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A staff nurse comments to the charge nurse that it is unnecessary to know how to formulate nursing diagnoses because the computerized documentation system generates them automatically. What is the most appropriate response by the charge nurse?

"A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated."

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate?

"I would like to schedule a time for me to perform a nursing history. It will take around 30 to

A nurse is applying Tanner's clinical judgment model in the care of a postpartum client. Which action by the nurse will constitute the first step in this process?

noticing the significant aspects of the client's condition

A nurse is applying Tanner's clinical judgment model to the care they provide. What action characterizes the first step in this process?

noticing what is significant about the client's status and circumstances

The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first

inspection

Which comprehensive assessment finding(s) will the nurse identify as objective data? Select all that apply.

laboratory test results breath sounds on auscultation laboratory test results breath sounds on auscultation

A nurse would like to study the effect that a new hand washing technique has on client infection rates. What is the independent variable?

new hand washing technique

The nurse is applying Tanner's Clinical Judgment Model in the care of a client. Building off the context and background information, place the components of the model in the correct sequence. Use all options.

noticing interpreting responding reflecting

Which nursing diagnosis is written incorrectly as a result of the health problem and etiology being reversed?

Prolonged Immobility related to impaired skin integrity

A nurse is conducting a review course on learning for nurses working in the community health center. The nurse explains the impact of experiential learning on clinical decision-making and clinical judgment. The nurse determines that the teaching was successful when the group makes which statement?

"Learning is ongoing and builds on previous experience."

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"Please tell me your thoughts about treating this diagnosis."

A nursing theorist examines a hospital environment by studying each ward and how it works individually, and then relates this information to the hospital as a whole working entity. This is an example of the use of which theory?

1. General systems theory

Which scenario is an example of a time-lapse reassessment?

A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

A nurse has recommended a regimen of over-the-counter medications for a client who has seasonal allergies. A colleague contends that the nurse has exceeded the scope of nursing practice by recommending medications to a client. To resolve this difference of opinion, the nurses should consult resources from what organization?

American Nurses Association

A community health nurse has been visiting a diabetic client whose morning fasting glucose levels are constantly elevated. Upon further assessment, the nurse determines that the client's spouse does not understand how to prepare meals following the prescribed diabetic diet. Using Dorothea Orem's Self-Care Theory, how can the nurse help meet the needs of this client?

Arrange an evaluation appointment with a dietitian.

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview?

Avoid the impulse to interrupt

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence

A nurse develops the following foreground question using the PICOT format in preparation for a research study: "In overweight clients, how do chromium supplements compared to no supplements help with weight loss?" Which part of the question reflects the intervention?

Chromium supplements

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this infant, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

What nursing activity forms the bridge between theory and practice?

Evidence-based research Evidence-based research is translational research that forms the bridge between theory and practice. Theoretical writing focuses on theory. Client-focused care and case management are focused on practice.

Which activity best helps the nurse apply theory to practice?

Evidence-based research Evidence-based research is translational research that forms the bridge between theory and practice. Theory development is how desirable change in society is best achieved. Client-focused care is care provided to a client that maintains the client as a functional component of healthcare team. Case management is when care is provided to an individual client by a healthcare provider.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

Who is considered to be the first nursing theorist who conceptualized nursing in terms of manipulating the environment?

Florence Nightingale

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

Which activities does the nurse perform during the diagnosing stage? Select all that apply.

Identify factors contributing to the client's health problem. Prioritize the client's health problems with input from the client. Validate the identified health problems with the clients.

A skilled nurse is providing care for a client with mental health needs who is recovering from a stroke. The client is experiencing dysphagia (difficulty swallowing), so the nurse is working together with the speech-language pathologist (SLP) to ensure the client's cooperation with a swallowing assessment. This nurse's action best demonstrates:

Interprofessional Education Collaborative (IPEC) core competencies.

Which is the most appropriate reason for a nurse to ask a client what the client would like to be called?

It communicates respect for the client.

