Nursing Fundamentals exam 3 practice test

Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. Place your answers on the lines provided. 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 the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (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 facility's policy. (1) ___________________ (2) ___________________ (3) ___________________ (4) ___________________ (5) ___________________ (6) ___________________

(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 care plan. (4) Systematic: The nurse gathers the information in an organized manner. (5) Accurate and relevant: The nurse verifies that the information is reliable. (6) Recorded in a standard format: The nurse records the data according to the facility's policy so that all caregivers can easily access what is learned.

A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client's postoperative period? 1) Turning frequently 2) Raising side rails on the bed 3) Providing range-of-motion exercises 4) Massaging the back three times a day

1

A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention? 1) Attempt to identify the client's concerns. 2) Reassure the client that the surgery is routine. 3) Report the client's anxiety to the healthcare provider. 4) Provide privacy by pulling the curtain around the client.

1

A nurse is assessing a child who is accompanied by a parent. The parent has remarried and has another child from the second marriage. What kind of a family does this child belong to? 1) Blended family 2) Extended family 3) Alternative family 4) Single-parent family

1

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? 1) Visceral pain 2) Somatic pain 3) Referred pain 4) Intractable pain

1

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and doing what next? 1) Bending and then straightening their knees 2) Bending at the waist and then straightening the back 3) Placing one foot in front of the other and then leaning back 4) Placing pressure against the client's axillae and then raising their arms

1

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect? 1) Demonstration of a personal bias 2) Problem solving based on assessment 3) Determination of client acuity to set priorities 4) Consideration of the complexity of client care

1

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is, "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? 1) Focusing 2) Restating 3) Exploring 4) Accepting

1

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? 1) Data collection 2) Data validation 3) Data clustering 4) Data interpretation

1

The nurse at the well baby clinic is assessing the gross motor skills of a five-month-old infant. Which finding is a cause for concern? 1) The baby has a head lag when pulled to sit. 2) The baby can turn from the side to the back. 3) The baby can turn from the abdomen to the back. 4) The baby supports much of his own weight when he or she is pulled to stand.

1

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? 1) Exploring 2) Reflecting 3) Refocusing 4) Acknowledging

1

Which approach is a comforting approach that communicates concern and support? 1) Touch 2) Listening 3) Knowing the client 4) Providing a positive presence

1

Which nurse collaborates directly with the client to establish and implement a basic plan of care after admission? 1) Primary nurse 2) Nurse clinician 3) Nurse coordinator 4) Clinical nurse specialist

1

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? 1) Pain 2) Anxiety 3) Depression 4) Fluid volume deficit

1 Rationale: A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior.

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? 1) Cliché 2) Giving advice 3) Being judgmental 4) Changing the subject

1 Rationale: Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition.

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? 1) "New mothers need support." 2) "The lack of a father is difficult." 3) "How are you today?" 4) "It is a very sad situation."

1 Rationale: The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles.

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? 1) Determining the progress made in achieving established goals 2) Clarifying when the patient should take medications 3) Reporting the progress made in teaching to the staff 4) Including all family members in the teaching session

1 Rationale: The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coordinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care.

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. 1) Group decision making 2) Group leadership 3) Group power 4) Group identity 5) Group patterns of interaction 6) Group cohesiveness

1, 4, 5, 6 Rationale: Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes.

A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? 1) A closed-ended answer 2) Information clarification 3) The nurse to give advice 4) Assertive behavior

2 Rationale: The patient's question allows the nurse to clarify information that is new to the patient or that requires further explanation.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1) Limit the client's fluid intake. 2) Teach the client how to exercise the legs. 3) Encourage use of the incentive spirometer. 4) Maintain the knee gatch position at an angle.

2

A nurse is taking the vital signs of a client who has just been admitted to the healthcare facility. Which intervention by the nurse provides greater client satisfaction? 1) The nurse records the vital signs and leaves the room. 2) The nurse adjusts the bed and asks if the client is comfortable. 3) The nurse leaves the door of the room open while attending to the client. 4) The nurse tells the client that the primary healthcare provider will visit soon.

