Module 36A Ques

The nurse is explaining how to develop an appropriate nursing diagnosis. Which participant statement indicates an appropriate understanding? "A nursing diagnosis is based on clinical judgment that is derived from assessment data." "A nursing diagnosis is developed after the nurse evaluates the interventions provided." "A nursing diagnosis is determined by the medical diagnosis and current patient needs." "A nursing diagnosis is derived after the nurse develops the plan of care for the patient."

"A nursing diagnosis is based on clinical judgment that is derived from assessment data."

The nurse is presenting how to differentiate between patient goals and outcomes. Which statement by the nurse is accurate? "Goals evaluate the patient's response to the plan of care developed by the nurse." "Goals include the subjective and objective data observed by the nurse." "Goals are patient responses, whereas outcomes are the patient's response to care." "Goals are established by the nurse and used to evaluate patient outcomes."

"Goals are patient responses, whereas outcomes are the patient's response to care."

The nurse is caring for a patient who is diagnosed with diabetes mellitus. Which evaluation statement should indicate that the plan of care is working? 04/03/2018: Goal unmet: Patient demonstrates use of insulin injection successfully. 04/03/2018, 1830: Goal partially met: Patient demonstrates use of home oxygen machine. 04/03/2018, 1800: Goal partially met: Patient is able to identify three foods instead of five foods high in sugar content. 04/03/2018, 1750: Goal met: Patient voices understanding of treatment therapy.

04/03/2018, 1800: Goal partially met: Patient is able to identify three foods instead of five foods high in sugar content.

The nurse is preparing to discharge a patient after a hospital stay. Which task should the nurse perform to determine if goals have been met? Collect data to provide discharge instructions to follow when at home. Collect data related to the goal and make decisions about nursing care effectiveness. Collect data to develop new nursing diagnoses for the home health nurse to follow. Collect data related to patient-specific outcomes for accrediting bodies.

Collect data related to the goal and make decisions about nursing care effectiveness.

The nurse has developed a plan of care for a patient with a specific goal. The patient was unable to meet the goal by the stated time frame. Before revising the goal, which step must the nurse perform? Compare patient progress with that of other patients. Document noncompliance with the plan. Ask the healthcare provider for a more reasonable goal. Evaluate factors impeding goal attainment.

Evaluate factors impeding goal attainment.

The nurse evaluates the plan of care for a patient admitted with pneumonia who still has difficulty breathing related to an ineffective breathing pattern. Which step should the nurse include to select new interventions for the plan of care? Setting more realistic patient goals and easier interventions Deleting the current nursing diagnosis because it was not meeting the patient's needs Delegating the selection of the new interventions to another nurse Evaluating the current interventions and patient needs

Evaluating the current interventions and patient needs

Which statement describes the evaluation phase of the nursing process? Evaluation is determined based on gathering subjective and objective data. Evaluation focuses on determining changes and preventing complications. Evaluation is performed throughout all phases of the nursing process. Evaluation is performed only after nursing interventions are performed.

Evaluation is performed throughout all phases of the nursing process.

The nurse is caring for a patient with schizophrenia. The patient is at risk for disturbed thought process. Which nursing intervention could the nurse implement without an order from the healthcare provider? Explaining that the nurse does not hear the voices Placing the client in a seclusion room for a time-out Complying with taking all medications as prescribed Referring the patient to an outpatient program on discharge

Explaining that the nurse does not hear the voices

The nurse determines the following nursing diagnosis for a patient: Impaired Urinary Elimination related to retention secondary to enlarged prostate. Which portion represents Axis 3 in the nursing diagnosis? Retention Enlarged prostate Urinary Impaired

Impaired

A patient who is recovering from a motor vehicle crash has been ordered complete bedrest for 3 months. The patient presents with skin breakdown. Which nursing diagnosis statement is correct? Impaired Skin Integrity related to time in bed Impaired Skin Integrity related to immobility Impaired Skin Integrity related to motor vehicle crash Impaired Skin Integrity related to skin breakdown

Impaired Skin Integrity related to immobility

The nurse is caring for a newly admitted patient. Which skills should the nurse use to build rapport and trust with the patient? Interpersonal Technical Multidisciplinary Cognitive

Interpersonal

The nurse is supervising an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP? Evaluating color of urine Measuring intake and output Determining a patient's hydration status Analyzing urine test results

