Unit 3 - Foundations Ch. 2-8 & Ch. 19 (part 1)

Using Maslow's Hierarchy of Needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. (Enter using the following format: 1, 2, 3, 4) 1) Anxiety 2) Risk for infection 3) Disturbed body image 4) Sleep deprivation

ANS: 4, 2, 1, 3 In Maslow's hierarchy, physiological needs and safety are the highest priority. Sleep is a basic physiological need. Infection can threaten physical health. In this question, infection is not present; therefore, there is only a risk for it. Sleep Deprivation is an immediate problem that affects general physical, mental, and emotional health. Neither Anxiety nor Disturbed Body image is a physiological or safety need. Anxiety is a more immediate need than is Disturbed Body Image; therefore, it probably deserves a higher ranking. Remind students that the ranking would depend on the severity of each problem, which is not known by the labels alone.

What is wrong with the following diagnostic statement? "Impaired Physical Mobility related to laziness and not having appropriate shoes." The statement is: a) Judgmental b) Too complex c) Legally questionable d) Without supportive data

ANS: A "Lazy" implies criticism of the client and therefore is judgmental. There need to be several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum "amount" of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose "lack of data" as the best answer because all the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use AMB and include defining characteristics).

Which of the following is an example of a cluster of related cues? a) Complains of nausea and stomach pain after eating b) Has a productive cough and states stools are loose c) Has a daily bowel movement and eats a high-fiber diet d) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 mm Hg

ANS: A A cue is an unhealthy response; a cluster of cues consists of cues related to each other, such as nausea and stomach pain after eating. Productive cough and loose stools are abnormal findings but are not obviously or usually related to each other. Daily bowel movement and high-fiber diet are related but normal responses. The vital signs are also within normal limits.

What makes a nursing history different from a medical history? a) A nursing history focuses on the patient's responses to the health problem. b) The same information is gathered in both; the difference is in who obtains the information. c) A nursing history is gathered using a specific format. d) A medical history collects more in-depth information.

ANS: A A medical history focuses on the patient's current and past medical/surgical problems. A nursing history focuses on the patient's responses to and perception of the illness/injury or health problem, his coping ability, and resources and support. Nursing history formats vary depending on the patient, the agency, and the patient's needs. Both nursing and medical histories typically use a specific format. A medical history does not necessarily contain more in-depth information. A nursing history can be thorough, covering a wide range of topics, including biographical data, reason(s) patient is seeking healthcare, history of present illness, patient's perception of health status and expectations for care, past medical history, medical history, use of complementary modalities, and review of functional ability associated with activities of daily living. Other topics might deal with nutrition, psychosocial needs, pain assessment, or other special needs topics.

The nurse has gathered her assessment data and notes several significant changes in the client's health status. The client's weight has increased by 5 lb over the past 24 hours, he is short of breath, and crackles are auscultated at both lung bases. To which step of the Nursing Process should the nurse proceed after organizing these data? a) Diagnosis b) Planning c) Implementation d) Evaluation

ANS: A After gathering and analyzing the assessment data, the nurse should next formulate a nursing diagnosis. The other options are not done until after the problem has been diagnosed. The problem is used to plan goals, which are then used to plan interventions. After implementing the intervention(s), evaluation is done to identify change in health status and determine whether goals have been met.

After identifying problems and etiologies and prior to writing a nursing diagnosis statement, the nurse would: a) Verify the nursing diagnosis with the patient b) Verify information with the primary care provider c) Check the medical diagnosis for consistency in treatments d) Review the data and the diagnosis with another nurse

ANS: A After identifying problems and etiologies, the nurse must verify them with the patient. A diagnostic statement is an interpretation of the data and the patient's interpretation may not be the same as that of the nurse. Verifying information with the primary care provider does not assist the nurse in developing a plan of care based on nursing diagnoses and interventions. Checking the medical diagnosis for consistency in treatments does not assist the nurse in tailoring the nursing diagnosis to individual patient needs, although when planning care, the nurse does need to be certain that nursing interventions do not conflict with medical therapies. Reviewing the data and the diagnosis with another nurse may reaffirm the nurse's conclusions; however, the diagnosis still needs to be verified with the patient.

It is important for nurses to be critical thinkers because: a) All clients are unique and have individual needs and differences b) All nursing actions are based on theoretical knowledge c) Nurses choose their actions primarily by following professional guidelines d) Nurses provide care based on individual client preferences

ANS: A All clients are unique and have individual differences. Nursing actions are not solely based on theoretical knowledge. Actions are based on theoretical knowledge, practical knowledge, and self-knowledge. Following guidelines does not usually require critical thinking, and guidelines often do not offer adequate help in managing complex situations. Client preferences are certainly included in the plan of care but they do not cover the broad spectrum of being a critical thinker—it does not require critical thinking merely to do what the client prefers.

How are standardized (model) care plans similar to unit standards of care? Standardized (model) care plans: a) Describe the care needed by patients in defined situations b) Include specific goals and nursing orders c) Become a part of the patient's comprehensive care plan d) Usually describe ideal nursing care

ANS: A All of the statements are true for standardized care plans, but only one statement is true of both standardized care plans and unit standards of care. Both describe care needed by patients in defined situations, although unit standards usually describe care for groups of patients (e.g., all women admitted to a labor unit), and standardized care plans are often organized around a particular or all nursing diagnoses commonly occurring with a particular medical diagnosis. Unit standards are more general and do not have goals for each patient. Unit standards are kept on file in a central place on the unit and do not become a part of the care plan. Unit standards describe minimal, not ideal, care.

What do initial, ongoing, and discharge planning have in common? a) They are based on assessment and diagnosis. b) They focus on the patient's perception of his needs. c) They require input from a multidisciplinary team. d) They have specific time lines in which to be completed.

ANS: A All planning is based on nursing assessment data and identified nursing diagnoses. The patient should have input, and multidisciplinary input may be used; however, the planning is based on the nursing assessment. The different types of planning are intertwined and may or may not be done at distinct, separate times. Discharge planning often requires a multidisciplinary team, but initial and ongoing planning may not. Initial planning is usually begun after the first patient contact, but there is no specified time for completion. Ongoing planning is more or less continuous and is done as the need arises. Discharge planning must be done before discharge.

What do the nursing assessment models have in common? a) They assess and cluster data into model categories. b) They organize assessment data according to body systems. c) They specify use of the nursing process to collect data. d) They are based on the ANA Standards of Care.

ANS: A All the models categorize or cluster data into functional health patterns, domains, or categories. None of the assessment models clusters data according to body system. Assessment is the first step of the nursing process; the nurse does not use the entire nursing process in data collection. The ANA Standards of Care describe a competent level of clinical nursing practice based on the nursing process; nursing models are not based on the ANA Standards of Care.

Which of the following is an example of an ongoing assessment? a) Taking the patient's temperature 1 hour after giving acetaminophen (Tylenol) b) Examining the patient's mouth at the time she complains of a sore throat c) Requesting the patient to rate intensity on a pain scale at the first perception of pain d) Asking the patient in detail how he will return to his normal exercise activities

ANS: A An ongoing assessment occurs when a previously identified problem is being reassessed—for example, taking an hourly temperature when a patient has a fever. Examining the mouth is a focused assessment to explore the patient's complaint of sore throat. Asking for a pain rating is a focused assessment at the first complaint of pain. A detailed interview about exercise is a special needs assessment; there is no way to know whether it is initial or ongoing.