2

The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source? 1) X-ray reports 2) Severity of pain 3) Results of blood work 4) Family caregiver interview

2

Which client assessment finding should the nurse document as subjective data? 1) Blood pressure 120/82 beats/min 2) Pain rating of 5 3) Potassium 4.0 mEq 4) Pulse oximetry reading of 96%

2

A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? 1) "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." 2) "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" 3) "I will need to call in on the 8th of August because I have a doctor's appointment." 4) "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

2 Rationale: Effective communication by the sender involves the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time.

A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? 1) "Would you prefer a bath or a shower?" 2) "May I help you with a bed bath now or later this morning?" 3) "I will be giving you your bath. Do you use soap or shower gel?" 4) "I prefer a shower in the evening. When would you like your bath?"

2 Rationale: The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones.

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1) Lactated Ringer solution 2) 5% dextrose and water 3) 0.9% normal saline 4) 0.45% normal saline

3

A client tells the nurse, "I am so worried about the results of the biopsy they took today." The nurse overhears the nursing assistant reply, "Don't worry. I'm sure everything will come out all right." What does the nurse conclude about the nursing assistant's answer? 1) It shows empathy. 2) It uses distraction. 3) It gives false reassurance. 4) It makes a value judgment.

3

A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen? 1) The oxygen had not been prescribed and therefore should not have been administered. 2) The symptoms were too vague for the nurse to determine a need for administering oxygen. 3) The nurse's observations were sufficient, and therefore oxygen should have been administered. 4) The primary healthcare provider should have been called for a prescription before the nurse administered the oxygen.

3

An adolescent who had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? 1) "I can ride my bike in about a week." 2) "I don't have to go to gym class for 3 months." 3) "I can't perform any weightlifting for at least 6 weeks." 4) "I can never participate in football again."

3

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1) Red blood cell count 2) Sputum culture 3) Arterial blood gas 4) Total hemoglobin

3

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1) The nurse notes nonverbal signs of discomfort. 2) The nurse observes the client's position in bed. 3) The nurse asks the client to explain the surgery. 4) The nurse asks the client to rate the severity of pain.

3

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1) Crohn disease 2) Cushing disease 3) End-stage renal disease 4) Gastroesophageal reflux disease

3

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1) Increase fluid intake. 2) Restrict fluids. 3) Encourage early mobility. 4) Elevate the knee gatch of the bed.

3

Which developmental changes should be evaluated in girls around 12 years of age? 1) Motor skills 2) Visual acuity 3) Skeletal growth 4) Hormonal changes

3

Which term refers to the exaggeration of the posterior curvature of the thoracic spine? 1) Lordosis 2) Scoliosis 3) Kyphosis 4) Osteoporosis

3

A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? 1) Determining the established goals of the institution 2) Ensuring that verbal and nonverbal communication is congruent 3) Engaging in self-talk to plan the day and decrease fear 4) Speaking with fellow colleagues about how they feel

3 Rationale: By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety.

Which are extrinsic factors responsible for falls in older adults? Select all that apply. 1) Impaired vision 2) Cognitive impairment 3) Environmental hazards 4) Inappropriate footwear 5) Improper use of assistive devices

3, 4, 5

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. 1) Fill the silence with lighter conversation directed at the patient. 2) Use the time to perform the care that is needed uninterrupted. 3) Discuss the silence with the patient to ascertain its meaning. 4) Allow the patient time to think and explore inner thoughts. 5) Determine if the patient's culture requires pauses between conversation. 6) Arrange for a counselor to help the patient cope with emotional issues.

3, 4, 5 Rationale: The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor.

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? 1) Teaching how to make a room allergy-free 2) Referring to a support group for individuals with asthma 3) Arranging with the college to ensure a speedy return to classes 4) Evaluating whether the necessary lifestyle changes are understood

4

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? 1) Time available for care 2) Validity of the problem 3) Method for providing care 4) Effectiveness of the interventions

4

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. What is it important for the nurse to inform the client of? 1) That the client is acting irresponsibly 2) That this action violates the hospital policy 3) That the client must obtain a new primary healthcare provider for future medical needs 4) That the client must accept full responsibility for possible undesirable outcomes

4

The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? 1) All nursing functions will be completed by discharge. 2) All invasive intravenous lines will remain patent. 3) The client will remain awake, alert, and oriented at all times. 4) The client will be free of signs and symptoms of infection by discharge.

