Chapter 5

A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following?

A referral EXPLAINATION Referring is the process of sending or guiding the patient to another source for assistance. Consultation is the process of inviting another professional to evaluate the patient and make recommendations to you about his or her treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of patient data to others.

A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?

Details are often missing EXPLAINATION CBE may pose legal problems, because details are often missing. CBE does not omit subjective assessment, CBE is an ethical form of charting, and the question does not indicate that the assessment skills of the nurse are lacking in any form.

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?

Diagnostic reasoning skills are required to interpret data accurately. EXPLAINATION As the second step or phase of the nursing process, data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately.

The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?

Focused EXPLAINATION The nurse performed a focused assessment to quickly assess for anticipated problems related to the medical diagnosis. This client underwent gastrointestinal surgery; therefore a focused abdominal assessment is warranted. A head to toe assessment is a type of comprehensive physical assessment. A comprehensive assessment is performed on admission and includes physical data, history, and psychosocial data. The shift assessment is performed at the beginning of each shift and includes an abbreviated exam of the client such as auscultation of heart and lungs and abdomen, assessment of circulation, and level of consciousness.

Essential characteristics for the development of critical thinking skills include all the following except:

Following instructions EXPLAINATION An open mind, recognition of evidence, and reflection on past experience all contribute to critical thinking, while following instructions does not.

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?

Make a referral to the dietician. EXPLAINATION Referring can be defined as connecting clients with other professionals and resources. This client would receive the greatest benefit from the professional that is able to give them the education required to manage their disease process.

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight. EXPLAINATION It is important to begin the assessment with less intrusive procedures such as vital signs and height and weight. These nonthreatening/nonintrusive procedures allow the client to feel more comfortable with the nurse and ease anxiety. Once a trusting relationship is established, the nurse can proceed in a systematic approach to ensure that all body systems are fully examined. Auscultation of all body systems is not an acceptable approach to a comprehensive assessment. The initial assessment data can be collected while the client is still dressed.

A hospitalized client reports pain 10/10 one hour after receiving a dose of intravenous morphine sulfate. The next dose is not due for over an hour. What is the nurse's best action?

Notify the healthcare provider. EXPLAINATION Uncontrolled pain, especially after narcotic administration, requires urgent reassessment and intervention. Without an order to administer other pain medication, the nurse must notify the healthcare provider. Administering another dose of morphine outside current orders is outside the RN's scope of practice. The client may have another problem occurring that needs to be investigated and should not just be told that additional pain medication is not an option. For example, the client could be suffering from compartment syndrome, a complication compromising circulation and characterized by pain not relieved by pain medication.

The nursing student demonstrates a need for further teaching when she states which of the following?

Patients do not need to understand their problems. EXAPLAINATION: It is esential for the patient to understand the problem so that treatment can be properly implemented. If the patient is not coherent, it is proper to consult with the family or significant other or even other health care workers. Validation is also important with the patient who has a collaborative problem or who requires a referral.

The nursing student demonstrates a need for further teaching when she states which of the following?

Patients do not need to understand their problems. EXPLAINATION It is essential for the client to understand the problem so that treatment can be properly implemented. If the client is not coherent, it is proper to consult with the family or significant other or even other health care workers. Validation is also important with the client who has a collaborative problem or who requires a referral.

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?

Reassess blood pressure EXPLAINATION The nurse can delegate the monitoring and documenting of specific assessments to UAPs; but the nurse always retain the responsibility to interpret delegated assessment data to evaluate the patient's condition. The nurse should retake the blood pressure immediately as it is abnormally low for this patient. Having the UAP retake the blood pressure does not allow the nurse to evaluate the client or assess the accuracy of the UAP's ability to take a blood pressure. The physician should not be notified until the blood presser has been reassessed.

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?

SBAR EXPLAINATION Verbal communication of a change in a client's condition would be most effective if the nurse used SBAR as it provides a standardized format and structure for communication. PIE, DAR and SOAP are all types of progress notes.

A nurse is teaching a patient newly diagnosed with diabetes about diet and the exchange list. After several teaching sessions, the patient continues to be confused and not sure about what to eat. The nurse's next best action is which of the following?

