Wellness ATI Review 2
A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process? a. "I will determine the most important client problems that we should address" b. "I will review the past medical history on the client's record to get more information." c. "I will go carry out the new prescriptions from the provider." d. "I will ask the client iff his nausea has resolved."
a
A weight-loss program that combines nutrition instruction with exercise is an example of teaching based on which domain of learning? a. Psychomotor b. Affective c. Psychosocial d. Cognitive
a
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, accord to the nursing process? a. reassess the client to determine the reasons for inadequate pain relief. b. wait to see whether the pain lessens during the next 24hr. c. Change the plan of care to provide different pain relief interventions d. teach the client about the plan of care for managing his pain
a
During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse's use of which intellectual standard of critical thinking? a. Clarity b. Logic c. Precision d. Significance
a
In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indication of bias? a. Collecting the patient's medical history b. Administering IV medications c. Performing oral care d. Completing a bed bath
a
What action by the nurse would most ensure accurate interpretation of patient communication? a. Providing feedback regarding the conveyed message b. Writing down the patient's conversational highlights c. Assuming significant cultural differences exist d. Verifying the patient's emotional state
a
What is the most significant problem that may result from improperly written nursing diagnostic statements? a. Lack of direction for formulating patient plans of care b. Omission of physician or primary care provider orders c. Combining of two unrelated patient concerns d. Increased team collaboration needs
a
What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis? a. Defining characteristics are not part of a risk diagnosis. b. There is no cause and effect relationship established. c. Defining characteristics are subjective in a risk diagnosis. d. There are no nursing interventions prescribed in a risk diagnosis.
a
What should be the primary focus for nursing interventions? a. Patient needs b. Nurse concerns c. Physician priorities d. Patient's family requests
a
What strategy would be most effective in communicating with a highly anxious adult immediately before surgery? a. Providing specific, concise information b. Detailing likely causes of their anxiety c. Focusing on postoperative details d. Using instructional multimedia DVDs
a
Which nursing diagnosis is appropriate if a patient expresses an interest in learning? a. Readiness for Enhanced Knowledge b. Knowledge Deficit c. Information Processing d. Health-Seeking Behaviors
a
Which of the following actions reflects inductive reasoning? a. Using subjective and objective data to confirm a diagnosis b. Assessing for specific clinical presentations based on a disease process c. Correlating elevated blood pressure with pathophysiology d. Validating an automatic blood pressure cuff reading with a manual measurement
a
Which situation indicates the greatest need for collaborative interventions provided by several health care team members? a. Hospice referral b. Physical assessment c. Activities of daily living d. Health history interview
a
Which statement is an appropriately written short-term goal? a. Patient will walk to the bathroom independently without falling within 2 days after surgery. b. Nurse will watch patient demonstrate proper insulin injection technique each morning. c. Patient's spouse will express satisfaction with patient's progress before discharge. d. Patient's incision will be well approximated each time it is assessed by the nurse.
a
a nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the use using when he reviews the medication information? a. knowledge b. experience c. intuition d. competence
a
a nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? a. orient the client to his room b. conduct a client care conference c. review medical prescription d. develop a plan of care
a
a patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first? a. Identify reasons the patient is unable to sleep. b. Request medication to help the patient sleep. c. Tell the patient that sleep will come with relaxation. d. Notify the physician that the patient is restless and anxious.
