NCLEX QUESTIONS FOR CONCEPTS TEST 3

Read the following scenario and identify the term for the characteristics of patient data that are numbered below. The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the hospital with a diagnosis of dehydration. The nurse: (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data, (2) first asks the patient about the most important details leading up to her diagnosis, (3) collects as much information as possible to understand the patient's health problems, (4) collects the patient data in an organized manner, (5) verifies that the data obtained is pertinent to the patient care plan, and (6) records the data according to agency policy.

(1) Purposeful: The nurse identifies the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. (2) Prioritized: The nurse gets the most important information first. (3) Complete: The nurse gathers as much data as possible to understand the patient health problem and develop a plan of care. (4) Systematic: The nurse gathers the information in an organized manner. (5) Factual and accurate: The nurse verifies that the information is reliable. (6) Recorded in a standard manner: The nurse records the data according to agency policy so that all caregivers can easily access what is learned.

Read the following patient scenario and identify the step of the n using process represented by each numbered and boldfaced nursing activity. Annie seeks the help of the nurse in the student health clinic because she suspects that her roommate, Angela, suffered date rape. She is concerned because Angela chose not to report the rape and does not seem to be coping well. (1) AFTER TALKING WITH ANNIE, THE NURSE LEARNS THAT ALTHOUGH ANGELA BLURTED OUT THAT SHE HAD BEEN RAPED WHEN SHE FIRST CAME HOME, SINCE THEN SHE HAS REFUSED VERBALIZATION ABOUT THE RAPE ("I DON'T WANT TO THINK OR TALK ABOUT IT"), HAS STOPPED ATTENDING ALL COLLEGE SOCIAL ACTIVITIES (A MARKED CHANGE IN BEHAVIOR), AND SEEMS TO BE HAVING NIGHTMARES. After analyzing the data, the nurse believes that Angela might be experienceing (2) RAPE-TRAUMA SYNDROME: SILENT REACTION. Fortunately, Angela trusts Annie and is willing to come to the student health center for help. A conversation with Angela confirms the nurse's suspicions, and problem identification begins. The nurse talks further with Angela (3) TO DEVELOP SOME TREATMENT GOALS AND FORMULATE OUTCOMES. THE NURSE ALSO BEGINS TO THINK ABOUT THE TYPES OF NURSING INTERVENTIONS MOST LIKELY TO YIELD THE DESIRED OUTCOMES. In the initial meeting with Angela, (4) THE NURSE ENCOURAGES HER EXPRESSION OF FEELINGS AND HELPS HER TO IDENTIFY PERSONAL COPING STRATEGIES AND STRENGTHS. The nurse and Angela decide to meet in 1 week (5) TO ASSESS HER PROGRESS TOWARD ACHIEVING TARGETED OUTCOMES. If she is not making progress, the plan of care might need to be modified.

(1) is an illustration of assessing: the collection of patient data. (2) is an illustration of the identification of a nursing diagnosis: a health problem that independent nursing intervention can resolve. (3) is an illustration of planning: outcome identification and related nursing interventions. (4) is an illustration of implementing: carrying out the plan of care. (5) is an illustration of evaluating: measuring the extent to which Angela has achieved targeted outcomes.

A high school nurse is counseling parents of teenagers who are beginning high school. Which issues would be priority topics of discussion for this age group? Select all that apply. a. The influence of peer groups b. Bullying c. Water safety d. Eating disorders e. Risk taking behavior f. Immunizations

a, b, d, e. Appropriate topics of discussion for parents of adolescents include peer groups, bullying, eating disorders, and risk-taking behaviors. Immunizations would be appropriate for parents of children from infants to school-age, and water safety should be taught in the preschool years.

A nurse researcher studies the effects of genomics on current nursing practice. Which statements identify genetic principles that will challenge nurses to integrate genomics in their research, education, and practice? Select all that apply. a. Genetic tests plus family history tools have the potential to identify people at risk for diseases. b. Pharmacogenetics tests can determine if a patient is likely to have a strong therapeutic response to a drug or suffer adverse reactions from the medication. c. Evidence-based review panels are in place to evaluate the possible risks and benefits related to genetic testing. d. Valid and reliable national data are available to establish baseline measures and track progress toward targets. e. Genetic variation can either accelerate or slow the metabolism of many drugs. f. It is beyond the role of the nurse to answer questions and discuss the impact of genetic findings on health and illness.

a, b, e. In the very near future, all health care providers will be challenged to integrate genomics into their research, education, and practice. Genetic tests plus family history tools have the potential to identify people at risk for diseases. Pharmacogenetics is the study of how genetic variation affects an individual's response to drugs. Pharmacogenetic tests can determine if a patient is likely to have a strong therapeutic response to a drug or suffer adverse reactions from the medication. Genetic variation can either accelerate or slow the metabolism of man drugs. Two emerging challenges related to genomic discoveries are (1) the need for evidence-based review panels to thoroughly evaluate the possible benefits and harms related to the expanding number of genetic tests and family health history tools, and (2) valid and reliable national data are needed to establish baseline measures and track progress toward targets. Nurses must be prepared to answer questions and discuss the impact of genetic findings on health and illness.

