Basics test bank ch 16, 38,17
Which of the following statements indicates that the client is at risk for an electrical shock at home? 1. I had to cut off the third prong on the electrical plug so that it would fit in the extension cord. 2. My bread got stuck in my toaster this morning, and I unplugged it before trying to remove it. 3. I always read the owners manual when I purchase a new electrical appliance. 4. I always make sure that I am standing in a dry area before operating electrical equipment.
1. I had to cut off the third prong on the electrical plug so that it would fit in the extension cord.
The primary source of information when completing an assessment of a client that is alert and oriented as he is admitted to the medical center for diagnostic testing is the: 1. Client 2. Physician 3. Family member 4. Experienced unit nurse
ANS: 1 A client is usually the best source of information. The client who is oriented and answers questions appropriately can provide the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living. The physician may have knowledge of the clients medical problem, but the client is the primary source of information for completing an assessment. Family members can be interviewed as primary sources of information about infants or children or critically ill, mentally handicapped, disoriented, or unconscious clients. Usually, however, they are secondary sources of information and can confirm findings provided by the client. The client in this situation is capable of being the primary source of information. An experienced nurse on the unit may offer insight into a clients health care needs and care, but is not the primary source of information when completing a client assessment.
During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about: 1. The onset and duration of his present breathing problem 2. His personal smoking, alcohol use, and exercise practices 3. Any extended family members who have diagnosed heart disease 4. Changes in other body systems that the client perceives as problematic
ANS: 1 A clients database originates with the clients perception of a symptom or health problem. If an illness is present, the nurse gathers essential and relevant data about the nature and onset of symptoms. The problem-seeking technique takes the information provided in the clients story to more fully describe and identify the clients specific problems. Habits and lifestyle patterns such as smoking, alcohol use, and exercise may be assessed in an admission history. However, it is not the first question the nurse should ask when obtaining data for a problem-oriented database after the client reports having a health problem. Information regarding family history, such as members who had heart disease, may be obtained in an admission history. However, if a client reports a problem, the nurse should first follow-up with questions relevant to the nature and onset of symptoms. The nurse may inquire about changes in other body systems during an admission history; however, if the client reports a problem, the nurse should first follow-up using a problem-oriented approach. This would include asking specific questions about the clients health problem, such as the nature and onset of symptoms.
The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur? 1. Impaired gas exchange 2. Decreased cardiac output 3. Ineffective airway clearance 4. Impaired spontaneous ventilation
ANS: 1 A potential etiology for impaired gas exchange may be atelectasis. Atelectasis would not support the diagnostic label for decreased cardiac output. Atelectasis would not be an etiology for ineffective airway clearance. Increased tenacious sputum production would be a possible etiology for ineffective airway clearance. Impaired spontaneous ventilation would not be an appropriate diagnostic label for atelectasis.
A confused client needs to have restraints to prevent him from pulling out his Foley catheter. Which of the following can the nurse delegate to the nursing assistive personnel? 1. Applying restraints 2. Obtaining a physicians order to restrain the client 3. Document the events that led to restraining the client 4. Evaluating the effectiveness of the restraints
ANS: 1 Although the nursing assistive personnel can apply the restraints under the nurses direction, they cannot document, evaluate, or take physicians orders.
A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors and symptoms in the database is known as: 1. Clustering data 2. Validating data 3. Peer reviewing 4. Problem statement
ANS: 1 Clustering data means the nurse organizes the information obtained into meaningful clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When clustering data, the nurse identifies relationships between factors and symptoms. Validating data means to compare the data obtained with another source to ensure its accuracy. Peer review is the evaluation of the quality of the work effort of an individual by his or her peers. After validating data and clustering data, the nurse may formulate a problem statement, usually in the form of a nursing diagnosis.
Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Diarrhea related to food intolerance 2. Alteration in comfort related to pain 3. Risk for impaired skin integrity related to poor hygiene habits 4. Potential complications related to insufficient vascular access
ANS: 1 Diarrhea related to food intolerance is a correctly written nursing diagnosis. It consists of a problem related to an etiology, and it is a condition that nursing interventions can treat or manage. Alteration in comfort related to pain is not written correctly because it is a circular statement. It would be appropriate to state ineffective breathing pattern related to incisional pain. Risk for impaired skin integrity related to poor hygiene habits is not written correctly because it uses a nurses prejudicial judgment. It would be more appropriate and professional to state risk for impaired skin integrity related to knowledge about perineal care. Potential complications related to insufficient vascular access is not written appropriately because it identifies a nursing problem, not a clients problem. It would be appropriate to state risk for infection related to presence of invasive lines.