4

The nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, what should the nurse do? 1) Prioritize psychosocial needs over physical needs. 2) Use the Nursing Outcomes Classification (NOC) only. 3) Use nursing knowledge to plan outcomes and disregard client and family desires. 4) Set priorities and outcomes using the client's and family input.

4

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer? 1) Place the client in a semi-Fowler position. 2) Stand behind the client during the transfer. 3) Turn the chair so it faces away from the bed. 4) Instruct the client to dangle the legs.

4

Which activity would the nurse explain can be performed by infants of aged 6 to 8 months? 1) Holding a pencil 2) Showing hand preference 3) Placing objects into containers 4) Transferring objects from hand to hand

4

Which activity would the nurse use as an example of fine motor skills of infants aged 2 to 4 months? 1) Turning from side to back 2) Sitting erect using support 3) Showing good head control 4) Bringing objects from hand to mouth

4

Which nursing action indicates that the nurse is actively listening to the client? 1) The nurse states his or her own opinions when the client is speaking. 2) The nurse refrains from telling his or her own story to the client. 3) The nurse reads the client's health record during the conversation. 4) The nurse interprets what the client is saying and reiterates in his or her own words.

4

Which nursing process involves delegation and verbal discussion with the healthcare team? 1) Planning 2) Evaluation 3) Assessment 4) Implementation

4

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? 1) The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." 2) The nurse places a hand on the patient's arm and states, "You feel so alone." 3) The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." 4) The nurse holds the patient's hand and asks, "What makes you feel so alone?"

4 Rationale: The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? 1) "Do you take two injections of insulin to decrease the complications?" 2) "Most health care providers recommend diet and exercise to regulate blood sugar." 3) "Most complications of diabetes are related to neuropathy." 4) "What specific complications have you experienced?"

4 Rationale: Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques.

During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? 1) "You need to speak to the patient quietly so you don't disturb the other patients." 2) "Let me help you with your transfer technique." 3) "When you are finished, be sure to apologize for your rough demeanor." 4) "When your patient is safe and comfortable, meet me at the desk."

4 Rationale: The charge nurse should direct the patient care technician to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic communication.

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? 1) "I'm just the IV therapist checking your IV." 2) "I've been transferred to this division and will be caring for you." 3) "I'm sorry, my name is John Smith and I am your nurse." 4) "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

4 Rationale: The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient.

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? 1) The use of reflective questions 2) The use of closed questions 3) The use of assertive questions 4) The use of clarifying questions

4 Rationale: The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication.

Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow. 1) Self-actualization 2) Love and belonging needs 3) Safety and security 4) Self-esteem 5) Physiological needs

5, 3, 2, 4, 1

A mother comes to the emergency department after receiving a phone call informing her that her son was involved in a motor vehicle accident. When she approaches the triage desk, she frantically asks, "How is my son?" Which response by the nurse is best? 1) "He's being examined now; he's awake and talking. We'll take you to see him soon." 2) "Don't worry, I'm sure he'll be fine; we have an excellent trauma team caring for him." 3) "Everything will be okay; please take a seat and I'll check on him for you." 4) "Your son is strong and has youth on his side; I'm sure he'll be fine."

Answer: 1) "He's being examined now; he's awake and talking. We'll take you to see him soon." Rationale:By telling the mother that her son is awake and talking and being examined by the doctor, the nurse provides accurate information and helps reduce the mother's anxiety. Responses such as "Don't worry, everything will be okay" and "I'm sure he'll be fine" offer false reassurance and fail to respect the mother's concern.

A patient is admitted to the medical surgical floor with a kidney infection. The nurse introduces herself to the patient and begins her admission assessment. Which goal is most appropriate for this phase of the nurse-patient relationship? The patient will be able to: 1) Describe how to operate the bed and call for the nurse. 2) Discuss communication patterns and roles within the family. 3) Openly express his concerns about the hospitalization. 4) State expectations related to discharge.

