determining what the patient already knows about diabetes and having the patient demonstrate the technique of blood glucose monitoring. If the nurse is correct, further education is needed. Before further education can occur, however; the nurse should determine if the patient has cognitive difficulties or a language barrier which would all contribute to an individualized plan of care. Reading material should typically be written at a fifth-grade level, but the nurse should not assume the patient needs third-grade level material.

The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. The nurse identifies which abbreviations to be unacceptable? (Select all that apply.) a. prn b. QD c. qod d. 0.X mg e. X mg

ANS: B, C Nurses must be aware of the danger of using abbreviations that may be misunderstood and compromise patient safety. The Joint Commission (2019) has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. QD, Q.D., qd, q.d. (daily), QOD, Q.O.D., qod, and q.o.d. (every other day) can be mistaken for each other. Periods after Q can be mistaken for I, and the O mistaken for I. Write daily or every other day. Trailing zero (X.0 mg) or a lack of leading zero (.X mg) can be confusing. Write as X mg or 0.X mg.

The nursing student is learning about SBAR reporting. What statements about the patient are matched with the correct part of the report? (Select all that apply.) a. Patient is an 84-year-old female with a history of hypertension: S. b. Patient's blood pressure has dropped from 142/92 to 98/48 mmHg: S. c. Patient is hemorrhaging with four saturated dressings in an hour: A. d. The patient took an overdose of antidepressants 3 days ago: B. e. By policy, the patient needs transferred to the ICU; please come write the orders: R.

ANS: B, C, D, E SBAR stands for situation (what is happening the current time), background (circumstances leading up to this situation), assessment (what the nurse thinks the problem is), and recommendation (what needs to be done to correct the situation). A history of hypertension would be background (if it were related to the current issue).

The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of cocaine. Which nursing diagnosis indicates an understanding of a nursing diagnostic statement? (Select all that apply.) a. Impaired breathing related to drug effect on the respiratory center b. Risk for injury related to hallucinations c. Insomnia d. Impaired socialization related to excessive stimulation of nervous system as evidenced by unintelligible speech e. Powerlessness

ANS: B, D Each type of nursing diagnostic statement contains sections or parts. Problem-focused nursing diagnostic statements are written with three parts: a diagnosis label, related factors, and defining characteristics. Risk nursing diagnoses have two segments: a diagnosis label and risk factors. Health-promotion nursing diagnoses are written with only two sections: the diagnosis label and defining characteristics. The first statement needs defining characteristics. Insomnia is a medical diagnosis. The last statement needs etiology and manifestations.

Prior to preparing to administer medications to the patient, the nurse should compare the provider orders with what document? a. Flow sheet b. Electronic health record c. MAR d. Admission summary

ANS: C A medication administration record (MAR) is a list of ordered medications, along with dosages, routes, and times of administration, on which the nurse initials medications given or not given. The EHR includes an electronic medication administration record (eMAR). Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, and intake and output measurements. Data collected on flow sheets may be converted to a graph, which pictorially reflects patient data. The electronic health record (EHR) is a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings. An admission summary includes the patient's history, a medication reconciliation, and an initial assessment that addresses the patient's problems, including identification of needs pertinent to discharge planning and formulation of a plan of care based on those needs.

Nursing students are analyzing the following nursing diagnostic statement during a study group session. Acute pain related to pressure on lumbar spinal nerves as evidenced by a pain level of 9, patient verbalizations of pain, and grimacing when walking. The students would be correct if they stated which response to be the etiology of the patient's problem? a. Patient verbalizations of pain b. Acute pain c. Pressure on lumbar spinal nerves d. Grimacing when walking

ANS: C According to the NANDA-I guidelines, the second part of a problem-focused nursing diagnosis consists of related factors. Related factors are the underlying cause or etiology of a patient's problem. Reviewing a patient's history can help the nurse determine accurate related factors. Nursing interventions are planned and implemented in the next two steps of the nursing process to treat the related factors identified as the cause of the patient's problem. In this case, the acute pain is being caused by pressure on the lumbar spinal nerves.