Which of the following is an appropriate etiology for a nursing diagnosis? 1. Incisional pain 2. Poor hygienic practices 3. Need to offer bedpan frequently 4. Inadequate prescription of medication
ANS: 1 Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a clients response to a health problem, and a condition that a nurse can treat or manage. Poor hygiene practices would not be an appropriate etiology for a nursing diagnosis because it insinuates a nurses prejudicial judgment. Need to offer bedpan frequently is not an appropriate etiology because it identifies a nursing intervention, not an etiology. Inadequate prescription of medication by the physician is not an appropriate etiology because it identifies the nurses problem, not the clients problem. The nursing diagnosis should center attention on client needs.
The nurses initial responsibility in the management of a clients collaborative problem is to: 1. Monitor for changes 2. Advocate for the client 3. Implement interventions 4. Evaluate client outcomes
ANS: 1 Nurses initially monitor to detect the onset of changes in a clients status. Although advocating for the client is a nursing role, it is not reserved exclusively to collaborative problems. Implement interventions is not the initial responsibility. Evaluate client outcomes is not the initial responsibility.
Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept map to client care? 1. Concept maps help me see the whole client, not just individual health problems. 2. Concept maps can be easily edited to reflect a clients ever changing health needs. 3. I need help organizing my assessment data and concept mapping is really good for that. 4. I like concept mapping because it helps me focus on how the disease processes affect the client.
ANS: 1 The advantage of a concept map is its central focus on the client rather than the clients disease or health alteration, thus concept maps help me see the whole client, not just individual health problems is the correct answer.
An inservice program is being offered in the hospital on bioterrorism and the response of the health care agency. During the program, the mitigation phase is described. The nurse is informed that this phase includes: 1. Determination of hazard vulnerability and the impact of the emergency situation 2. Steps taken to manage the effects of the event and an inventory of available resources 3. Steps taken by staff to triage victims 4. Restoration of essential services
ANS: 1 The mitigation phase consists of the assessment process to determine hazard vulnerability for the hospitals service area. This includes an identification of the kinds of emergency situations that are most likely to occur and their probable impact. During the preparedness phase, steps are taken to manage the effects of the event, and an inventory of available resources is taken. During the response phase, steps are taken by staff to triage victims. During the recovery phase, steps are taken to restore essential services.
The goal of the orientation phase of a nursing interview is to: (select all that apply) 1. Initiate the nurse-client relationship 2. Begin identifying the clients needs 3. Earn the trust and confidence of the client 4. Assume the decision role for the client 5. Welcome the client to the nursing unit 6. Gather the clients demographic information
ANS: 1, 2, 3 Initiating the nurse-client relationship, beginning to identify the clients needs and earning the clients trust and confidence. During the orientation phase you establish trust and confidence with a client. One important goal for the initial interview is to make the foundation for understanding the clients primary needs. Another is to begin a relationship that allows the client to become an active partner in decisions about care. As the orientation phase proceeds, the client should begin to feel more comfortable speaking with you so the necessary information can be obtained. Assuming the decision role isnt correct as the client should be involved in all care decisions; assuming this role is not appropriate. While welcoming the client to the nursing unit is an expected outcome of the orientation phase of the interview process, it is not a goal. While gathering the clients demographic information is an exp
The nurse recognizes that children living in older housing that may contain lead-based paints may exhibit which of the following signs and symptoms? (Select all that apply.) 1. Vomiting 2. Anorexia 3. Headaches 4. Bloody urine 5. Thoracic rash 6. Swollen joints
ANS: 1, 2, 3 Signs and symptoms of lead poisoning typically include impaired hearing, vomiting, headaches, appetite loss, and learning and behavioral problems. The remaining options are not typically seen with this condition.
Which of the following statements made by the nurse should be included in the orientation phase of a nursing interview? (Select all that apply.) 1. Youre answers will be kept confidential. 2. My name is Susan Smith and Im a registered nurse. 3. We are here to make your hospitalization as pleasant as possible. 4. I need to ask you some questions that will help with planning your care. 5. Only those directly involved in your care will have access to this information. 6. If there is anything you need or help you require simply use your call bell and someone will be right in.
ANS: 1, 2, 4, 5 The orientation phase begins with you introducing yourself and your position and explaining the purpose of the interview. Explain to clients why you are collecting data (e.g., for a nursing history or for a focused assessment) and assure them that any information obtained will remain confidential and will be used only by health care professionals. The statements We are here to make your hospitalization as pleasant as possible and I need to ask you some questions that will help with planning your care are more appropriate for the termination phase.
The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the clients anxiety regarding the procedure? 1. Assure the client that preoperative sedation will be administered. 2. Discuss the pre- and postprocedure care that will be provided. 3. Provide a detailed explanation of why the procedure is necessary. 4. Guarantee that family will be regularly updated during the procedure.