a
The nurse obtains a lower than normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the critical-thinking skill of analysis in the nursing process? (Select all that apply.) a. Assessing the patient for symptoms of hypoxia b. Providing oxygen according to standing orders c. Elevating the head of the bed, if not contraindicated d. Allowing the patient to be alone to rest more comfortably e. Discussing adaptations needed for daily activities with the patient
a b c
What should be taken into consideration by the nurse when deciding on interventions to include in a patient's plan of care? (Select all that apply.) a. Patient's treatment preferences b. Cultural and ethnic influences c. Professional level of expertise d. Current evidence-based research e. Convenience to the nursing staff
a b c d
What should the nurse consider before implementation of all nursing interventions? (Select all that apply.) a. Potential communication barriers b. Diverse cultural practices c. Scope of nursing practice d. Functional status of the patient e. Time of most recent shift change
a b c d
Which factor influences whether a message is effectively communicated? (Select all that apply.) a. Timing of the conversation b. Educational level of participants c. Mode of communication used d. Physical environment of discussion e. Clothing that the nurse is wearing
a b c d
A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply). a. explain the roles of other care delivery staff b. begin discharge planning c. provide information about advance directives d. document the client's wishes about organ donation e. introduce the client to his roommate
a b c e
If the nurse chooses the Nursing Outcome Classification (NOC) Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.) a. Expressed desire to eat b. Report that food smells good c. Use of relaxation techniques before meals d. Preparation of home-cooked meals for self and family e. Uses nutritional information on labels to guide selections
a b d
Which action does the nurse need to take before determining the types of nursing diagnoses that are applicable to a patient? (Select all that apply.) a. Thoroughly review the patient's medical history b. Analyze the nursing assessment data to determine whether information is complete c. Outline an individualized plan of care to address each concern d. Consider potential complications to which the patient is susceptible e. Evaluate how the patient has responded to treatment
a b d
a nurse is caring for a client who had a stroke and is scheduled offer transfer to a rehab center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply). a. ensure that the client has possession of his valuables b. confirm that the rehab center has a room available as the time of transger c. assess how the client tolerates the transfer d. give a verbal transfer report via telephone e. complete a transfer form for the receiving facility
a b d e
Which of the following actions should the nurse take when using the communication technique of active listening? (select all that apply). a. use an open posture b. write down what the client says to avoid forgetting details c. establish and maintain eye contact d. nod in agreement with the client throughout the conversation e. respond positively when giving feedback.
a c e
Which actions are a part of the evaluation step in the nursing process? (Select all that apply.) a. Recognizing the need for modifications to the care plan b. Documenting performed nursing interventions c. Determining whether the nursing interventions were completed d. Reviewing whether a patient met the short-term goal e. Identifying realistic outcomes with patient input
a d
. The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select all that apply.) a. Teamwork b. Intuition c. Judgment d. Conflict management e. Advocacy f. Reasoning
a d e
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply). a. respiratory rate is 22/min with even, unlabored respirations b. the client's partner states, "He said he hurts after walking about 10 minutes." c. pain rating is 3 on a scale of 1-10. d. skin is pink, warm, and dry e. the assistive personnel reports the client walked with a limp
a d e
. Which defense mechanism is being exhibited when a 27-year-old patient insists on having a parent present during routine care? a. Denial b. Regression c. Repression d. Displacement
b
A nurse in a provider's office is collecting data from the mother of a 12-month-old infant. The client states that her son is old enough for toilet training. Following an educational session with the nurse, the client now states that she will postpone toilet training until her son is older. Learning has occurred in which of the following domains? a. cognitive b. affective c. psychomotor d. kinesthetic.
b
A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements should the nurse make? a. "Sounds like something you should discuss with her when you get home." b. "it sounds like you are concerned about sexual functioning. Let's discuss your concerns." c. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." d. "Just make sure you take your medication as directed, and you should be fine."
b
A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." Which clarifying technique is the nurse using to enhance communication with the client? a. pacing b. reflecting c. paraphrasing d. restating
b
A nurse is caring for a client whose partner passed away 4 months ago and how has been recently diagnosed with diabetes mellitus. He is tearful and states, "How docile you possibly understand what I am going through?" Which of the following responses should the nurse make? a. "it takes time to get over the loss of a loved one" b. "you are right. I cannot really understand. Perhaps you'd like to tell me more about what you are feeling" c. "why don't you try something to take your mind off your troubles, like watch a funny movie" d. " I might not share your exact situation, but I do know what people go through when they deal with . loss"
b
A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? a. touch the child's arm b. sit at eye level with the child c. stand facing the child d. stand with a relaxed posture
b
A nurse is evaluating how well a client learned the information he presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions should the nurse take to evaluate the client's learning? a. encourage the client to ask questions b. ask the client to explain how to select or prepare meals c. encourage the client to fill out a evaluation form d. ask the client if she has resources for further instruction on this topic
b
A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. the client is able to discuss the appropriate technique b. the client is able to demonstrate the appropriate technique c. the client states that he understands d. the client is able to write the steps on a piece of paper
b
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a prescription for a different one. Which of the following critical thinking attitudes did the nurse demonstrate? a. fairness b. responsibility c. risk taking d. creativity
b
A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take? a. Resume all interventions for previously identified nursing diagnoses. b. Perform the steps of the nursing process related to the patient's current condition. c. Seek physician input related to updating the nursing diagnostic statements. d. Evaluate the success of the acute care plan for management of the cardiac arrest.