A nurse is participating in a task force that has been formed at a hospital to increase interdisciplinary collaboration. Specifically, the task force is pursuing the competencies of the Interprofessional Education Collaborative (IPEC). What goal indicates the achievement of these competencies?

Members of diverse disciplines will collaborate on decision-making in an environment of mutual respect.

A nurse is planning to conduct a nursing research study and is seeking federal funding. Which institution would be most helpful for the nurse to contact regarding acquiring funding?

National Institute of Nursing Research

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the health care provider for additional orders.

A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care?

Nursing diagnosis

Which is most important for the nurse to include in a client's plan of care?

Nursing interventions

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective

After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first?

Review the client's recent food and fluid intake.

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan?

Risk for Allergy Response related to latex allergy

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

Start from client's knowledge, teach about diet modifications, and check for learning.

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing.

The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of being pregnant. What assessment data would be appropriate to lead the nurse to select this diagnosis?

The client states, "I do not know how to take care of an infant."

A nurse is using quantitative research for a question related to nursing practice. When conducting the research, which aspect would the nurse need to keep in mind? Select all that apply.

The focus needs to be holistic. Concepts are fairly well-developed. An existing body of literature is available. Data are collected in real-world settings. Statistical processes are used to interpret the data.

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments?

The nurse

A community health nurse has a reputation that is described as "stellar" by peers and colleagues. Apart from the nurse's years of experience, the nurse's skillfulness is the attribute most described by others. According to cognitive continuum theory (CCT), what characteristic of the nurse suggests that the nurse has achieved the highest level of competence?

The nurse is able to apply intuition to complex clinical scenarios.

A student nurse who is soon to graduate is completing a preceptorship with a nurse who has many years of clinical experience. The student has marveled at the nurse's ability to derive meaning from complex and rapidly changing situations, relying heavily on nurse intuition. What characteristic of this nurse does this ability demonstrate most clearly?

The nurse is an expert, according to Benner's novice-to-expert model of development.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

The nurse uses open-ended questions when working with a crying client.

For which scenario will the nurse consult resources from the American Nurses Association?

The nurse is unsure whether a particular intervention is in the nursing scope of practice.

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern.

A student nurse has been challenged to apply the principles of critical thinking during laboratory simulations. What characteristic of the student nurse's actions suggests that the student nurse engaged in critical thinking?

The student nurse thought systematically and reflectively before deciding what to do.

Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include?

Tracheobronchial suctioning

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first?

Validate the questionable data.

A novice nurse is sharing a newly published research article which outlines a different approach in preventing a wound infection after surgery with a colleague and states the nurse is going to try this new method. Which is the best response from the colleague?

Wait until the method is analyzed to ensure it will be appropriate for their clients. Before adopting any new practices presented in research or a study, nurses should take time to ensure it will be appropriate for their clients and suitable for their situation. The nurse should not assume that just because something has been published, it will be appropriate for their situation. It must be analyzed by their facility to ensure it has been properly analyzed and approved for use before implementing. There is no need for the nurses to conduct their own research before implementing the changes.

A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being:

able to prioritize.

The nurse on the night shift is caring for a hospitalized client who reports being unable to sleep. The client states, "I just cannot sleep here. I miss my home. There are too many lights and it is too hot." Which nursing concern does the nurse identify?

altered sleep pattern

The nurse has completed a comprehensive assessment of the client and is now organizing data. Which finding(s) does the nurse categorize as subjective data? Select all that apply.

anxiety light-headedness nausea

What action by the nurse in a hospital setting best exemplifies the goals of the Interprofessional Education Collaborative (IPEC) core competencies?

coordinating with the physical therapist to amend a client's activity orders in the plan of care

A nurse is providing care to several clients. Which situation(s) reflects the nurse using clinical judgment? Select all that apply.

deciding on appropriate actions based on the facility's approved algorithm providing evidence to revise a current protocol for intravenous insertion gathering additional assessment findings to support changes in a client's status