Schedule a dietary consult. EXPLAINATION Although the nurse has knowledge of diabetes and diet, a referral to a dietitian can provide the patient with updated materials and allow the nurse more time to deal with problems within the nursing domain. Getting another nurse will not help. Neither will not doing anything. Asking why the patient does not understand would put the patient on the defensive and may be insulting.

Subjective and objective data are both important parts of an assessment. Subjective data are things the patient or his or her family tells the nurse.

TRUE

A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.

The client's occupation The client's family history of cancer The client's weight-lifting routine EXPLAINATION Subjective data include information that the client or significant others tell the nurse and typically consist of biographic data, present health concern(s) and symptoms, personal health history, family history, and lifestyle and health practices information. Objective data are what the nurse observes through inspection, palpation, percussion, or auscultation.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath. EXPLAINATION Inspection involves conscious observation of the patient's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the patient's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

Which of the following statements is true of nursing diagnoses?

They focus on the responses of clients to health problems and events. EXPLAINATION A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems and life processes. They are not solely psychologically based, nor are they necessarily less specific than medical diagnoses. They are based on both subjective and objective data.

Which assessment finding on a hospitalized adult client requires urgent intervention?

Urine output of 100 mL in 8 hours EXPLAINATION An acute change in urine output less than 50 mL (about 1-3/4 oz) over 4 hours requires urgent intervention. Some weakness is expected after a stroke. +2 pulses are normal. An oxygen saturation of 95% is not a great cause for concern in an adult.

The nurse is preparing to document assessment findings in a client's record. The nurse should

avoid slang terms or labels unless they are direct quotes. EXPLAINATION Use correct grammar and spelling. Use only abbreviations that are acceptable and approved by the institution. Avoid slang, jargon, or labels unless they are direct quotes.

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?

create a genogram EXPLAINATION A genogram is a diagram of the family history. It provides a visual record that allows the provider to quickly identify disease patterns within the family. The family history does not need to be documented in a narrative note. This information is not part of the client's past medical history. It is not typically used when planning care.

A nursing student demonstrates understanding of the different types of nursing diagnoses when choosing which of the following to be an actual diagnosis?

impaired skin integrity EXPLAINATION Risk for impaired skin integrity and risk for infection are both "risk for" diagnoses, while readiness for enhanced skin integrity is a wellness diagnosis. The only actual diagnosis is impaired skin integrity.

Light palpation is most appropriate to assess the

inflamed areas of skin EXPLAINATION Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an intravenous site).

Before the nurse analyzes the data collected, the nurse should

perform the steps of the assessment process accurately. EXPLAINATION Before analyzing data, the steps of the assessment phase of the nursing process (collection and organization of assessment data, validation of data, and documentation of data) should be accurately performed.

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?

use as a drape EXPLAINATION During the examination, one body part should be exposed at a time. The sheet serves as a drape to keep the other body parts covered. The sheet is not used to pad the table, collect body fluids, or to be a head support.

The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor?

"A way of processing information using to formulate conclusions or diagnoses." EXPLAINATION Critical thinking is the way in which the nurse processes information using knowledge, past experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses.

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a patient who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered?

Actual Nursing Diagnosis EXPLAINATION This patient is having an actual problem--pain--which therefore would be classified as an actual nursing diagnosis and provides a description of the problem that the patient is currently having.

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data?

Anxious appearance EXPLAINATION Based on the data gathered from the client, the nurse can classify the anxious appearance of the client as an objective abnormal finding. Complaints of hair loss and having an itching sensation are information provided by the client, and worrying about her appearance is an inference the nurse is making; all of these are subjective abnormal findings.

What is the primary purpose of the patient record?

Communication EXPLAINATION The primary purpose of the patient record is to help healthcare professionals from different disciplines communicate with one another.

A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?

Critical thinking EXPLAINATION Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems. Diagnostic reasoning is important in developing diagnostic statements, not in caring for multiple clients with complex care needs. Physical assessment is important in the building the foundation of the nursing care plan. The nursing care plan directs the care that will be provided for the individual client, but does not address the needs of caring for multiple clients.

Which of the following is an example of a recent trend in nursing roles?

Gathering forensic evidence for a legal proceeding EXPLAINATION Forensic nursing is an example of one of the rapidly evolving roles of nursing that requires extensive focused assessments and the development of related nursing diagnoses. Auscultation, palpation, and inspection are all techniques that have been used by nurses for over 100 years.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?

