Nurs 235 Ch.1
A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?
Making incorrect nursing judgments or diagnoses
An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?
Nursing intervention
The client has a murmur. This is what type of data?
Objective
After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?
Ongoing
Which of the following statements is true of nursing diagnoses?
They focus on the responses of clients to health problems and events.
A hospital nurse is in the process of analyzing physical assessment data the nurse has collected on a client. Which characteristics of critical thinking should the nurse employ in the analysis? Select all that apply.
Use rationale to support opinions and decisions. Reflect on thoughts before reaching a conclusion. Use past clinical experience to build knowledge
The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next?
Validate that the client understands how to use the inhalers.
During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?
environmental
A nurse has been clustering the data collected during the initial assessment of a frail elderly client. When making inferences about the data clusters, the nurse is unsure whether to associate a cluster of data with a nursing diagnosis or with a collaborative problem. What question would best guide the nurse's decision?
"Does this issue require medical intervention?"
A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?
"I'm sorry, but assessment is ongoing and continuous."
A nurse working in a long-term care facility is performing a comprehensive assessment on an 84-year-old male resident.
-last bowel movement was charted 7 days ago. -No urine output has been charted in the last 24 hours -heart rate 120 beats/min and irregular; -oxygen saturations 88% on room air
When assisting a client with health promotion, what must the nurse also nurture?
A healthy environment
The nurse notes that a client has a 2 cm x 5 cm area of redness over the left greater trochanter. Which category should the nurse use when creating the nursing diagnosis for this finding?
Actual
What are nurses able to detect through the health assessment?
Areas in need of health adjustments
A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?
Ask the client about the most recent experiences of pain.
The nurse reviews a 70-year-old client's labs: sodium (Na+) 134 mEq/L (135-145 mEq/L), potassium (K+) 5.8 mEq/L (3.5-5 mEq/L), BUN 40 mg/dL (10-20mg/dL), creatinine 2.5 mg/dL ( 0.5-1.5 mg/dL), hematocrit 33% (35%-45%), hemoglobin 10 g/dL (12-15 g/dL). The nurse is concerned about renal function. What action should the nurse take? Select all that apply.
Assess urine output. Assess client's weight. Determine client's 24-hour intake
The student nurse asks the instructor, "What is the difference between the data analysis and the diagnostic phase?" What is the best response by the instructor?
Data analysis is also referred to as the diagnostic phase because the end result is the identification of the nursing diagnosis."
Essential characteristics for the development of critical thinking skills include all the following except:
Following instructions
Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of
Healthy People 2030
A nurse is writing down hunches about certain cue clusters related to a client. Which of the following hunches would seem to indicate the need to generate a collaborative problem as opposed to a nursing diagnosis?
Inflamed appendix is causing severe abdominal pain.
Which of the following is the best example of assessment in everyday life?
Measuring the remaining tread on a car tire to determine whether it is time to replace it
A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?
Ongoing or partial
A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?
Perform an emergency assessment.
The nurse is exhibiting critical thinking in which client care situation?
Performing a focused assessment on a client who is complaining of shortness of breath.
After completing the diagnostic reasoning process, the nurse documents a wellness diagnosis. Which of the following would the nurse have most likely identified?
Strengths
When the nurse knows after drawing an inference that there is a need for both medical and nursing interventions, the client's problem is which type?
collaborative problem
Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?
evaluation
An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)
focused or problem-oriented assessment.
A nursing student is learning how to use critical thinking in formulating a plan of care. The student understands which of the following to be things needed to demonstrate that the process of thinking critically has begun? (Select all that apply.)
reserves a final opinion until further collecting data explores other alternatives before making a decision uses past knowledge and experience to analyze data
The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis?
status of breath sounds
A nurse is performing a focused assessment on a client admitted with symptoms of meningitis who underwent a lumbar puncture this morning and is now reporting a headache and photophobia. The nurse identifies clear drainage on the dressing and redness and swelling around the site. The nurse documents which of the following objective findings in the chart? Select all that apply.
swelling redness around the site clear drainage on dressing
The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor?
"A way of processing information using to formulate conclusions or diagnoses."
A nurse is preparing to document conclusions after analyzing data and includes information about related factors and manifestations. What is the nurse formulating?
Actual nursing diagnosis
The nurse has clustered assessment data on a client with cirrhosis of the liver that has altered mental status due to the accumulation of ammonia toxins. What type of priority nursing diagnosis would be indicated for this client?
Actual nursing diagnosis.
A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take?
Ask the client if they have allergies.
A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first?
Assess the client.
Using both verbal and nonverbal clues given by the client, what is the nurse constantly doing?
Assessing
Which assessment finding should the nurse document as objective data?
Body functions
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?
Diagnosis
Revising the plan as needed occurs in what part of the nursing process?
Evaluation
A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?
Assess the nasogastric tube for proper functioning.
The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions?
Uses evidence-based techniques
The nurse receives a report on a group of clients. What client statement requires further clarification to ensure client safety? Select all that apply.
"I do not usually take insulin." "This looks like a new pill." "I fell at home last month."
A nurse is formulating a risk nursing diagnosis. Which piece of data would be most useful?
Effect of illness on social activity in the community
A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?
emergency
A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?
Empathy
A nursing student demonstrates understanding of the different types of nursing diagnoses when choosing which of the following to be an actual diagnosis?
impaired skin integrity
Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first?
Conduct a focused assessment.
The nurse collected extensive data during a client assessment and is performing the first step in the process of data analysis. Successful completion of this step requires the nurse to do which of the following?
Differentiate between expected findings and abnormal findings.
The nurse is reviewing the laboratory report for a client with poorly controlled diabetes. This action falls within which step of clinical reasoning?
identifying abnormal or positive findings
The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority?
significantly impaired hearing
