PrepU | Assignment 1 | Chapter 2: Nursing Process

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.

The nurse determines that a client has not met the goal of consuming at least 80% of each meal served by a designated date. Which response(s) by the nurse would be appropriate regarding this lack of goal attainment? Select all that apply.

"Do you think it is possible that you will be able to eat 80% of the food served here?" "What kinds of things have we been doing to increase your appetite?" "Do you think you could meet the goal if we check on it in one week or so?"

A nurse is caring for a client with a complete spinal cord injury that has caused paraplegia. The client is very distraught and asks the nurse, "Are they sure, even with therapy, I will never walk again?" Which statement made by the nurse demonstrates veracity?

"You have a complete injury, which results in a total loss of movement and sensation below the level of injury."

The nurse is admitting a new client. What action will the nurse take to identify actual or potential health problems?

Gather data from sources.

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.

Which nursing student would most likely be held liable for negligence?

A nursing student administers medication to a resident while working as an unlicensed assistive personnel (UAP) at a local nursing home.

The 40-year-old client is admitted for repair of a femoral fracture. The client discloses a history of an addiction to painkillers and asks that the nurse assist in adhering to the recovery from this addiction by not administering any opioids. As the nurse reviews postoperative prescriptions for the client, the nurse notes that the health care provider has prescribed codeine 30 mg p.o. q6 hours for pain. How does the nurse best approach this situation?

Ask the health care provider to remove this prescription from the client's chart.

Which ethical principle is related to the idea of self-determination?

Autonomy

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a 1-month-old infant with a heart rate of 124 beats/min and a respiratory rate of 36 breaths/min. What action should the nurse take to analyze the significance of the infant's vital signs?

Consult reference materials to determine the normal vital signs for 1-month-old infants.

What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation?

Critical thinking

What is a systematic way to form and shape one's thinking?

Critical thinking

The nurse prepares a concept map for a client who is newly diagnosed with atrial fibrillation. According to the concept map pictured above, what is the highest prioritized nursing diagnosis?

Decreased cardiac output

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data.

A client comes to the health care provider's office reporting abdominal pain, for which the client has previously sought care. Which type of assessment would the nurse perform?

Focused

The client is a 2-month-old infant extremely ill from herpes simplex virus (HSV) sepsis. The parents have decided to stop additional medical intervention and allow the infant to pass away naturally. One parent does not want relatives to know that they plan to stop pursuing aggressive medical treatment because it is against their family's religious beliefs to withdraw medical support. What does the nurse tell the client's parent?

It is the parents' decision who to inform about the family's medical decision.

A nurse is providing care to two clients who are sharing the same room. The nurse is preparing to give one of the clients a complete bed bath. Which action by the nurse would suggest liability related to invasion of the client's privacy?

Keeping the curtain between the two clients in the room open

The health care provider has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)?

Nurses do carry out interventions in response to a health care provider's order.

Upon entering the hospital system, the nurse discusses the rights and responsibilities that the client is entitled to in the institution. The information the nurse discusses is commonly referred to as:

Patient's Bill of Rights.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?

Risk factors for and prevention of diabetes mellitus

A new unlicensed assistive personnel (UAP) is preparing to ambulate a client with a BMI of 35. The nurse is concerned about the UAP's ability to safely ambulate the client. Which action by the nurse is appropriate?

Tell the UAP that the nurse will assist the UAP with the client's ambulation.

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factor(s) should the nurse identify as strengths of the client? Select all that apply.

The client states they are grateful their family members help with home care. The client states a belief in a reward in heaven after death. The client has demonstrated effective coping skills in the past.

The client has experienced a fasting blood sugar in excess of 300 mg/dl (16.65 mmol/l) and is now diagnosed as having diabetes. The nurse plans care for this client based on the nursing concern of the client's knowledge deficit. Place in order the actions of using the nursing process for this client. Use all options.

The client's blood sugar is over 300 mg/dl (16.65 mmol/l). The client is diagnosed as having diabetes. The nurse assesses the client's understanding as having no previous exposure to diabetes or care to manage health problems. The nurse analyzed the data and determined this client has multiple problems requiring education. The nurse writes one of the nursing concerns is a knowledge deficit related to client's lack of exposure as evidenced by verbalizing inaccurate information. The nurse addresses the client's learning needs by writing outcomes and education plans that involve disease process, self-monitoring of blood glucose, medications, diet, and checking the feet daily. The nurse teaches the client addressing all domains—affective, cognitive, and psychomotor. The nurse evaluates the client as achieving or not achieving each outcome.

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 nursing concern of constipation, what assessment must the nurse make?

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

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing concern to address this issue?

The nurse should determine the reason for the client's refusal.

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

A client's care plan contains the following information. Which would the nurse identify as the client outcome criteria?

demonstrates coughing exercises at next session

An older adult was just diagnosed with stage 4 pancreatic cancer. The client states, "I am so overwhelmed and I feel like everyone has already decided that I need to be put in hospice care."

offering to answer questions the client may have about care and treatment options and providing the client with the information needed to obtain a second opinion

Which nursing diagnosis is an example of a health promotion diagnosis?

ready or improved parenting

What would be an example of the nurse practicing fidelity? The nurse:

stays with a client during death as promised.

A client is in a persistent vegetative state following a severe motor vehicle collision. The client has no immediate family. Whom should the nurse consult when seeking direction for care?

surrogate decision maker

A risk nursing diagnosis indicates that:

the client is more vulnerable to a certain problem than other individuals are.

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client.