It provides quick access to abnormal findings. EXPLAINATION Charting by exception provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?

Medication reconciliation EXPLAINATION Medication reconciliation is a preventive measure to ensure the continuity of care for a client and the continuation of medications taken at home that are necessary for the client's well being. SBAR is a communication tool to ensure appropriate information is given to the healthcare provider to care for the client. High-alert labeling is utilized to identify many sound alike medications. The teaching of side effects is crucial to informed care, yet is not the most likely cause of omission of medication from home.

When formulating a nursing diagnosis, the format that is most useful to clearly document the client's problem is

NANDA label (for problem) + related to + etiology + AMB (as manifested by) + defining characteristics. EXPLAINATION The most useful format for an actual nursing diagnosis is: NANDA label (for problem) + related to (r/t) + etiology + as manifested by (AMB) + defining characteristics.

A client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse?

Place on cardiac monitor. EXPLAINATION The nurse should prioritize care and address physiological, urgent needs first. The client should be placed on the cardiac monitor. The health history and medication use data can be collected while the client is being monitored. The nurse should ask the client about any allergies first as the client may be allergic to certain stickers used for cardiac monitoring. However, any allergies can be recorded after place on continous monitoring.

Which of the following events during the assessment process most indicates a need for validation?

The client denies feeling upset or anxious about her recent cancer diagnosis but fidgets throughout the interview and assessment. EXPLAINATION A client who denies anxiety, yet appears upset, indicates an incongruity between subjective and objective data and would require validation. The other answers do not indicate inconsistencies or incongruities in findings that would require particular validation.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax. EXPLAINATION The nurse uses the technique of percussion to produce sounds over various parts of the body. The nurse detects resonance over the lungs by percussing the thorax. Inspection involves smelling for odors and conscious observation of the patient's physical characteristics and behaviors, such as noting symmetry of the thorax. The nurse uses palpation to detect crepitus over the thorax by the use of touch. Auscultation is used by the nurse to assess lung sounds, such as rustling.

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

To establish a database against which subsequent assessments can be measured EXPLAINATION A health assessment is performed to gain further insight into the current condition and to establish a database that subsequent assessments can be measured against.

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.)

Use rationale to support opinions or decisions. Be nonjudgmental and keep an open mind. Acquire an adequate knowledge base that continues to build. EXPLAINATION: The essential elements of critical thinking are: Keep an open mind, use rationale to support opinions or decisions, reflect on thoughts before reaching a conclusion, use past clinical experiences to build knowledge, acquire an adequate knowledge base that continues to build, be aware of the interactions of others, and be aware of the environment.

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions?

Uses evidence-based techniques EXPLAINATION To accomplish pertinent and comprehensive data collection the nurse uses appropriate evidence-based assessment techniques and instruments when collecting data. The ABC approach may not be necessary. Although measure vital signs can be delegated to unlicensed staff, this does not ensure that the data will guide the identification of appropriate interventions. Focusing on one system may be appropriate in specific situations however the admission assessment should include all body systems

The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to

discuss the plan with the patient EXPLAINATION Sharing the assessment and plan with the patient will allow the patient to offer his or her opinion, concerns, and willingness to proceed with the interventions. This makes the patient an active participant in his or her plan of care.

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should

explain the role and purpose of the nurse. EXPLAINATION When interacting with an anxious client provide the client with simple, organized information in a structured format and explain who you are, along with your role and purpose.

A nurse is working with a patient who has a history of chronic obstructive pulmonary disease (COPD). While bathing the patient, the nurse senses that something is not quite right and takes the patient's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following?

intuition EXPLAINATION The nurse is acting on intuition, in this case, the feeling that something is not quite right. Scientific rationale is an explanation based on science. Knowledge is based on science and theories that the nurse learned in school. Prior history of the patient is not what the nurse is acting upon in this case.

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information?

past medical history EXPLAINATION An adult medical illness is documented as part of the past medical history. Health patterns identify the client's personal/social history and daily living routines that may influence health and illness. The review of systems focuses on the presence or absence of common symptoms related to each major body system. Health maintenance is a part of the past medical history and identifies actions taken to improve or maintain health.