A nurse caring for older adults in a long-term care facility knows that several physical changes occur in the aging adult. Which characteristics best describe these changes? Select all that apply. a. Fatty tissue is redistributed. b. The skin is drier and wrinkles appear. c. Cardiac output increases. d. Muscle mass increases. e. Hormone production increases. f. Visual and hearing acuity diminishes.

a, b, f. Physical changes occurring with aging include these: fatty tissue is redistributed, the skin is drier and wrinkles appear, and visual and hearing acuity diminishes. Cardiac output decreases, muscle mass decreases, and hormone production decreases, causing menopause and andropause.

The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply. a. A patient tells the nurse that she is feeling nauseous. b. A patient's ankles are swollen. c. A patient tells the nurse that she is nervous about her test results. d. A patient complains of having a rash on her arm that is itchy. e. A patient rates his pain as a 7 on a scale of 1 to 10. f. A patient vomits after eating supper.

a, c, d, e. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, itchy, or chilly and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101 degrees fahrenheit), edema, and vomiting.

The nurse caring for infants in a hospital nursery knows that newborns continue to grow and develop according to individual growth patterns and developmental levels. Which terms describe these patterns? Select all that apply. a. Orderly b. Simple c. Sequential d. Unpredictable e. Differentiated f. Integrated

a, c, e, f. Growth and development are orderly and sequential, as well as continuous and complex. Growth and development follow regular and predictable trends, and are both differentiated and integrated.

A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. a. Dyspnea b. Hypotension c. Small pulse pressure d. Decreased respiratory rate e. Pallor f. Increased pulse rate

a, c, e, f. If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendation of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. a. Basing patient care on continuous healing relationships b. Customizing care to reflect the competencies of the staff c. Using evidence-based decision making d. Having a charge nurse as the source of control e. Using safety as a system priority f. Recognizing the need for secrecy to protect patient privacy

a, c, e. Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized.

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. a. Monitoring patient status every hour b. Using intuition to troubleshoot patient problems c. Turning a patient on bed rest every 2 hours d. Becoming a nurse mentor to a student nurse e. Administering pain medication ordered by the physician f. Becoming involved in community nursing events

a, c, e. Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They ares established by authority, custom, or consent.

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being when planning care? Select all that apply. a. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. b. The nurse uses a binary decision tree for stepwise assessment and intervention. c. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. d. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. e. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has even validated through research. f. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

A nurse is teaching parents of preschoolers what type of behavior to expect from their children based on developmental theories. Which statements describe this stage of development? Select all that apply. a. According to Freud, the child is in the phallic stage. b. According to Erikson, the child is learning to get along with others. c. According to Havighurst, the child is learning to get along with others. d. According to Fowler, the child imitates religious behavior of others. e. According to Kohlberg, the child defines satisfying acts as right. f. According to Havighurst, the child is achieving gender-specific roles.

a, d, e. According to Freud, the child is in the phallic stage. According to Fowler, the child imitates religious behavior of others. According to Kohlberg, the child defines satisfying acts as right According to Erikson, the child is initiative versus guilt stage. According to Havighurst, the child is learning sex differences, forming concepts, and getting ready to read. According to Havighurst, the adolescent, not the preschooler, is achieving gender-specific social roles.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. a. The nurse carefully removes the bandages from a burn victim's arm. b. The nurse assesses a patient to check nutritional status. c. The nurse formulates a nursing diagnosis for a patient with epilepsy. d. The nurse turns a patient in bed every 2 hours to prevent pressure ulcers. e. The nurse checks a patient's insurance coverage at the initial interview. f. The nurse checks for community resources for a patient with dementia.

a, d, f. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. a. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" c. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." e. "We need to check your health status and see what kind of nursing care you may need." f. "We need to see if you require a referral to a physician or other health care professional.

a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgement about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. a. The nurse uses critical thinking skills to plan care for a patient. b. The nurse correctly administers IV saline to a patient who is dehydrated. c. The nurse assists a patient to fill out an informed consent form. d. The nurse learns the correct dosage for patient pain medications. e. The nurse comforts a mother whose baby was born with Down syndrome. f. The nurse uses the proper procedure to catheterize a female patient.

a,d. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? a. 2, 4, 1, 3 b. 3, 1, 4, 2 c. 2, 4, 3, 1 d. 3, 2, 4, 1

a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." Which of the following comments is the nurse most likely to hear from the instructor? a. "Hold on a minute...Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." b. "Job well done...you've identified this problem early and we can manage it before it becomes more acute." c. "Is this an actual or a possible diagnosis?" d. "This is a medical, not a nursing problem."

a. A data cluster is a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than form a single cue. There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual's normal pattern.