The diagnostic label, or patient problem, is used primarily to suggest: a) Client goals b) Cue clusters c) Interventions d) Etiology

ANS: A As a general rule, the problem suggests goals for client outcomes. The etiology suggests interventions. Cue clusters support whether the correct nursing diagnosis has been identified.

The nurse has just been assigned to the clinical care of a newly admitted patient. To know how best to care for the patient, the nurse uses the Nursing Process. Which step would the nurse probably undertake first? a) Make an assessment b) Make a diagnosis c) Plan outcomes d) Plan interventions

ANS: A Assessment is the first step of the Nursing Process. The nursing diagnosis is derived from the data gathered during assessment, outcomes from the diagnosis, and interventions from the outcomes.

Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I? a) There is little research to support nursing diagnosis labels. b) A perfect nursing diagnosis must be written for it to be useful. c) Standardized diagnoses are not included in all states' nurse practice acts. d) Other professions do not recognize nursing diagnoses.

ANS: A Best practice is evidence-based practice; that is, it is developed through sound, scientific research. Research is currently being conducted, but many of the diagnoses are not research based. A perfect nursing diagnosis is impossible to write, so that is not an issue. Having standardized nursing diagnoses recognized in state practice acts or by other professions has nothing to do with the value of the NANDA-I taxonomy.

The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is very anxious and cannot seem to focus on what the nurse is saying. Which of the following would be best for the nurse to say to begin gathering data about the headaches? a) "When did your migraines begin?" b) "Tell me about your family history of migraines." c) "What are the types of things that trigger your headaches?" d) "Describe what your headaches feel like."

ANS: A For someone who is anxious, it is best to use closed questions. ("When did your migraines begin?") A closed question can be answered in one or very few words and has a very specific answer. The others require an open-ended response.

In caring for a patient with both diabetes and Impaired Skin Integrity (comorbidity), the nurse draws on her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. The nurse has demonstrated: a) Full-spectrum nursing b) Critical thinking c) Nursing Process d) Nursing knowledge

ANS: A Full-spectrum nursing involves the use of critical thinking, nursing knowledge, Nursing Process, and patient situation. Although the other answers are important for planning and delivering nursing care, they do not reflect all the nurse has demonstrated.

The nurse is caring for a client with heart failure. She begins to obtain the client's history and vital signs and then listens to breath sounds. The nurse is practicing which aspect of the Nursing Process? a) Assessment b) Planning interventions c) Planning outcomes d) Evaluation

ANS: A Obtaining the history, auscultating breath sounds, and obtaining vital signs are part of the assessment process. In the assessment step, the nurse gathers patient data and information. In the planning interventions step, the nurse chooses nursing activities aimed at meeting patient goals (and thus relieving the patient's problem). In the planning outcomes phase, the nurse and patient identify goals for the patient's health—expected or desired outcomes of the care. After performing nursing activities, in the evaluation stage the nurse reassesses the patient to determine whether goals have been met.

The nurse is individualizing Mr. Wu's plan of care by writing a plan for his nursing diagnosis of Anxiety. The nurse needs to write goals/outcomes on the plan of care because outcomes describe: a) Desirable changes in the patient's health status b) Specific patient responses to medical interventions c) Specific nursing behaviors to improve a patient's health d) Criteria to evaluate the appropriateness of a nursing diagnosis

ANS: A Outcomes describe changes in the patient's health status in response to nursing rather than medical interventions. Outcomes relate to patient behavior, not nursing behaviors. Outcomes are a measure of the effectiveness of nursing care for a specific nursing diagnosis, not whether the nursing diagnosis is appropriate.

Which statement made by the nurse is an example of stereotyping? a) "Be sure to take your shoes off when entering a Japanese family's home." b) "Patients with type 1 diabetes do not make insulin; therefore, they will need to take insulin regularly." c) "The patient in room 3 cries every time she gets out of bed. She needs to understand that getting out of bed is helping her." d) "My 2-year-old child never had a temper tantrum. I don't understand why the 2-year-old child in room 4 is having one."

ANS: A Stereotypes are judgments and expectations about an individual based on the personal beliefs one may have about a specific group. The statement to remove shoes in a Japanese family's home is stereotyping this particular culture. Patients with type 1 diabetes will need insulin therapy, as this is a medical treatment for all patients with diabetes. The comment related to the patient in room 3 needing to get out of bed is judgmental. The example of the 2-year-old demonstrates a bias, as the nurse is reflecting her opinion of this 2-year-old based on her personal opinion.

A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now: a) Analyze the assessment data b) Consult standards of care c) Decide which interventions are appropriate d) Ask for the client's perceptions of her health problem

ANS: A The basis of the nursing diagnosis is the assessment data. Standards of care are referred to when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment.

Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking: a) Requires reasoned thought b) Asks the questions "why" or "how" c) Is a hierarchical process d) Demands specialized thinking skills

ANS: A The definitions listed in the text as well as definitions contained in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor hierarchical. The steps involved in critical thinking are not necessarily sequential, wherein mastery of one step is necessary to proceed to the next. Critical thinking is a purposeful, dynamic, analytical process that contributes to reasoned decisions and sound contextual judgments.

The patient verbalizes an overwhelming lack of energy. He says, "I still feel exhausted even after I sleep. I feel guilty when I can't keep up with my usual daily activities or sleep during the day. I've been a little depressed lately, too." The patient seems to have difficulty concentrating, but has no apparent physical problems. Which of the following diagnoses best describes his health status? a) Fatigue related to depression b) Fatigue related to difficulty concentrating c) Guilt related to lack of energy d) Chronic confusion related to lack of energy

ANS: A The diagnosis that best describes the overall health status is Fatigue. The only cue that might cause Fatigue is depression. You cannot use depression as the problem because it is a medical diagnosis, and it is not a NANDA-I label. The other cues (difficulty concentrating, lack of energy, and guilt) are symptoms of Fatigue, not etiologies. These diagnoses would lead the nurse to focus on dealing with guilt and confusion, so the source of the Fatigue would not be addressed.

The nurse obtains the following information from the patient: Alert and oriented, is married, and has a history of heart disease. This is an example of: a) Collecting data b) Analyzing data c) Categorizing data d) Making a comprehensive physical assessment

ANS: A The nurse is collecting data on this patient. Once the complete data are collected, they can then be categorized and analyzed to formulate nursing diagnoses and plan for care. Using the information given in the question, a comprehensive physical assessment has not been completed.

During the assessment process the patient states, "I am having numbness and tingling in my right arm." Which of the following best describes the patient's statement? a) Subjective data b) Objective data c) Secondary data d) Focused assessment

ANS: A The patient statement of experiencing numbness and tingling down the right arm is an example of subjective data, as the statement is in the patient's own words. Objective data are overt and gathered by the nurse, either through physical assessment, laboratory findings, or diagnostic testing results. Secondary data are obtained through a source other than the patient, such as a family member. There is not enough information in the patient statement's to categorize it as comprehensive data, as the nurse would have to complete a physical assessment and obtain all data.