An experienced nurse draws on a variety of models, frameworks, and concepts related to clinical judgment, depending on the particular circumstance. Which clinical scenario will be directly addressed by Rest's framework?

decision-making with regard to assigning scarce organs for transplant when many people require organs

After meeting with a client and their family, the nurse has identified a nursing diagnosis of Effective Family Coping. In this diagnosis, the term "Effective" constitutes what part of the nursing diagnosis?

descriptor

n a 1983 study, the Institute of Medicine (IOM) urged the federal government to increase the level of funding for nursing research. What historical development resulted from this action?

establishment of the National Institute of Nursing Research (NINR)

A new client is suffering from confusion and is unable to provide detailed or consistent information about their health history. Whom should the nurse consult about the client's past history?

family

When the nurse inspects a postoperative incision site for infection, which type of assessment is the nurse performing?

focused

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

functional assessment

Rapid growth in nursing research took place in the 1970s and 1980s. This was largely a result of which phenomenon?

increased numbers of nurses with master's degrees

During assessment, a client verbalizes specific preferences for communication and care to the nurse. The nurse communicates this information to other members of the health care team. The nurse is demonstrating which QSEN competency?

patient-centered care

During assessment, a client verbalizes specific preferences for communication and care to the nurse. The nurse communicates this information to other members of the healthcare team. The nurse is demonstrating which QSEN competency?

patient-centered care

A client is being transferred to a rehabilitation facility. The nurse is giving a handoff report to the receiving nurse at the facility and provides detailed information about the client's status, care, and progress to ensure that the receiving nurse has all the information needed to provide a seamless transition. The nurse is demonstrating which Quality and Safety Education for Nurses (QSEN) competency?

teamwork and collaboration

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:

the initial comprehensive client assessment.

A nurse is reading an article about competencies developed by numerous professional organizations as a single entity. For which purpose will the nurse integrate knowledge of this information when providing client care?

to foster teamwork

A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered?

Ongoing planning

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client?

Pain

The focus of nursing is always on which of the four common concepts in nursing theory?

Person

Which is a focus of medical research rather than nursing research?

Drug metabolism

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?

Gastrointestinal upset from food poisoning

An experienced nurse has received a new client and will apply the principles of inductive reasoning in the care-planning process. What action will the nurse perform first when applying this form of clinical reasoning?

Gather objective and subjective assessment data.

A nursing theorist examines a hospital environment by studying each ward and how it works individually, and then relates this information to the hospital as a whole working entity. This is an example of the use of which theory?

General systems theory

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?

Health promotion

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?

High Risk for Injury related to unsafe home environment

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight?

Impaired Low Nutritional Intake

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain

Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply.

Impaired mobility due to recent stroke Unable to turn in bed without assistance Uncontrolled diabetes

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

Ineffective Health Maintenance related to client's denial of illness

The nurse has provided analgesia to a client who was reporting pain, and the nurse used the NCSBN Clinical Judgment Measurement Model (CJMM) to inform the process. What action by the nurse represents the final step in this model?

Interprofessional Education Collaborative

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature

The nurse is caring for a hospitalized client. The nurse explains to the client that a care plan will be used for which reason(s)? Select all that apply.

to revise the care provided when planned interventions are not effective to ensure that the client is involved in decision making about car to improve the communication between nurses about the client's care needs

A nurse is discussing dietary issues with a client in the clinic. The client states, "My grandparent always told me that I needed to include milk in my diet so that my muscles would grow." The information that the client is expressing is known as what?

traditional knowledge

Evidence-based care emphasizes decision making based on the best available evidence and:

use of outcome studies to guide decisions.

A nurse enters a client's room and observes the client sitting in a chair looking out the window. The nurse obtains the client's vital signs and gathers information about the client's current level of pain. Based on this information, the nurse identifies a potential problem with pain control and decides to call the provider to obtain a prescription for an analgesic. The nurse is engaged in which action?

using the nursing process

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused.