Nursing Process Chapter 11-14

The nurse is reviewing a client's plan of care. Which statements indicate that this care plan has been completed accurately and appropriately? Select all that apply. 1. Ineffective coping related to drug abuse as evidenced by drug overdose. 2. The client will identify two healthy coping mechanisms by time of discharge. 3. The client has identified two health coping mechanisms to replace inappropriate drug use. 4. The client will be provided with guidance in identifying healthy coping mechanisms.5. The client has apologized to his family for drug abuse behaviors.

1, 2, 3, 4 Explanation: 1. The care plan is often organized into sections that include nursing diagnoses. 2. The care plan is often organized into sections that include goals/outcomes. 3. The care plan is often organized into sections that include evaluations. 4. The care plan is often organized into sections that include nursing interventions. Page Ref: 198

The nurse is creating goals for a client's plan of care. For what reasons should the nurse expect to use these goals? Select all that apply. 1. Serve as criteria to evaluate the client's progress2. Determine when the problem has been resolved 3. Motivate the client to provide a sense of achievement 4. Use as a measuring stick to limit the use of hospital resources 5. Provide direction when planning the client's nursing interventions

1, 2, 3, 5 Explanation: 1. Desired outcomes/goals serve as the criteria for judging the effectiveness of nursing interventions and client progress in the evaluation step. 2. Desired outcomes/goals enable the client and nurse to determine when the problem has been resolved. 3. Desired outcomes/goals help motivate the client and nurse by providing a sense of achievement. As goals are met, both client and nurse can see that their efforts have been worthwhile. This provides motivation to continue following the plan, especially when difficult lifestyle changes need to be made. 5. Desired outcomes/goals provide direction for planning nursing interventions. Ideas for interventions come more easily if the desired outcomes state clearly and specifically what the nurse and client hope to achieve.

The nurse is preparing to formulate nursing diagnoses for a client desiring information to help with chronic low back pain. Which human response patterns should the nurse keep in mind when formulating the diagnoses for this client? Select all that apply. 1. Moving 2. Choosing 3. Perceiving 4. Anticipating 5. Communicating

1, 2, 3, 5 1. For the client requesting information for chronic low back pain, the human response pattern of moving would be appropriate because it addresses activity. 2. For the client requesting information for chronic low back pain, the human response pattern of choosing would be appropriate because it addresses a selection of alternatives. 3. For the client requesting information for chronic low back pain, the human response pattern of perceiving would be appropriate because it addresses the reception of information. 5. For the client requesting information for chronic low back pain, the human response pattern of communicating would be appropriate because it addresses the sending of messages.

The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which criteria should the nurse ensure is used when planning interventions for this client? Select all that apply .1. Congruent with the client's values, beliefs, and culture 2. Are within established standards of care 3. Based on scientific and medical knowledge 4. Achievable with the resources available 5. Must be safe and appropriate for the client's age

1, 2, 4, 5 Explanation: 1. This is a recognized guideline. 2. This is a recognized guideline. 4. This is a recognized guideline. 5. This is a recognized guideline. Page Ref: 201

The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis? Select all that apply 1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 3. The client does not drive. 4. The client states that he does not use alcohol or drugs. 5. The client's clothes are soiled. 6. The client has obvious body odor.

1, 2, 5, 6 Explanation: 1. Data that support this problem are clustered around the condition of the client's skin. 2. Data that support this problem are clustered around the condition of the client's skin. 5. Data that support this problem are clustered around the condition of the client's clothes. 6. Data that support this problem are clustered around the condition of the client's general

The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions for a client. Which data did the nurse use to support this diagnosis? Select all that apply. 1. The client has dry, cracked skin. 2. The client has one large and several smaller open, ulcerated areas on his right leg. 3. The client does not drive. 4. The client states that he does not use alcohol or drugs. 5. The client's clothes are soiled. 6. The client has obvious body odor.