Which of the following regarding nursing diagnosis are accurate? Select all that apply. a) Provide the basis for nursing interventions b) Are validated with patient and family when possible c) Have historically been well substantiated by research d) Are descriptions of pathological disease processes

ANS: A, B Nursing diagnosis is the second step in the Nursing Process. It is the link between the preceding assessment data and all future phases. It further provides the basis for planning client-centered goals and interventions. When possible, the nursing diagnosis as well as all other steps in the Nursing Process should be validated with the patient. The diagnostic statement is written after all data are collected and reflects the nurse's clinical reasoning in establishing the nursing problem. Nursing diagnoses are human responses to health problems, whereas medical diagnoses establish disease processes. Many nursing diagnoses have been verified and established through research; however, this has not been a historical strength of the taxonomy. This continues to be a criticism of nursing diagnosis.

Which of the following questions would be effective for obtaining information from a patient? Select all that apply. a) How did this happen to you? b) What was your first symptom? c) Why didn't you seek healthcare earlier? d) When did you start having symptoms?

ANS: A, B, D How, what, and when are acceptable lines of questioning. Asking "why" can put the patient on the defensive and may suggest disapproval, limiting the amount of information the patient is willing give.

Which aspects of healthcare are affected by a client's culture? Select all that apply. a) How the client views healthcare b) How the client views illness c) Whether insurance will pay for healthcare services d) The types of treatments the client will accept e) When the client will seek healthcare services f) The environment in which the healthcare services are provided g) The ease of accessibility of healthcare services

ANS: A, B, D, E Culture impacts clients' views of health and healthcare. It influences how they will define illness, when they will seek healthcare, and what treatments are acceptable in their culture. How services are paid for is related to social environment and economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services.

Which of the following statements are true regarding professional standards of nursing assessment? Select all that apply. a) Assessment is a professional nursing responsibility. b) Assessment helps the nurse identify problems and assign priorities for patient care. c) Assessment helps the nurse formulate the medical diagnosis. d) Only patients complaining of pain need to be assessed for pain. e) Parts of nursing assessments can be delegated according to state practice acts and agency policies.

ANS: A, B, E Assessment is a professional responsibility and assists the nurse to identify problems and prioritize care. Parts of the assessment may be delegated depending on state boards of nursing and agency policies. Assessment helps the nurse formulate a nursing diagnosis; a medical diagnosis is not within the nurse's scope of practice. All patients are assessed for pain.

Which of the following are examples of high-quality nursing documentation? Select all that apply. a) Patient states, "When I get up in the morning, I feel dizzy." b) Patient is alert and oriented to person, place, time, and surroundings. c) Drainage from midline abdominal incision appears normal. d) Patient is angry with wife over arriving late for Dr. appointment. e) Patent has no complaints of pain at this time.

ANS: A, B, E Patient statements using the patient's own words, documentation of patient level of consciousness, and documentation of patient denial of pain are all examples of high-quality documentation. These statements are not subjective or vague. The statement regarding the patient's incision is vague as what is considered normal cannot be measured. Noting that the patient is angry is subjective and unclear.

Which of the following are examples of objective data? Select all that apply. a) Blood pressure reading 120/80 mm Hg b) Pain rated as 6 on a pain scale of 0 to 10 c) Moderate amount of yellow drainage from right ear d) Wife states, "He has not been sleeping well at night." e) Patient states, "I have a stomach ache."

ANS: A, C Blood pressure and yellow ear drainage are examples of objective data. These data are obtained by the nurse through assessment. Patient statements are subjective data. The wife's statement constitutes secondary data and is vague and subjective.

The benefits for nursing practice in using a standardized nursing language include which of the following? Select all that apply. a) Define and communicate nursing knowledge b) Assist the nurse in understanding medical diagnoses c) Facilitate nursing research d) Help nurses provide consistent interventions for all patients

ANS: A, C Standardized nursing languages are a comparatively recent attempt to bring clarity to communication about nursing knowledge and nursing thinking. A standardized language can define, communicate, and expand nursing knowledge, increase visibility and awareness of nursing interventions, facilitate research, and improve patient care by providing better communication among nurse and other healthcare providers. A medical diagnosis describes a disease, illness, or injury. Its purpose is to identify a pathology so that appropriate medical treatment can be given. Nurses deliver nursing care and actions in different ways for different patients. All patients do not have the same needs and problems; therefore, care is planned on an individual basis.

Which of the following are cues rather than inferences? Select all that apply. a) Ate 50% of his meal. b) Patient feels better today. c) States, "I slept well." d) White blood cell count is 15,000/mm3.

ANS: A, C, D Cues are what the client says and what you observe: "just the facts." The only inference in the list is "feels better." What did the nurse observe to tell her the client feels better? Those would be cues. States, "I slept well" is a cue because it is a fact—that is what the client stated.

A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Select all that apply. a) Developing culturally appropriate outcomes b) Using the standardized outcomes on the clinical pathway c) Choosing the best outcome for the patient, regardless of the cost d) Involving the patient and family in formulating the outcomes

ANS: A, D ANA standard 3 includes the following: "derives culturally appropriate expected outcomes from the diagnosis" and "involves the healthcare consumer, family . . . in formulating expected outcomes. . . ." It is acceptable for the nurse to use outcomes on a clinical pathway, but these are not individualized; ANA standard 3 says that the nurse "defines . . . outcomes in terms of the healthcare consumer. . . culture, values, and ethical considerations" The standard also says that the nurse should consider "associated risks, benefits, and costs. . . ."

A nurse with a large caseload of patients needs to delegate some assessment tasks to other members of the health team. The nurse is unsure which tasks can be delegated to nursing assistive personnel (NAP) and which are appropriate for a licensed practical nurse (LPN) or a registered nurse (RN). To which sources should the nurse turn find out to whom to delegate which tasks? Select all that apply. a) Nurse practice act of his state b) American Medical Association guidelines c) Code of Ethics for Nurses d) ANA Scope and Standards of Practice

ANS: A, D State nurse practice acts specify which portions of the assessment can legally be completed by individuals with different credentials. The ANA Scope and Standards of Practice provides a guide for determining who is ultimately responsible and qualified to collect assessment data. The American Medical Association provides guidelines and standards for physicians, not nurses. The Code of Ethics for Nurses says merely that the nurse should delegate tasks appropriately; it does not speak to credentials of personnel.

A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to: a) Consider all the possible advantages and disadvantages b) Maintain an open mind about the proposed change c) Apply the Nursing Process to the situation d) Make a decision based on past experience with documentation

ANS: B A critical attitude enables the person to think fairly and keep an open mind.

The most obvious reason for using a framework when assessing a patient is to: a) Prioritize assessment data b) Organize and cluster data c) Separate subjective data from objective data d) Identify both primary and secondary data

ANS: B A framework is used to organize and cluster data to find patterns. During the assessment phase, the nurse is collecting and recording data, not prioritizing the data. A framework includes subjective and objective data as well as primary and secondary data; it does not help you to separate them.

A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would be most important to perform? a) Family b) Functional c) Community d) Psychosocial

ANS: B A functional assessment is most important because of discharge needs (e.g., self-care ability at home) and patient safety. A family and community assessment would be helpful to evaluate support systems, and a psychosocial assessment would be helpful to evaluate a patient's understanding of and coping with his recent stroke. Remember that special needs assessments are lengthy and time consuming, so they should be used only when in-depth information is needed about a topic.

Which of the following is an example of a problem that nurses can treat independently? a) Hemorrhage b) Nausea c) Fracture d) Infection

ANS: B A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems.

How does a risk nursing diagnosis differ from a possible nursing diagnosis? a) A risk diagnosis is based on data about the patient. b) A possible diagnosis is based on partial (or incomplete) data. c) Nurses collect the data to support risk diagnoses. d) A possible diagnosis becomes an actual diagnosis when symptoms develop.