Answer: 1) Describe how to operate the bed and call for the nurse. Rationale:This is the orientation phase of the relationship. The orientation phase begins when the nurse introduces herself to the patient and begins to gather data. In this phase, the nurse and patient are getting to know each other. As part of the orientation phase, the nurse will orient the patient to the hospital room and routines. In the preinteraction phase, the nurse gathers information about the patient before she meets him. Discussion of personal information, particularly if sensitive or complex, is suitable for the working phase of the nurse-patient interaction. The patient expressing feelings and concerns also occurs during the working phase. During the working phase, care is communicated, thoughts and feelings are expressed, and honest verbal and nonverbal communication occurs. Stating expectations related to discharge is most appropriate for the termination phase—the conclusion of the relationship.

What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse to: 1) Identify personal biases that may affect his thinking and actions 2) Identify the most effective interventions for a patient 3) Communicate more efficiently with colleagues, patients, and families 4) Learn and remember new procedures and techniques

Answer: 1) Identify personal biases that may affect his thinking and actions Rationale:The most basic reason is that self-knowledge directly affects the nurse's thinking and the actions he chooses. Indirectly, thinking is involved in identifying effective interventions, communicating, and learning procedures. However, because identifying personal biases affects all the other nursing actions, it is the most basic reason.

How are critical thinking skills and critical thinking attitudes similar? Both are: 1) Influences on the nurse's problem solving and decision making 2) Like feelings rather than cognitive activities 3) Cognitive activities rather than feelings 4) Applicable in all aspects of a person's life

Answer: 1) Influences on the nurse's problem solving and decision making Rationale:Cognitive skills are used in complex thinking processes, such as problem solving and decision making. Critical thinking attitudes determine how a person uses her cognitive skills. Critical thinking attitudes are traits of the mind, such as independent thinking, intellectual curiosity, intellectual humility, and fair-mindedness, to name a few. Critical thinking skills refer to the cognitive activities used in complex thinking processes. A few examples of these skills involve recognizing the need for more information, recognizing gaps in one's own knowledge, and separating relevant from irrelevant data. Critical thinking, which consists of intellectual skills and attitudes, can be used in all aspects of life.

Which factor(s) in the patient's past medical history place(s) him at risk for falling? Select all that apply. 1) Orthostatic hypotension 2) Appendectomy 3) Dizziness 4) Hyperthyroidism

Answer: 1) Orthostatic hypotension 3) Dizziness Rationale:Orthostatic hypotension, cognitive impairment, difficulty with walking or balance, weakness, dizziness, and drowsiness from certain medications place the patient at risk for falling. A history of right appendectomy and hyperthyroidism do not place that patient at risk for falling.

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? 1) Sims' 2) Supine 3) Dorsal recumbent 4) Semi-Fowler's

Answer: 1) Sims' Rationale:Sims' position is typically used to examine the rectal area. However, the position should be avoided if the patient has undergone hip replacement surgery The patient with a hip replacement can assume the supine, dorsal recumbent, or semi-Fowler's positions without causing harm to the joint. Supine position is lying on the back facing upward. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. In semi-Fowler's position, the patient is supine with the head of the bed elevated and legs slightly elevated.

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? 1) Sitting upright 2) Lying flat on the back with knees flexed 3) Lying flat on the back with arms and legs fully extended 4) Side-lying with the knees flexed

Answer: 1) Sitting upright Rationale:If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally, patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on the back) and can have direct eye contact with the examiner. However, other positions can be suitable when the patient's physical condition restricts the comfort or ability of the patient to sit upright.

During a presentation at a nursing staff meeting, the unit manager speaks very slowly with a monotone. She uses medical and technical terminology to convey her message. Dressed in business attire, the manager stands erect and smiles occasionally while speaking. Which elements of her approach are likely to cause the staff to lose interest in what she has to say? Select all answers that apply. 1) Slow speech 2) Monotone 3) Occasional smile 4) Formal dress

Answer: 1) Slow speech 2) Monotone Rationale:Speaking slowly with a monotone can contribute to reduced attention as the listener can think faster than the speaker is speaking, and the monotone voice has an almost hypnotizing effect. Smiling improves personal interest and connection between the speaker and listener so should not cause a loss of interest. Wearing formal business attire would not directly detract from listeners' engagement in the speaker's message unless it was unusual enough to distract listeners; nothing in the situation above indicates that is so.