The nurse is preparing to administer an anticoagulant when the patient says, "Why do I have these bruises on my arms?" The nurse reviews the patient's blood tests and notes an abnormal bleeding time. When the nurse then decides to hold the medication and notify the health care provider, the nurse recognizes this to be an example of which action? a. Thinking ahead b. Reviewing the literature c. Critical thinking d. Analyzing cues

ANS: C Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. In this case, the nurse is able to connect the medication, physical signs, and laboratory data to determine a course of action. Thinking ahead requires being prepared, anticipating potential challenges, and identifying necessary resources that can provide helpful information. The literature review is used to address knowledge gaps through the review of scholarly journals. Analyzing cues is being able to organize and link the recognized cues to the patient's clinical presentation.

A mother of a young child kicks a trashcan in anger and says to the nurse, "You just don't understand! Why can't the doctor find out what is wrong with my child?" The nurse understands that this behavior is most likely an example of which defense mechanism? a. Suppression b. Sublimation c. Displacement d. Rationalization

ANS: C Displacement is an unconscious defense mechanism that transfers emotional energy away from an actual source of stress to an unrelated person or object. The mother is upset that the health care team is not able to determine the cause of her child's illness and expresses her anger by kicking the trashcan. Suppression is the conscious decision to conceal unacceptable or painful thoughts. Sublimation is the rechanneling of unacceptable impulses into socially acceptable activities. Rationalization is the act of denying true motives for an action by identifying a more socially acceptable explanation.

The nurse recognizes that patient goals include which characteristic? a. They are considered short-term if achieved within a month of identification. b. They always have established time parameters, such as "long-term" or "short-term." c. They are mutually acceptable to the nurse, patient, and family. d. They can be vague to facilitate flexibility when evaluating achievement.

ANS: C Goals are broad statements of purpose that describe the aim of nursing care. Goals represent short- or long-term objectives that are determined during the planning step. Some sources establish time parameters for short- and long-term goals, whereas others do not. According to Carpenito, goals that are achievable in less than a week are short-term goals, and goals that take weeks or months to achieve are long-term goals. Useful and effective goals have certain characteristics. They are mutually acceptable to the nurse, patient, and family. They are appropriate in terms of nursing and medical diagnoses and therapy. The goals are realistic in terms of the patient's capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the patient and other nurses. They can be measured to facilitate evaluation.

The nurse is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations should be carried out within which parameters? a. They must be done at the end of every shift. b. They should be done at least every 24 hours. c. They depend on intervention and patient condition. d. They are always done at time of discharge.

ANS: C In most cases, goal statements need to include a time for evaluation. The time depends on the intervention and the patient's condition. Some goals may need to be evaluated daily or weekly, and others may be evaluated monthly. The health care setting affects the time of evaluation. If the goal is set during hospitalization, the goal may need to be evaluated within days, whereas a goal set for home care may be evaluated weekly or monthly. At the time of evaluation, the goal is assessed for goal attainment, and new goals are set or a new evaluation date for the same goal may be chosen if the goal is still applicable for the patient care plan.

During the health history interview, the patient tells the nurse, "Just walking to the mailbox and back makes my calves ache. Is this normal?" Which framework would the nurse most likely choose to document this data? a. Head-to-toe model b. Gordon's Functional Health Patterns c. Body systems model d. Cephalic-caudal model

ANS: C The body systems model organizes data on the basis of each system of the body. As this patient report is confined to the patient's leg pain, the nurse would document the data according to this model. Organizing assessment data in a head-to-toe (cephalic-caudal) pattern ensures that all areas of the body are assessed, including vital signs and other data not pertinent to this report by the patient. Gordon's Health Patterns allow the nurse to organize data in a holistic manner and reveals relationships between data. The cephalic-caudal model allows for a head to toe assessment.

A patient is admitted to a skilled nursing facility with a closed head injury. The nurse believes that the patient has been pocketing food in his cheeks during the noon meal although she has not found any food pocketed. The nurse refers the patient to the speech therapist for a swallowing evaluation. The nurse is using which critical thinking component in making this decision? a. Thinking ahead b. Reflection c. Intuition d. Thinking through

ANS: C Intuition is the feeling that you know something without specific evidence. Intuition is a by-product of knowledge and experience. It allows a nurse to respond to situations automatically or know what to do because of having been exposed to similar circumstances in the past. Thinking ahead is the critical thinking activity that requires being prepared, anticipating potential challenges, and identifying necessary resources that can provide helpful information. Reflection (or thinking back or contemplating or considering) is an essential strategy for improving critical thinking skills. Thinking through is not a component of critical thinking.