ANS: B A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and does not have enough data to support it; it is based on incomplete data. A risk diagnosis describes a problem that may develop in a vulnerable client if nursing care is not initiated to prevent it; it is made when risk factors are present in the data. Nurses collect data to support both risk and possible diagnoses; therefore, this statement does not differentiate them. A risk diagnosis becomes an actual diagnosis when symptoms develop.

For which of the following purposes is a graphic flowsheet superior to other methods of recording data? a) Providing easy documentation of routine vital signs b) Seeing the patterns of a patient's fever c) Describing the symptoms accompanying a rising temperature d) Checking to make sure vitals signs were taken

ANS: B All are benefits of the graphic flowsheet, but to easily and graphically see trends over time, the graphic flowsheet is superior to other methods of documentation. For the other options, other kinds of flowsheets would be equally effective.

The nurse is performing an initial interview on a 75-year-old male. Which of the following statements by this patient indicates the need to perform a special needs assessment? a) "I don't go to church as much as I used to but I watch the services on TV." b) "I have fallen twice at home in the past 6 months, so my wife thinks I need a walker." c) "I don't eat much red meat anymore but I get my protein from other foods." d) "I had a toothache but I already saw the dentist."

ANS: B An older adult who has fallen twice in 6 months has a safety risk. Although the wife thinks the patient needs a walker, there is no indication that a walker has been obtained. Falling and risk for falls requires the nurse to perform a special needs assessment most likely related to functional status. The patient verbalizes he misses church but follows by saying how he is able to view services on TV. He also verbalizes eating less red meat but adds that he obtains protein from other sources. The client verbalizes a physiological concern in his toothache but he has addressed this by seeing his dentist.

Which is the best example of a critical-thinking attitude? The nurse: a) Has extensive knowledge of principles and theories b) Has a lively curiosity and enjoys discovering new ways of doing things c) Applies the problem-solving process he was taught in nursing school d) Responds to patients mainly on the basis of what is socially approved

ANS: B Attitudes are more akin to feelings and traits than to intellectual skills. Therefore, extensive knowledge is not a good example of an attitude. Attitudes are addressed in nursing school but it is unlikely that one can "teach" attitudes. A problem-solving process does necessarily require critical thinking; moreover, applying a process simply because one learns it in school would mean the person is not demonstrating an attitude of intellectual independence. Society and culture do help to form attitudes, but that is not the same as basing actions on what is socially approved. Again, that would not demonstrate independent thinking or any of the other critical-thinking attitudes.

What do critical thinking and the Nursing Process have in common? a) They are both linear processes used to guide one's thinking. b) They are both thinking methods used to solve a problem. c) They both use specific steps to solve a problem. d) They both use similar steps to solve a problem.

ANS: B Critical thinking and the Nursing Process are ways of thinking that can be used in problem-solving (although critical thinking can be used for other than problem-solving applications). Neither method of thinking is linear. The Nursing Process has specific steps; critical thinking does not.

The nurse documents in the client plan of care that the wound treatment to the client's left foot has resulted in wound healing. She removed the Skin Integrity diagnosis from the plan of care. The nurse is using which aspect of the Nursing Process? a) Assessment b) Evaluation c) Planning outcomes d) Planning interventions

ANS: B Documenting nursing interventions and a patient's immediate responses (e.g., expressed pain, became restless) is done in the implementation stage. However, in this scenario the nurse also documented that the wound was healing and she removed the nursing diagnosis from the care plan. This demonstrates evaluation.

Which of the following examples includes both objective and subjective data? a) The client's blood pressure reading is 132/68 mm Hg and heart rate is 88 beats/min. b) The client's cholesterol is elevated, and he states he likes fried food. c) The client states she has trouble sleeping and that she drinks coffee in the evening. d) The client states he gets frequent headaches and that he takes aspirin for the pain.

ANS: B Elevated cholesterol is objective and "states he likes fried food" is subjective. Objective data can be observed by someone other than the patient (e.g., from physical assessments or laboratory and diagnostic tests). Subjective data are information given by the client. Blood pressure and heart rate measurements are both objective. "States . . . trouble sleeping and . . . drinks coffee . . ." are both subjective. States ". . . frequent headaches and . . . takes aspirin . . ." are both subjective.

Which of the following reflects the most accurate use of an etiology? a) Knowledge deficit related to abdominal ultrasound b) Knowledge deficit related to incorrect use of walker c) Knowledge deficit related to diabetes d) Knowledge deficit related to age

ANS: B Etiologies contain factors that cause, contribute to, or create a risk to the health problem. These contributing factors can be independently acted upon by a nurse. Knowledge deficit (abdominal ultrasound) describes the knowledge problem; lack of prenatal teaching describes the likely reason for the Knowledge deficit and is a factor the nurse can address independently. Knowledge deficit (use of walker) has no etiology. Knowledge deficit (use of walker) r/t muscle weakness is illogical. Muscle weakness may be interfering with the ability to use the walker; however, it is not a factor contributing to the problem of Knowledge deficit. Knowledge deficit related to diabetes is incorrect because diabetes is a medical diagnosis that a nurse cannot act upon without direction or PCP orders. Age is not specified in the example and is demographic data that cannot be altered; this etiology is too vague and general to be useful.

Based only on Maslow's Hierarchy of Needs, which nursing diagnosis should have the highest priority? a) Self-Care Deficit b) Risk for Aspiration c) Impaired Physical Mobility d) Functional Urinary Incontinence

ANS: B Highest priority is given to problems that are life threatening or that could be destructive to the client. Safety is most basic in Maslow's hierarchy. Even though Risk for Aspiration is not an actual problem, it poses the most immediate life-threatening risk to the client; nursing interventions must be performed to prevent it from becoming an actual problem.

A client arrives in the emergency department. He is pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that are needed. This scenario demonstrates: a) Formal planning b) Informal planning c) Ongoing planning d) Initial planning

ANS: B Informal planning is performed while doing other nursing process steps and is not written; this nurse is forming a plan in her mind. The end product of formal planning is a holistic plan of care that addresses the patient's unique problems and strengths; this nurse has no time to create a holistic plan of care. Ongoing planning refers to changes made in the plan as the nurse evaluates the patient's responses to care; no care has been given at this point. Initial planning does indeed begin with the first patient contact. However, it refers to the development of the initial comprehensive plan of care; this nurse does not have enough data for a comprehensive plan, nor does she have time to make such a plan at the moment.

Which statement related to prioritizing patient problems is most accurate? a) Nurses must resolve one problem before addressing another problem. b) Nurses prioritize problems in order of urgency. c) Actual problem always take priority over risk problems. d) Nurses give the highest priority to problems that the patient thinks are most important.

ANS: B Patients often have more than one problem, so the nurse must use nursing judgment to decide which to address first and which can wait. Nurses do not need to resolve one problem before attending to another. Actually, in many circumstances nurses may be assessing and intervening for several problems at the same time. Prioritization implies a ranking of urgency to patient problems according to the degree of threat they pose to the patient's life or to the immediacy with which treatment is needed. Highest priority is always given to life-threatening problems; however, not all patient problems are life threatening. Frequently, nurses encounter risk problems that may earn a higher priority ranking than an actual problem. Giving priority to problems tht the patient thinks are most important is important, providing this does not conflict with the basic/survival needs or medical treatments.