ANS: 2 A nursing diagnosis focuses on a clients actual or potential response to a health problem rather than on the physiological event, complications, or disease. In the case of the diagnosis deficient knowledge regarding surgery, the nurse will best minimize anxiety by providing information regarding pre- and postoperative routines so as to facilitate the client in formulating realistic expectations. Although the other options are appropriate, they are limited in scope and do not have as much impact on anxiety.
What is the most appropriate method for the nurse to communicate a clients wishes to the nurses on the next shift? 1. Document the request in the nursing notes. 2. Include the clients request in the shift report. 3. Place instructions regarding the clients wishes above the clients bed. 4. Verbally inform the unit clerk of the clients request.
ANS: 2 In the acute care setting, the change-of-shift report is the way for nurses from one shift to communicate information to nurses on the next shift Documenting the request in the nursing notes is not appropriate for inclusion in the nursing notes because it does not reflect information regarding the clients condition, response to treatment, or current health status. Placing the instructions regarding the clients wishes above the bed is not appropriate because there is no guarantee that staff will see the posting, but more importantly there are confidentiality issues being ignored. While verbally informing the unit clerk of the clients request may result in the clients wishes being respected, it is not the most effective option.
After visiting with the client, the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as objective data? 1. Pain in the left leg 2. Elevated blood pressure 3. Fear of impending surgery 4. Discomfort upon breathing
ANS: 2 Objective data are observations or measurements made by the data collector, such as a blood pressure reading. Subjective data are clients perceptions about their health problems, such as pain. Fear of surgery would be subjective data because it is the clients perception and not something the data collector can measure. Subjective data are clients perceptions about their health problems, such as discomfort during breathing. A respiratory rate would be an example of objective data.
The process of data collection should begin with the nurse performing a: 1. Physical exam 2. Client interview 3. Review of medical records 4. Discussion with other health team members
ANS: 2 The first step in establishing the database is to collect subjective information by interviewing the client. The physical examination follows the client interview so that data can be verified. A review of medical records is not the first step the nurse should take in the process of data collection. The medical record is a valuable tool for checking the consistency and congruency of personal observations made during the client interview. Discussion with other health team members may provide additional information and be used to relay information, but is not the first step in the process of data collection.
The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job. Job loss best fits into which of the following categories? 1. Family history 2. Psychosocial history 3. Biographical history 4. Environmental history`
ANS: 2 The psychosocial history reveals the clients support system, if there are any recent losses or stressful events, and how the individual copes with such stressors. The loss of a job would fit the psychosocial history category. Family history is used to obtain data about immediate and blood relatives to determine whether the client is at risk for illnesses of a genetic or familial nature. It also provides information about the family itself. The biographical history provides factual demographic data about the client. The environmental history provides data about the clients home and working environments.
Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the clients depression? 1. Have you ever felt this depressed before? 2. What do you believe is the cause of your depression? 3. What makes you feel that you are experiencing depression? 4. What can we do to make you comfortable while you are here?
ANS: 2 This option is an open-ended question that encourages the client to express his insight regarding his condition. This option is a closed-ended question requiring only a yes or no response and so provides minimal information regarding the clients condition. While this is an open-ended question, it is not the best option because it is not directed towards assessment of the clients current complaint. While this is an open-ended question, it is not the best option because it is directed at the clients comfort, not towards assessing his current complaint.
Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process? 1. Paternal family history of osteoarthritis has been reported. 2. Client is observed grimacing when walking to bathroom. 3. Right knee appears edematous when compared to left knee. 4. Client rated the pain felt after walking at a 6 on a scale of 1 to 10.
ANS: 2 To collect complete, relevant, and correct assessment data it helps to identify assessment activities that produce specific kinds of data. When possible, the nurse should collect objective data because they are often more supportive than subjective data. Observation of the clients response to the use of the affected joint is the most supportive of the options.
The nurse recognizes that a clients hearing deficits impact the development of the nurse-client relationship. Which of the following has the greatest impact on minimizing this obstacle? 1. Speaking slowly, clearly, and in a normal tone 2. Using various forms of nonverbal communication 3. Relying heavily on touch to convey caring and interest 4. Involving family in discussions concerning meeting clients needs
ANS: 2 When a client has limited hearing or visual deficits, it becomes more important for a nurse to use nonverbal communication when establishing nurse-client relationships. Speaking slowly, clearly and in a normal tone may make verbal communication more effective, but it will not have the greatest positive impact of the offered options. Relying heavily on touch is only one form of nonverbal communication that can positively impact the development of the relationship. While involving family in discussions may help in the identification of client needs, it does not necessarily have positive impact on developing a healthy
Research has shown that which of the following nursing skills is best strengthened through the use of concept mapping? (Select all that apply.) 1. Client teaching related to health and wellness topics 2. Evaluation of client outcomes in regards to nursing care 3. Identification of patterns in the clients health assessment data 4. Recognition of relationships among the clients various health issues 5. Planning specialized nursing interventions to meet a clients health needs 6. Facilitating assessment data collection through observation and communication
ANS: 2, 3, 4, 5 Concept mapping significantly improved students abilities to see patterns and relationships as well as to organize, plan, and evaluate nursing care. Client teaching and assessment collecting are not markedly affected by concept mapping.