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion. EXPLAINATION Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations enable the examiner to assess underlying structures.

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status. EXPLAINATION The physician performing a medical assessment focuses primarily on the client's physiologic status. Less focus may be placed on psychological, sociocultural, or spiritual well-being.

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.

seeing things as only right or wrong EXPLAINATION: Developing expertise with making professional judgments comes with accumulation of both knowledge and experience. It is a process that develops over time and with practice. Seeing things as only right or wrong does not allow for seeing things as gray and may make you miss the bigger picture.

When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying?

the rapport that exists between the nurse and the client EXPLAINATION The amount of success that nurse has in discovering the reason behind the client's crying is heavily dependent upon the relationship (rapport) that exists between the nurse and the client. It is this mutual respect and trust that allows the nurse to enter into conversations that would otherwise be off limits. The remaining options have the potential to affect the conversation, but the conversation will not likely occur without the presence of an effective nurse-client relationship.

One characteristic of a nurse who is a critical thinker is the ability to

validate information and judgments. EXPLAINATION: One characteristic of a critical thinker is the ability to validate information and judgments with experts in the field.

A nursing student is explaining to a roommate the relationship between diagnostic reasoning and critical thinking. Which of the following is the correct statement for the nursing student to make?

"Diagnostic reasoning is a form of critical thinking used to interpret data correctly." EXPLAINATION As the second step or phase of the nursing process, data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately. Diagnostic reasoning is a form of critical thinking.

During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?

"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." EXPLAINATION Documentation should be as objective and precise as possible. Answers A and B attribute the client's behavior to being agitated and upset, both of which are terms lacking in precision and objectivity. Answer D is more objective, but answer C provides the most detailed, objective account of what transpired.

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response?

"It's acceptable for a client to be admitted for observation." EXPLAINATION Assessment is one of the primary reasons a client is hospitalized. It is not uncommon that a client is hospitalized entirely for observation. The healthcare provider does not need to change the diagnosis. Telling the client that insurance will not pay for observation is not a true statement for all insurance companies.

A nurse is gathering biographic data from a new client who is visiting the office for the first time. Which of the following pieces of data would likely be included in the biographic section of the client's health history? Select all that apply.

1212 South Maple St., Sylvan, VA 23236 Caucasian Lamar P. Thompson EXPLAINATION Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client's birth date, Social Security Number, medical record number, or similar identifying data may be included in the biographic data section. The client's culture, ethnicity, and subculture may begin to be determined by collecting data about date and place of birth; nationality or ethnicity; marital status; religious or spiritual practices; and primary and secondary languages spoken, written, and read. Gathering information about the client's educational level, occupation, and working status at this point in the health history assists the examiner to tailor questions to the client's level of understanding. The information regarding the client's mother, including the date and cause of death, would appear in the family health history section. The information on the head and neck would appear in the review of systems section.

A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this?

Active listening EXPLAINATION Active listening is the ability to focus on the client and their perspectives. It requires the nurse to constantly decode messages including thoughts, words, opinions, and emotions. For example, if a client is sad, it is appropriate for a nurse to place a hand over the client's and to show a facial expression of compassion. The purpose of restatement is to have the client elaborate on what was originally stated by the client. Reflection uses summarizing by the nurse to find the true meaning of a client's words. Encouraging elaboration encourages the client to explain or go into more detail in the client's responses.

The nurse notes that a client has a 2 cm x 5 cm area of redness over the left greater trochanter. Which category should the nurse use when creating the nursing diagnosis for this finding?

Actual EXPLAINATION: An actual nursing diagnosis indicates that the client is currently experiencing the problem such as a reddened area. A risk diagnosis indicates the client does not currently have the problem but is at high risk for developing it. A syndrome diagnosis is used when a cluster of nursing diagnoses is related in a way that they occur together. A health promotion diagnosis indicates that the client has the motivation to increase well-being and enhance health behaviors.

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan?