The nurse manager of the emergency room believes that efficiency is the expected standard for the department and believes that efficiency lies in following established rules, policies, and guidelines. The only way to change procedures is to changes rules, policies, and guidelines. To run the emergency room with this philosophy, the nurse manager must take on which role? a. Laissez-faire leader b. Democratic leader c. Bureaucratic leader d. Autocratic leader

ANS: C Like the autocratic leader, the bureaucratic leader assumes that employees are motivated by external forces. This type of leader relies on policies and procedures to direct goals and work processes. The nurse using bureaucratic leadership tends to relate impersonally to staff and exercises power on the basis of established rules. The permissive or laissez-faire leader thinks that employees are motivated by their own desire to do well. The laissez-faire leader provides little or no direction to followers, who develop their own goals and make their own. The participative or democratic leader believes that employees are motivated by internal means and want to participate in decision-making. The primary function of the leader in this situation is to foster communication and develop relationships with followers. The authoritarian or autocratic leader exercises strong control over subordinates.

The nurse is developing a plan of care for a patient with gastritis and an inflammation of the intestines. The patient is complaining of severe abdominal discomfort and nausea. The patient also reports having restless leg syndrome and an inability to urinate. What should the nurse write as a problem statement for the nursing diagnosis? a. Gastritis related to inflammation b. Alterations in comfort and ability to void c. Abdominal pain and nausea related to inflammation d. Alteration in comfort related to restless leg syndrome and inflammation

ANS: C One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. Abdominal pain, nausea, and inflammation (of the intestines) are clustered together.

When creating a nursing diagnosis, the nurse knows the related factor is based on what premise? a. It should be based on the medical diagnosis. b. It is unrelated to the pathophysiology causing the problem. c. It is the underlying etiology of the patient's situation. d. It does not reflect the nurse's understanding of pathophysiology.

ANS: C Related factors are the underlying cause or etiology of a patient's problem. Reviewing a patient's history can help the nurse determine accurate related factors. Nursing interventions are planned and implemented in the next two steps of the nursing process to treat the related factors identified as the cause of the patient's problem.

A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. When the nurse asks the manager if there is a document written by the physician for this type of reaction, the nurse is referring to which concept? a. Protocol b. Clinical pathway c. Standing order d. Care map

ANS: C Standing orders are written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when care is common to a certain type of situation, such as what to do if a patient experiences chest pain or what actions to take after a colonoscopy. Protocols are written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician's order. Health care agencies have established protocols outlining procedures for admitting patients or handling routine care situations. Clinical pathways, sometimes referred to as care pathways, care maps, or critical pathways, are multidisciplinary resources designed to guide patient care.

The nurse recognizes that the Lasater Clinical Judgment Rubric does not include which of the following concepts? a. Lasater's Clinical Judgment Rubric seeks to expand on Tanner's Clinical Judgment Model that identifies four key aspects of clinical judgment: Noticing, Interpreting, Responding, and Reflecting. b. Lasater's Clinical Judgment Rubric identifies 11 dimensions (specific actions) involved in clinical judgment. c. These four key aspects are listed along the side of the Lasater rubric. d. The rubric is an extremely helpful tool for student self-evaluation and faculty assessment of student clinical judgment progress.

ANS: C Tanner's four key aspects are listed across the top of the Lasater rubric. The remaining options (A, B and D) are all true concepts.

The nurse is admitting a patient who has had several previous admissions. To obtain a knowledge base about the patient's medical history, the nurse would access which document? a. Electronic medical record (EMR) b. The computerized provider order entry (CPOE) c. Electronic health record (EHR) d. Primary provider's office notes

ANS: C The EHR is a longitudinal record of health that includes the information from inpatient and outpatient episodes of health care from one or more care settings. The EMR is a record of one episode of care, such as an inpatient stay or an outpatient appointment. CPOE allows clinicians to enter orders in a computer that are sent directly to the appropriate department. It does not provide historical data. The primary provider's office notes may not include all the patient's information if the patient has other providers.

