Foundations of Nursing Exam 1

After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which client information as objective data?

Auscultation of the lungs

The primary purpose of nursing implementation is to help the client achieve optimal levels of health

True

Subjective data are also known as signs and are observable, perceptible, and measurable.

False

The nurse-patient relationship can be thought of in terms of three phases: orientation, evaluation, and termination.

False

During assessment, a 27-year-old patient tells the nurse, "Dying is better than constantly seeing the scar on my face." Which statement made by the nurse conveys empathy?

"How long have you been feeling this way?"

The circle of confidentiality is essential in maintaining sensitive information among appropriate professionals. A nurse overhears a conversation about an unknown patient's care in the elevator. The best immediate response would be:

"I'm concerned to hear discussions like this in nonprivate areas; let's be mindful of patient privacy"

The nurse is talking with a client who is thinking about obtaining a second opinion regarding the surgeon's recommendation for surgery. Which response by the nurse is considered an advocacy response?

"Let us know if we can answer any further questions after you obtain your second opinion."

Non-therapeutic communication may interfere with professional nursing care by hindering the patient-nurse relationship. Which of the following are examples of non-therapeutic communication? Select all that apply:

A nurse is sending a pediatric patient for cardiac surgery. As he leaves, she states "Don't worry, everything will be fine!" A nurse attempts to distract a patient at the end of their life: "Let's focus on your walking for the day, not your worries about death." A nurse provides education on smoking cessation: "The same thing happened to me and I was able to quit." A nurse states during report that "the patient should not get an abortion because it is wrong."

What are the two priority nursing diagnoses? Select all that apply.

Acute pain Ineffective airway clearance

__________ supports the patient's right to the information necessary to make his or her own decisions about treatment options and nursing care.

Advocacy

What would be a nursing priority when assessing a client who weighs 250 lbs and stands 5 feet, 3 inches tall?

Assess blood pressure with a large cuff

Based on the work of Marjory Gordon and the nursing process, which component is associated with problem identification?

Assessment

A patient's sister expresses her dissatisfaction to the nurse regarding the discharge care coordination between the physician and cardiology team. In order to practice patient advocacy, what should the nurse do first?

Assist the patient's sister in compiling a list of questions related to discharge.

The nurse is assessing the client's self-care capabilities for after discharge from the hospital. Which barrier greatly contributes to the nursing goals being unmet? Select all that apply.

Family's lack of interest in the plan of care Inadequate emotional coping skills Debilitating illness Poor communication skills

An element in the communication process is the communication __________, which is the medium or carrier of the message.

Channel

A person __________ by gestures, facial expressions, posture, space, appearance, body movement, touch, voice tone and volume, and rate of speech.

Communicates

What ensures continuity of care?

Communication

When there is a "good fit" among verbal communication, nonverbal communication, and metacommunication, this is known as a __________ relationship.

Congruent

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?

Focused

Which of the following is classified as a nursing diagnosis?

Grieving

Communication is the:

Heart of nursing

Which would be considered examples of subjective data? Select all that apply.

Description of a symptom by a client. Comments made by the client's family. A mother telling a nurse what the baby looked like when he or she was very ill.

A client had surgery 3 weeks ago, and now the nurse notes that the client has partial healing of the surgical wound. This assessment would occur in which phase of the nursing process?

Evaluation

A goal of therapeutic communication is that patients will totally comply with the therapeutic routine that nurses have planned for them.

False

In the nurse-patient relationship, the nurse's experiences, problems, and issues are the main subject of communication.

False

The nurse changes a client's surgical dressing daily. This is considered to be part of which phase of the nursing process?

Implementation

When the nurse is administering furosemide 20 mg to a client with heart failure, what phase of the nursing process does this represent?

Implementation

The nurse observes the client while walking into the room. What information will this provide the nurse?

Information regarding the client's gait

In order for a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

Initial

__________, culture, and experiences are crucial to the process of communication.

Language

How can a nurse obtain additional information about a client?

Read the client's history and assessment

In communicating with a developmentally delayed adult patient, which of the following would be the best techniques for the nurse to use?

Setting clear limits while allowing participation

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

Subjective

An unconscious client is brought to the emergency department. Which assessment should be implemented first?

The client's airway should be assessed

When the nurse communicates with a newly admitted client, the nurse must pay particular attention to nonverbal behaviors. The nurse considers which characteristic as nonverbal communication?

The client's tone of voice

Which nursing action reflects evaluation?

The nurse assesses the client's response to pain medication

During the interview component of the health assessment, sitting at eye level with the client is the best way for the nurse convey to the client that the information is important.

True

The following is an example of objective data: A client's temperature

True

Which nurse-patient interaction is an example of a nonverbal communication?

The nurse is assessing a patient in pain who is grimacing.

The 32-year-old client in a mental health unit discusses his personal thoughts and feelings with the nurse. The nurse is maintaining the circle of confidentiality by reporting this information to which individuals? Select all that apply.

The unit's mental health technicians, The client's physician, The nurse from the oncoming shift (NOT the closest friend or family)

In order to provide effective nursing care, the nurse should engage in what type of communication with the client and significant others?

Therapeutic communication

What is the primary goal of the planning phase of the nursing process?

To prepare a plan of care

A priority problem requires a nursing intervention before another problem is addressed.

True

An accurate nursing history assists in comparing a patient's past and present health status, lifestyle behaviors, and coping abilities.

True

Before conducting a health assessment on a client, the nurse should introduce him- or herself to the client

True

Communication is a continuous, dynamic, ongoing, and ever-changing operation.

True

A previously healthy and active 31-year-old patient with a radical mastectomy snaps at the nurse and asks her to leave her alone. In analyzing this, the nurse is able to attribute the behavior to:

Vulnerability of illness

The phase of the nursing process when the nurse gathers data about the client to establish a plan of care is the:

assessment

In the provision of care and the establishment of the therapeutic relationship, the nurse must first:

be aware of one's own personality

When the nurse prepares to discharge a client, and subsequently evaluates the effectiveness of the nursing care, the nurse should determine whether the:

client's goals have been achieved

A nurse is asking questions about a client's sexual history. It is important for the nurse to:

collect data in a quiet, private environment

When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is:

conveying information

Nursing actions should be:

goal-directed

The purpose of obtaining a nursing history is to:

identify actual and potential nursing diagnoses

When communicating with clients, nurses need to be very careful in their approach. This is particularly true when communicating using:

medical terminology

During an annual performance review with an employee, the nurse manager does not maintain eye contact and seems concerned about the time and the next appointment. This use of communication is considered:

nonverbal

The nurse is assessing the client's behavioral response to a nursing intervention. This type of evaluation is known as:

outcome evaluation

The nurse writes the following on the client's chart: The client will show complete healing of the surgical incision on the right lower quadrant of the abdomen in 3 weeks. This is a(an):

outcome identification

The term nursing process is synonymous with the:

problem-solving approach

After the nurse has formulated expected outcomes, the next step of the nursing process is to:

write the plan of care