The Joint Commission requires which type of assessment to be performed on all patients? a) Functional ability b) Pain c) Cultural d) Wellness

ANS: B The Joint Commission requires that pain and nutrition assessment be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors.

The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patient's position every 2 hours. In the evaluation phase of the Nursing Process, which of the following would the nurse do first? a) Determine whether she has gathered enough assessment data b) Judge whether the interventions achieved the stated outcomes c) Follow up to verify that care for the nursing diagnosis was given d) Decide whether the nursing diagnosis was accurate for the patient's condition

ANS: B The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the Nursing Process steps and revising the care plan.

Which of the following is an example of the most basic motivation in Maslow's Hierarchy of Needs? a) Experiencing loving relationships b) Having adequate housing c) Receiving education d) Living in a crime-free neighborhood

ANS: B The most basic needs are centered on physiological survival—shelter (housing), food, and water. All other options are for higher needs. The order from most basic to highest level is physiological; safety and security; love and belonging; esteem; and self-actualization. Loving relationships fall under the love and belonging category. Education is a form of self-actualization. Living in a crime-free neighborhood meets the need for safety and security.

Select the answer that best completes the following statement: The primary purpose of employing the full-spectrum nursing model is to: a) Assist nurses in testing psychomotor skills b) Have a positive effect on a client's health outcomes c) Adequately use all aspects of the Nursing Process d) Assist nurses in completing their work on time

ANS: B The question is asking for the best answer to complete the statement. The best answer is "to have a positive effect on a client's health outcomes," which is also a goal of nursing in general. The full-spectrum model may assist nurses in performing psychomotor skills and even in completing their work on time—especially when something unexpected occurs. However, that is not the focus of the model. Full-spectrum nursing would likely improve the nurse's problem-solving ability (as in the Nursing Process); however, that is not the end purpose of full-spectrum nursing. It is merely a means to achieving the purpose of positively affecting health outcomes.

Which of the following nursing diagnosis statements, using the three-part format (PES), are correct? Select all that apply. a) Chronic pain related to osteoarthritis AMB rates pain at 8 on a 0 to 10 pain scale and has difficulty with ambulation. b) Ineffective airway clearance related to excessive mucus AMB cough, shortness of breath, change in respiratory rate and rhythm c) Caregiver role strain related to increasing care needs AMB wife states, "He is just getting too heavy for me to lift" d) Anxiety (moderate) related to cardiac catheterization AMB crying and yelling at family members

ANS: B, C The ineffective airway clearance and caregiver role strain statements contain all components of a correctly written nursing diagnosis statement. The problems are stated in correct NANDA-I format and reflect a patient response to a health problem. The connecting "related to" statements reflect etiologies that cause or contribute to the health problem and can direct nursing interventions. The AMBs reflect signs and symptoms that have validated the patient response to the health problem. The statement beginning with "Chronic pain" contains an etiology that is a medical diagnosis and cannot be used by the nurse to act on independently. The anxiety statement contains an etiology that describes a diagnostic procedure and cannot be independently acted on by a nurse.

Caring is a central concept in nursing that involves which of the following? Select all that apply. a) Treating all clients with a similar disease in exactly the same way b) Responding compassionately to client needs c) Acting in ways to preserve human dignity d) Connecting with others to give and receive help e) Using active listening

ANS: B, C, D, E Treating all clients in exactly the same way just because they share similar disease processes does not consider their uniqueness nor honor their personhood—and thus does not reflect caring. The other options are all aspects of caring.

Which statement below is the best example of high-quality nursing documentation? a) Patient breathing is normal, no pain noted, urine output is adequate at this time. b) Good strength in both lower extremities. Ambulating with walker down hall. c) Started on solid foods. Ate 75% of dinner. No complaints of any nausea or vomiting. d) Patient seems upset with wife visiting in room; will perform physical assessment at a later time.

ANS: C "Started on solid foods. Ate 75% of dinner. No complaints of nausea or vomiting" is clear, concrete, and specific. Noting that patient breathing is normal and urine output is adequate does not give enough information about breathing or urine output. These statements contain vague and subjective words. "Good strength in both lower extremities" is vague as the word good is subjective. "Patient seems upset" does not give enough information nor is it specific.

Which of the following is an example of an active listening behavior? a) Taking frequent notes b) Asking for more details c) Leaning toward the patient d) Sitting comfortably with legs crossed

ANS: C Active listening behaviors include leaning toward the patient; facing the patient; exhibiting an open, relaxed posture without crossing arms or legs; and maintaining eye contact. Taking frequent notes makes it difficult to keep eye contact. Asking for more details may seem like idle curiosity. Sitting with legs crossed may indicate to the patient that you are not open to her.

The patient shows the necessary defining characteristics, and the nurse has diagnosed Decisional Conflict related to unclear personal values and beliefs. What essential action should the nurse take to help ensure the accuracy of this diagnosis? a) Ask a more experienced nurse to confirm it. b) Request a social worker interview the patient. c) Ask the patient to confirm the diagnosis. d) Read about Decisional Conflict in the NANDA-I handbook.

ANS: C After identifying problems and etiologies (which this nurse has done), the nurse should verify them with the patient to help ensure that her conclusions are accurate. If the patient does not agree that he has Decisional Conflict, the nurse might interview him more in depth to clarify the meaning of the data. Certainly the nurse could ask another nurse's opinion, but that is not essential. It would make no sense to have a social worker interview the patient unless the situation remains unclear even after confirming with the client. If the nurse did have adequate theoretical knowledge of Decisional Conflict for this patient, she should have been informed by reading the NANDA-I handbook before making the diagnosis. If the patient does not confirm the diagnosis, and the nurse concludes the diagnosis is in error, she might then reread the NANDA-I guide.

Which of the following is the best approach to validate a clinical inference? a) Have another nurse evaluate it b) Have the physician evaluate it c) Have sufficient supportive data d) Have the client's family confirm it

ANS: C All clinical inferences should be well supported by data. The more reliable the data are that you gather, the more certain you can be that your inference is accurate. Because inferences are nursing diagnoses, it would be inappropriate to have a physician evaluate them. Although another experienced nurse could evaluate the inference, it still needs to be supported by sound and sufficient data. Even clients can validate clinical inferences in some situations; however, adequate supporting data are still needed. Keep in mind that the client's data might or might not be sufficient to "prove" the inference.

A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform? a) Comprehensive b) Ongoing c) Initial focused d) Special needs

ANS: C An initial focused assessment is performed during a first examination for specific abnormal findings. A comprehensive assessment is holistic and is usually done on admission to a healthcare facility. An ongoing assessment follows up after an initial database is completed or a problem is identified. A special needs assessment is performed when there are cues that more in-depth assessment is needed.

The nurse is caring for a client with skin breakdown of the coccyx area. The physician has ordered a medication to be applied to the area. In applying the medication, the nurse is practicing which aspect of the Nursing Process? a) Assessment b) Planning interventions c) Implementation d) Evaluation

ANS: C Application of a medication to the coccyx area is an "action." The nurse both plans and carries out the intervention. The nurse carries out (and records) interventions in the implementation phase. Evaluation is done after the plan (or nursing action) is implemented.

How are critical pathways and standardized nursing care plans similar? Both: a) Specify daily, or even hourly, outcomes and interventions b) Prescribe minimal care needed to meet recommended lengths of stay c) Describe care common to all patients with a certain condition or situation d) Emphasize medical problems and interventions

ANS: C Both critical pathways and standardized care plans are preplanned documents; they describe care common to all patients who have a certain condition (e.g., all patients who have a heart attack need some of the same interventions). The other statements are true of critical pathways but not of standardized nursing care plans.