The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from local fast-food restaurants and plans a nutrition workshop. The nurse is applying which characteristic of the nursing process? a. Organization b. Dynamics c. Adaptability d. Collaboration

ANS: C The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. The nurse has planned actions based on the needs of this specific population. Organization is another key concept, however; there is no information in the stem on organization. A care plan should be dynamic, changing over time to meet changing needs. The nurse may or may not have to collaborate with other providers in planning and conducting the seminar, but that is another characteristic of a good nursing care plan.

Since the nursing process is cyclic rather than linear, the nurse knows that as an individual patient's condition changes the nurse should anticipate what concept? a. The nurse's thought processes do not have to vary. b. Plans of care are easier to use and do not need modification. c. The accuracy and effectiveness of thought processes must be considered. d. Reflective thought is not necessary since issues tend to be repetitive.

ANS: C The nursing process is cyclic rather than linear. As an individual patient's condition changes, so does the way a professional nurse thinks about that patient's needs, forcing modification of earlier plans of care. At each step of the nursing process, nurses must consider the accuracy and effectiveness of their thought process. This form of reflective thought is an essential aspect of critical thinking. The evolutionary nature of the nursing process allows nurses to adjust to changing patient needs. Plans of care must evolve as patients' needs change.

The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The nurse knows which essential step was added in 1991? a. Assessment b. Diagnosis c. Outcome identification d. Evaluation

ANS: C The term nursing process was first used by Lydia Hall in 1955. In 1973, the American Nurses Association (ANA) identified five specific steps of the nursing process in its Standards of Clinical Practice (1991). These five steps—assessment, diagnosis, planning, implementation, and evaluation—define how professional nursing practice is conducted. Outcome identification was added as an essential aspect of the nursing process by the ANA in 1991. Most nursing professionals and educators recognize outcome identification as part of the planning step of the traditional five-step nursing process.

The nursing student submits a care plan to the nursing instructor for a review prior to implementing the nursing interventions. The instructor identifies which nursing diagnostic statement that is written incorrectly? a. Difficulty coping related to inadequate support systems as evidenced by patient's verbalization, "I don't have any friends or family in town. I just moved here a week ago." b. Activity intolerance related to immobility as manifested by shortness of breath and patient's verbalization of fatigue. c. Impaired sleep and lack of knowledge related to stress as evidenced by patient report of difficulty sleeping and lack of energy. d. Impaired self-feeding related to upper extremity weakness as manifested by inability to get food onto spoon.

ANS: C To correctly formulate a nursing diagnostic statement, the student needs to cluster related data and choose one diagnosis label per statement. In the incorrect example, two nursing diagnosis labels were combined in one statement.

The nurse understands that the five rights of delegation include which components? (Select all that apply.) a. Right patient b. Right time c. Right person d. Right supervision e. Right task

ANS: C, D, E Delegation principles focus on the appropriate intervention (task) being performed under the correct circumstances, by the correct personnel, and with the correct direction and supervision. The right patient and the right time refer to components of the "6 Rights" of medication administration.

The nurse identifies what decisional roles that are included in Mintzburg's description of management in terms of behavior? (Select all that apply.) a. Figurehead b. Spokesperson c. Entrepreneur d. Resource allocator e. Negotiator

ANS: C, D, E Mintzberg described management in terms of behaviors. Underlying his descriptions were two assumptions: much of a manager's time is spent in human relations, and managers are more reactive than proactive. These assumptions provided the basis for three categories of behaviors: interpersonal roles, informational roles, and decisional roles. Mintzberg described three interpersonal roles: figurehead, leader, and liaison. The three informational roles he described are monitor, disseminator, and spokesperson. The third category of Mintzberg's behavioral roles comprises the four decisional roles: entrepreneur, disturbance handler, resource allocator, and negotiator.

The nurse is admitting a patient with severe dehydration. Assessment data reveal a decreased blood pressure, an increased pulse rate, and a low circulating blood volume. The student observes that the patient is confused and restless. Which patient information would the nurse consider as a contributing factor when choosing the nursing diagnostic label? a. Blood pressure, pulse rate b. Blood pressure, pulse rate, blood volume c. Blood pressure, pulse rate, blood volume, mental status d. Blood pressure, pulse rate, blood volume, mental status, dehydration

ANS: D All patient information should be considered as potentially contributing to the identification of diagnostic labels. This information includes subjective and objective data collected through physical assessment of the patient, interview of the patient and family members, and laboratory and diagnostic test results, including x-rays, physicians' orders, and documentation from health care providers. Verifying specific nursing diagnoses for a particular patient or situation follows accurate analysis and clustering of data.