b
If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care? a. Fatigue b. Acute Pain c. Knowledge Deficit d. Body Image Disturbance
b
If a patient's verbal and nonverbal communication is inconsistent, which form of communication is most likely to convey the true feelings of the patient? a. Written notes b. Facial expressions c. Implied inferences d. Spoken words
b
In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking? a. What do I know about this situation? b. What additional details do I need to gather? c. Does the clinical presentation correlate with the diagnosis? d. Are the treatments appropriate for the diagnosis?
b
The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she states, "You don't have to go over those—I'll read them at home." What should the nurse do? a. Contact the physician immediately. b. Consider the possibility of health literacy limitations and assess further. c. Stop the teaching, because the mother obviously has taken care of casts before. d. Explain to the mother that reading the instructions with her is required.
b
The nurse is completing an assessment of a patient with sudden onset of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient's clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient's abdominal pain? a. Evaluation b. Interpretation c. Reflection d. Inference
b
The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider? a. Elevating the head of the patient's bed b. Administering oxygen by nasal cannula c. Assessing the patient's oxygen saturation d. Evaluating the patient's peripheral circulation
b
The nurse receives a change of shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse's action? a. Problem solving b. Decision making c. Judgment d. Reasoning
b
What is the primary purpose of the nursing diagnosis? a. Resolving patient confusion b. Communicating patient needs c. Meeting accreditation requirements d. Articulating the nursing scope of practice
b
When a patient is grimacing, what assessment statement or question would be most beneficial for identifying the underlying cause of the nonverbal communication? a. "Did you lose something?" b. "You appear to be having pain." c. "I will turn off the lights and let you rest." d. "May I get you something to relieve your tension?"
b
Which is true about patient teaching sessions? a. Present all of the information so the patient can learn all that is needed. b. Present the patient with one idea at a time. c. Ensure the presence of a family member at each session. d. End with a written quiz to ensure understanding of the information.
b
Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery? a. Nurse will encourage use of sterile technique during each dressing change. b. Patient's white blood count will remain within normal range throughout hospitalization. c. Patient's visitors will be instructed in proper handwashing before direct interaction with patient. d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.
b
Which nursing intervention is most important to complete before giving medication to a patient? a. Provide water to aid in the patient's ability to swallow the medication. b. Double-check the patient's allergies before giving the drug. c. Ask the patient to verify having taken the medication before. d. Place the patient in a side-lying position to prevent aspiration
b
Which of the following strategies should a nurse use to establish a helming relationship with a client? a. make sure the communication is equally reciprocal between the nurse and the client b. encourage the client to communicate his thoughts and feelings c. give the nurse-client communication no time limits d. allow communication not occur spontaneously throughout the nurse-client relationship
b
a nurse educator is teaching a class on culture and food to a group of newly hired nurses. which of the following statements by a nurse indicates an understanding of the teaching? a. "clients who practice Roman Catholicism do not drink caffeinated beverages." b. "clients who practice Orthodox Judaism do not eat meat with dairy products." c. "clients who are Mormon eat only the protein of animals that are slaughtered under strict guidelines." d. "clients who practice Hinduism do not eat dairy products."
b
a nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." which of the following responses should the nurse make? a "Really, you look just fine to me. There's no need too feel undesirable." b." I'm interested in finding out more about how your body feels to you." c. "Consider an afternoon at a spa. A facial will make you feel more attractive." d. "It's still too soon to expect to feel normal. Give it a little more time."
b
a nurse is teaching a group of clients to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self-concept? a. "I was having difficulty with attaching the appliance at first, but my wife was able to help." b. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" c. "I met a eighty who also has a colostomy, and he taught e a few things." d. "It may take me a while to get the hang of this. I have to admit, I am pretty nervous."
b
Which interventions can the nurse initiate independently while providing patient care? (Select all that apply.) a. Ordering a blood transfusion b. Auscultating lung sounds c. Monitoring skin integrity d. Applying heel protectors e. Adjusting antibiotic dosages
b c d
Which of the following nursing diagnoses is appropriately written? (Select all that apply.) a. Risk for Infection related to elevated temperature and white blood count b. Readiness for Enhanced Relationship as evidenced by mutual respect verbalized by spouses and expressed desire for improved communication c. Noncompliance related to an inability to access care as evidenced by failure to keep appointments, homebound status d. Risk for Bleeding with the risk factor of prolonged clotting time e. Chronic Pain related to osteoarthritis as manifested by verbalized postoperative discomfort.