The nurse is recording assessment data. She writes, "The patient seems worried about his surgery. Other than that, he had a good night." Which errors did the nurse make? Select all that apply. 1) Used a vague generality 2) Did not use the patient's exact words 3) Used a "waffle" word (e.g., appears) 4) Recorded an inference rather than a cue

Answer: 1) Used a vague generality 3) Used a "waffle" word (e.g., appears) 4) Recorded an inference rather than a cue Rationale:The nurse recorded a vague generality: "he has had a good night." The nurse did not use the patient's exact words, but she did not quote the patient at all, so that is not one of her errors. The nurse used the "waffle" word, "seems" worried instead of documenting what the patient said or did to lead her to that conclusion. The nurse recorded these inferences: worried and had a good night.

For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques?A. Palpation B. Auscultation C. Inspection D. Percussion 1) D, B, A, C 2) C, A, D, B 3) B, C, D, A 4) A, B, C, D

Answer: 2) C, A, D, B Rationale:Inspection begins immediately as the nurse meets the patient, as she observes the patient's appearance and behavior. Observational data are not intrusive to the patient. When performing assessment techniques involving physical touch, the behavior, posture, demeanor, and responses might be altered. Palpation, percussion, and auscultation should be performed in that order, except when performing an abdominal assessment. During abdominal assessment, auscultation should be performed before palpation and percussion to prevent altering bowel sounds.

In which step of the nursing process does the nurse analyze data and identify client problems? 1) Assessment 2) Diagnosis 3) Planning outcomes 4) Evaluation

Answer: 2) Diagnosis Rationale:In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client's health status. In the planning outcomes phase, the nurse formulates goals and outcomes. In the evaluation phase, which occurs after implementing interventions, the nurse gathers data about the client's responses to nursing care to determine whether client outcomes were met.

Which situation requires intrapersonal communication? 1) Staff meetings 2) Positive self-talk 3) Shift report 4) Wound care committee meeting

Answer: 2) Positive self-talk Rationale:The nurse engaging in positive self-talk is using intrapersonal communication—conscious internal dialogue. Staff meetings, shift report, and a committee meeting are all examples of group or interpersonal communication.

The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately thinks to herself, "I know I tend to feel negatively about people who use tobacco, especially when they have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember how physically and psychologically difficult that is, and be very careful not to let be judgmental of this patient." This best illustrates: 1) Theoretical knowledge 2) Self-knowledge 3) Using reliable resources 4) Use of the nursing process

Answer: 2) Self-knowledge Rationale:Personal knowledge is self-understanding—awareness of one's beliefs, values, biases, and so on. That best describes the nurse's awareness that her bias can affect her patient care. Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena. Using reliable resources is a critical thinking skill. The nursing process is a problem-solving process consisting of the steps of assessing, diagnosing, planning outcomes, planning interventions, implementing, and evaluating. The nurse has not yet met this patient, so she could not have begun the nursing process.

In which phase of the nursing process does the nurse decide whether her actions have successfully treated the client's health problem? 1) Assessment 2) Diagnosis 3) Planning outcomes 4) Evaluation

Answer: 4) Evaluation Rationale:In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. In the diagnosis phase, the nurse identifies the client's health status. In the planning outcomes phase, the nurse and client decide on goals they want to achieve. In the intervention planning phase, the nurse identifies specific interventions to help achieve the identified goal. During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem.

The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? 1) Dorsal recumbent 2) Semi-Fowler's 3) Lithotomy 4) Sims'

Answer: 2) Semi-Fowler's Rationale:If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed elevated. Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position, except that the patient's legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep patient covered as much as possible. The patient in Sim's position is on left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm is placed comfortably. Sims' position is used to examine the rectal area. In semi-Fowler's position, the patient is supine with the head of the bed elevated and legs slightly elevated.

Which of the following is an example of data that should be validated? 1) The urinalysis report indicates there are white blood cells in the urine. 2) The client states she feels feverish; you measure the oral temperature at 98°F. 3) The client has clear breath sounds; you count a respiratory rate of 18. 4) The chest x-ray report indicates the client has pneumonia in the right lower lobe.