Which of the following is the most important reason for nurses to be critical thinkers? a) Nurses need to follow policies and procedures. b) Nurses work with other healthcare team members. c) Nurses care for clients who have multiple health problems. d) Nurses have to be flexible and work variable schedules.

ANS: C Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. Following policies and procedures does not necessarily require critical thinking; working with others or being flexible and working different schedules do not necessarily require critical thinking.

A full-spectrum nurse uses a critical-thinking model to organize her thinking when caring for a patient. The nurse realizes she lacks some facts about the patient's pathophysiology, so she makes sure to use a credible source for the information. She considers the alternatives for action, then again looks up some information. Before deciding what to do, she thinks about the patient's family situation. What aspect of a critical-thinking model does this best illustrate? The nurse is: a) Following model guidelines for specific interventions b) Using linear processes to think critically c) Moving back and forth between steps, and not thinking sequentially d) Using self-knowledge in the decision-making process

ANS: C Critical thinking is not sequential, and critical-thinking models are not applied sequentially. Critical-thinking models do not proceed from top to bottom, nor are they linear. Nurses may jump back and forth between the various steps. Critical-thinking models do not prescribe guidelines for specific interventions. Although self-knowledge may be used as part of a decision-making process, this is not the best answer to complete the statement. The only way self-knowledge is involved in this scenario is that the nurse recognizes that she is lacking some information/knowledge.

The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient? a) Validating conflicting data with the patient b) Transcribing medical orders c) Stating the frequency for ambulation d) Performing a comprehensive assessment

ANS: C Individualizing the care plan means identifying specific problems, outcomes, and interventions and the frequency of those interventions to meet the patient's needs. Validating data ensures your assessment is accurate. Transcribing orders is a part of developing and implementing the care plan but not of individualizing the plan. Performing an assessment is the beginning step in developing a care plan. Assessment helps you to know the ways in which a standardized plan needs to be individualized.

Nondirective interviewing is a useful technique because it: a) Allows the nurse to have control of the interview b) Is an efficient way to interview a patient c) Facilitates open communication d) Helps focus patients who are anxious

ANS: C Nondirective interviewing helps build rapport and facilitates open communication. Because it puts the patient in control, it can be very time consuming (inefficient) and produce information that is not relevant. Directive interviewing should be used to focus anxious patients.

Which of the following most accurately describes nursing diagnoses? A nursing diagnosis: a) Supports the nurse's diagnostic reasoning b) Supports the client's medical diagnosis c) Identifies a client's response to a health problem d) Identifies a client's health problem

ANS: C Nursing diagnoses are statements that nurses use to describe a client's physical, mental, emotional, spiritual, and social response to disease, injury, or other stressor. Diagnostic reasoning is used to identify the appropriate nursing diagnosis; it is not meant to "support" the diagnosis. A health problem is a condition that requires intervention to promote wellness or prevent illness; it is sometimes, but not always, a nursing diagnosis. Nursing diagnoses are not medical diagnoses.

Which of the following is an example of an open-ended question? a) Have you had surgery before? b) When was your last menstrual period? c) What happens when you have a headache? d) Do you have a family history of heart disease?

ANS: C Open-ended questions, such as "What happens when you have a headache?" are broadly worded to encourage the patient to elaborate. The questions about surgery, menstrual period, and family history can all be answered with a "yes," "no," or short, specific answer (e.g., a date).

Which of the following is the best example of an outcome statement? The patient will: a) Use the incentive spirometer when awake b) Walk two times during day and evening shift c) Maintain oxygen saturation above 92% while performing ADLs each morning d) Tolerate 10 sets of range-of-motion exercises with physical therapy

ANS: C Outcome statements should have specific performance criteria and a target time; "maintain oxygen saturation" is the only one that meets those criteria. The incentive spirometer goal should state how many times the incentive spirometer should be used each hour as well as the volume. The walking goal should state how far the patient should walk. In the range-of-motion goal, tolerate is a vague word and is difficult to measure, and the outcome needs to specify how often.

Which of the following is an example of practical knowledge? Assume all are true. a) The tricuspid valve is located between the right atrium and ventricle of the heart. b) The pancreas does not produce enough insulin in type 1 diabetes. c) When assessing the abdomen, you should auscultate before palpating. d) Research shows pain medication given intravenously acts faster than medication given by other routes.

ANS: C Practical knowledge is knowing what to do and how to do it, such as how to make an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), facts (type 1 diabetes), and research (intravenous pain medication).

Which of the following is an example of self-knowledge? The nurse thinks, "I know that I: a) Should take the client's apical pulse for 1 full minute before giving digoxin" b) Should follow the client's wishes even though it is not what I would want" c) Have religious beliefs that may make it difficult to take care of some clients" d) Need to honor the client's request not to discuss his health concern with the family"

ANS: C Self-knowledge is being aware of your religious and cultural beliefs and values. Taking the pulse is an example of practical knowledge. Following client wishes and honoring client requests are examples of ethical knowledge.

Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? a) Bowel Obstruction related to recent abdominal surgery AMB: nausea, vomiting, and abdominal pain b) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight c) Impaired Skin Integrity related to physical immobility AMB skin tear over sacral area d) Caregiver Role Strain related to alienation from family and friends AMB 24-hour care responsibilities

ANS: C The components of NANDA-I nursing diagnosis might include the following four parts: diagnostic label, defining characteristics, related factors, and risk factors. "Impaired Skin Integrity . . ." has the problem statement, etiology, and symptoms. For "Bowel Obstruction . . ." the problem is a medical diagnosis. The cause-and-effect order of "Inability to Ingest Food . . ." is incorrect; it starts with the etiology. The etiology and symptoms (A.M.B.) of "Caregiver Role Strain . . ." are reversed (alienation from family and friends are the symptoms that support the diagnosis).

Which nursing diagnosis is written in the correct format? a) Imbalanced Nutrition: Less than Body Requirements related to body weight less than 20% under ideal weight b) Ineffective Airway Clearance related to increased respiratory rate and irregular rhythm c) Impaired Swallowing related to absent gag reflex d) Excess Fluid Volume related to 3 lb weight gain in 24 hours

ANS: C The etiology should describe what is causing or contributing to the problem. The etiologies for Ineffective Airway Clearance, Impaired Swallowing, and Excess Fluid Volume describe signs or symptoms rather than causal factors.

Which of the following is true for goals/outcomes for collaborative problems? a) They are monitored only by other disciplines. b) They are usually sensitive to nursing interventions. c) They state that a complication will not occur. d) They state only broad performance criteria.

ANS: C The goal for a collaborative problem is always that the complication will not occur. Other disciplines may be involved in helping to prevent the problem, but nurses still monitor for the complication. The outcomes to collaborative problems are not affected by nursing interventions alone. Goals for collaborative problems are specific to the medical condition/treatment.

Which situation is the most conducive to conducting a successful interview of an elderly woman whose husband and two children are in the hospital room visiting and watching television? The woman is alert and oriented. a) Provide enough chairs so the family and you are able to sit facing the client. b) Introduce yourself and ask, "Dear, what name do you prefer to go by?" before asking any further questions. c) After the family leaves, ask the client whether she is comfortable and willing to answer a few questions. d) Ask the client whether you can talk with her while her family is watching the television.