The nurse performing an assessment of a newborn in the neon unit records these findings: heart rate 85 bpm, irregular respiratory rate, normal muscle tone, weak crying, and bluish tint to skin. Using the APGAR scoring chart (see Table 18-1, p. 389) what would be the score for this newborn? a. 5 b. 7 c. 8 d. 10

a. A newborn with a heart rate less than 100 bpm, irregular respiratory effort, normal muscle tone, weak cry, and bluish tint to the skin scores a 5 on the APGAR chart.

To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: a. Compare this reading to standards b. Check the taxonomy of nursing diagnoses for a pertinent label c. Check a medical text for the signs and symptoms of high blood pressure d. Consult with colleagues

a. A standard, or norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, approximate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.

A nurse is assessing a 15-year-old female patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: a. Clinical judgement b. Clinical reasoning c. Critical thinking d. Blended competencies

a. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgement as it refers to the result or outcome of critical thinking or clinical reasoning----in this case the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical/legal skills combined with willingness to use them creatively and critically when working with patients.

A nurse is caring for an 80-year-old female patient who is living in a long-term care facility. To help this patient adapt to her present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? a. "Tell me about how you celebrated Christmas when you were young." b. "Tell me how you plan to spend your time this weekend." c. "Did you enjoy the choral group that performed here yesterday?" d. "Why don't you want to talk about your feelings?"

a. Asking questions about events in the past can encourage the older adult to relive and restructure life experiences.

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? a. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their career on scientific problem solving. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it's time to champion intuitive, creative thinking! d. It's simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

a. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a stroke that caused right-sided paresis. An example of this type of outcome is: a. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. b. By 8/15/15, patient will be able to use right arm to dress, comb hair, and feed herself. c. Following physical therapy, patient will begin to gradually participate in walking/running events. d. By 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events.

a. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? a. Cognitive b. Psychomotor c. Affective d. Physical changes

a. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; affective outcomes pertain to change in patient values, beliefs, and attitudes; and physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

A 2-year-old grabs a handful of cake from the table and stuffs it in his mouth. According to Freud, what part of the mind is the child satisfying? a. Id b. Superego c. Ego d. Unconscious mind

a. Freud defined the id as the part of the mind concerned with self-gratification by the easiest and quickest available means.

Which factor initially influences moral development as described in Kohlberg's theory? a. Parent-child communications b. Societal rules and regulations c. Social and religious rules d. One's beliefs and values

a. Maral development in the young child results from communications as the child tries to please his or her parents.

A nurse is teaching new mothers about infant care and safety. What would the nurse accurately include as a teaching point? a. Keep infants younger than 6 months out of direct sunlight. b. Use honey instead of sugar in homemade baby food. c. Place the baby on his or her stomach for sleeping. d. Keep crib rails down at all times.

a. Nurses should tach parents to keep infants younger than 6 months out of direct sunlight and cover them with protective clothing and hats. The nurse should also teach parents not to add honey or sugar to homemade baby food, to place the baby on the back for sleeping to prevent SIDS, and to keep the crib rails up at all times.

A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed? a. Perform the focused assessment. This is an independent nurse-initiated intervention. b. Request an order from Jill's physician since this is a physician-initiated intervention. c. Request an order from Jill's physician since this is a collaborative intervention. d. Request an order from the nutritionist since this is a collaborative intervention.

a. Performing a focused assessment is an independent nurse-initiated intervention, thus the nurse does not need an order from the physician or the nutritionist.

A mother tells the nurse that she is worried about her 4-year-old daughter because she is "overly attached to her father ad won't listen to anything I tell her to do." What would be the nurse's best response to this parental concern? a. Tell the mother that this is a normal behavior for a preschooler. b. Tell the mother that she and her family should see a counselor. c. Tell the mother that she should try to spend more time with her daughter. d. Tell the mother that her child should be tested for autism.

a. Preschoolers, according to Freud, are in the phallic stage, with the biologic focus primarily genital. The child has a sexual desire for the opposite-sex parent, but as means of defense strongly identifies with the same-sex parent. This is normal behavior for a preschooler, and the family does not need counseling or autism testing. Spending more time with the child is always a good idea, but it is not the solution to this concern.

A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the folks responsible for these errors and see if we can replace them." This is an example of: a. Quality by inspection b. Quality by punishment c. Quality by surveillanace d. Quality by opportunity

a. Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity (d) focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Answers b and c are distractors.

A nurse caring for elderly patients in a long-term care facility encourages an older adult to reminisce about her past life events. This life review, according to Erikson, is demonstrating what development stage of the later adult years? a. Ego integrity b. Generativity c. Intimacy d. Initiative

a. Reminiscence during the older years of one's life provides a sense of fulfillment and purpose (ego integrity). Generativity is a developmental stage of the middle adult years. Intimacy is a developmental task of the adolescent to adult years, and initiative is a task of the preschooler to early school-age years.