Answer: 2) The client states she feels feverish; you measure the oral temperature at 98°F. Rationale:Validation should be done when subjective and objective data do not make sense. For instance, it is inconsistent data when the patient feels feverish and you obtain a normal temperature. The other distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results.

A local church organizes a group for people who are having difficulty coping with the death of a loved one. Which type of group has been organized? 1) Work-related social support group 2) Therapy group 3) Task group 4) Community committee

Answer: 2) Therapy group Rationale:Therapy groups are designed to help individual members cope with issues, such as the death of a spouse, divorce, or motherhood. Work-related social support groups help members of a profession cope with work-associated stress. Task groups meet to accomplish a specified task. Community-based committees meet to discuss community issues.

Arrange the steps of the nursing process in the sequence in which they generally occur. A. Assessment B. Evaluation C. Planning outcomes D. Planning interventions E. Diagnosis 1) E, B, A, D, C 2) A, B, C, D, E 3) A, E, C, D, B 4) D, A, B, E, C

Answer: 3) A, E, C, D, B Rationale:Logically, the steps are assessment, diagnosis, planning outcomes, planning interventions, and evaluation. Keep in mind that steps are not always performed in this order, depending on the patient's needs, and that steps overlap.

A woman of Orthodox Jewish faith who underwent a hysterectomy for cancer is being cared for on the surgical floor. Which healthcare team member(s) could be assigned to bathe this patient? Choose all correct answers. 1) Male nursing assistant 2) Male licensed practical nurse 3) Female graduate nurse 4) Female registered nurse

Answer: 3) Female graduate nurse 4) Female registered nurse Rationale:Orthodox Judaism prohibits personal care being provided by a member of the opposite sex. The patient who underwent a hysterectomy is female; therefore, out of respect for her religious beliefs, she should not be bathed by the male licensed practical nurse or nursing assistant.

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? 1) Ongoing assessment 2) Comprehensive physical assessment 3) Focused physical assessment 4) Psychosocial assessment

Answer: 3) Focused physical assessment Rationale:The nurse is performing a focused physical assessment, which is done to obtain data about an identified problem, in this case shortness of breath. An ongoing assessment is performed as needed, after the initial data are collected, preferably with each patient contact. A comprehensive physical assessment includes an interview and a complete examination of each body system. A psychosocial assessment examines both psychological and social factors affecting the patient. The nurse conducting a psychosocial assessment would gather information about stressors, lifestyle, emotional health, social influences, coping patterns, communication, and personal responses to health and illness, to name a few aspects.

The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data collection form organized according to (select all that apply): 1) A body systems model 2) A head-to-toe framework 3) Maslow's hierarchy of needs 4) Gordon's functional health patterns

Answer: 3) Maslow's hierarchy of needs 4) Gordon's functional health patterns Rationale:Nursing models produce a holistic database that is useful in identifying nursing rather than medical diagnoses. Body systems and head-to-toe are not nursing models, and they are not holistic; they focus on identifying physiological needs or disease. Maslow's hierarchy is not a nursing model, but it is holistic, so it is acceptable for identifying nursing diagnoses. Gordon's functional health patterns are a nursing model.

When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? 1) NA 2) NDA 3) NKA 4) NPO

Answer: 3) NKA Rationale:The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NA is an abbreviation for not applicable. NDA is an abbreviation for no known drug allergies. NPO is an abbreviation that means nothing by mouth.

The nurse suspects that a patient is being physically abused at home. What is the best environment in which to discuss the possibility of abusive events? 1) The patient's shared semiprivate room 2) The hallway outside the patient's room 3) An empty corner at the nurse's station 4) A conference room at the end of the hall

Answer: 4) A conference room at the end of the hall Rationale:The best environment in which to discuss sensitive matters is a quiet room where conversation can occur in private, particularly when the space is nonthreatening. The patient might be distracted if conversation takes place in a room where others (e.g., patients and visitors) are present. The hallway outside the patient's room and the nurses' station are public areas and should not be used for private conversation.