ANS: C The interview should be done when the client is comfortable and there are no distractions. Endearing terms are inappropriate unless the client prefers them. Family members may offer information that may or may not be pertinent, and may distract from the interview. The presence of family members may also inhibit full disclosure of information by the client.

The patient comes to the emergency department complaining of chest pain. What question by the nurse will encourage the patient to provide the most details about the pain? a) "When did your chest pain begin?" b) "On a scale of 0 to 10, what is your pain level?" c) "Would you please tell me more about the pain you are having?" d) "Have you taken any medication for your pain?"

ANS: C The most information is gained by asking the patient to tell the nurse more about the pain. This is an open-ended question and will give the nurse more information about pain. All other questions are closed questions and will only elicit short answers specific to that question. Each question is asked in pain assessment; however, the question that will elicit the most information the one that asks the patient to tell the nurse more.

The nurse enters a room to find the client sitting up in the chair, crying. The nurse best displays a critical-thinking attitude, as well as a caring attitude, by: a) Telling the client that she'll be back to chat after she sees her other clients b) Calling the family to come and sit with the client c) Trying to determine the reasons for the client's crying d) Placing a "do not disturb" sign on the door to protect the client's privacy

ANS: C The nurse should try to find out why the client is crying so that she may intervene appropriately and correctly. Postponing talking with the client does not assist the client nor does it enable the nurse to make an appropriate intervention. Telling the client she'll be back may cause the client to feel that her needs are less important. Calling the family may be helpful to the client once the nurse identifies why the client is crying. However, depending on the reason, the family may not be at all helpful. A "do not disturb" sign, without obtaining more information, may isolate the client. Upon further exploration, the nurse may discover that the client is already feeling alone and that she does not want or need privacy right now.

The nurse receives the following report on four patients on the medical-surgical unit. Which patient will the nurse attend to first? a) Gait unsteady, uses walker, needs 2-person assist with ambulation b) Abdominal wound is draining foul-smelling fluid, incision margins are red, heart rate 100 beats/min c) Blood pressure 90/50 mm Hg, heart rate 40 beats/min, rates chest pain at 8 on a 0 to 10 pain scale d) Verbalizes history of migraine headaches, eyes closed during assessment interview

ANS: C Unstable vital signs with chest pain is of the highest priority because these symptoms may be life threatening. These instabilities must be addressed at once. Although an unsteady gait places a patient at risk for falls, this answer indicates that the patient uses a walker and 2-person assist. The draining wound is infected; however, this can be addressed with medications. Infections do not usually progress rapidly (i.e., as compared with chest pain). The wound symptoms are not immediately life threatening. A patient with a history of migraine headaches is not a priority at this time, although the patient's pain should be relieved as quickly as possible after dealing with the highest priority problem(s).

When conducting the patient interview, which of the following statements by the nurse are appropriate? Select all that apply. a) "You shouldn't be smoking cigarettes; you have already had one heart attack." b) "Why don't you take your blood pressure medications? You need them to keep your blood pressure normal." c) "I can see that you are in pain right now. Would you like your pain medication and then I can complete the interview a little later?" d) "I am going to be completing your interview now. Is this a good time for you?" e) "Have you noticed any changes in your pattern of sleeping?"

ANS: C, D, E Observing that the patient is in pain, offering pain medication, postponing the interview, and asking about sleeping patterns are all appropriate actions when performing the nursing interview. Patients should be comfortable and pain free during the process. Asking the patient about time of interview is appropriate and accommodating. Statements in which nurses give advice or use "why" questions may often offend patients.

How does a nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is: a) Terminology for the client's disease or injury b) A part of the client's medical diagnosis c) The client's presenting signs and symptoms d) A client's response to a health problem

ANS: D A nursing diagnosis is the client's response to actual or potential health problems.

A nursing instructor is guiding nursing students on best practices for interviewing patients. Which of the following comments by a student would indicate the need for further instruction? a) "My patient is a young adult, so I plan to talk to her without her parents in the room." b) "Because my patient is old enough to be my grandfather, I will call him Mr." c) "When reading my patient's health record, I thought of a few questions to ask." d) "When I give my patient his pain medication, I will have time to ask questions."

ANS: D A patient should be comfortable when interviewing. The pain medication should have time to work before the nurse would consider interviewing the patient, so asking questions when giving the medication is not a good idea. It is appropriate to interview patients without family/friends around. In nearly every culture, calling a patient Mr. or Mrs. shows respect and is, therefore, correct. Reading the patient's health record is appropriate preparation for an interview.

Of the following recommended interviewing techniques, which one is the *most* basic? (That is, without the intervention, the others will all be less effective.) a) Beginning with neutral topics b) Individualizing your approach c) Minimizing note taking d) Using active listening

ANS: D All are important techniques, but active listening focuses the attention on the patient and lets her know you are trying to understand her needs. The interviewer is more likely to get the patient to open up. Patients will forgive you for most errors in technique, but if they think you are not listening, that can negatively affect your relationship.

Which of the following describes the difference between a collaborative problem and a medical diagnosis? a) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. b) A collaborative problem is a nursing diagnosis that requires specific orders from a physician; a medical diagnosis directs all nursing care. c) A collaborative problem has the potential to become an actual nursing diagnosis; a medical diagnosis rarely changes. d) A collaborative problem requires intervention by the nurse and physician or other professional; a medical diagnosis requires intervention by a physician.

ANS: D Collaborative problems are physiological complications for which a client may be at risk based on her medical diagnosis, medical treatment, or diagnostic studies. A collaborative problem requires monitoring by the nurse and intervention by a physician. A medical diagnosis requires interventions (medications, treatments) by the physician. Medical diagnoses do not direct all nursing care. Collaborative problems have the potential to become medical, not nursing, diagnoses.

Which client has the greatest need for comprehensive discharge planning? a) A woman who has just given birth to her second child and lives with her husband and 18-month-old daughter b) A man who has been readmitted for exacerbation of his chronic obstructive pulmonary disease c) A 12-year-old boy who had outpatient surgery on his knee and lives with his mother d) A woman who was just diagnosed with renal failure and has started peritoneal dialysis

ANS: D Comprehensive discharge planning should be done for patients who have a newly diagnosed chronic disease (e.g., renal failure) or have complex needs (e.g., peritoneal dialysis). The other patients may require discharge planning, but the planning would not be as comprehensive as it would be for someone with a new diagnosis resulting in a complex treatment regimen.

Which of the following is the best example of a nursing diagnosis statement? a) Pain related to appendicitis b) Fractured left leg related to impaired mobility c) Impaired mobility related to fractured left leg d) Acute pain related to out of bed activities

ANS: D Each of these nursing diagnoses contains a problem and etiology. A problem describes the human response to a health problem and should be written in NANDA-I format. The etiology contains factors that cause or contribute to the problem and should direct nursing interventions. Acute pain is a nursing diagnosis because it is a human response to a health problem. The etiology, out of bed activities, is an example of a contributing factor that the nurse can direct and for which she can make nursing interventions. Pain related to appendicitis is not descriptive of pain nor is appendicitis a nursing etiology; it is a medical diagnosis. Fractured left leg is a medical diagnosis and cannot be used as a nursing diagnosis. Impaired mobility is not appropriate because a medical diagnosis is used in the etiology.

