Nur exam 2

A nurse is teaching a patient how to administer insulin, with the expected outcome that the patient will be able to self-administer the insulin injection. How would this outcome be evaluated?

asking the patient to demonstrate self injection

The staff in a long-term care facility often plays loud rock music on the radio and designs children's games as exercise. What is the staff doing in this situation?

ignoring the developmental needs of older adults

A nurse writes down the following outcome for a depressed patient: "By 6/9/12, the patient will state three positive benefits of receiving counseling." This is an example of which of the following types of outcomes?

Affective

Which of the following examples of nursing actions involve direct care of the patient?

A nurse counsels a young family who is interested in natural family planning, A nurse massages the back of a patient while preforming a skin assessment, a nurse helps a patient in hospice fill out a living will form, a nurse arranges for physical therapy for a patient who had a stroke.

Which of the following are examples of common factors that may influence assessment priorities?

A patient's diet and exercise program, a patient's developmental stage, a patients need for nursing.

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?

Actual nursing diagnosis

A student is reviewing a patient's chart before giving care. She notes the following diagnoses in the content of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnoses?

Appendicitis (Medical diagnoses identify diseases)

A student is ambulating a patient for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome?

Ask another student to help with ambulation.

A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The patient has visitors in the room. What should the nurse do?

Ask the patient if visitors should remain in the room

Which of the following statements accurately describe a recommended guideline for implementation?

Before implementing any nursing action, reassess the patient to determine whether the action is still needed, Consult colleagues and the nursing and related literature to see if other approaches might be more successful, Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success, Check to make sure that the nursing interventions selected are consistent with standards of care.

A nurse is evaluating the outcomes of a plan of care to teach an obese patient about the calorie content of foods. What type of outcome is this?

Cognitive

A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected patient outcomes), what must the nurse do next?

Collect data about patient responses.

Which of the following terms best defines assessing in the nursing process?

Collection, validation, communication of patient data.

Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the patient's situation?

Concept map care plan

Which of the following are verbs that are helpful in writing measurable outcomes?

Define, verbalize, list

A nurse writes the following nursing diagnoses for a patient with Alzheimer's: Disturbed thought processes related to Alzheimer's disease as evidence by incoherent language. Which part of this diagnosis is considered the problem statement.

Disturbed thought process

In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over let side of face, what part of the nursing diagnosis if "presence of large scar over left side of face"?

Etiology

What type of patient record data would the nurse find in the medical history progress note?

Findings of the physicians assessment and treatment

Mrs. James comes to her healthcare provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?

Focused assessment

A father runs into the emergency room with his 18-month-old son in his arms. The fahter screams "Help, he's not breathing!" The nursing diagnoses of impaired Gas Exchange is what level of priority diagnoses?

High priority

A nurse is reviewing the health history and physical assessment findings for a patient who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnoses for this problem?

I get out of breath when I walk a few steps.

A nurse formulating a nursing diagnosis for a patient with a respiratory disease. Which of the following would be correct?

Ineffective airway clearance related to thick mucus.

Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describes a guideline for using this process.

Keep an open mind and trust you intuition when formulating diagnoses

Of the following information collected during a nursing assessment, which are subjective data?

Nausea and abdominal pain.

A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing health habits. What conclusion did the nurse reach after interpreting and analyzing data?

No problem

Which of the following outcomes is correctly written?

On discharge, patient will be able to list five symptoms of infection

A nurse assesses the vital signs of a patient who is one day post surgery in which a colostomy was performed. The nurse uses the data to update the patient plan of care. What are these actions considered?

On-going planning

Which of the following illustrates a common error when writing patient outcomes?

Patient will be less anxious and fearful before and after surgery

What activity is carried out during the implementing step of the nursing process?

Planned nursing actions (interventions) are carried out

A nurse caring for an elderly patient in a long-term care facility notices that the bedding is wet when the patient gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in the scenario?

Possible problem

A nurse documents the following diagnosis for a hospitalized patient: Risk for Imbalanced Nutrition: More Than Body Requirements. What is the major goal of interventions for a risk diagnosis?

Prevent the problem

After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a patient. What are the nursing diagnoses used for?

Selecting nursing interventions to meet expected outcomes.

Each time a nurse administers an insulin injection to a patient with diabetes, she tells the patient what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting?

Self care

A nurse is preparing to conduct a health history for a patient who is confined in bed. How should the nurse position herself?

Sitting at a 45 degree angle to the bed.

A nurse preforms an assessment of patient in a long-term care facility and records baseline data. The nurse reassesses the patient a month later and makes revisions in the care plan. What type of assessment is the second assessment?

Time lapsed

What is the primary purpose of the outcome identifications and planning step of the nursing process?

To design a plan of care for and with the patient

The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surgery. What is the purpose of the initial assessment?

To establish a database to identify problems and strengths.

A nurse performing triage in an emergency room makes assessments of patients using critical thinking skills. Which of the following are critical thinking activities linked to assessment?

Using the nursing process to diagnose a blocked airway Privately interviewing a patient suspected of being a victim of abuse. Checking the data supplied by a patient with dementia with the family.

Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning?

What problems require my immediate attention or that of the team?

Which of the following is categorized as a psychomotor outcome?

Within 2 days of teaching, the patient's wife will demonstrate abdominal dressing change.

Which of the following is a descriptor that helps to define the term criteria?

acceptable level of performance

Which of the following would not be part of the nurse's decision about care after evaluating the patient's responses to the plan of care?

begin the plan of care

A nurse is catheterizing a patient. What action illustrates respect for the patient's privacy?

closing the door to the room

Which of the following statements best describes the relationship between nursing diagnoses and medical diagnoses

he nursing diagnoses is based on the patient's response to the medical diagnoses

A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what patient need should have priority?

the need to feel good about oneself

Which of the following best summarizes the evaluating step of the nursing process?

the nurse and patient measure achievement of planned outcomes of care