The nurse caring for clients in an acute care facility recognizes that attending to the safety of each client is most likely to result in: (Select all that apply.) 1. Freedom from illness 2. A shorter hospital stay 3. Attention to the basic human needs 4. A well-founded sense of well-being 5. Preservation of the optimal functioning level 6. Minimal exposure to bacterial cross-contamination
ANS: 2, 3, 4, 5, 6 Safety in health care settings reduces the incidence of illness and injury, prevents extended length of treatment and/or hospitalization, improves or maintains a clients functional status, and increases the clients sense of well-being. A safe environment gives protection to the staff as well, allowing them to function at an optimal level. A safe environment includes meeting basic needs, reducing physical hazards, reducing the transmission of pathogens, maintaining sanitation, and controlling pollution. While a reduction of illness is an expectation, there is no assurance of the freedom from illness.
The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning? 1. Is your pain worse or better than it was an hour ago? 2. Do you believe that your nausea is from the new antibiotic? 3. What do you think has been causing your current depression? 4. What have you done to alleviate the side effects from your medications?
ANS: 3 An open-ended question prompts the client to describe a situation in more than one or two words. This option demonstrates the open-ended question technique. This question limits the clients answers to one or two words. It is an example of a closed-ended question. The question in this option limits the clients answer to one or two words such as yes or no. It is an example of a closed-ended question. This option only requires a few words to form an answer. It does not use the open-ended question technique.
1. The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs? 1. Bacterial contamination of foods is uncontrollable. 2. Fire is the greatest cause of unintentional death. 3. Carbon dioxide levels should be monitored in home settings. 4. Temperature extremes seldom affect the safety of clients in acute care facilities.
ANS: 3 Annual inspections of heating systems, chimneys, and appliances should be done in private homes. Carbon monoxide detectors are available but should not be used as a replacement for proper use and maintenance of fuel-burning appliances. Bacterial contamination of foods is controllable. The FDA is a federal agency responsible for the enforcement of federal regulations regarding the manufacture, processing, and distribution of foods, drugs, and cosmetics to protect consumers against the sale of impure or dangerous substances. Motor vehicle accidents are the leading cause of unintentional death, not fire. Temperature extremes can affect the safety of clients in acute care facilities, especially the elderly.
Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Anxiety related to cardiac monitor 2. Pain related to difficulty ambulating 3. Chronic pain related to insufficient use of medication 4. Bedpan required frequently as a result of altered elimination pattern
ANS: 3 Chronic pain related to insufficient use of medication is an example of an appropriately written nursing diagnosis. It consists of a diagnostic label and the associated etiology. Nursing interventions can be directed at treating or managing the behavior of insufficient medication use. Anxiety related to cardiac monitor is written incorrectly because it identifies the equipment rather than the clients response to the equipment. It would be appropriate to state deficient knowledge regarding the need for cardiac monitoring. Pain related to difficulty ambulating is not written correctly. What could be a defining characteristic is used as an etiology. This nursing diagnosis could be rewritten more appropriately as impaired mobility related to pain as evidenced by difficulty ambulating. Or it could be an inaccurate diagnostic label and could be rewritten as anxiety related to difficulty in ambulating. Bedpan required frequently as a result of altered elimination pattern is written incorrectly because it identifies a nursing intervention, not the clients problem. It could be reworded as diarrhea related to food intolerance.
A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurses mentor? 1. Conducting the interview with the clients boyfriend present 2. Stopping the interview to answer a page from the nursing station 3. Frequently checking the time while waiting for the client to answer 4. Heard asking the client, Am I correct; youve rated your pain a 9 out of 10?
ANS: 3 Clients are less likely to fully reveal the nature of their health care problems when nurses show little interest, appear rushed, or are easily distracted by activities around them. As long as the nurse had the clients permission, this would not require follow-up. While interrupting an assessment is not recommended, a page is an example of an acceptable exception and so this would not require follow-up. If the nurse were confirming the information, it would not require follow-up. If the mentor felt the nurse was questioning the validity of clients pain rating, a follow-up would be appropriate because a clients pain rating should not be questioned.
Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Risk for change in body image related to cancer 2. Cardiac output decreased related to motor vehicle accident 3. Ineffective airway clearance related to increased secretions 4. Potential for injury related to improper teaching in the use of crutches
ANS: 3 Ineffective airway clearance related to increased secretions is written appropriately. It identifies a problem using a NANDA International diagnostic statement and connects it to its etiology. Risk for change in body image related to cancer is written incorrectly. It uses a medical diagnosis for the etiology. Cardiac output decreased related to motor vehicle accident is written incorrectly. The etiology is not treatable. Potential for injury related to improper teaching in the use of crutches is written incorrectly. It identifies the nurses problem, not the clients.
When asked to define Nursing Diagnosis the nurses best response is: 1. It is the second step in the Nursing Process. 2. It is the process of defining a clients problems. 3. It correlates a clients problem with a condition a nurse is competent to treat. 4. It focuses care a licensed nurse can provide with the identified needs of a client.
ANS: 3 It correlates a clients problem with a condition a nurse is competent to treat is a statement that describes the clients actual or potential response to a health problem that the nurse is licensed and competent to treat. Although It is the second step in the Nursing Process is true, it does not define the term. Although It is the process of defining a clients problems is true, is does not address the nursing aspect of the term. Although It focuses care a licensed nurse can provide with the identified needs of a client is true, the focus is not primarily on care.
The client recently became febrile and stated he felt hot. The nurse takes the clients temperature and finds it to be 38.2 C. In addition, the pulse rate is 88 beats per minute, and his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data? 1. Pulse rate of 88 beats per minute 2. Blood pressure of 168/80 mm Hg 3. The statement regarding his feeling hot 4. The supported fact that he became febrile
ANS: 3 Subjective data are clients perceptions about their health problems. The statement by the client regarding his feeling hot is an example of subjective data. A pulse rate of 88 beats per minute is an example of objective data. Objective data are observations or measurements made by the data collector. A blood pressure of 168/80 mm Hg is something that can be measured, and therefore is an example of objective data. Becoming febrile can be determined by measurement, and therefore is an example of objective data.
Which of the following responses best reflects an understanding of the purpose of the related to phrase attached to the diagnostic label deficient knowledge regarding postoperative routines? 1. To focus on the cause of the clients needs 2. To identify the etiology of the clients diagnosis 3. To provide for individualization of the nursing interventions 4. To communicate the clients deficits to the nursing staff
ANS: 3 The inclusion of the related to phrase requires you to use critical thinking skills to individualize the nursing diagnosis and then select personalized nursing interventions. Although the other options are not incorrect, they do not reflect the best understanding of the purpose of the phrase, To provide for individualization of the nursing interventions is the correct answer.
The primary purpose of a nursing diagnosis, according to the nurses, is to: 1. Support the medical plan of care 2. Provide a standardized approach for all clients 3. Recognize the clients response to an illness or situation 4. Offer the nurses subjective view of the clients behaviors
ANS: 3 The primary purpose of a nursing diagnosis is to recognize the clients response to an illness or situation. The nurse can then use the nursing diagnosis to select appropriate nursing interventions to achieve positive client outcomes. A nursing diagnosis is based on the client, not on the medical plan of care. Although nursing diagnoses may facilitate communication, it does not mean they provide a standardized approach for all clients. Nursing diagnoses are individualized to meet the clients needs. The primary purpose of nursing diagnoses is not to offer the nurses subjective view of the clients behaviors. Nursing diagnoses are based on subjective and objective client data and should not include the nurses personal beliefs and values.
Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Acute pain related to left mastectomy 2. Impaired gas exchange related to altered blood gases 3. Deficient knowledge related to need for cardiac catheterization 4. Need for high protein diet related to alteration in client nutrition
ANS: 3 This nursing diagnosis is written correctly. It defines a problem and its etiology. In this case the problem is the clients response to a diagnostic test. A medical diagnosis should not be recorded as the etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state acute pain related to impaired skin integrity secondary to mastectomy incision. This nursing diagnosis is written incorrectly because it uses supportive data of the problem as the etiology. This nursing diagnosis does not identify the problem and etiology. It identifies the clients goal rather than the problem. It could be reworded as imbalanced nutrition: less than body requirements related to inadequate protein intake.
