PrepU Chp.2

Which of the following nursing diagnoses has the highest priority when caring for an older adult client with Alzheimer's disease? a) Risk for injury b) Impaired physical mobility c) Impaired memory d) Self-care deficit

a) Risk for injury

The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal? a) Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear. b) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. c) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma. d) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased.

b) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics? a) Wellness diagnosis b) Possible nursing diagnosis c) Actual nursing diagnosis d) Risk nursing diagnosis

c) Actual nursing diagnosis

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? a) Complete b) Time-lapse c) Focused d) General

c) Focused

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? a) Risk b) Actual c) Possible d) Wellness

b) Actual

The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required? a) "Nursing interventions must be approved by other members of the health care team." b) "Nursing interventions must be consistent with standards of care and research findings." c) "Nursing interventions must be compatible with other therapies planned for the client." d) "Nursing interventions must be culturally sensitive and individualized for the client."

a) "Nursing interventions must be approved by other members of the health care team."

Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes? a) Evaluation b) Assessment c) Planning d) Implementation

a) Evaluation

What nursing organization first legitimized the use of the nursing process? a) American Nurses Association b) State Board of Nursing c) National League for Nursing d) International Council of Nursing

a) American Nurses Association

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? a) Ineffective health maintenance related to client's denial of illness b) Risk for injury related to client's mismanagement of disease c) Ineffective coping related to client's inability to manage the diabetic regimen d) Risk for unstable blood glucose related to client's reluctance to manage the diabetic regimen

a) Ineffective health maintenance related to client's denial of illness

A preceptor reviews the client outcomes written by a new nurse. Which outcome is the highest priority for the client with paranoid delusions? a) Within 3 days, client will mingle in the day room without violence. b) Within 2 days, client will perform personal hygiene without reminders. c) Client will verbalize side effects of antipsychotic medications within 24 hours. d) Client will discuss delusions in therapy sessions before discharge.

a) Within 3 days, client will mingle in the day room without violence.

A client has just been taught about lowering cholesterol with diet and exercise. What is the best way to evaluate that the client understands the material? a) Accept silence as client understanding. b) Ask direct questions about the teaching plan. c) Allow the client to discuss personal issues. d) Redirect conversation to the topic.

b) Ask direct questions about the teaching plan.

One hour after receiving pain medication, a postoperative client complains of intense pain. What is the nurse's most appropriate first action? a) Discuss the frequency of pain medication administration with the client. b) Assess the client to determine the cause of the pain. c) Assist the client to reposition and splint the incision. d) Consult with the physician for additional pain medication.

b) Assess the client to determine the cause of the pain.

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? a) Plan to decrease the pain medication next time. b) Document the effectiveness of the intervention. c) Instruct the client to use imaging and slow breathing. d) Instruct the client to wait as long as possible to ask for medication.

b) Document the effectiveness of the intervention.

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make? a) "Nursing diagnoses are used to bill insurance for nursing care." b) "Nursing diagnoses are necessary to schedule the amount of nursing care required by the client." c) "Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions." d) "Nursing diagnoses are necessary to validate the medical diagnosis."

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

When a nurse notices the client is in pain and needs to learn to walk on crutches, which outcome identification is the priority? a) Capillary refill b) Safe walking c) Pain management d) Crutch walking

c) Pain management

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? a) Ineffective coping b) Impaired urinary elimination c) Risk for body image disturbance d) Ineffective airway clearance

c) Risk for body image disturbance

Which nursing action reflects evaluation? a) The nurse sets an anxiety level of 3 or less with the client. b) The nurse identifies that the client has wound drainage. c) The nurse performs a colostomy irrigation. d) The nurse assesses the client's response to pain medication.

d) The nurse assesses the client's response to pain medication.

Implementation of the plan of care is most successful when: a) the nurse avoids further collecting of data until the evaluation phase. b) the nurse takes on care and decision making for the patient. c) the nurse recognizes documentation will occur during another phase. d) the nurse includes family members and other healthcare professionals.

d) the nurse includes family members and other healthcare professionals.

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem? a) Investigate the circumstances that contributed to client falls b) Reprimand the nursing personnel responsible for the clients when the falls occurred c) Institute a new policy on the prevention of client falls on the unit d) Determine if client falls have increased on other nursing units in the hospital

a) Investigate the circumstances that contributed to client falls

The nurse is caring for a client admitted to the hospital for renal calculi. What is the best action to take first? a) Assess for bladder distention. b) Force fluids by mouth. c) Diet as tolerated. d) Strain urine after each void.

a) Assess for bladder distention.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority? a) Inform the client what to expect after the surgery. b) Discuss discharge plans with the client. c) Instruct the client and family in wound care. d) Teach the client about dietary restrictions during recovery.

a) Inform the client what to expect after the surgery.

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? a) Tell the client to report any side effects experienced. b) Assess the client's blood pressure to determine if the medication is indicated. c) Determine the client's reaction to the medication in the past. d) Ask the client to verbalize the purpose of the medication.

b) Assess the client's blood pressure to determine if the medication is indicated.

A client is being admitted from the emergency room with complaints of shortness of breath, wheezing, and coughing. Which of the following would the nurse as an appropriate nursing diagnosis? a) Bronchial pneumonia b) Ineffective airway clearance c) Asthma attack d) Acute dyspnea

b) Ineffective airway clearance

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." In order to assure the safety of the client, what nursing diagnosis would the nurse address? a) Knowledge deficit related to surgical procedure b) Risk for allergy response related to latex allergy c) Risk for injury related to latex allergy d) Anxiety related to surgical procedure

b) Risk for allergy response related to latex allergy

The client's expected outcome is "The client will maintain skin integrity by discharge." Which of the following measures is best in evaluating the outcome? a) The client's ability to reposition self in bed. b) Percent intake of a diet high in protein. c) Condition of the skin over bony prominences. d) Pressure-relieving mattress on the bed.

c) Condition of the skin over bony prominences.

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? a) Revise the plan to include the inclusion of a support group. b) Report the client's inability to learn to the case manager. c) Reassess the appropriateness of the method of instruction. d) Teach the content again utilizing the same method.

c) Reassess the appropriateness of the method of instruction.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include? a) Medications used to treat diabetes mellitus b) The cellular metabolism of glucose c) Risk factors and prevention of diabetes mellitus d) The severity of the client's disease

c) Risk factors and prevention of diabetes mellitus

Which of the following best summarizes the evaluating step of the nursing process? a) The nurse and client identify nursing diagnoses and appropriate interventions. b) The nurse completes a health assessment to establish a database. c) The nurse and client measure achievement of planned outcomes of care. d) The client and family have met health care goals and no longer need care.

c) The nurse and client measure achievement of planned outcomes of care.

Which of the following group of terms best defines assessing in the nursing process? a) Design a plan of care, implement nursing interventions b) Problem focused, time lapsed, emergency based c) Nurse focused, establishing nursing goals d) Collection, validation, communication of client data

d) Collection, validation, communication of client data

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? a) Continue assisting the client to the bathroom to ensure the client's safety. b) Instruct the client's family to assist the client to ambulate to the bathroom. c) Consult with the physical therapist to determine the client's ability. d) Revise the care plan to allow the client to ambulate to the bathroom independently.

d) Revise the care plan to allow the client to ambulate to the bathroom independently.