Why is it important to obtain information about nutritional and herbal supplements as well as about complementary and alternative therapies? a) To determine what type of therapies are acceptable to the client b) To identify whether the client has a nutrition deficiency c) To help you to understand cultural and spiritual beliefs d) To identify potential interaction with prescribed medication and therapies

ANS: D Herbs and nutritional supplements can interact with prescription medications, and complementary and alternative treatments can interfere with conventional therapies. Physical assessment and laboratory tests are needed to assess a nutritional deficiency. To identify cultural and spiritual beliefs and well as what therapies are acceptable to the client, you need more than just information about nutritional and herbal supplements.

The certified nursing assistant (CNA) tells the nurse: "I can help you with your assessment." What is the most appropriate response by the nurse? a) "Thank you. I am having a busy day and I can use your help." b) "I'm sorry, but nurses are responsible for all patient assessment." c) "How long have you been a CNA?" d) "If you will obtain the vital signs and place them in the chart then that would be a big help."

ANS: D In making decisions about which parts of an assessment can be delegated to the CNA, the nurse must consider agency policies and the regulations of the state board of nursing. The length of time one has been a CNA does not determine scope of practice or which parts of assessment can be delegated, but the nurse must consider the CNA's competence and the patient's conditions. In most states, the CNA can obtain vital signs and record them in the patient's chart; however, these must first be validated by the nurse.

The nurse administering pain medication every 4 hours is an example of which aspect of patient care? a) Assessment data b) Nursing diagnosis c) Patient outcome d) Nursing intervention

ANS: D Interventions are activities that will help the patient achieve a goal, such as administering pain-relieving medication. An example of assessment data might be: "Patient reports pain is a 5 on a 1 to 10 scale." The nursing diagnosis would be "pain." The nurse might define the patient outcome in this scenario as, "The patient will state the level of pain is less than 4."

Which of the following outcome statements contains the best example of performance criteria? The patient will: a) Turn herself in bed frequently while awake b) Understand how to use crutches by day two c) State that pain is decreased after being medicated d) Eat 75% of each meal without complaint of nausea

ANS: D Performance criteria should be specific and measurable. "75% of each meal" is specific and measurable. "Frequently" is vague. You cannot observe whether someone "understands." "Decreased" is vague; a numerical pain rating would be better.

What is the best description of the Nursing Process? The Nursing Process is: a) A way to create nursing knowledge for use in practice b) A systematic view of a specific phenomenon in nursing c) A linear process for providing nursing care d) A systematic process for the delivery of nursing care

ANS: D The Nursing Process is central to nursing care. It is a systematic problem-solving process that guides all nursing actions. The process does not create knowledge. Knowledge is created through theoretical and practical research. The Nursing Process is not a view of a specific phenomenon. Finally, the Nursing Process is not linear; the steps are reflexive and overlapping.

Which of the following describes the most important use of making a nursing diagnosis? Assume all are true. a) Differentiates the nurse's role from that of the physician b) Identifies a body of knowledge unique to nursing c) Helps nursing develop a more professional image d) Describes the client's needs for nursing care

ANS: D The benefits to nurses and nursing are that nursing diagnoses differentiate the nurse's role, they identify a unique body of nursing knowledge, and some think they help nursing to develop a more professional image. However, the primary goal of nursing is to serve the good of the patient. Therefore, the most important use of a diagnosis is to specifically identify the client's needs for quality nursing care.

When making a diagnosis using NANDA-I, which of the following provides support for the diagnostic label you choose? a) Etiology b) Related factors c) Diagnostic label d) Defining characteristics

ANS: D The defining characteristics are the signs and symptoms that must be present to support any given nursing diagnosis. The etiology and related factors are the causes of or contributing factors to the problem. The diagnostic label is the name NANDA-I has given the problem; it is chosen based on the presence of defining characteristics.

The nurse documents in the progress notes: "Admitted to emergency department accompanied by wife. Patient is alert and oriented, blood pressure is 120/80 mm Hg, and pulse is 80 beats/min. The patient is anxious. He becomes nervous and when asked about his smoking history." Which statement from the nurse's note is the best example of an inference? a) Blood pressure reading 120/80 mm Hg b) Patient is accompanied by wife. c) Patient has a history of smoking. d) The patient is anxious.

ANS: D The inference in this item is that the patient is anxious. The nurse observes that the patient is nervous and shaky. She can document these observations but she cannot infer that these observations mean that the patient has anxiety. Blood pressure and patient accompaniment by wife are objective data. History of smoking is subjective data.

A patient is not feeling well at home and comes to the emergency department to be evaluated. In the initial nursing interview, what is the first question the nurse would ask? a) "Do you live alone?" b) "Are you having any pain?" c) "What is your past medical history?" d) "Why did you come to the hospital today?"

ANS: D The nurse should first ask in the initial interview why the patient is seeking nursing or medical assistance. This broad question will elicit the most information because it is open ended. It is important to ask the patient about pain, medical history, and home situation; however, these questions can all be addressed later on when taking the health history and physical assessment, as the nurse follows the patient's leads.

When should the nurse make systematic observations about a patient? a) When the patient has specific complaints b) With the first assessment of the shift c) Each time the nurse gives medications to the patient d) Each time the nurse interacts with the patient

ANS: D The nurse should make observations about the patient each time she enters the room or interacts with the patient to gain ongoing data about the patient.

Which of the following is an example of data that should be validated? a) The client's weight measures 185 lb at the clinic. b) The client's liver function test results are elevated. c) The client's blood pressure reading is 160/94 mm Hg; he states that is typical for him. d) The client states she eats a low-sodium diet; she reports eating processed food.

ANS: D Validation should be done when the client's statements are inconsistent (processed foods are generally high in sodium). Validation is not necessary for laboratory data when you suspect an error has been made in the results. Personal information that patients might be embarrassed about, such as weight, is best validated with a scale.

A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching? a) "I find it difficult to avoid using phrases like 'the patient tolerated the procedure well.'" b) "It's confusing to have to remember which abbreviations this hospital allows." c) "I need to work on charting assessments and interventions right after they are done." d) "My patient was really quiet and didn't say much, so I charted that he acted depressed."

ANS: D When charting data, chart only what was observed, not what it meant. Inferences should not be made about a patient's behavior during data collection ("he acted depressed"), so that response reflects the student's lack of knowledge and need for teaching. Chart specific data, not vague phrases; the student is acknowledging the importance of this. There are no universally accepted phrases, just agency-approved abbreviations; the student is acknowledging the need to use agency-approved abbreviations. The student is correct that charting should be completed as soon after data collection as possible.

The client's weight is appropriate for his height. His laboratory values and other assessments reflect normal nutritional status. However, he has told the nurse, "I probably eat a little too much red meat. And what is this I hear about needing omega 3 oils in my diet? I don't like to take supplements, and I think I could really improve my nutrition." Which of the following nursing diagnoses should the nurse use? a) Balanced Nutrition b) Possible Imbalanced Nutrition: Less Than Body Requirements c) Risk for Imbalanced Nutrition: Less Than Body Requirements d) Readiness for Enhanced Nutrition

ANS: D You will use a wellness diagnosis when a person's present level of wellness is effective, and when the person wants to move to a higher level of wellness—in this case, a higher level of nutrition. The format for a wellness diagnosis is "Readiness for Enhanced. . . ." Use a possible diagnosis when you have enough data to suspect a problem but need more data to support a diagnosis. Use a risk diagnosis when there are risk factors for a problem.