b c d
A 61-year-old male is undergoing an emergency cardiac catheterization when the nurse gives his wife a packet of registration paperwork and asks her to complete the forms. Which observed actions may indicate a health literacy issue? (Select all that apply.) a. Putting on glasses before beginning the paperwork b. Asking someone in the waiting area to read the forms to her "because I need to get new glasses—these just don't work" c. Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the forms d. Setting the clipboard aside and staring tearfully out the window e. Returning the forms only partially filled out, with missing or inaccurate information
b c e
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing inventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply). a. suggest coping skills for the client to use in this situation. b. allow the client to provide input in the treatment plan. c. assist the client with time management, and address the client's priorities. d. provide extensive instructions on the client's treatment regimen e. Encourage the client in the expression of feelings and concerns.
b c e
A nurse is caring for a client who is 24hr postoperative following abdominal surgery. The nurse suspects the client's pain management is inadequate. Which of the following data reinforces this suspicion? (Select all that apply). a. the client seems easily agitated b. the client is non adherent with coughing, deep breathing and dangling c. the client may have pain medication every 4 to 6 hr but accept sit every 6 to 7hr. d.. the client reports tenderness in his right lower leg e. the client's vital signs are heart rate 110/min, respiratory rate 20/min, temperature 98.6 degrees, and blood pressure 136/80mmHg.
b c e
What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.) a. Denies any difficulty falling asleep b. Elevated pulse rate auscultated at 140 BPM c. Continuous foot tapping throughout intake interview d. Demonstrates how to give insulin self-injection without hesitation e. Patient states, "I feel nervous all the time, especially when I am alone."
b c e
a nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at risk for body image disturbances? (select all that apply). a. 30 yo male client following laparoscopic appendectomy b. 45 yo female client following mastectomy c. 20 yo female client following left above the knee amputation d. 65 yo male client following cardiac catheterization e. 55 yo male client following stroke with right sided hemiplegia
b c e
a nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply). a. advance directives status b. Follow-up care c. instructions for diet and medications d. most recent vital sign. data e. contact information for the home health care agency
b c e
Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.) a. Noncompliance b. Readiness for Enhanced Knowledge c. Ineffective Coping d. Health-Seeking Behaviors e. Anxiety
b d
A hospitalized patient experiences a sharp, stabbing pain while visiting with his spouse. Both the patient and his wife become very concerned, and the patient's call light is activated. What referent initiated communication between the patient and the nurse? a. Interaction between the patient and his wife b. Concern on the part of the patient's spouse c. Pain experienced by the patient d. Activation of the call light
c
A nurse is assisting a client with selecting food choices on a menu. Which of the following actions by the nurse demonstrates ethnocentricity? a. asking the client what he likes to eat b. notifying the dictation to complete the menu c. recommending one's ow favorite foods d. asking the client's family to fill out the menu
c
A nurse is caring for a client awaiting transport to the surgical suite for a coronary tot. eh surgical suite for a coronary artery by[ass graft. Just as the transport ream arrives, the nurse takes the client's vital signs and notes an elevation in bp and hr. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? a. exhaustion stage b. resistance stage c. alarm reaction d. recovery. reaction
c
A nurse is caring for an Asian client who has hypertension. Which of the traditional Asian dietary patterns please the client at risk for the condition? a. incorporation of plant based foods in the diet b. consumption of raw fruits c. preparation of foods using sodium d. focus on shellfish in the diet
c
A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. "I don't want my spouse to see my incision." b. "will you give me pain medicine after the surgery" c. "Can you tell me about how long the surgery will take?" d. "my roommate listens to everything I say"
c
On what premise is a nursing diagnosis identified for a patient? a. First impressions b. Nursing intuition c. Clustered data d. Medical diagnoses
c
The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first? a. Ask the patient to describe the chief complaint. b. Request that another nurse be assigned to this patient. c. Review data about the medical diagnosis and routine management. d. Complete a physical assessment of the patient.
c
The nurse is providing home care to a 62-year-old female who was recently diagnosed with insulin-dependent diabetes mellitus. What is the most important reason for the nurse to document the teaching session? a. The patient's insurance company requires documentation. b. The nurse's employer requires documentation of home care sessions. c. Other members of the health care team need to know the patient's progress. d. Insulin is a potentially dangerous medication and needs to be documented.