Ask the client for opinions and willingness to proceed with the interventions. EXPLAINATION The plan of care should be agreeable to the patient. Before finalizing the plan, it is important for the nurse to share the information with the patient and seek out opinions and willingness to proceed with the interventions. Although discussing the plan of care with the all health care providers involved, involving the client in the process is the only way to know if the goals are realistic for his unique needs. Sharing the assessment and plan of care with the client's primary health care provider will only be necessary once the client has voiced his opinion and willingness to proceed with the interventions. The client's family should be involved in the plan of care and likely serve to make it more effective. The client must agree first and demonstrate willingness prior to discussing it with the family.

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key EXPLAINATION The nurse needs a coin or a key to test the client for stereognosis, which is the ability to recognize objects by touch. A reflex hammer is used to determine deep tendon reflexes. A tuning fork is used to test for vibratory sensation. A tongue depressor is used to test for the rise of the uvula and gag reflex.

What can the nurse use to learn new information and add to their knowledge base?

Clinical experience. EXPLAINATION The critical thinker uses each clinical experience to learn new information and to add to the knowledge base. Another important aspect of critical thinking involves awareness of human interactions and the environment, which provides cues and directly influence decisions and judgments.

What is pivotal to determining how to move from each client problem to its goals?

Clinical reasoning process EXPLAINATION Clinical reasoning process is pivotal to determining how the nurse interprets the client's history and physical examination, single out the problems listed in assessment, and move from each problem to its goals and then the implementation with specific nursing interventions.

Which step in the diagnostic reasoning process does the nurse look at the identified abnormal findings and strengths for cues that are related?

Cluster Data EXPLAINATION During the second step of the diagnostic reasoning process, the nurse looks at the identified abnormal findings and strengths for cues that are related. Cluster both abnormal cues and strength cues; a particular nursing framework should be used as a guide when possible.

A nurse is busy analyzing data collected for an elderly Indian client with Alzheimer's disease who is in the hospital for pneumonia. The nurse originally had "demonstrates dementia" and "does not respond when spoken to" grouped together as symptoms of Alzheimer's. Later, however, the nurse learned that the client is also hearing impaired, which better explains the fact that the client does not respond when spoken to. Which error did the nurse commit in this case?

Clustering together unrelated cues EXPLAINATION This case involves the nurse clustering together cues that are actually unrelated (hearing impairment and dementia). The other errors listed do not apply to this case, as the nurse has not yet formulated a diagnostic statement or diagnosed the client, and the client's cultural background is not relevant.

A patient has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the patient's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered?

Collaborative problem EXPLAINATION Collaborative problems are defined as "certain physiological complications that nurses monitor to detect their onset or changes in status; nurse manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize the complication of events

A patient has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the patient's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered?

Collaborative problem EXPLAINATION: Collaborative problems are defined as "certain physiological complications that nurses monitor to detect their onset or changes in status; nurse manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize the complication of events.

During the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. Which of the following demonstrates the most appropriate documentation of these findings?

Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye. EXPLAINATION Documentation needs to be clear and specific. Documentation should describe and provide a location of the areas. Documentation should not include any assumptions or judgements.

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface EXPLAINATION The dorsal (back) surface of the hand is the part most sensitive to temperature and thus is the correct part to use when palpating for temperature. The fingerpads are for fine discriminations, such as for palpating for pulses, texture, size, consistency, shape, and crepitus. The ulnar or palmar surface is used to palpate for vibrations, thrills, and fremitus.

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case?

Overlooking consideration of the clients cultural background EXPLAINATION The nurse erred in this case by interpreting the lack of eye contact on the part of the client as an unwillingness to listen to recommendations. In some cultures, including Japanese, eye contact is not considered appropriate in certain social situations. The other errors listed do not apply in this case, as the nurse did not cluster together unrelated cues, diagnose the client without hypothesizing several diagnoses, or incorrectly word a diagnostic statement.

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes EXPLAINATION In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?

Resonance EXPLAINATION Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields. Hyper-resonance is a very loud, low-pitched sound that is normally heard in lungs with a lot of air such as in emphysema. Tympany is a very loud, high-pitched, drumlike sound that is heard over an air-filled structure, such as the stomach. Dullness is a medium-pitched, thudlike sound that is percussed over solid tissue such as the liver.

A nurse assesses an older adult client with confusion. When collecting clinical information from the client, which factor is the most important for the nurse to consider?