The nurse is learning to identify readiness to learn in patients. Which patient would the nurse identify correctly as ready to learn? a. The patient requesting pain medication for treatment of severe discomfort. b. The patient reporting nausea and vomiting. c. The patient who was just told the diagnosis of cancer of the pancreas. d. The patient who was recently diagnosed with diabetes mellitus and is scheduled to be discharged in 2 days.

ANS: D Choosing opportunities when the patient's condition and environment are most conducive to learning is recommended when attempting to teach patients. Patients who are in pain, are nauseated, or who have been given recent traumatic diagnoses are not psychologically able to retain information.

The nurse is reviewing the last 3 days of a patient's pain history and notes that the pain level has remained constant. The nurse validates the pain level with the patient and decides to contact the provider for further orders. In this scenario, which process is the nurse is using? a. Reflection b. Clinical reasoning c. Problem recognition d. Clinical judgment

ANS: D Clinical judgment is defined by the National Council of State Boards of Nursing (NCSBN) as, "the observed outcome of critical thinking and decision-making. It is an iterative (repetitious) process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care." Reflection, thinking about actions and outcomes, is an integral part of professional development. Practice experiences and negative and positive patient outcomes can trigger the need for reflection. Clinical reasoning is the ability to focus and filter clinical data to recognize what is most and least important, so the nurse can identify if an actual problem is present. Early problem recognition is critical to safe patient care. Early problem recognition is critical to safe patient care. Noticing slight or dramatic changes in a patient's condition and preventing complications is expected of all nurses. Accurate and ongoing assessment of a patient's condition is essential throughout nurse-patient interaction.

The nurse identifies which skills that are not components of both critical thinking and clinical reasoning? a. Psychomotor competencies b. Attitudes c. Knowledge development d. Interdependence

ANS: D Critical thinking and clinical reasoning skills are essential to developing strong clinical judgment. Both involve knowledge development, psychomotor competencies, certain attitudes, and behaviors to acquire. Interdependence is not a skill that is a component of both critical thinking and clinical reasoning.

The nurse recognizes which action to be a dependent nursing intervention? a. Utilizing heel protectors b. Preadmission teaching c. Medication reconciliation d. Oxygen administration via mask

ANS: D Dependent nursing interventions originate from health care provider orders. These interventions include orders for oxygen administration, dietary requirements, medications and diagnostic tests. The nurse incorporates these orders into the patient's overall care enact independent interventions has expanded in recent years, allowing nurses to initiate care that they recognize as essential in meeting patient needs or preventing complications. Utilizing heel protectors for patients susceptible to skin breakdown and initiating preventive measures (e.g., activity regimens, consultations with social workers, preadmission teaching) are often independent, nurse-initiated interventions. Collaborative interventions require cooperation among several health care professionals and unlicensed assistive personnel (UAP). Collaborative interventions include activities such as physical therapy, home health care, personal care, spiritual counseling, medication reconciliation, and palliative or hospice care.

The nurse is writing the care plan for a patient admitted to the hospital for complications associated with muscular dystrophy. Which nursing diagnosis written on the care plan indicates a need for further instruction in constructing the diagnostic statement? a. Constipation related to immobility as manifested patient passing hard, dry stool with difficulty b. Activity intolerance related to weakness as evidenced by verbal report of fatigue c. Impaired self-feeding related to fatigue as manifested by inability to open containers and bring food to the mouth d. Impaired airway clearance related to muscle weakness

ANS: D Each type of nursing diagnostic statement contains sections or parts to comply with NANDA-I guidelines. Problem-focused nursing diagnostic statements are written with three parts: (1) a diagnosis label, (2) related factors, and (3) defining characteristics. Risk nursing diagnoses have two segments: (1) a diagnosis label and (2) risk factors preceded by the phrase as evidenced by. Health promotion nursing diagnoses also are written with only two sections: (1) the diagnosis label and (2) defining characteristics. The impaired airway clearance label is missing the defining characteristics.