c
What action should the nurse take if an alert and oriented patient asks the nurse for personal contact information? a. Ask the patient why the personal information is needed. b. Report the interaction to the nursing supervisor immediately. c. State that it would not be appropriate to share that information. d. Change the subject, and hope that the patient does not ask again.
c
What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery? a. Consult the surgeon to see if the clinical pathway is being followed. b. Discontinue the plan of care because the patient has met the established goal. c. Monitor patient urine output to evaluate the need for the current plan of care. d. Notify the patient that the goal has been attained and no further intervention is needed.
c
What is the purpose of the nursing process? a. Providing patient-centered care b. Identifying members of the health care team c. Organizing the ways nurses think about patient care d. Facilitating communication among members of the health care team
c
What would be the best therapeutic response to a patient who expresses indecision about recommended chemotherapy treatments? a. "Can you tell me why you are undecided?" b. "It's always a good idea to have chemotherapy." c. "What are you thinking about the treatments at this point?" d. "You should follow whatever your health care provider recommends."
c
Which action by the day-shift nurse provides objective data that enables the night-shift nurse to complete an evaluation of a patient's short-term goals? a. Encouraging the patient to share observations from the day b. Leaving a message with the charge nurse before the shift change c. Documenting patient assessment findings in the patient's chart d. Checking with the pharmacist regarding possible drug interactions
c
Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult? a. Providing a written copy of care options to the patient and family b. Collaborating with the patient's social worker to determine resources c. Listening to the patient's concerns and beliefs about proposed treatment d. Engaging the patient's family, friends, or care providers in conversation
c
Which intervention would be most important for the nurse to include in the care plan if the patient is unable to complete activities of daily living without becoming fatigued? a. Instruct the patient to shower and shave simultaneously. b. Discourage the patient from bathing while hospitalized. c. Encourage the patient to rest between bathing activities. d. Ask the patient's spouse to assist with all bathing.
c
Which nursing action is critical before delegating interventions to another member of the health care team? a. Locate all members of the health care team. b. Notify the physician of potential complications. c. Know the scope of practice for the other team member. d. Call a meeting of the health care team to determine the needs of the patient.
c
Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data? a. Do these findings make sense? b. How can this information be verified? c. What are the most significant factors in the problem? d. What is the relation of this information to other data?
c
Which resource is most helpful when prioritizing identified nursing diagnoses? a. Nursing Interventions Classification (NIC) b. Gordon's functional health patterns c. Maslow's hierarchy of needs d. Nursing Outcomes Classification (NOC)
c
Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention? a. Ambulating a patient with ataxia and new right-sided paresthesia b. Feeding a patient with cerebral palsy who recently aspirated c. Transporting a patient to the hospital entrance for discharge d. Administering prescribed programmed medications
c
Written instructions showing pictures of the steps necessary to test a blood sugar, along with demonstration and a return demonstration of the steps, would most benefit which learners? a. Affective b. VARK c. Psychomotor d. Cognitive
c
which phrase best represents a related factor in an actual nursing diagnosis? a. Unsteady gait requiring the assistance of two people b. Redness and swelling around the incision site c. Ineffective adaptation to recent loss d. Patient complaint of restlessness
c
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply). a. writing a prescription for morphine sulfate as needed for pain b. inserting nasogastric (NG) tube to relieve gastric distention c. showing a client how to use progressive muscle relaxation d. performing a daily bath after the evening meal e. repositioning a client every 2hr to reduce pressure ulcer risk
c d e
a nurse is caring for a client who is concerned about his impending discharge ;to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (select all that apply) a. "you will do great! you just have to get used to it." b. "why are you worried about going home?" c. "your daily routines will be different when you get home." d. "tell me about your support system you'll have after you leave the hospital." e. "let me tell you about a friend of mine with a colostomy who else enjoys swimming."