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident with the procedure. What would be the student's best response? a. Tell the RN that he or she lacks the technical competencies to change the dressing independently. b. Assemble the equipment for the procedure and follow the steps in the procedural manual. c. Ask another student nurse to work collaboratively with him or her to change the dressing. d. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

a. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the plan of care. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? a. "You made an inference that she is fine because she has no complaints. How did you validate this?" b. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." c. "Sometimes everyone gets lucky. Why don't you try to help another patient?" d. "Maybe you should reassess the patient. She has to have a problem---why else would she be here?"

a. The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it is possible that the condition is resolving.

A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? a. Quickly position the patient on his or her side. b. Put on disposable gloves and remove the oral airway c. Check that the airway is the appropriate size for the patient. d. Put on sterile gloves and suction the airway.

a. When a patient vomits upon insertion of an oropharyngeal airway, the nurse should immediately position the patient on his or her side to prevent aspiration, remove the oral airway, and suction the mouth if needed.

A nurse is planning care for a male adolescent patient who is admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. a. The nurse formulates nursing diagnoses. b. The nurse identifies expected patient outcomes. c. The nurse selects evidence-based nursing interventions. d. The nurse explains the nursing care plan to the patient. e. The nurse assesses the patient's mental status. f. The nurse evaluates the patient's outcome achievement.

b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected outcomes, select evidence-based nursing interventions, and communicate the plan of nursing care. Although all theses steps may overlap, formulating and validating nursing diagnoses occurs most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating the patient outcomes occurs during the evaluation step of the nursing process.

A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply. a. Thoracentesis b. Spirometry c. Pulse oximetry d. Peak expiratory flow rate e. Diffusion capacity f. Maximal respiratory pressure

b, c, d. Spirometers are used to monitor the health status of patients with respiratory disorders, such as asthma. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma, along with PEFR to monitor airflow. These three tests may be administered by the nurse. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular cases of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.

An RN working on a busy hospital unit delegates patient care to unlicensed assistive personnel (UAPs). Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. a. Performing the initial patient assessments b. Making patient beds c. Giving patients bed baths d. Administering patient medications e. Ambulating patients f. Assisting patients with meals

b, c, e, f. Performing the initial patient assessment and administering medications are the responsibility of the registered nurse. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

A nurse uses critical thinking skills to focus on the care plan of an elderly patient who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. a. It functions independently of nursing standards, ethics, and state practice acts. b. It is based on the principles of the nursing process, problem solving, and the scientific method. c. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. d. It is not designed to compensate for problems created by human nature, such as medication errors. e. It is constantly re-evaluating, self-correcting, and striving for improvement. f. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

b, c, e. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethic codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve.

A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. a. Bronchial pneumonia b. Impaired gas exchange c. Ineffective airway clearance d. Potential complication: sepsis e. Infection related to pneumonia f. Risk for septic shock

b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, "potential complication: sepsis" is a collaborative problem.

A nurse who is caring for older adults in a senior daycare center documents findings as related to which normal aging process? Select all that apply. a. A patient's increased skin elasticity causes wrinkles on the face and arms. b. Exposure to sun over the years causes a patient's skin to be pigmented. c. A patient's toenails have become thinner with a bluish tint to the nail beds. d. A patient experiences a hip fracture due to porous and brittle bones. e. Fragile blood vessels in the dermis allow for more easy bruising of a patient's forearm. f. Increased bladder capacity causes decreased voiding in an older patient.

b, d, e. Exposure to sun over the years can cause a patient's skin to be pigmented. Bone demineralization occurs with aging, causing bones to become porous and brittle, making fractures more common. The blood vessels in the dermis become more fragile, causing an increase in bruising and purport. Wrinkling and sagging of skin occur with decreased skin elasticity. A patient's toenails may become thicker, with a yellowish tint to the nail beds. Bladder capacity decreases by 50%, making voiding more frequent; two or three times a night is usual.

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. a. A nurse sits down with a patient and prioritizes existing diagnoses. b. A nurse assesses a woman for postpartum depression during routine care. c. A nurse plans interventions for a patient who is diagnosed with epilepsy. d. A busy nurse takes time to speak to a patient who received bad news. e. A nurse reassesses a patient whose PRN pain medication is not working. f. A nurse coordinates the home care of a patient being discharged.

b, d, e. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. Refrain from exercise. b. Reduce anxiety. c. Eat meals 1 to 2 hours prior to breathing treatments. d. Eat a high-proteing/high-calorie diet. e. Maintain a high-Fowler's position when possible. f. Drink 2 to 3 pints of clear fluids daily.

b, d, e. When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily is recommended.

