Nursing Process

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

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

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make?

"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions."

The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply.

A patient tells the nurse that she is feeling nauseous. A patient tells the nurse that she is nervous about her test results. A patient rates his pain as a 7 on a scale of 1 to 10.

Which authoritative statements guide current professional nursing practice?

ANA Standards of Nursing Practice

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

Ask the client to demonstrate self-injection of insulin.

In order to successfully implement the plan of care, what parties are essential for the nurse to include?

Client, family, and physician

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What is the nurse's next action?

Document the effectiveness of the intervention.

A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this client's care?

Educate the client about the benefits of early mobilization and offer to assist him.

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 this nurse following?

Gordon's functional health patterns

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?

Interpersonal

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Make recommendations for revising the plan of care.

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation?

Record an evaluative statement in the client's plan of care.

The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

The nurse is aware that development of nursing diagnoses are:

both within the nursing scope of practice and are client focused.

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

developing the plan without client input

A client has come into the clinic for a postoperative visit. The client states that the postoperative pain continues to be 6 on a 0 to 10 rating scale. The nurse evaluates the client and the current plan of care. Based on the information provided by the client, the nurse should:

modify the plan of care.

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?

to ambulate the client to a bedside chair