c d e
A nurse is caring for a client who follows a vegan diet. Which of the following foods should the nurse offer the client? a. bagel with cream cheese b. fried egg c. fruit with yogurt d. wheat toast with peanut butter
d
A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? a. prescribing tasks unilaterally b. delegating care to one member c. speaking to the primary client privately d. convening a family meeting
d
A nurse is preparing an instructional session for an older about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? a. encourage the client to participate actively in learning b. select instructional materials appropriate for the older adult c. identify goals the nurse and the client agree are reasonable d. determine what the client knows about stress incontinence
d
A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first? a. Family history of diabetes b. Medications the patient is taking c. Operations the patient has had in the past d. Severity and duration of the nausea and vomiting
d
An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient? a. Family member b. Physician c. Another nurse d. Patient
d
As part of the admission process, a nurse at a long-term care facility gathering a nutrition history for a. client who has dementia. Which of the following components of the nutrition. evaluation is the priority for the nurse to determine from the client's family? a. body mass index b. usual times for meals and snacks c. favorite foods d. any difficulty swallowing
d
The nurse is providing care to an 88-year-old male patient who just returned from the recovery room after a right hip replacement. The nurse plans to teach the patient prevention techniques for deep vein thrombosis. What is the best time to provide teaching? a. Do it right before the patient's next intravenous pain medication. b. Wait until tomorrow morning because he is in too much pain today. c. Leave written materials on his over-the-bed tray that he can read at his convenience. d. Wait until 10 to 15 minutes after his next intravenous pain medication.
d
What is the most important action for a nurse to take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy? a. Share concerns with the nurse manager on the nursing unit. b. Offer alternative care for a patient and family members. c. Discuss how to address patient needs with physicians. d. Provide evidence-based research to support nursing care.
d
What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I? a. Insurance documentation b. Professional autonomy c. Role delineation d. Patient safety
d
What is the primary purpose of quality improvement? a. Recognizing the need to discipline employees violating policies b. Preventing patient injury that may contribute to the death of others c. Increasing institutional profits to support further scientific research d. Enhancing current practice to improve patient outcomes and care
d
Which action would the nurse undertake first when beginning to formulate a patient's plan of care? a. List possible treatment options. b. Identify realistic outcome indicators. c. Consult with health care team members. d. Rank patient concerns from assessment data
d
Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer? a. Reassessing for changes in the patient's physical condition b. Teaching the patient various methods of stress reduction c. Referring the patient for music and massage therapy d. Encouraging the patient to explore options for care
d
Which notation is most appropriate for the nurse to include in a patient's chart regarding evaluation of the goal, "Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)"? a. Goal not met; patient states he is tired. b. Goal not met; patient ambulated three times in room. c. Goal met; patient ambulated three times in the hallway. d. Goal met; patient ambulated three times in the hallway without SOB.
d
Which statement best describes the relationship of medical diagnoses and nursing diagnoses? a. Medical diagnoses are imbedded in nursing diagnoses. b. Nursing diagnoses are derived from medical diagnoses. c. Medical diagnoses are not relevant to nursing diagnoses. d. Medical diagnoses may be interrelated to nursing diagnoses.
d
Which statement illustrates a characteristic of goals within the care planning process? a. Goals are vague objectives communicating expectations for improvement. b. Short-term goals need not be measurable, unlike long-term goals. c. Goal attainment can be measured by identifying nursing interventions. d. Long-term goals are helpful in judging a patient's progress.
d
Which statement is most accurate regarding symbolic expression? a. Skills confidence can be shared most effectively by nurses wearing distinctive clothing. b. Clothing choices by a hospitalized patient rarely reflect his or her economic resources. c. Make-up use by a patient is unnecessary for any reason during hospitalization. d. Nondramatic make-up use and minimal accessorizing by nurses demonstrates professionalism.
d
a nurse is caring for a client who is 3 days postoperative following a below the knee amputation as a result of a motor vehicle accident. Which of the following client statements indicates to the nurse that the client has a distorted body image? a. "I'll be bale to function exactly as I did before the accident." b. "I can't stop crying." c. "I am so mad at the guy you hit us. I wish he lost a leg." d. " I don't even want to look at my leg. You can check the dressing."
d
a nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? a. confidence b. perseverance c. integrity d. discipline
d
A 58-year-old male is admitted for a small-bowel obstruction late Saturday night. The nurse obtains admitting orders, which include the need to place a nasogastric (NG) tube to low intermittent suction. During the assessment, the nurse determines that the patient does not speak English. What should the nurse do before placing the tube? a. Assess the presence of any family members who may speak English and the patient's native language. b. Take two additional staff members into the room when placing the tube so the patient can be restrained if needed. c. Request an interpreter by leaving a voicemail on his or her office extension. d. Do not place the NG tube because the physician would not want to frighten the patient.
a
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads ever 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pay is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? a. assessment b. planning c. intervention d. evaluation
a
A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? a. role conflict b. role overload c. role ambiguity d. role strain
a
A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food". The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? a. basic b. Commitment c. complex d. integrity
a