When obtaining subjective assessment data, the nurse recognizes which of the following client scenarios as being the most likely to produce accurate, credible information? 1. A 50-year-old in the ED reporting chest pain 2. A 70-year-old admitted with fever of unknown origin 3. A 81-year-old receiving follow-up treatment for a hip replacement 4. A 22-year-old being treated at a clinic for a sexually transmitted disease
ANS: 3 This option where the 81-year-old is receiving follow-up treatment for a hip replacement presents a client who is not necessarily experiencing pain, embarrassment, guilt, or any other emotion/factor that would inhibit the free communication of subjective symptom data. The 50-year-old client is experiencing pain; this is likely to inhibit the communication process. The 70-year-old client is febrile; this could interfere with the communication process, especially for an older adult because it may cause confusion and the 22-year-old client may be experiencing guilt and/or embarrassment; both may interfere with the communication process.
When following up on a clients report of hip pain during an admission assessment, the most nursing conclusive observation would be: 1. The client tearing when being ambulated to the chair 2. A report from the ancillary staff that the client is reporting pain 3. The client observed grimacing when positioning self in the bed 4. Overhearing the client discuss hip pain with family on the phone
ANS: 3 This option where the client was observed grimacing describes nonverbal actions that are associated with pain when the client is unaware of being observed and so represents the most conclusive follow-up evidence of pain. The options where the client is tearing when ambulated to the chair, the ancillary staffs report of the clients pain as well as overhearing the client discuss hip pain may well be an observation of pain, but they are not the most conclusive of the options because the client is aware of being observed.
An ambulatory client is admitted to the extended care facility with a diagnosis of Alzheimers disease. In using a falls assessment tool, the nurse knows that the greatest indicator of risk is: 1. Confusion 2. Impaired judgment 3. Sensory deficits 4. History of falls
ANS: 4 According to the falls assessment tool, the greatest indicator of risk is a history of falls. According to the falls assessment tool, the second leading risk factor for falls is confusion. According to the falls assessment tool, impaired judgment is the fourth leading risk factor for falls. According to the falls assessment tool, sensory deficit is the fifth leading risk factor for falls.
The nurse is going to perform the admission history for a newly admitted client on the medical unit. The optimum time for completion of the history is planned for: 1. Coordination with the physicians visit 2. The time when the clients family are visiting 3. Immediately before the clients scheduled MRI testing 4. After the client has become comfortably oriented to the room
ANS: 4 Completion of the admission history is scheduled for a time when interruptions by other staff or visiting family members are minimal. The nurse should create an environment where the client feels comfortable. Conducting the admission history after the clients orientation to the room and completion of lunch would be optimum because the client will not be distracted by hunger, and the interview will less likely be interrupted. The admission history should be scheduled for a time when interruptions by other staff are minimal. During the physicians visit would not be an optimum time. The nurse should provide an environment private enough to allow the client to be comfortable when providing personal information. Inclusion of family members should be left up to the client to decide. Information obtained should remain confidential. Immediately before a clients testing would not be an optimum time for obtaining a nursing history. The client may feel more anxious about the upcoming test, impeding communication, and there may not be sufficient time allowed to gather all of the information.
Which of the following statements best reflects the nurses understanding of the primary nursing-related purpose of a concept map? 1. To facilitate holistic nursing care 2. To provide visualization of the clients health problems 3. To assist in the identification of client-oriented nursing diagnoses 4. To demonstrate the relationship between the clients various health problems
ANS: 4 Concept mapping is one way to graphically represent the connections between concepts and ideas that are related to a central subject (e.g., the clients health problems). Although the other options are correct, they do not provide the best understanding of the purpose of concept mapping in nursing practice as well as to demonstrate the relationship between the clients various health problems.
Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences. 1. Altered speech 2. As evidenced by 3. Recent neurological disturbances 4. Inability to speak in complete sentences
ANS: 4 Defining characteristics are assessment findings that support the nursing diagnosis. In this example, the inability to speak in complete sentences supports the nursing diagnosis of altered speech. Altered speech is the diagnostic label identifying the problem. As evidenced by is a connecting statement for the problem and the defining characteristics. Recent neurological disturbances is the etiology.
When asked to define the purpose of diagnostic reasoning, the best nursing response is: 1. Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis. 2. The diagnostic reasoning process flows from the assessment process and includes decision-making steps. 3. Diagnostic reasoning includes data clustering, identifying client needs and formulating the diagnosis or problem. 4. Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis.
ANS: 4 Diagnostic reasoning is a process of using the assessment data gathered about a client to logically explain a clinical judgment, in this case a nursing diagnosis. The remaining options do not describe purpose but rather identify outcomes of diagnostic reasoning.
Which of the following assessment data provided by a clients family will have the greatest impact on the clients care while hospitalized? 1. Mom falls asleep fastest with the television on. 2. Dad starts off the day with hot coffee; it regulates his bowels. 3. My wifes sister died 4 months ago, and she is still grieving over her loss. 4. My husband doesnt like to let people know his arthritis is bothering him.