1, 2, 5, 6 1. Data that support this problem are clustered around the condition of the client's skin. 2. Data that support this problem are clustered around the condition of the client's skin. 5. Data that support this problem are clustered around the condition of the client's clothes. 6. Data that support this problem are clustered around the condition of the client's general

The nurse is reviewing assessment data collected for a client's care plan. What criteria should the nurse use when formulating this client's nursing diagnoses? Select all that apply. 1. Nonjudgmental statements 2. Stated in terms of a need 3. Must be legally advisable 4. Cause/effect correctly stated 5. Medical terminology used to describe the cause 6. Diagnosis worded specifically and precisely

1, 3, 4, 6 Explanation: 1. This option reflects an accepted guideline for formulating nursing diagnoses. 3. This option reflects an accepted guideline for formulating nursing diagnoses. 4. This option reflects an accepted guideline for formulating nursing diagnoses. 6. This option reflects an accepted guideline for formulating nursing diagnoses.

The nurse is reviewing assessment data collected for a client's care plan. What criteria should the nurse use when formulating this client's nursing diagnoses? Select all that apply. 1. Nonjudgmental statements 2. Stated in terms of a need 3. Must be legally advisable 4. Cause/effect correctly stated 5. Medical terminology used to describe the cause 6. Diagnosis worded specifically and precisely

1, 3, 4, 6 1. This option reflects an accepted guideline for formulating nursing diagnoses. 3. This option reflects an accepted guideline for formulating nursing diagnoses. 4. This option reflects an accepted guideline for formulating nursing diagnoses. 6. This option reflects an accepted guideline for formulating nursing diagnoses.

The nurse attends an educational program that provides information about the Nursing Intervention Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been effective? Select all that apply. 1. "I can look up interventions according to the nursing diagnosis that I've selected." 2. "The interventions connected to a diagnosis are appropriate for any client with that diagnosis." 3. "If there is a NANDA diagnosis, I should be able to find some appropriate interventions." 4. "Care plans are best written when the interventions are broad and flexible." 5. "I find NIC interventions a really good place to start when I'm working on client interventions."

1, 3, 5 Explanation: 1. The nurse can look up a client's nursing diagnosis to see which nursing interventions are suggested. 3. All NIC interventions have been linked to NANDA nursing diagnostic labels. 5. Not all activities suggested for the intervention would be needed for every client, so the nurse chooses the activities appropriate for the client and individualizes them to fit the supplies, equipment, and other resources available in the agency.

The nurse is using the PES model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Select all that apply. 1. Ineffective coping related to depression as evidenced by suicide attempt 2. Noncompliance (DASH diet) related to denial of having disease 3. Risk for infection related to recent surgery 4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds 5. Ineffective Breathing Pattern as evidenced by cyanotic lips

1, 4 1. The basic three-part nursing diagnosis statement is called the PES format and problem, etiology, and signs and symptoms. 4. The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms.

The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care? Select all that apply. 1. Ineffective Breathing Pattern 2. Risk of Infection 3. Readiness for Enhanced Nutrition 4. Readiness for Enhanced Family Coping 5. Anxiety

1, 5 Explanation: 1. An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms. 5. An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms.

The nurse is providing care to a client. Which nursing diagnoses can the nurse apply when providing client care? Select all that apply. 1. Ineffective Breathing Pattern 2. Risk of Infection 3. Readiness for Enhanced Nutrition 4. Readiness for Enhanced Family Coping 5. Anxiety

1, 5 1. An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms. 5. An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms.

The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? 1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends' families. 2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. 3. The grandparents go to weekly services and have formal interaction with clergy. 4. The children have attended private, religious schools, and the parents are involved in the school's activities.

1. A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. The data cluster that describes the questioning, searching, and reflecting would support an attitude of readiness.

One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention? 1. 60 to 90 degrees during feeding times 2. Position in chair 3. Upright in a chair 4. Impaired swallowing

1. Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. In this case, defining "upright" as 60 to 90 degrees and "during feeding times" gives when this should be done.

After an assessment, the nurse reviews the list of client problems. For which problems should the nurse create nursing diagnoses? 1. The ones that the nurse is licensed to treat 2. The ones that address other health professionals' interventions 3. The ones that focus on the client's primary illness 4. The ones that have standardized care available

1. The domain of nursing diagnoses includes only those health states that nurses are educated on and licensed to treat. A nursing diagnosis is a judgment made only after data collection. Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth.

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately? 1. Client will ambulate without a walker by 6 weeks. 2. Client will ambulate freely in house. 3. Client will not fall. 4. Client will have freer movement in daily activities.

1. Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable.

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis

1. A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses (in this situation, Urinary elimination alteration, Impaired skin integrity, and Powerlessness).

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. Which diagnosis should the nurse select for this client? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis

1. A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses (in this situation, Urinary elimination alteration, Impaired skin integrity, and Powerlessness). Page Ref: 176

The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis? 1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends' families. 2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities. 3. The grandparents go to weekly services and have formal interaction with clergy. 4. The children have attended private, religious schools, and the parents are involved in the school's activities.

1. A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. The data cluster that describes the questioning, searching, and reflecting would support an attitude of readiness.

The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the client's coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information? 1. Strengths can be an aid to mobilizing health and the healing process. 2. The client will be more active in the plan. 3. It will be easier for the nurse to educate the client about other interventions. 4. The nurse won't have to spend time going over the pathology of the client's disease.

1. Establishing strengths, resources, and ability to cope will help the client develop a more well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and regenerative processes.

The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In iooking at the client's coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. Why should the nurse utilize this information? 1. Strengths can be an aid to mobilizing health and the healing process. 2. The client will be more active in the plan. 3. It will be easier for the nurse to educate the client about other interventions. 4. The nurse won't have to spend time going over the pathology of the client's disease.

1. Establishing strengths, resources, and ability to cope will help the client develop a more well-rounded self-concept and self-image. Strengths can be an aid to mobilizing health and regenerative processes.

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis? 1. Unfamiliarity of disease process 2. Anxiety 3. Restlessness 4. Tachycardia

1. The etiology is the underlying cause and a contributing factor of the client's response. In this case, the uncertainty of the diagnosis, fear of the unknown, and response to the diagnosis cause the client to become anxious and upset.

A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. What is the etiology of this diagnosis? 1. Unfamiliarity of disease process 2. Anxiety 3. Restlessness 4. Tachycardia

1. The etiology is the underlying cause and a contributing factor of the client's response. In this case, the uncertainty of the diagnosis, fear of the unknown, and response to the diagnosis cause the client to become anxious and upset.

The nurse being oriented to a new position is reviewing the hospital's standards of care, standardized care plans, protocols, policies, and procedures. For which reasons should the nurse realize that these documents are being used by the nursing staff? Select all that apply. 1. Making sure all clients have the same types of care 2. Ensuring that minimally accepted standards are met 3. Promoting efficient use of the nurse's time 4. Eliminating care disparities among clients 5. Ensuring medication errors do not occur

2, 3 Explanation: 2. Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff in order to ensure that minimally acceptable criteria are met. 3. Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff in order to promote efficient use of nurses' time by removing the need to author common activities that are done repeatedly for many of the clients on a nursing unit.

The nurse is using the Taxonomy II nursing diagnoses system. What axes should the nurse realize are coded within this system? Select all that apply. 1. Gordon's health pattern groupings 2. Age 3. Time 4. Health status 5. Gender 6. Location

2, 3, 4, 6 2. The Taxonomy II system codes diagnoses according to seven axes that include age. 3. The Taxonomy II system codes diagnoses according to seven axes that include time. 4. The Taxonomy II system codes diagnoses according to seven axes that include health status. 6. The Taxonomy II system codes diagnoses according to seven axes that includes location.

An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to in a new nursing diagnosis in this client's plan of care? 1. The client's eyes are closed. 2. The client's skin is pale and mottled. 3. The client's spouse is asleep in the chair next to the bed. 4. The television is on and the volume is turned up.

2. Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. An observation is considered significant if it points to changes in the client's health status or pattern, varies from norms of the client population, or indicates a developmental delay. Pale, mottled skin could indicate coldness, a problem with circulation, or even death.

The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention? 1. Assist client with ambulation. 2. Ambulate with client, using a gait belt, twice daily for 15 minutes. 3. Make sure client understands the rationale for using the gait belt. 4. Client will ambulate in hallway twice daily.

2. A well-written intervention should include a verb, conditions, and modifiers, plus a time element. Identifying what to do (ambulate), how to do it (with a gait belt), and how long (twice daily for 15 minutes) is the most precise statement.