The nurse is caring for a patient diagnosed with blood clots in the right lower extremity. The admitting provider orders bed rest. The patient tells the nurse, "I usually exercise three times a week. It helps me go to the bathroom." The nurse determines that the patient may have difficulty with bowel movements. Which nursing diagnosis statement accurately reflects the nurse's concern? a. Constipation related to bed rest as manifested by hard, dry stools b. Constipation resulting from reduced peripheral circulation manifested by patient's anxiety c. Risk for constipation related to immobility as manifested by verbal complaint d. Risk for constipation related to insufficient physical activity

ANS: D Each type of nursing diagnostic statement contains sections or parts to comply with NANDA-I guidelines. Problem-focused nursing diagnostic statements are written with three parts: (1) a diagnosis label, (2) related factors, and (3) defining characteristics. Risk nursing diagnoses have two segments: (1) a diagnosis label and (2) risk factors preceded by the phrase as evidenced by. Health promotion nursing diagnoses also are written with only two sections: (1) the diagnosis label and (2) defining characteristics. There are no data suggesting the patient is constipated at this time.

The nurse is assigned the admission health history and physical for a patient diagnosed with a fever of unknown etiology. The patient tells the nurse, "I just don't feel good. I'm so hot and I feel sick to my stomach. Can you ask me those questions later?" What would be the best response by the nurse? a. "It will not take too long. I can hurry." b. "We need the information to complete your admission paperwork." c. "I will come back in a few minutes and we can start over." d. "Let me see if you can have something for the nausea and then talk later."

ANS: D If a patient being admitted to the hospital is too ill to interact for an extended period, the interview can be broken into smaller segments. Interviews with patients already hospitalized or established in the health care system are less extensive and more focused on newly identified patient concerns or problems. Ensuring that the patient is comfortable and relaxed is a priority and often takes prior thought and planning by the nurse.

The nurse is caring for a patient who is blind. When reviewing the care plan, the nurse would modify which goal? a. The patient will report any drainage from the wound with a foul odor to the primary care provider after discharge. b. The patient will agree to report pain promptly while hospitalized. c. The patient will obtain no injuries while in the hospital. d. The patient will report any purulent wound drainage to the primary care provider after discharge.

ANS: D Interventions must be individualized for each patient and adapted for any limitations (e.g., amputation, learning disability, blindness, deafness). The patient would be able to detect a foul odor, report pain, and remain injury free, but would not be able to tell if drainage is purulent.

The nurse has made patient care assignments and expects all team members to set their own goals for the day and manage their time to meet their goals. The nurse is implementing what style of leadership? a. Autocratic b. Democratic c. Bureaucratic d. Laissez-faire

ANS: D Like the democratic leader, the permissive or laissez-faire leader thinks that employees are motivated by their own desire to do well. The laissez-faire leader provides little or no direction to followers, who develop their own goals and make their own decisions. The authoritarian or autocratic leader exercises strong control over subordinates. The participative or democratic leader believes that employees are motivated by internal means and want to participate in decision-making. The primary function of the leader in this situation is to foster communication and develop relationships with followers. Like the autocratic leader, the bureaucratic leader assumes that employees are motivated by external forces. This type of leader relies on policies and procedures to direct goals and work processes. The nurse using bureaucratic leadership tends to relate impersonally to staff and exercises power on the basis of on established rules.

The nurse is caring for an adult patient with a recent below-the-knee amputation. During shift report, the nurse reports that the patient has urinated in the bed multiple times since the surgery. The nurse knows which defense mechanism best describes this behavior? a. Compensation b. Denial c. Rationalization d. Regression

ANS: D Regression is the return to an earlier developmental stage as a means of avoiding unpleasant or unacceptable thoughts. The adult patient recently lost a limb and reverted to bedwetting as a coping mechanism. Compensation refers to a strategy that uses a personal strength to counterbalance a weakness or a feeling of inadequacy. Refusing to accept a fact or reality as truth is termed denial. Rationalization is the act of suggesting a different explanation for one that is painful, negative, or unacceptable.