A patient is agitated and continues to try to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next? 1) Apply a vest restraint. 2) Move the patient to a quieter room. 3) Ask another nurse to care for the patient. 4) Provide comfort measures.

Answer: 4) Provide comfort measures. Rationale:Patients sometimes become agitated because they are uncomfortable or in pain. Providing comfort measures may decrease agitation. If the patient continues to be agitated, the nurse should encourage a family member or friend to sit with the patient. Applying a physical restraint should be kept as a last resort for use only when less restrictive measures fail. The patient should be placed in a room near the nurses' station so he can be checked frequently if there is no one available to provide one-on-one supervision. A quieter room would probably not help.

Which of the following is an example of appropriate behavior when conducting a client interview? 1) Recording all the information on the agency-approved form during the interview 2) Asking the client, "Why did you think it was necessary to seek health care at this time?" 3) Using precise medical terminology when asking the client questions 4) Sitting, facing the client in a chair at the client's bedside, using active listening

Answer: 4) Sitting, facing the client in a chair at the client's bedside, using active listening Rationale:Active listening should be used during an interview. The nurse should face the patient, have relaxed posture, and keep eye contact. Asking "why" may make the client defensive. Note-taking interferes with eye contact. The client may not understand medical terminology or health care jargon.

A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk for Impaired Skin Integrity? 1) Age 2) Weight 3) Dehydration 4) Impaired nutrition

Answer: Dehydration Rationale:Dehydration places the patient at risk for impaired skin integrity. Dehydration, caused by fluid volume deficit, causes the skin to become dry and crack easily, impairing skin integrity. People who are very thin or very obese are more likely to experience impaired skin integrity. This patient is of normal height and weight; therefore, his body stature does not place him at risk. There is nothing to suggest that this patient has an impaired nutritional status.

The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? 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 Rationale: A standard, or a 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, appropriate 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.

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." What would be the instructor's BEST response to this student's diagnosis? a. "Was this diagnosis derived from a cluster of significant data or a single clue?" b. "This early diagnosis will help us manage the problem before it becomes more acute." c. "Have you determined if this is an actual or a possible diagnosis?" d. "This condition is a medical problem that should not have a nursing diagnosis."

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

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 Rationale: 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 accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.

The nurse collects objective and subjective data when conducting patient assessments. Which patient situations 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 that the skin on her arms is tingling. 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 Rationale: 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, tingling, 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°F), edema, and vomiting.

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 Rationale: 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 judgment 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.

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest 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 bed rest c. As evidenced by d. As evidenced by reddened areas of skin on the heels and back

b Rationale: "Related to prescribed bed rest" 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 working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written 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-lb 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. (1), (2), (3), (4), and (5)

b Rationale: (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 which blames home health aides for the patient's problem. Statements that may be interpreted as libel or that imply nursing negligence are legally hazardous to all the nurses caring for the patient. Assigning blame in the written record is problematic.

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

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

A nurse is performing an initial comprehensive assessment of a 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 this nurse following? a. Maslow's human needs b. Gordon's functional health patterns c. Human response patterns d. Body system model

b Rationale: 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.

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 baseline 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 facility has its own assessment form you must use."

b Rationale: Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when 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 facility assessment tools does not allow for individualized patient care or critical thinking.

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 Rationale: 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 nurse is planning care for a patient who was 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 Rationale: 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 patient outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diagnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

A nurse is caring for a 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 Rationale: 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, and "potential complication: sepsis" is a collaborative problem.

A registered nurse is writing a diagnosis for a patient who is in traction because of 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 assesses the patient's mental status. f. The nurse identifies community resources to help his family cope.

b, d, f Rationale: 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. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to 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 nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? a. Inform the charge nurse. b. Inform the surgeon. c. Validate the finding. d. Document the finding.

c Rationale: 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 nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient 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 Rationale: Altered Health Maintenance is a nursing problem, because the diagnosis 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.

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. (1), (2), (3), and (4)

d Rationale: 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.

A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing 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 Rationale: 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 Rationale: Quick priority assessments (QPAs) 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 facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? a. Thank the wife for being present. b. Ask the wife if she wants to remain. c. Ask the wife to leave. d. Ask the patient if he would like the wife to stay.

d Rationale: The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse 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.