Prep U: Ch 17 and 18

Which are components of an evaluative statement? Select all that apply.

Description of how the client outcome was met Client data that support how the outcome was met

A student nurse has reported for a clinical preceptorship in a hospital and has been reassigned from the medical surgical unit to a pediatric unit. The student nurse has never worked with pediatric clients. Which of the following actions should the student nurse take in this situation?

Inform the supervisor that she cannot accept this assignment because of a lack of experience with pediatric clients

Which are cognitive client outcomes?

The client identifies signs and symptoms of hypoglycemia. The client describes how to perform progressive muscle relaxation.

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? a. Insurance company b. Nurse case manager

b. Nurse case manager The nurse case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The physician is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage.

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? a. Secure the client's jewelry before surgery. b. Provide the client with assistance in transferring to the bedside commode.

b.Provide the client with assistance in transferring to the bedside commode. Assisting with toileting is one of the tasks the state board of nursing permits UAPs to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.

For which client would a standardized plan of care most likely be appropriate?

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia Standardized care plans are most appropriate for clients who are experiencing a common and specific health problem, such as pneumonia. Clients with multiple pathologies or symptoms of unknown etiology are unlikely to have their unique needs reflected in a standardized care plan.

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action?

Reschedule the client's bath to the evening shift. The client's preferences are a primary consideration in scheduling interventions. The client's preference to have a bath at night requires a change in scheduling. Asking for permission to give the bath in the morning does not address the client's preference. The schedule of the nurses should not take priority over client needs. Informing the client about sleep medication does not address the client's preference.

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

The client will understand the effects of smoking related to heart disease. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that is unable to be measured; moreover, it does not include a time target.

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? a. A client with a high fever receiving intravenous fluids, antibiotics, and oxygen b. An older adult with pneumonia who is being discharged to the son's home tomorrow

a. A client with a high fever receiving intravenous fluids, antibiotics, and oxygen For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described.

The nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair and holds the client's hand while listening to the client's concerns. What additional type of nursing supportive intervention could the nurse provide? a. Arranging for clergy to visit with the client b. Providing humor in conversation to assist in alleviating stress

a. Arranging for clergy to visit with the client supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems and could include the use of humor. Coordinating interventions involve many different activities, such as acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care and would include medication administration.

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? a. Go to the client and assess the client's pain. b. Determine the frequency of pain medication.

a. Go to the client and assess the client's pain. The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.

A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome?

affective Affective outcomes pertain to changes in client values, beliefs, and attitudes and are more complex to evaluate. Changes in behaviors, such as the cessation of smoking or nutritional changes that lead to weight loss, are examples of affective outcomes. Cognitive outcomes involve an increase in client knowledge and are evaluated by asking the client to repeat information. Psychomotor outcomes describe the client's achievement of a new skill and are evaluated by having the client perform the skill. Physiologic outcomes result in physical changes and are evaluated through physical assessment.

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response? a. "You always have the right to refuse any medication or treatment." b. "You should always speak up if you have any questions about your care."

b. "You should always speak up if you have any questions about your care." The priority is to empower the client into taking an active role in the client's care, so the nurse should tell the client to feel free to ask questions. The client does have the right to refuse, but this does not address the issue. Speaking to the nurse manager or the night nurse does not help the client deal with a similar situation in the future. Reference:

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action? a. Read the policy and procedure manual. b. Ask a skilled nurse to assist with the procedure.

b. Ask a skilled nurse to assist with the procedure. Professional nurses should only undertake tasks that they have been properly trained to perform. Because the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? a. Consult with the physician for additional pain medication. b. Assess the client to determine the cause of the pain.

b. Assess the client to determine the cause of the pain. One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain.

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? a. Feed a client who is eating for the first time following an ischemic stroke. b. Bathe a client with stable angina who has a continuous IV infusing.

b. Bathe a client with stable angina who has a continuous IV infusing. The nurse can instruct the UAP to bathe the client with stable angina who has a continuous IV infusing. The other clients require the clinical reasoning skills of the nurse to evaluate their response.

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement? a. cognitive b. psychomotor

psychomotor