Following a fall that left an elderly male patient temporarily bedridden, the nurse is using the SPICES assessment tool to evaluate him for cascade iatrogenesis. Which are correct aspects of this tool? Select all that apply. a. S - Senility b. P - Problems with feeding c. I - Irritableness d. C - Confusion e. E - Edema of the legs f. S - Skin breakdown

b, d, f. The SPICES acronym is used to identify common problems in older adults and stands for: S - Sleep disorders P - Problems with eating or feeding I - Incontinence C - Confusion E - Evidence of falls S - Skin breakdown

A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. a. The nurse uses the nursing interview to collect patient data. b. The nurse analyzes data collected in the nursing assessment. c. The nurse develops a care plan for the patient. d. The nurse points out the patient's strengths. e. The nurse assess the patient's mental status. f. The nurse identifies community resources to help his family cope.

b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situations

b, interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? a. Risk for Impaired Skin Integrity b. Related to prescribed bedrest c. As evidenced by d. As evidenced by reddened areas of skin on the heels and back

b. "Related to prescribed bedrest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. Which nursing diagnoses are correctly write as three-part nursing diagnoses? (1) Disabled Family Coping related to lack of knowledge about home care of child on ventilator (2) Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-pound weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height weight charts (3) Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" (4) Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?," "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" (5) Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression a. (1) and (3) b. (2) and (4) c. (1), (2), and (3) d. All of the above

b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement.

A nurse makes a clinical judgment that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnosis? a. Actual b. Risk c. Possible d. Wellness

b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem that others in the same or similar situation is a Risk nursing diagnosis.

The nurse records an APGAR score of 4 for a newborn. What would be the priority intervention for this newborn? a. No interventions are necessary; this is a normal score b. Provide respiratory assistance. c. Perform CPR d. Wait 5 minutes and repeat the scoring process

b. A newborn who scores a 4 on the APGAR chart requires special assistance such as respiratory assistance. Normal APGAR scores are 7-10. Neonates who score between 4 and 6 require special assistance, and those who score below 4 are in need of life-saving support.

When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a. The oxygen must be humidified. b. The rate will be no more than 2 to 3 L/min or less. c. Arterial blood gases will be drawn every hours to assess flow rate. d. The rate will be 6 L/min or more.

b. A rate higher than 3 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rats do not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate.

A nurse working with adolescents in a group home discusses the developmental tasks appropriate for adolescents with the staff. What is an example of a primary developmental task of the adolescent? a. Working hard to succeed in school b. Spending time developing relationships with peers c. Developing athletic activities and skills d. Accepting the decisions of parents

b. Adolescence is a time to establish more mature relationships with both boys and girls of the same age.

A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68-year-old male patient. What type of diagnosis does this intervention seek to confirm? a. Actual b. Possible c. Risk d. Collaborative

b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse and physical-prescribed interventions.

A nurse is about to perform pin site care for a patient who has a halo traction devise installed. What is the first nursing action that should be taken prior to performing this care? a. Administer pain medication b. Reassess the patient c. Prepare the equipment d. Explain the procedure to the patient.

b. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and if necessary administer pain medications.

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? a. High Fowler's position b. Left side with pillow under chest wall c. Lying position/half on abdomen and half on side d. Trendelenberg position

b. For postural drainage, the nurse should place the patient lying on the left side with a pillow under the chest wall to drain the right lobe of the lung, use high Fowler's position to drain the apical sections of the upper lobes of the lungs, place the patient in a lying position, half on the abdomen and half on the side, right and left, to draw the posterior sections of the upper lobes of the lungs, and place the patient in the Trendelenburg position to drain the lower lobes of the lungs.

A nurse is performing an initial comprehensive assessment of an 84-year-old male patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is the nurse following? a. Maslow's human needs b. Gordon's functional health patterns c. Human response patterns d. Body system model

b. Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

Based on Erikson's theory, middle adults who do not achieve their developmental tasks may be considered to be in stagnation. Which statement is one example of this finding? a. "I am helping my parents move into an assisted-living facility." b. "I spend all of my time going to the doctor to be sure I am not sick." c. "I have enough money to help my son and his wife when they need it." d. "I earned this gray hair and I like it!"

b. Middle adults who do not reach generativity tend to become overly concerned about their own physical and emotional health needs.

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good vaseline data What would be the instructor's best reply? a. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep?" b. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." d. "Don't worry about learning all of the questions to ask. Every agency has its own assessment form you must use."

b. Once you learn what constitutes the minimum data set, you can adapt this to any patient situation. It is not true that each assessment is the same even when you are using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard agency assessment tools does not allow for individualized patient care or critical thinking.

The nurse encourages parents of hospitalized infants and toddlers to stay with their child to help decrease what potential problem? a. Problems with attachment b. Separation anxiety c. Risk for injury d. Failure to thrive

b. Separation anxiety, with crying initially and then appearing depressed, is common during late infancy in infants who are hospitalized.

Nurses use the Nursing Interventions Classification Taxonomy structure as a resource when planning nursing care for patients. What information would be found in this structure? a. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings c. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention d. A complete list of reimbursable charges for each nursing intervention

b. The Nursing Interventions Classification Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? a. The age of the patient b. The size of the endotracheal tube c. The type of secretions to be suctioned d. The height and weight of the patient

b. The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.