The nurse correctly identifies which referral as an inappropriate nursing referral? a. Music therapist b. Community agencies c. Adaptive care services d. Dermatologist

ANS: D Some referrals may require the order of a physician, advanced practice nurse, or physician's assistant. A primary care provider (PCP) may refer a patient to a medical or surgical specialist for further assessment, testing, or treatment. Nurses are often instrumental in initiating these types of referrals but do not complete the actual referral. Referral to a community agency is usually a collaborative action. Obtaining adaptive services and music therapy are independent nursing actions.

A patient is transported to the emergency department from a local skilled nursing facility and admitted for a bacterial blood infection. The nurse reviews the transferring physician notes, which indicate that the patient has dementia. The nurse contacts the patient's son for additional health history information. Information provided by the son would be considered which type of data? a. Primary, objective data b. Primary, subjective data c. Secondary, objective data d. Secondary, subjective data

ANS: D Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Family members, friends, and other members of the health care team can contribute valid secondary, subjective data. Objective data, also referred to as signs, can be measured or observed. The nurse's senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results. Primary data come directly from the patient.

What fact is the nurse aware of when charting using paper nursing notes? a. Use red ink so the nursing entries stand out. b. When mistakes are made in documentation, the nurse should white out the entry. c. Only one nurse should document on a sheet so that it can be removed in case of error. d. The medical record, in any format, is the most reliable source of information in a legal action.

ANS: D The medical record is seen as the most reliable source of information in any legal action related to care. When legal counsel is sought because of a negative outcome of care, the first action taken by an attorney is to acquire a copy of the medical record. Entries into paper medical records were traditionally made with black ink to enable copying or scanning, unless a facility required or allowed a different color. No blank spaces were left between entries because this could allow someone to add a note out of sequence. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry.

The nurse identifies which true statement regarding the medical record? a. It serves as a major communication tool but is not a legal document. b. It cannot be used to assess quality-of-care issues. c. It is not used to determine reimbursement claims. d. It can be used as a tool for biomedical research and provide education.

ANS: D The medical record promotes continuity of care and ensures that patients receive appropriate health care services. The record can be used to assess quality-of-care measures, determine the medical necessity of health care services, support reimbursement claims, and protect health care providers, patients, and others in legal matters. It is a clinical data archive. The medical record serves as a tool for biomedical research and provider education, collection of statistical data for government and other agencies, maintenance of compliance with external regulatory bodies, and establishment of policies and regulations for standards of care. The record serves as the major communication tool between staff members and as a single data access point for everyone involved in the patient's care. It is a legal document that must meet guidelines for completeness, accuracy, timeliness, accessibility, and authenticity.

The nurse is caring for a patient who is unable to take oral medications because of persistent nausea and vomiting. When the nurse decides to call the primary care physician and ask for a different medication administration route, this is a demonstration of what act? a. Collaboration b. Delegation c. Assertiveness d. Advocacy

ANS: D The nurse acts as a patient advocate by promoting what is best for the patient and ensuring that the patient's needs are met. Since the patient is unable to take medications by mouth, it is the nurse's responsibility to inform the physician and obtain alternative medication routes, as appropriate. Assertive communication allows for the expressions of feelings and ideas without hurting or judging. Collaboration refers to the interactions with patients and health care workers to accomplish mutually acceptable goals. Delegation is the art of transferring responsibility of an assigned task to another while at the same time retaining accountability for the outcome.

The charge nurse is discussing a patient's care plan during a team meeting. The team determines that the patient has not met the goal of "ambulating to the nurse's station twice a day" and decides to revise the plan. The nurse recognizes which characteristic of the nursing process most represents this decision? a. Organization b. Dynamics c. Adaptability d. Outcome oriented

ANS: D The nursing process is designed to achieve specific, well-defined outcomes. Patient care plans are developed to meet each patient's goals, not the goals of standardized patients or members of the health care team, including the nurse. Decisions regarding which nursing interventions and medical treatments to implement are made on the basis of safety and their effectiveness in meeting a patient's identified needs and desired outcomes. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any setting and at every level of care. The plan of care is individualized for the patient on the basis of assessment findings, changing needs, setting, and timing of interaction, not just outcomes. Following the steps of the nursing process ensures that patient care is well organized and thorough. The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. It is an equally useful method for addressing the needs of a specific population.