The nurse formulates the nursing diagnosis. Acuie pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client? 1. Provide a calm, quiet atmosphere in the client's room. 2. Administer pain medication. 3. Educate the client and family regarding treatment and therapies. 4. Monitor for changes in the client's condition.

2. Collaboration occurs between the nurse, physician, and other health care professionals to treat the client's problem. In this case, the physician prescribes medications, and the nurse administers them-a primarily dependent action that requires physician orders.

The nurse formulates the nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing for a client experiencing an acute myocardial infarction. Which collaborative action would be appropriate for this client? 1. Provide a calm, quiet atmosphere in the client's room. 2. Administer pain medication. 3. Educate the client and family regarding treatment and therapies .4. Monitor for changes in the client's condition.

2. Collaboration occurs between the nurse, physician, and other health care professionals to treat the client's problem. In this case, the physician prescribes medications, and the nurse administers them—a primarily dependent action that requires physician orders.

The nurse is caring for a client with Parkinson's disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client? 1. Provide assistance as needed with dressing and grooming. 2. Provide assistive devices and educate client to use grab bar and large handled utensils. 3. Make sure lighting and space are adequate for client. 4. Administer medications to improve muscle tone.

2. Collaborative interventions are actions the nurse carries out with other health team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel. Providing assistive devices and educating on their proper use would fall into the discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the teaching and information.

The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a multi-system health care facility. Why are these documents important to the nursing staff when providing client care? Select all that apply 1. To make sure all clients have the same type of care 2. To ensure that minimally accepted standards of care are met 3. To promote efficient use of the nurse's time 4. To eliminate care disparities among clients 5. To minimize health care costs

2. Ensuring that minimally accepted standards of care are met is a reason for the actions mentioned in the scenario. 3. Ensuring that nurses' time is used efficiently is a reason for the actions mentioned in the scenario.

An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new narsing diagnosis in this client's plan of care? 1. The client's eyes are closed. 2. The client's skin is pale and mottled. 3. The client's spouse is asleep in the chair next to the bed. 4. The television is on and the volume is turned up.

2. Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. An observation is considered significant if it points to changes in the client's health status or pattern, varies from norms of the client population, or indicates a developmental delay. Pale, mottled skin could indicate coldness, a problem with circulation, or even death.

The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant. Which type of document did the nurse use to find these actions? 1. Standardized care plan 2. Protocol 3. Standards of care 4. Policy and procedure manual

2. Protocols are preprinted to indicate the actions commonly required for a particular group of clients. Protocols may include both physicians' orders and nursing interventions.

A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose will the implementation of this taxonomy serve? 1. Help the nurse with documentation of the care plan 2. Require that the nurse use sound judgment and knowledge of the client 3. Match nursing diagnoses to exact interventions 4. Help the nurse choose activities that are individualized to the client

2. The NIC taxonomy, like NOC, is similar to NANDA diagnoses-broadly stated interventions that are standardized in language and generalized in nature. Each nursing diagnosis contains suggestions for several interventions under the NIC taxonomy, and nurses must select the appropriate interventions based on their judgment and knowledge of the client.

According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client? 1. Make sure that he or she is able to get to the client's home. 2. Assist the client in finding an alternative plan for the achieving the therapy's outcomes. 3. Tell the client that this therapy will be impossible to receive. 4. Make arrangements to have the client moved to a long-term care facility.

2. The nurse must consider a variety of factors when assigning priorities, including resources available to the nurse and client. Factors in this case include the distance between the client's home and the hospital and the fact that therapy is ordered on a twice-daily basis. Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered (e.g., a neighbor who might be willing to drive the client, or someone in the area who may be able to assist with the therapy). Page Ref: 195

After communicating with the client and family, the nurse compares a client's problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors? 1. Understanding what is normal vs. what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns

2. The nurse, while taking the information and collecting data, begins to hypothesize possible explanations of the data and then realizes all diagnoses are only tentative until they are verified. The client and family should be included in the beginning and also at the end of the diagnostic process to verify the nurse's diagnoses.

After communicating with the client and family, the nurse compares a client's problem list with identified nursing diagnoses. What action is the nurse performing to minimize diagnostic errors? 1. Understanding what is normal vs. what is not normal 2. Verifying 3. Consulting resources 4. Basing diagnoses on patterns

2. The nurse, while taking the information and collecting data, begins to hypothesize possible explanations of the data and then realizes all diagnoses are only tentative until they are verified. The client and family should be included in the beginning and also at the end of the diagnostic process to verify the nurse's diagnoses.

