PrepU Nursing Process

10. While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking? a. Clarity b. Accuracy c. Precision d. Relevance

Answer 10: a. Explanation: The nurse's question reflects clarity, or the need for more information. Accuracy would be reflected in questions about the information being true. Precision is reflected by questions asking for more details or specifics. Relevance would be reflected by questions related to how something connects to the issue. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; Chapter 10: Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care, 2015: p. 218. Chapter 10: Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care - Page 218

11. During the interview component of the health assessment, how does the nurse convey to the client that the information is important? a. nodding frequently during the interview b. sitting at eye level with the client c. standing next to the client while interviewing d. limiting questions to those with yes or no answers

Answer 11: b. Explanation: When the client responds to a question, convey interest by maintaining eye contact, occasionally nodding, or verbally responding to the client's remarks. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 11: Assessing, p. 245.

13. An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming that afternoon to do some kind of check-up. Which type of check would be most appropriate for the nurse to perform on this client? a. Developmental stage assessment b. Time-lapsed assessment c. Emergency assessment d. Focused assessment

Answer 13: b. Explanation: A time-lapsed assessment is scheduled to compare a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time are scheduled for this type of check. Reference: Taylor, C., et al. Fundamentals of Nursingg, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 11: Assessing, p. 239.

14. A nurse is interviewing a hospitalized patient. Which nurse-patient positioning facilitates an easy exchange of information? a. If the patient is in bed, the nurse stands at the foot of the bed. b. both the nurse and patient are seated, their chairs are at right angles to each other, 30 cm apart. c. If the patient is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. d. If the patient is in bed, the nurse stands at the side of the bed.

Answer 14: c. Explanation: If the patient is in bed, the nurse sitting in a chair placed at a 45-degree angle to the bed ensures the nurse is sitting at eye-level with the patient, which promotes communication. If the nurse is standing at the foot or at the side of the patients bed, an authoritative position is established, which does not promote good communication. If both the nurse and the patient are seated, being 30 cm apart intrudes upon personal space; ideally the nurse and patient should be about 1 metre apart. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 11, Assessment, p. 245.

16. A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? a. Bowel Incontinence b. Ulcerative Colitis c. Irritable Bowel Syndrome d. Small Bowel Obstruction

Answer 16: a. Explanation: Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 258.

17. What is the nurse accountable for, according to state nurse practice acts? a. managing the care team effectively b. making nursing diagnoses c. prescribing PRN (as needed) medications d. mentoring other nurses

Answer 17: b. Explanation: State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held accountable. Overall management of the care team is not an explicit responsibility of nurses. Nurses generally do not have prescriptive authority. The responsibility for mentorship is not enacted in law. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 255-256.

18. 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? a. Notify the physician for additional orders. b. Document the client's level of consciousness. c. Consult with another nurse to validate the assessment. d. Decrease stimulation and allow the client to rest.

Answer 18: a. Explanation: The client's decreased level of consciousness could indicate that the client is developing an electrolyte imbalance. The change in the client's status requires notification of the physician. Medication orders are required to treat the electrolyte imbalance. Documenting the level of consciousness is appropriate, but not as the priority action. Another nurse is not necessary to check the nurse's assessment. Decreasing stimulation and allowing the client to rest with no further action may result in harm to the client. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 12: Diagnosing, p. 254.

19. A client with diabetes mellitus has been admitted to the intensive care unit with a serum glucose reading of 400 mg/dL (22.20 mmol/L). Because the care for this client will involve multiple disciplines, which diagnostic statement would be most appropriate for the nurse to select? a. Risk for unstable blood glucose related to diabetes b. PC: Hyperglycemia related to uncontrolled serum glucose c. Diabetes mellitus as evidenced by serum glucose of 400 mg/dL (22.20 mmol/L) d. Need for glucose control as evidenced by hyperglycemia

Answer 19: b. Explanation: PC: Hyperglycemia is the only diagnostic statement that addresses the services of multiple disciplines. Risk for unstable blood glucose relates to independent nursing interventions and the etiology is inappropriate. Diabetes mellitus is a medical diagnosis. Need for glucose control is incorrectly phrased. It addresses a client need, rather than a nursing diagnosis. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 12: Diagnosing, p. 258.

1. The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as a. Supervisory b. Technical c. Surveillance d. Maintenance

Answer 1: a. Explanation: The term "supervisory intervention" is applied in the context of overseeing a client's overall care.