ANS: 4 Family and friends can make important observations about the clients health status, changes, and needs that can affect the way care is delivered. Being aware of the clients reluctance to discuss his pain will impact the frequency and way his pain is assessed. While this information will affect the way the staff prepares the client for sleep, it does not have priority over pain assessment. While this information will allow the staff to meet the clients morning coffee need, it does not have priority over pain assessment. While this information will affect the way the staff address the clients emotional needs, it does not have priority over pain assessment.
A client expresses concern over a scheduled intravenous pyelogram by stating, I dont know what to expect. Which of the following nursing diagnoses is most appropriate for this client need? 1. Anxiety related to scheduled diagnostic testing 2. Knowledge deficit regarding need for diagnostic testing 3. Knowledge deficit related to need for intravenous pyelogram 4. Anxiety related to lack of knowledge concerning intravenous pyelogram
ANS: 4 Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself. The client need, identified by the statement, is not related to the necessity for the test but concern over a lack of knowledge about what to expect before, during, and after the test. The remaining options fail to identify a client need.
The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about: 1. A family history of heart problems 2. Medications currently being taken at home 3. Questions or concerns about hospitalization 4. The onset, severity, and duration of the chest pain
ANS: 4 If a client comes to the emergency department with chest pain, the nurse should first ask the client about the onset, severity, and duration of the chest pain. In an emergency situation, the clients current health problem becomes the priority assessment. Initially, the nurse should not ask questions regarding family history. Gathering data about the problem currently affecting the client has greater priority. Asking the client about medications taken at home is appropriate, but not at this time. The priority is to assess the symptoms the client is experiencing. Asking the client about concerns regarding hospitalization is not the priority.
An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time? 1. Can you describe your pain? 2. Have you had this problem before? 3. What have you done to ease the pain? 4. When did your abdominal pain begin?
ANS: 4 If a client presents to the emergency department with pain, the nurse should first ask the client about the onset, severity, and duration of the pain. In an emergency situation, the clients current health problem becomes the priority assessment. Gathering data about the problem currently affecting the client has greater priority, but a description of the pain does not have priority over onset. Asking the client about medical history is appropriate but not at this time. The priority is to assess the symptoms the client is experiencing. Gathering data about the problem currently affecting the client has greater priority, but attempted self-treatment does not have priority over onset.
The nurse is conducting an interview with the client and wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication? 1. I understand how you must feel. 2. This medication is used to lower your blood pressure. 3. You appear anxious. Youre wringing your hands constantly. 4. Could you give me an example of how you handle stressors?
ANS: 4 In this option, the nurse is seeking further clarification of information by asking the client to provide an example. Clarification helps the nurse to gain accurate understanding of a clients situation. This is not an example of clarifying information. This response provides information. The nurse is not using the clarifying technique of communication. In this option the nurse describes his or her observations. It does not seek clarification.
A client with a history of epilepsy arrives in the emergency department experiencing status epilepticus. The nurse should never do which of the following? 1. Document sequence of events, including any adverse outcomes. 2. Prepare to initiate IV access. 3. Access oxygen and suctioning equipment. 4. Open clients mouth by placing fingers on jaw and inserting thumb on bottom teeth to place oral airway between seizures.
ANS: 4 Nurses should never put their fingers in or close to a clients mouth who is or has been experiencing seizure activity, to prevent being bitten in the event that the client should experience more seizure activity. The nurse is responsible for all of these measures in Answers 1, 2, and 3 to provide for the safety of the client, as well as document the sequence of events including any unexpected outcomes.
The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain? 1. What makes the pain worse? 2. When did you first notice the pain? 3. What do you do to lessen the pain? 4. Can you rate your pain using the pain scale that weve discussed?
ANS: 4 Once you complete the assessment, you thoroughly analyze the extent and nature of the clients problem so you are able to later develop a care plan. Identifying the degree of pain the client is experiencing has priority over the other options. While this option is an appropriate pain assessment question, it is more directed towards identifying contributing factors than the characteristics (nature) of the pain. While this option is an appropriate pain assessment question regarding the nature of the pain, it does not have priority over the degree of pain because that represents an issue that requires immediate intervention. While this option is an appropriate pain assessment question, it is more directed towards identifying effective self-treatment rather than the characteristics (nature) of the pain.
Which subjective assessment data are most supportive of a clients diagnosis of anxiety? 1. Diaphoretic and cool skin 2. An apical pulse rate of 120 beats per minute 3. Reports needing to leave now 4. Claims something is terribly wrong
ANS: 4 Subjective data are clients perceptions about their health problems. The statement by the client regarding his sense of impending doom is the best example of subjective data regarding his anxiety because it is his own verbalization of the problem. Cool, damp skin is an example of objective data. Objective data are observations or measurements made by the data collector. A pulse rate is an example of objective data. Objective data are observations or measurements made by the data collector. While a client statement regarding the need to leave the hospital is subjective in nature, it is not as strong an indicator of anxiety as is the verbalization of impending doom.