A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? 1. Pain due to unknown factors 2. Pain related to unknown etiology 3. Pain caused by psychosomatic condition 4. Pain manifested by client's report

2. The second part of the nursing diagnosis statement is the etiology (E)- the factors contributing to or probable causes-and should be joined to the first part, the problem (P), by the words "related to" rather than "due to." The phrase "related to" implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem evident.

A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client? 1. Pain due to unknown factors 2. Pain related to unknown etiology 3. Pain caused by psychosomatic condition 4. Pain manifested by client's report

2. The second part of the nursing diagnosis statement is the etiology (E)—the factors contributing to or probable causes-and should be joined to the first part, the problem (P), by the words "related to" rather than "due to." The phrase "related to" implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem is evident. Page Ref: 182

The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that planning for this client's discharge was started by the nurse? Select all that apply. 1. The client is scheduled for cardiac catheterization and echocardiogram. 2. Recent laboratory data indicates the development of heart failure. 3. The client does not have a scale to perform daily weights at home. 4. The client's spouse has care needs that the client will not be able to complete going forward. 5. The client is pleasant and eager to learn how to control newly diagnosed health problem.

3, 4 Explanation: 3. Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client's ongoing needs. The lack of a scale at home for daily weights indicates that the nurse is planning ahead for the client's needs once discharged. 4. Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client's ongoing needs. Concern about the client's activity level at home indicates planning ahead for the client's needs once discharged.

The nurse formulates nursing diagnoses for a client with chronic renal failure. Which statements indicate the nurse appropriately used a two-part format? Select all that apply. 1. Pruritis related to toxin build-up in the blood 2. Hypertension related to fluid volume overload 3. Deficient fluid volume related to fluid restriction 4. Personal care challenges related to fistula in left arm 5. Acute confusion related to delayed hemodialysis treatment

3, 5 3. The nursing diagnosis should include a problem statement, such as deficient fluid volume, and the etiology, which is fluid restriction. These two parts are connected by the phrase "related to." 5. The nursing diagnosis should include a problem statement, such as acute confusion, and the etiology, which is delayed hemodialysis treatment. These two parts are connected by the phrase "related to."

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis

3. A wellness diagnosis describes the human response to levels of wellness in an individual. This client is seeking information about behavior changes and improvement to assist him in making choices and changes to enhance his life.

The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client? 1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days 2. Risk for infection, because of new incision, related to episiotomy 3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion 4. Altered urinary elimination, secondary to childbirth

3. The problem statement is listed first (NANDA label), followed by the etiology-factors that contribute to or are the cause of the client's response. The two parts are joined by the words "related to," implying a relationship between the two. Adding a second part to the etiology statement makes it more descriptive and useful.

The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients.

3. The purpose of the nursing process is to identify a client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.

A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses use to help plan this client's care? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan

3. A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. For example, all clients undergoing hip replacement surgery would have basic, similar needs or problems such as pain, skin integrity disruption, risk for infection, decreased mobility, or risk for fall or injury.

The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale? 1. Have suction equipment available at all times. 2. Clear secretions from oral/nasal passageways as needed. 3. Keep client in low-Fowler's position to prevent reflux. 4. Provide frequent assessment for presence of obstructive material in mouth and throat.

3. A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain "why" an intervention would be implemented. Keeping the client in a position with the head elevated 30 to 45 degrees helps prevent the risk of reflux (food/liquids returning up through the esophagus after having been swallowed).

A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client? 1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis

3. A wellness diagnosis describes the human response to levels of wellness in an individual. This client is seeking information about behavior changes and improvement to assist him in making choices and changes to enhance his life.

After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the client's lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take? 1. Verify the information with the client. 2. Compare all findings to the national norms and standards. 3. Consult other professionals and colleagues. 4. Improve critical thinking skills so answers come more easily.

3. Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are all appropriate resources.

After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the client's lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take? 1. Verify the information with the client. 2. Compare all findings to the national norms and standards. 3. Consult other professionals and colleagues. 4. Improve critical thinking skills so answers come more easily.

3. Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are all appropriate resources.Page Ref: 184

The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? 1. Mental status of the client 2. Chronic nature of the illness 3. Nursing care focus 4. Prognosis

3. Nursing focus is an area that differs.

The nurse is reviewing information about the formulation of nursing diagnoses. What should the nurse identify as the area in which nursing diagnoses differ from medical diagnoses and collaborative problems? 1. Mental status of the client 2. Chronic nature of the illness 3. Nursing care focus 4. Prognosis

3. Nursing focus is an area that differs.

A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention? 1. Turn and reposition client every 2 hours. 2. Cushion bony prominences with soft foam while in bed. 3. Provide ongoing assessment for skin breakdown every shift. 4. Apply lotion to dry skin twice daily.

3. Observations include assessments made to determine whether a complication is developing as well as observations of the client's responses to nursing and other therapies. Assessment for skin breakdown would fall under this category.

A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this client's care? 1. The admitting nurse 2. All nurses who work with the client 3. Everybody involved in this client's care 4. The client and the client's support system

3. Planning is basically the nurse's responsibility, but input from the client and support persons is essential if a plan is to be effective. In this case, therapies from other disciplines (occupational, physical, speech, etc.) would be involved because the client is in a comprehensive rehabilitation center. The client's support people and caregivers are also going to be involved in the plan of care, but not exclusively.

The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy? 1. Nursing diagnosis statement 2. Planning portion of the care plan 3. Goal statement of the traditional care plan 4. Implementation phase of the care plan

3. The Nursing Outcomes Classification (NOC) describes client outcomes that respond to nursing interventions seen in traditional care plans.

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label? 1. Activity intolerance 2. Weakness and debilitation 3. Reports of fatigue 4. Physical activity

3. The defining characteristics are those reports given by the client, or the signs and symptoms.

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label? 1. Activity intolerance 2. Weakness and debilitation 3. Reports of fatigue 4. Physical activity

3. The defining characteristics are those reports given by the client, or the signs and symptoms.

The graduate nurse is struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? 1. Depend on knowledge gained from peers' experiences. 2. Work with seasoned and experienced nurses and learn from them. 3. Take assessment notes and utilize information from textbooks for comparison. 4. Know that this will take time, and experience is the best teacher.

3. The novice nurse must take careful assessment notes, search data for abnormal cues, and use textbook resources for comparing the client's cues with the defining characteristics and etiologic factors of the accepted nursing diagnoses.

The graduate nurse struggling with identifying cues from clustered data. What should the nurse use to recognize data patterns and cues? 1. Depend on knowledge gained from peers' experiences. 2. Work with seasoned and experienced nurses and learn from them. 3. Take assessment notes and utilize information from textbooks for comparison. 4. Know that this will take time, and experience is the best teacher.

3. The novice nurse must take careful assessment notes, search data for abnormal cues, and use textbook resources for comparing the client's cues with the defining characteristics and etiologic factors of the accepted nursing diagnoses.

The nurse is caring for a client recovering from a long and difficult childbirth experience. Which nursing diagnosis did the nurse write appropriately for this client? 1. Constipation, due to tissue trauma, manifested by no bowel movement for 2 days 2. Risk for infection, because of new incision, related to episiotomy 3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion 4. Altered urinary elimination, secondary to childbirth

3. The problem statement is listed first (NANDA label), followed by the etiology—factors that contribute to or are the cause of the client's response. The two parts are joined by the words "related to," implying a relationship between the two. Adding a second part to the etiology statement makes it more descriptive and useful.

The nurse wants to propose a new nursing diagnosis. What action should the nurse take first? 1. Using the proposed nursing diagnosis when constructing client care plans 2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility 3. Submitting the diagnosis to NANDA's Diagnostic Review Committee 4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting

3. This is the recognized procedure for initiating the approval of a new nursing diagnosis.

The nurse wants to propose a new nursing diagnosis. What action should the nurse take first? 1. Using the proposed nursing diagnosis when constructing client care plans 2. Getting permission for the proposed nursing diagnosis to be implemented by a nursing facility 3. Submitting the diagnosis to NANDA's Diagnostic Review Committee 4. Presenting the proposed nursing diagnosis at the local AMA (American Medical Association) meeting

3. This is the recognized procedure for initiating the approval of a new nursing diagnosis.

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process? 1. Formulate a diagnosis. 2. Verify the data. 3. Research collaborative and nursing-related interventions. 4. Identify the client's problem, health risks, and strengths.