A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? a. Offer the patient 60 mL fluid every 2 hours while awake. b. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. c. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/15 d. At the next visit, 12/23/15, the patient will know that he should drink at least 3 liters of water per day.

b. The outcomes in a and c make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60 mL fluid every 2 hours while awake." Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/31/15." The outcome in d makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware."

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: a. Quality assurance b. Quality improvement c. Process evaluation d. Outcome evaluation

b. Unlike quality assurance, quality improvement is internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than individuals, and has no end points. Its goal is improving quality rather than assuring quality. Answers c and d are types of quality-assurance programs.

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? a. No problem b. Possible problem c. Actual nursing diagnosis d. Clinical problem other than nursing diagnosis

b. When a possible problem exists, such as situational low self-esteem related to effects of stroke the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

A school nurse is preparing a talk on safety issues for parents of school-aged children to present at a parent-teacher meeting. Which topics should the nurse include based on the age of the children. Select all that apply. a. Child-proofing the home b. Choosing a car seat c. Teaching pedestrian traffic safety d. Providing swimming lessons and water safety rules e. Discussing alcohol and drug consumption related to motor vehicle safety f. Teaching child how to "stop, drop, and roll"

c, d, f. Important safety topics for school-aged children include pedestrian traffic safety, water safety, and fire safety. Childproofing a home would be appropriate for parents of a toddler, choosing a care seat would be an appropriate topic for parents of an infant or toddler, and teaching drug and alcohol as it relates to motor vehicle safety would be a more appropriate topic for parents of adolescents.

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. a. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. b. A nurse consults with a psychiatrist for a patient who abuses pain killers. c. A nurse checks the skin of bedridden patients for skin breakdown. d. A nurse orders a kosher meal for an orthodox Jewish patient. e. A nurse records the I&O of a patient as prescribed by his physician. f. A nurse prepares a patient for minor surgery according to facility protocol.

c, d, f. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician. Consulting with a psychiatrist is a collaborative intervention.

A nurse caring for adults in a physician's office notes that some patients age more rapidly than other patients of the same age. The nurse researchers aging theories attempt to how and why aging occurs. Which statements apply to the immunity theory of aging? Select all that apply. a. Chemical reactions in the body produce damage to the DNA. b. Free radicals have adverse effects on adjacent molecules. c. Decrease in size and function of the thymus causes infections. d. There is much interest in the role of vitamin supplementation. e. Lifespan depends on a great extent to genetic factors. f. Organisms wear out from increased metabolic functioning.

c, d. The immunity theory of aging focuses on the functions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, causing more infections. There is much interest in vitamin supplements (such as vitamin E) to improve immune function. In the cross-linage theory, cross-linkage is a chemical reaction that produces damage to the DNA and cell death. The free radical theory states that free radicals, formed during cellular metabolism, are molecules with separated high-energy electrons, which can have adverse effects on adjacent molecules. The genetic theory of aging holds that the lifespan depends to a great extent of genetic factors. According to the wear-and-tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stressors.

The nurse paretics using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTI is: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice. d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

c, evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

The nurse writes to following outcome for a patient who is trying to stop smoking: "The patient appreciates or values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? a. Cognitive b. Psychomotor c. Affective d. Physical changes

c. Affective outcomes pertain to changes in patient values beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

A nursing instructor teaching classes in gerontology to nursing students discuss myths related to the aging of adults. Which statement is a myth about older adults? a. Most older adults live in their own homes. b. Healthy older adults enjoy sexual activity. c. Old age means mental deterioration. d. Older adults want to be attractive to others.

c. Although response time may be longer, intelligence does not normally decrease because of aging. Most older adults own their own homes, and although sexual activity may be less frequent, the ability to perform and enjoy sexual activity lasts well into the 90s in healthy older adults. Older adults want to be attractive to others.

What is the leading cause of cognitive impairment in old age? a. Stroke b. Malnutrition c. Alzheimer disease d. Loss of cardiac reserve

c. Alzheimer disease is the most common degenerative neurologic illness and the most common cause of cognitive impairment. It is irreversible, progressing from deficits in memory and thinking skills to an inability to perform even the simplest of tasks.

A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? a. Decreased Cardiac Output related to difficulty breathing b. Impaired Gas Exchange related to use of bronchodilators c. Fatigue related to impaired oxygen transport system d. Ineffective Airway Clearance related to fatigue

c. Fatigue related to an impaired oxygen transport system is an example of a nursing diagnosis with alteration in oxygenation as the etiology or cause of other problems. Ineffective Airway Clearance, Decreased Cardiac Output and Impaired Gas Exchange are examples of nursing diagnoses indicating alterations in oxygenation as the problem.