20. The nurse is caring for a client with AIDS (acquired immune deficiency syndrome) who frequently misses clinic appointments. The client states that transportation to the clinic is very difficult. What would be the nurse's most appropriate diagnosis? a. Ineffective health maintenance related to transportation difficulties b. Ineffective health maintenance related to AIDS (acquired immune deficiency syndrome) c. Risk for noncompliance related to missed clinic appointments d. Risk for noncompliance related to seriousness of illness

Answer 20: a. Explanation: Ineffective health maintenance related to transportation difficulties is the correct answer. The client is having difficulty coming to clinic appointments necessary to monitor the progression of AIDS. The client states the cause of the missed appointments is transportation difficulties. The client does have AIDS, but that is not why the appointments are missed. The client is at risk for noncompliance with the prescribed therapy, but the actual diagnosis of "Ineffective health maintenance" is most appropriate to address the situation. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 12: Diagnosing, pp. 263, 269-270.

21. Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan? a. Initial b. Ongoing c. Discharge d. Standardized

Answer 21: d. Explanation: Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 13: Outcome Identification and Planning, p. 280.

22. A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care? a. Include the client and the client's power of attorney in the discussion. b. Ask the client what the priority needs are c. Consult the oncology nurse specialist in order to determine priorities. d. Hold a unit meeting to determine needs.

Answer 22: a. Explanation: During the planning step of the nursing process the nurse develops and prioritizes an individualized plan of care in partnership with the client, family, and others as appropriate. The client with mental or physical limitations should be included in the plan as much as possible. When there are cognitive limits, the client's power of attorney (POA) should also be included in the plans. Reference: Taylor, C. R.Fundamentals of Nursing: The Art and Science of Nursing Care,8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 13: Outcome Identification and Planning, p. 279.

23. 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? a. "I will take insulin until my blood sugar levels are normal." b. "I will take my medications between meals for maximum effect." c. "I will mix insulin glargine with insulin lispro at bedtime." d. "I will test my glucose level before meals and use sliding scale insulin."

Answer 23: d. Explanation: The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration and storage, and conditions that require contact with the health care provider. Reference: Taylor, C. R. Fundamentals of Nursing: The Art and Science of Nursing Care,8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 13: Outcome Identification and Planning, pp. 277-278.

24. When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: a. Identifies the unhealthy response preventing desired change b. Identifies factors causing undesirable response and preventing desired change c. Suggests patient goals to promote desired change d. Identifies patient strengths

Answer 24: b. Explanation: The cause of the patient health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the patient goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Patient strengths are identified during the nursing diagnosis phase. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 13, Outcome Identification and Planning, p. 285.

25. A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? a. Individualize the plan to the client. b. Expect to modify the plan significantly. c. Identify the appropriate nursing diagnoses. d. Include the rationale for the interventions.

Answer 25: a. Explanation: Standardized plans of care are written by a group of nurses who are experts in a given area of practice (e.g., obstetrics, rehabilitation, orthopedics). The plans are written for a client population with a specific medical diagnosis (e.g., total hip replacement, pressure ulcer, vaginal delivery, coronary artery bypass surgery). These experts identify the most common nursing diagnoses for this client population and write the goals and interventions usually necessary to resolve the problem. Each time a standardized plan of care is used, it must be individualized for a specific client. The danger of a standardized plan of care lies in the fact that it may not fit a specific client. Nurses must make judgments as to the degree to which standardized plans should be modified or whether they should not be used in individual cases. With a standardized plan of care, the most common nursing diagnoses have already been identified. Rationales are typically not included on clinical plans of care. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; Chapter 13: Outcome Identification and Planning, 2015: p. 281.

26. Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? a. Collaborate with other disciplines to revise the discharge plans. b. Instruct the client to make alternate living arrangements. c. Communicate with the physician about additional orders. d. Inform the family that it is not possible to change the discharge plans.

Answer 26: a. Explanation: The discharge needs of this client are complicated and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The physician may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 14: Implementing, p. 311.

27. A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate first action? a. The nurse should address the concern with the surgeon. b. The nurse should address the concern with the hospital attorney. c. The nurse should address the concern with the hospital ethics committee. d. The nurse should address the concern with the client's family.

Answer 27: a. Explanation: The nurse should first address the concern with the surgeon who has scheduled the procedure. If the nurse still has concerns after the discussion with the surgeon, the other choices are possible courses of action. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 14: Implementing, pp. 312-313.

28. What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Mark all that apply. a. The client verbalizes understanding of the instructions. b. The client is able to answer the nurse's questions. c. The client asks the nurse to repeat the instructions. d. The client tells the nurse that his wife will handle his care. e. The client discusses the specifics of what was taught during the session.

Answer 28: a., b., e. Explanation: After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that his wife will handle his care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 14: Implementing, pp. 307-308.

29. The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do? a. Delay the instruction until the visitors leave. b. Give the visitors instructions to leave in 10 minutes. c. Ask the client if the client has any questions. d. Leave written information for the client to read later.

Answer 29: a. Explanation: The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors left. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 14: Implementation, p. 308.

30. 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. Risk factors and prevention of diabetes mellitus c. The severity of the client's disease d. The cellular metabolism of glucose

Answer 30: b. Explanation: An important nursing function is to enable clients to prevent illness. Since a member of the family has developed diabetes, the other family members are also at risk. The nurse would most appropriately educate the family about the risk factors and prevention of diabetes mellitus. Knowledge of the medications used to treat diabetes is not necessary at this time and does not help meet the family's needs. The severity of the client's disease does not have an impact on the family's health. Knowledge of the cellular metabolism of glucose is not necessary for the family's health. Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 14: Implementation, p. 310.

31. The nurse is collecting data on a client presenting to the medical short-stay unit for a colonoscopy. A client reports to the nurse that he quit smoking six months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome? a. Affective outcome b. Cognitive outcome c. Psychomotor outcome d. Physiologic outcome

Answer 31: a. Explanation: Affective outcomes pertain to changes in client values, beliefs, and attitudes and are more complex to evaluate. Changes in behaviors, such as the cessation of smoking or nutritional changes that lead to weight loss, are examples of affective outcomes. Cognitive outcomes involve an increase in client knowledge and are evaluated by asking the client to repeat information or perform a skill. Psychomotor outcomes describe the client's achievement of a new skill. Physiologic outcomes result in physical changes and are evaluated through physical assessment. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 15: Evaluating, p. 325.

32. The client demonstrates stair climbing using a quad cane. What type of outcome is this an example of? a. Affective outcome b. Psychomotor outcome c. Physiologic outcome d. Cognitive outcome

Answer 32: b. Explanation: Psychomotor outcomes describe the client's achievement of new skills, such as stair climbing using a quad cane. An affective outcome involves changes in the client's values, beliefs, and attitude. Cognitive outcomes demonstrate increases in client knowledge. Physiologic outcomes are physical changes in the client. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 15: Evaluating, p. 325.

33. The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of what type of outcome? a. Affective outcome b. Psychomotor outcome c. Physiologic outcome d. Cognitive outcome

Answer 33: d. Explanation: Cognitive outcomes demonstrate increases in client knowledge, such as strategies for minimizing leakage of an ileostomy bag. An affective outcome involves changes in the client's values, beliefs, and attitude. Physiologic outcomes are physical changes in the client. Psychomotor outcomes describe the client's achievement of new skills. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 15: Evaluating, p. 325.

34. Which of the following actions should the nurse take during the evaluation phase of the nursing process? a. Document improved pain after pain medication administered b. Provide client with follow-up appointment after discharge c. Have client give input into plan of care upon admission d. Discontinue indwelling urinary catheter per provider's order

Answer 34: a. Explanation: Documenting improved pain after pain medication is an evaluation of pain relief after an intervention. Providing a client with an appointment and discontinuing an indwelling urinary catheter are interventions. Having a client give input into a plan of care is part of the planning process. Reference: Taylor, C. R. Fundamentals of Nursing 8th ed. Philadelphia: Wolters, Kluwer, Health/Lippincott Williams & Wilkins, 2015, Chapter 15: Evaluating, p. 326.

35. Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse will then make a judgment and document a statement summarizing those findings. This is called which of the following? a. Criteria b. Evaluative statement c. Standard d. Evidence-based practice

Answer 35: b. Explanation: An evaluative statement is a statement summarizing the client's outcome achievement. Criteria are "measurable qualities, attribute, or characteristics that identify skill, knowledge, or health status." Standards are the "levels of performance accepted by and expected of nursing staff or other health team members." Evidence-based practice incorporates delivering nursing care that evidence supports as likely to result in meeting the expected patient outcomes. Reference: Taylor, C.R., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 15: Evaluating, p. 326.

3. What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations? a. Memorization b. Reflection c. Reminiscing d. Evangelization

Answer 3: b. Explanation: Reflection is defined as those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 226. Chapter 10: Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care - Page 226

4. The nurse is performing an assessment on a client who presents with a rash on the back that is red and raised. What would be the most appropriate nursing action? a. Assess the client's back visually. b. Document it in the client's chart. c. Establish a nursing diagnosis of Altered Skin Integrity. d. Report it to the health care provider.

Answer 4: a. Explanation: Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. Assessment should be documented accurately, completely, concisely, factually, and timely. For the nurse to document an accurate and concise assessment, a visual assessment of the rash is necessary. This assessment should be performed before it is reported or documented and before a nursing diagnosis can be formulated. Reference: Taylor, C.R. Fundamentals of Nursing: The Art and Science of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 10: Blended Skills and Critical Thinking Throughout the Nursing Process, pp. 215, 220.