4. The step that follows data analysis is identification of the client's health problems, health risks, and strengths.

A client is admitted for complications following a routine diagnostic procedure of the colon. Which type of care plan will most likely be implemented for this client? 1. Informal nursing care plan 2. Formal nursing care plan 3. Standardized care plan 4. Individualized care plan

4. An individualized care plan is tailored to meet a specific client need that is not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine procedure-something that is unplanned and a rare occurrence.

The nurse is reviewing interventions written for a client's plan of care. Which intervention should the nurse recognize as being dependent? 1. Repositioning the client every 2 hours 2. Assisting the client with transfers to the bathroom 3. Providing ongoing physical assessment, especially of the incisional sites 4. Administering medications for pain

4. Dependent interventions are those activities carried out under the physician's orders or supervision or according to specified routines. The nurse is responsible for assessing the need for and administering medications, but the physician prescribes them.

A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client? 1. Altered oral mucous membranes, related to dry mouth 2. Activity intolerance, related to oxygen supply imbalance 3. Knowledge deficit, related to medication regimen 4. Ineffective airway clearance, related to increased secretions

4. Prioritizing care must begin with the basic needs, in this case, the airway.

A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client? 1. Altered oral mucous membranes, related to dry mouth 2. Activity intolerance, related to oxygen supply imbalance 3. Knowledge deficit, related to medication regimen 4. Ineffective airway clearance, related to increased secretions

4. Prioritizing care must begin with the basic needs, in this case, the airway.Page Ref: 185

A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation? 1. A STAT order 2. A one-time order 3. A prn order 4. A standing order

4. Standing orders are a written document about policies, rules, regulations, or orders regarding client care.

The nurse identifies for a client the nursing diagnosis "Fluid volume deficit, related to active fluid loss, secondary to diarrhea." What would be and appropriate goal statement for this diagnosis? 1. Client will drink more fluids by tomorrow. 2. Client will have good skin turgor. 3. Client will have moist mucous membranes. 4. Client will have intake of at least 1000 mL within 24 hours.

4. The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress, and all options must have a time frame for evaluating the desired performance. This option includes all necessary components.

The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the client's problem is adequately described? 1. Chronic low self-esteem, related to factors too numerous to mention 2. Risk for self-harm, related to many psychiatric problems 3. Impaired social interaction, due to long history of institutionalization 4. Alteration in thought processes, related to complex factors

4. The phrase "complex factors" may be used when there are too many etiologic factors or when they are too complex to state in a brief phrase. The actual cause of this client's altered thought process may be due to psychiatric diagnoses, medication tolerances and noncompliance, history of institutionalization, and life history of mental disease. This is a variation of the basic two-part statement, but is acceptable to use.

The nurse is formulating a nursing diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood, who is being placed in a long-term, structured institutional environment. Which diagnosis indicates the client's problem is adequately described? 1. Chronic low self-esteem, related to factors too numerous to mention 2. Risk for self-harm, related to many psychiatric problems 3. Impaired social interaction, due to long history of institutionalization 4. Alteration in thought processes, related to complex factors

4. The phrase "complex factors" may be used when there are too many etiologic factors or when they are too complex to state in a brief phrase. The actual cause of this client's altered thought process may be due to psychiatric diagnoses, medication tolerances and noncompliance, history of institutionalization, and life history of mental disease. This is a variation of the basic two-part statement, but is acceptable to use.

The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing

4. The purpose of the NANDA label is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. This label describes the health problem or response by the client for which nursing therapy is given.

The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label? 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing

4. The purpose of the NANDA label is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. This label describes the health problem or response by the client for which nursing therapy is given.

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process? 1. Formulate a diagnosis. 2. Verify the data. 3. Research collaborative and nursing-related interventions. 4. Identify the client's problem, health risks, and strengths.

4. The step that follows data analysis is identification of the client's health problems, health risks, and strengths.