The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse? 1. How long have you been dealing with GERD? 2. Are you currently taking any medications for your GERD? 3. Do you follow a particular diet to help manage your GERD? 4. Do you have any other gastrointestinal problems besides GERD?
ANS: 4 The nurse should ask relevant questions and collect relevant history and physical assessment data related to the clients presenting health care needs in order to produce the most inclusive, effective nursing care plan. The questions How long have you been dealing with GERD? and Are you currently taking any medications for your GERD? as well as Do you follow a particular diet to help manage your GERD? are directed towards the GERD itself and not towards conditions that might be related to the presence of GERD.
The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression? (Select all that apply.) 1. My work environment would depress anyone. 2. It seems like almost anything can make me cry. 3. Being here away from my family makes me sad. 4. I just cant seem to get excited about anything anymore. 5. The family always thought that my father was depressed. 6. I like winter because I can just cover up on the couch and sleep.
ANS: 4, 5 I just cant seem to get excited about anything anymore and The family always thought that my father was depressed. Remember to always have supporting cues before you make an inference. These options relate a broad lack of interest in life and a family history of depression. While mentioning My work environment would depress anyone as a depressing situation, this option does not infer personal depression. While mentioning It seems like almost anything can make me cry as a potential sign of depression, this option is not a strong inference because crying can be a result of other emotions. While mentioning Being here away from my family makes me sad notes sadness, this option describes a normal reaction to being separated from loved ones. While mentioning I like winter because I can just cover up on the couch and sleep shows withdrawal behaviors, this option is not a strong inference because winter often evokes stay-at-home tendencies in people.
During an interview, the nurse needs to obtain specific information about the signs and symptoms of the clients health problem. To obtain these data most efficiently, the nurse should use: 1. Channeling 2. Open-ended questions 3. Closed-ended questions 4. Problem-seeking responses
LOOK OVER QUESTION ANS: 3 Using closed-ended questions helps the nurse to acquire specific information about health problems such as symptoms, precipitating factors, or relief measures in an efficient manner. Channeling is where the nurse uses active listening techniques, such as all right, go on, or uh-huh, to indicate the nurse has heard what the client said and encourage the client to elaborate further. Using open-ended questions prompts the client to describe a situation in more than one or two words. Because it allows the client the opportunity to tell their story and reveal what is important to them, it is not the most efficient method of obtaining specific information regarding a clients signs and symptoms of a health problem. In problem-seeking technique, the nurse takes the information provided in the clients story to more fully describe and identify the clients specific problems. Using closed-ended questions would be the most efficient method for obtaining specific information about the signs and symptoms of a clients health problem.
When clustering data according to functional health patterns, the nurse determines that the client is only able to ambulate short distances without becoming fatigued and requires rest periods during morning care. The health pattern that requires intervention is identified by the nurse as: 1. Respiratory 2. Activity and exercise 3. Sleep and rest pattern 4. Self-care deficit: activities of daily living
LOOK OVER QUESTION ANS: 2 Using the functional health pattern format, the nurse clusters data that pertain to a functional health category. Fatigue upon ambulating short distances and requiring frequent periods of rest are examples of data belonging to the category of activity and exercise. Respiratory would be found in a systems approach of health assessment, not a functional health pattern assessment. The functional health pattern category of sleep and rest would focus more on the number of hours of sleep the client obtains, use of sleep aids, and any difficulties associated with sleep. Self-care deficit: activities of daily living would include such aspects as bathing, feeding, and dressing self. The symptoms described would be clustered more accurately under the functional health pattern category of activity and exercise.
A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, what the diagnosis means. Which of the following rationales best supports the nurses determination that the client has knowledge deficit rather than a readiness for enhanced knowledge? 1. The client initiated the question. 2. This is a new diagnosis for the client. 3. The client identified a lack of understanding. 4. Type 2 diabetes mellitus is a complicated disease process.
NS: 2 Although all the options are accurate, this is a new diagnosis for the client best reflects the need for knowledge because the client had no previous experience with the condition and so had a true knowledge deficit.
Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor? 1. I can tell when my Hispanic clients are in pain. 2. Moaning is a classic sign of pain in most cultures. 3. All clients will tell you when they need pain medication. 4. Chronic pain is difficult to manage especially for the stoic individual.
Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor? 1. I can tell when my Hispanic clients are in pain. 2. Moaning is a classic sign of pain in most cultures. 3. All clients will tell you when they need pain medication. 4. Chronic pain is difficult to manage especially for the stoic individual.