5. The nurse is developing a plan of care for a client with a fractured femur, is in traction, and will be restricted to bed for some time. Which domain should the nurse look to for developing a nursing diagnosis based on this client's musculoskeletal health problems? a. Activity/Rest b. Health Promotion c. Nutrition d. Self-perception

Answer 5: a. Explanation: Nursing diagnosis should be based on the collection of data from that client that contains a precise statement related to the client's health problems. This question is specifically related to this client's inability to move and musculoskeletal issues; therefore, the domain that would provide the most options for nursing diagnosis would be that of activity and rest. Reference: Taylor, C.R. Fundamentals of Nursing: The Art and Science of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 10: Blended Skills and Critical Thinking Throughout the Nursing Process, pp. 215, 220.

6. An obese client is in the clinic to be started on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for this client? The client will: a. create an exercise plan that is realistic and valued. b. exercise every day for at least 30 minutes. c. only eat three meals per day. d. stop eating meat and walk every day after dinner.

Answer 6: a. Explanation: Outcomes should realistic and valued by the client and family. If this client creates an exercise plan that she values and is realistic, then she is more than likely to meet their outcome. Exercising every day, only eating three meals per day, or excluding meat from the diet may not be realistic or valued by the client that has reported that she likes to eat and does not like to exercise. Reference: Taylor, C.R. Fundamentals of Nursing: The Art and Science of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 10: Blended Skills and Critical Thinking Throughout the Nursing Process, pp. 215, 220.

7. Which intervention is the most appropriate for a client newly diagnosed with diabetes and a nursing diagnosis of deficient knowledge? a. Administer insulin as prescribed b. Monitor blood sugar before meals c. Monitor for hypo-/hyperglycemia d. Teach the client how to administer insulin

Answer 7: d. Explanation: The implementation phase is the phase of the nursing process in which the plan of care is carried out. It is designed to promote wellness and restore health to clients through interventions that are collaborative and nursing driven. The plan of care and implementation should be individualized and should specify client outcomes to resolve problems identified in the nursing diagnosis. Because this client has a deficient knowledge about his newly diagnosed medical condition of diabetes, the nurse needs to educate him about insulin administration in order to address the problem identified in his nursing diagnosis. Administering insulin and monitoring blood sugar and symptoms of hypo-/hyperglycemia are nursing measures used to treat the client and do not directly impact the client's knowledge deficit. Reference: Taylor, C.R. Fundamentals of Nursing: The Art and Science of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 10: Blended Skills and Critical Thinking Throughout the Nursing Process, pp. 215, 220.

9. A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply. a. Heart failure b. Pneumonia c. Impaired mobility d. Imbalanced nutrition e. Ineffective coping

Answer 9: c., d., e. Explanation: NANDA-International defines nursing diagnosis as "a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes." A medical diagnosis describes a disease, whereas a nursing diagnosis describes an individual, family, or group response to an actual or potential health problem. A nursing diagnosis provides the basis for selection of nursing interventions to achieve positive client outcomes. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; Chapter 10: Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care, 2015: p. 215. Chapter 10: Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care - Page 215

12. When performing an assessment, the nurse should focus on the developmental stage for which client? a. Toddler b. Young adult c. Middle-age adult d. Adolescent

Answer 12: a. Explanation: Nursing assessments vary according to the client's developmental needs. When assessing an infant, toddler, or child, special attention is given to physiologic and psychosocial aspects of growth and development to identify client problems. It is not as important to focus assessment on the developmental stages in the other age groups. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 11: Assessing, p. 239.

2. Which students study the best in a group setting? a. People-oriented learners b. Kinesthetic learners c. Auditory learners d. Sensory learners

Answer 2: a. Explanation: People-oriented learners are social; they prefer to study in groups rather than alone, and they enjoy the process more than focusing on the task at hand.

15. The nurse is interviewing a client that is newly admitted to the unit. Which techniques used by the nurse will facilitate communication during the interview? Select all that apply. a. Use broad opening statements. b. Share observations. c. Use silence. d. Use reassuring clichés. e. Give approval.

Answer 15: a., b., c. Explanation: Using broad opening statements, sharing observations, and using silence are just a few of the techniques nurses use to establish rapport, elicit clients' thoughts and feelings, and encourage conversation and understanding.

8. The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What does the nurse determine this phase will include? Select all that apply a. Evaluation does not involve patient assessment. b. Evaluation is the last part of the nursing process. c. Evaluations should be documented daily in the client record. d. Only factors that positively affect the outcome should be identified during evaluation. e. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.

Answer 8: b., c., e. Explanation: The evaluation phase of the nursing process measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. Evaluation does involve nursing assessment to determine if the client has met the outcome. Factors that positively and negatively affect the outcome should be identified to assist with meeting the client outcomes. Reference: Taylor, C.R. Fundamentals of Nursing: The Art and Science of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 10: Blended Skills and Critical Thinking Throughout the Nursing Process, pp. 215, 220.