A nurse who is working with women in a drop-in shelter studies Carol Gilligan's theory of morality in women to use when planning care. According to Gilligan, what is the motivation for female morality? a. Law and justice b. Obligations and rights c. Response and care d. Order and selfishness

c. In Gilligan's theory, males and females have different ways of looking at the world. Males are more likely to associate morality with obligations, rights, and justice. Females are more likely to see moral requirements emerging from the needs of others within the context of a relationship.

A nurse is interviewing Anthony, a 42-year-old patient who visits his internist for a blood pressure screening. Anthony tells the nurse that he is currently a sales associate but it considering a different career. He states that he is "a little anxious about the process." According to Levinson, what phase of adult life is Anthony experiencing? a. Entering the adult world b. Settling down c. Midlife transition d. The pay-off years

c. Midlife transition (age 40-45) involves a reappraisal of one's goals and values. The established lifestyle may continue, or the individual may choose to reorganize and change careers. This is an unsettled time, with the individual often anxious and fearful. The years of the middle to late 20s (age 22-28) are a time to build on previous decisions and choices are to try different careers and lifestyles. In the settling-down phase (age 30-40), the adult invests energy into the areas of life that are most personally important. The years from 45 to 65 are a time of maximum self-direction and self-approval.

When helping a patient turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of what type of planning? a. Initial planning b. Standardized planning c. Ongoing planning d. Discharge planning

c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

A nurse examining a toddler in a pediatric office documents that the child is in the 90th percentile for height and weight and has blue eyes. These physical characteristics are primarily determined by: a. Socialization with caregivers b. Maternal nutrition during pregnancy c. Genetic information on chromosomes d. Meeting developmental tasks

c. Physical appearance and growth have a predetermined genetic base in inheritance patterns carried on the chromosomes.

A nurse is teaching parents of toddlers how to spend quality time with their children. Which activity would be developmentally appropriate for this age group? a. Playing video games b. Playing peek-a-boo c. Playing in a sand box d. Playing board games

c. Playing in a sand box with toys that emphasize gross motor skills and creativity is a developmentally appropriate activity for a toddler. Video games are appropriate for school-aged children and adolescents, but should be monitored. Playing peek-a-boo is developmentally appropriate for an infant, and playing board games usually begins with preschool and older children.

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a plan of care for this patient. Which QSEN competency does this action represent? a. Patient-centered care b. Evidence-based practice c. Quality improvement d. Informatics

c. Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? a. The nurse judges whether the patient database is adequate to address the problem. b. The nurse considers whether or not to suggest a counseling session for the patient. c. The nurse reassesses the patient and decides how best to intervene in her care. d. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

c. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

A nurse uses the following classic elements of evaluation when caring for patients. Which item below places them in their correct sequence? (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting one's judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what one is looking for when evaluating, e.g., expected patient outcomes) a. 1, 2, 3, 4, 5 b. 3, 2, 1, 4, 5 c. 5, 2, 1, 3, 4 d. 2, 3, 1, 4, 5

c. The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards, (2) collecting data to determine whether these criteria and standards are met, (3) interpreting and summarizing findings, (4) documenting your judgment, and (5) terminating, continuing, or modifying the plan.

The nurse is surprised to detect an elevated temperature (102 degrees fahrenheit) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do? a. Inform the charge nurse b. Inform the surgeon c. Validate the finding d. Document the finding

c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate, thus all data should be validated before documentation if there are any doubts about accuracy.

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the RN? a. Allow the UAPs to do the admission assessment and report the findings to the RN. b. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. c. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. d. Contact his or her labor representative and complain about this practice.

c. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

A nurse develops a detailed plan of care for a 16-year-old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? a. "You know your personal situation better than I do, so I will respect your wishes." b. "If you don't accept these services, your baby's health will suffer." c. "Let's take a look at the plan again and see if we can adjust it to fit your needs." d. "I'm going to assign your case to a social worker who can explain the services better."

c. When a patient does not follow the plan of care despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the plan of care is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? a. The nurse collects data to identify health problems. b. The nurse collects data to identify patient strengths. c. The nurse collects data to justify terminating the plan of care. d. The nurse collects data to measure outcome achievement.

d, The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the plan of care, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a. "I will be careful not to shake up the canister before using it." b. "I will hold the canister upside-down when using it." c. "I will inhale the medication through my nose." d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the devise while continuing to inhale."

d, e, f. Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.

The school nurse uses the principles and theories of growth and development when planning programs for high school students. According to Havighurst, what is a developmental task for this age group? a. Finding a congenial social group b. Developing a conscience, morality, and a scale of values c. Achieving personal independence d. Achieving a masculine or feminine gender role

d. According to Havighurst, it is the role of the adolescent to achieve a masculine or feminine gender role. Developing a conscience, morality, and a scale of values and achieving personal independence are roles of middle childhood. Finding a congenial social group is a role of young adulthood.

