The Nursing Process Chapter 2
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
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?
Actual
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?
Assess the client's blood pressure to determine if the medication is indicated.
Which type of health problem requires both physician- and nurse-prescribed actions to address?
Collaborative health problem
Which types of data would be collected during a physical assessment?
Color, moisture, and temperature of the skin
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 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to 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.
A client comes into the clinic for a routine postoperative visit. While the nurse is assessing the level of pain, the client states that there is occasional discomfort but that pain levels have improved daily since returning home from the hospital. What should the nurse's response be regarding the client's plan of care?
Continue the plan of care.
What is a systematic way to form and shape one's thinking?
Critical thinking
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, 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
A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?
Decreased Cardiac Output related to cardiac tissue damage
A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?
Determine whether the prescribed treatment was effective.
When the nurse inspects a postoperative incision site for infection, which type of assessment is the nurse performing?
Focused
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
Which is a characteristic of person-centered care?
It is a framework for providing care.
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs?
Physiological
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 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
The nurse has been providing care to a client during a divorce. The client is now divorced from the spouse, effective 2 weeks ago. The nurse identified a nursing diagnosis of "Readiness for Enhanced Coping." What statement by the client would support this nursing diagnosis?
The client states, "I feel like I can finally get along with my life now that the divorce is final."
The purpose of obtaining a nursing history is to:
identify actual and potential health problems.