Measuring intake and output

The nurse is examining the following nursing diagnosis statement: Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to diabetes. The use of "secondary to" in this diagnosis reflects which component? Subjective data obtained Primary identifiable nursing problem Axis 2 of the nursing diagnosis Pathophysiological disease process

Pathophysiological disease process

The nurse is developing a plan of care for a patient admitted to the hospital for pneumonia. Which phase of the nursing process will the nurse use to develop interventions? Assessment Nursing diagnosis Implementation Planning

Planning

The nurse is implementing care for patients in an acute care facility and asks a patient about dietary restrictions related to religion or ethnicity. Which nursing goal is the nurse meeting with this question? Promote contentment in the patient. Provide culturally competent care. Follow prescribed dietary needs. Determine need for special services.

Provide culturally competent care.

The nurse is developing a plan of care for a patient with the nursing diagnosis Impaired Physical Mobility related to inactivity secondary to arthritis. The nurse and patient develop a goal of ambulating the hall three times a day with a wheeled walker. Which purpose should this goal help achieve? Provide direction for nursing interventions. Measure the end result of nursing action. Identify a time frame for an action to occur. Evaluate the patient's response to the plan of care.

Provide direction for nursing interventions.

The nurse determines that the patient has not met the plan of care for the nursing diagnosis Skin Integrity, Impaired because the wound has not healed within the time frame specified. The nurse chooses to revise the plan of care. Which step should the nurse perform first? Set a new, reachable goal. Talk to the healthcare provider. Reassess the wound. Change the interventions.

Reassess the wound.

A patient presents to the emergency department with high fever and coughing. Which information should the nurse collect for analysis? Subjective data Judgments Opinions Inferences

Subjective data

A patient is admitted to the hospital with pneumonia. The nurse develops a plan of care with a nursing diagnosis of Impaired Gas Exchange related to inadequate ventilation secondary to atelectasis. Which goal includes all elements of a goal statement? The patient will be instructed in use of the incentive spirometer every hour. The patient will demonstrate correct use of the incentive spirometer after the teaching session. The patient will be given supplemental oxygen to use via nasal cannula. The patient will be given bronchodilators as prescribed.

The patient will demonstrate correct use of the incentive spirometer after the teaching session.

The nurse is caring for a patient with malnutrition and identifies a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to poor oral intake secondary to cancer treatment. Which goal set by the nurse is an example of a specific and measurable goal? The patient will verbalize foods that are needed to gain weight. The patient will take in 80 grams of protein per day. The patient will experience no further nausea and vomiting. The patient will gain weight over the next few months.

The patient will take in 80 grams of protein per day.

Which short-term goal should the nurse view as appropriate for a patient with the nursing diagnosis Deficient Knowledge related to disease process secondary to diabetes? The patient will identify ways to prevent complications from diabetes within 2 months. The patient will maintain blood sugars between 80 and 120 mg/dL within 1 month. The patient will verbalize understanding of how insulin affects blood sugar by the end of the day. The patient will follow a diabetic diet with 90% compliance within 3 months.

The patient will verbalize understanding of how insulin affects blood sugar by the end of the day.

The nurse is caring for a patient who is 8 weeks pregnant, reports never having been pregnant before, and does not know what to expect. The nurse instructs the patient to keep all scheduled prenatal clinical visits and states, "These classes will help you and your baby to stay healthy." Which is the reason for the nurse to make this statement? To develop a nursing diagnosis of Knowledge, Deficient for the patient To motivate the patient by associating a personal meaning with the goal To educate the patient on the importance of attending the classes To provide the patient a list of reasons why attending classes is important.

To motivate the patient by associating a personal meaning with the goal

A patient reports hematuria along with the pain. After reviewing the patient's chart and assessing the patient, the nurse documented the following nursing diagnosis: Acute Pain related to urinary obstruction secondary to prostate cancer. Which part of the nursing diagnosis statement reflects the etiology? Urinary obstruction Hematuria Acute Pain Prostate cancer

Urinary obstruction

The nurse is planning interventions for a patient with a nursing diagnosis of Activity Intolerance related to weakness, as evidenced by inability to walk two steps. Which part of the nursing diagnosis statement is used as the framework for planning nursing interventions? Inability to walk two steps Previous health history Activity Intolerance Weakness

Weakness