Following assessment of an obese adolescent, a nurse considers nursing diagnoses for the patient. Which diagnosis would be most appropriate? a. Risk for injury b. Risk for delayed development c. Social isolation d. Disturbed body image

d. Adolescents who are obese are at a high risk for a disturbed body image. Risk for injury would be appropriate for a risk taker, a risk factor for delayed development may be ADHD, and social isolation may occur with low self-esteem.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An example of an affective outcome for this patient is: a. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. b. By 6/12/15, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c. By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size shrinks form 3" to 2.5"). d. By 6/12/15, the patient will verbalize valuing health sufficiently to produce new health behaviors to prevent recurrence of leg ulcer.

d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills. c is an outcome describing a physical change in the patient.

An experienced nurse tells a younger nurse who is working in a retirement home that older adults are different and do not have the same desires, needs, and concerns as other age groups. The nurse also comments that most older adults have "outlived their usefulness." What is the term for this type of prejudice? a. Harassment b. Whistle blowing c. Racism d. Ageism

d. Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their age group. Harassment occurs when a dominant person takes advantage of or overpowers a less dominant person (may involve sexual harassment or power struggles). Whistle blowing involves reporting illegal or unethical behavior in the workplace. Racism is prejudice against other races and ethnic groups.

A student nurse is organizing clinical responsibilities for an 84-year-old female patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? a. Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. b. Schedule the testing and meal planning first and complete hygiene as time permits. c. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. d. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

d. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? (1) Ineffective Coping related to inability to maintain marriage (2) Defensive Coping related to loss of job and economic security (3) Altered Thought Processes related to panic state (4) Decisional Conflict related to placement of parent in a long-term care facility a. (1) and (2) b. (3) and (4) c. (1), (2), and (3) d. All of the above

d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

Which of the following nursing diagnoses would be appropriate for many middle adults? a. Risk for Imbalanced Nutrition: Less Than Body Requirements b. Delayed Growth and Development c. Self-Care Deficit d. Caregiver Role Strain

d. Many middle adults help care for aging parents and have concerns about their own health and ability to continue to care for an older family member. Caregivers often face 24-hour care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver.

A nurse is counseling a 60-year-old female patient who refuses to look at or care for a new colostomy. She tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? a. Collaborative problem b. Interdisciplinary problem c. Medical problem d. Nursing problem

d. Nursing Problem, because it describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate? a. Correct the initial assessment form b. Redo the initial assessment and document current findings. c. Conduct and document an emergency assessment. d. Perform and document a focused assessment of skin integrity.

d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? a. Comprehensive b. Initial c. Time-lapsed d. Quick priority

d. Quick priority assessments (QPA) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care agency or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

A student health nurse is counseling a female college student who wants to lose 20 pounds. The nurse develops a plan to increase the student's activity level and decrease the consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 pounds, the student has lost only 1 pound. Which is the best nursing response? a. Congratulate the student and continue the plan of care. b. Terminate the plan of care since it is not working. c. Try giving the student more time to reach the targeted outcome. d. Modify the plan of care after discussing possible reasons for the student's partial success.

d. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the plan of care. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the plan of care since the student has not met her targeted outcome. The student may need more time to reach her outcome, which makes (c) the wrong response.

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes the theory of which theorist? a. Travelbee b. Watson c. Benner d. Swanson

d. Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience or illness and suffering, and if necessary to find meaning in these experiences. Brenner and Wrubel (1989) write that caring is a basic way of being in the world and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.

A nurse is writing an evaluative statement for a patient who is trying to lower her cholesterol through diet and exercise. Which evaluative statement is written correctly? a. "Outcome not met." b. "1/21/15---Patient reports no change in diet." c. "Outcome not met. Patient reports no change in diet or activity level." d. "1/21/15---Outcome not met. Patient reports no change in diet or activity level."

d. The evaluative statement must contain a date; the words "outcome met," "outcome partially met," or "outcome not met"; and the patient data or behaviors that support this decision. Answers a, b, and c are incomplete statements.

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. What should the nurse do? a. Introduce oneself and thank the wife for being present. b. Introduce oneself and ask the wife if she wants to remain. c. Introduce oneself and ask the wife to leave. d. Introduce oneself and ask the patient if he would like the wife to stay.

d. The patient has the right to indicate home he would like to be present for the nursing history and exam. You should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.

A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is NOT an example of a well-stated nursing intervention? a. Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. b. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. c. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. d. Manage patient's pain.

d. This statement lacks sufficient detail to effectively guide nursing intervention. The set of nursing interventions written to assist a patient to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what observations (assessments) need to be made and how often, what nursing interventions need to be done and when they must be done, and what teaching, counseling, and advocacy needs patients and families may have.

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patient airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. The patient vomits during suctioning. b. The secretions appear to be stomach contents. c. The catheter touches an unsterile surface. d. Epistaxis is noted with continued suctioning.

d. When epistaxis is noted with continued suctioning, the nurse should notify the physician and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.