The quality of the data may be low. EXPLAINATION Due to client confusion, the quality of the data obtained directly from the client will likely be low. In order to ensure the quality of the client data, the nurse will need to confer with colleagues and client family members. In addition, the nurse should review the client history and pertinent literature to clarify uncertainties. The incorrect options may be likely; however, they are not possible if the nurse is unable to obtain reliable assessment data.

To make a legal entry into the medical record, the nurse must document what?

Time of the assessment EXPLAINATION The nurse must record normal assessment data, abnormal assessment data, and the time of the assessment. The nurse does not have to document laboratory tests ordered, the attending physician, or the nature of the assessment.

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client?

Weight gain of 3 pounds (1.5 kilograms) over 1-2 days EXPLAINATION Nursing diagnoses are based on alterations in body system processes, lifestyle, personal issues, and specific causes. For the client with heart failure, the problem that would have the highest priority would be the weight gain of 3 pounds (1.5 kilograms) over 1-2 days. This change can related to a decline in cardiac functioning and needs to be addressed first. Once this priority problem has been investigated, other problems can be addressed. Ineffective health maintenance can be addressed last. Knowledge deficit related to lack of information regarding low-sodium diet would be the next in priority after activity intolerance because learning how to reduce sodium could help control the heart failure. Anxiety about hospitalization and inability to attend to home and work needs would be addressed after the knowledge deficit.

The nurse is working with a 14-year-old girl who has told the nurse that she would like to try getting to bed a little sooner to get a full night's sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to client's expressed desire to go to bed earlier. Which type of nursing diagnosis is this?

Wellness EXPLAINATION Health promotion diagnoses represent those situations in which the client does not have a problem but is at a point at which a higher level of health can be attained. In other words, this client has the desire to increase her well-being and actualize her human potential. This type of diagnosis is often worded readiness for enhanced. It indicates an opportunity to make greater, to increase quality of, or to attain the most desired level of function in the area of the diagnostic category. The other answers clearly do not describe this diagnosis.

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?

health maintenance EXPLAINATION Health maintenance includes any preventative diagnostics or health-promoting activities the client completed in the past. This is a subsection of the past history in the health assessment. The physical examination and review of systems capture the objective data that arises from the health assessment conducted by the nurse. Personal and social history capture client lifestyle factors such as family, employment, and habits.

The nurse is reviewing the laboratory report for a client with poorly controlled diabetes. This action falls within which step of clinical reasoning?

identifying abnormal or positive findings EXPLAINATION Laboratory reports provide objective information about potential client problems. This falls within identifying abnormal or positive findings step of clinical reasoning. In order to make a hypothesis about the nature of the client's problem, the nurse will need more information to cluster the findings first and then interpret the findings in terms of probable process.

A patient who is 2 days postoperative reports pain and requests pain medication. After assessing the patient's pain level, the nurse decides to give the patient oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?

implementation EXPLAINATION This step is implementation, because the nurse is taking appropriate action by giving oral medication. Assessment is the first step of the nursing process when the nurse collects data. Diagnosis is determining the problem. Evaluation is the final step to see if patient has achieved established goals.

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have

knowledge of his or her own thoughts and feelings about these issues. EXPLAINATION Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client's health and may need to be discussed with someone.

One advantage for an institution to use an integrated cued/checklist type of assessment data form is that it

may be easily used by different levels of caregivers, which enhances communication. EXPLAINATION Integrated cued checklist promotes use by different levels of caregivers, resulting in enhanced communication among the disciplines.

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?

nursing diagnosis EXPLAINATION: Data analysis is referred to as the diagnostic phase of the nursing process because the end result is the identification of a nursing diagnosis. A nursing intervention is done during the implementation phase, nursing rationale is identified when choosing the interventions, and data organization must be done during the collection of the data while still in the assessment phase.

The nurse is developing goals after completing the assessment of a newly admitted medical patient. The nurse would document the goals under which part of the nursing process?

planning EXPLAINATION Goal setting and interventions are part of the planning section of the nursing process.

A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to

quickly make a diagnosis without hypothesizing several diagnoses. EXPLAINATION A beginning nurse attempts to make accurate diagnoses but, because of a lack of knowledge and experience, often finds that he or she has made diagnostic errors.

To adhere to standard precautions, the nurse should remember to (Select all that apply.)

wash hands before and after client contact change white coat frequently EXPLAINATION