Chapter 05, Chapter 2, chapter 4

The order in which the nursing process is approached is

assessment, nursing diagnosis, planning, implementation, evaluation.

A nurse will arrive at a nursing diagnosis through the nursing process step of

assessment.

When a resident in the nursing home complains of constipation, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an example of

assessment.

The nurse assesses that a person is in the acceptance stage of illness when the patient:

assumes the "sick" role.

In giving nursing care to persons of Asian origin, the nurse should::

ask permission before touching the patient

The nurse explains that an idiopathic disease is one that:

has an unknown cause.

When the brain perceives a situation as threatening, the sympathetic nervous system reacts by stimulating which of the following physiological functions? (Select all that apply.)

-Dilation of the bronchial tubes. -Dilation of the pupils.

Which defines the holistic approach to caring for the sick and promoting wellness? (Select all that apply.)...

-The nurse realizes that each person has a responsibility for his or her own health. -Health care providers are required to intervene on behalf of all persons to ensure that health goals are met. -Providers combine traditional methods of health care with relaxation techniques for pain management. -A change in one aspect of a person's life may or may not alter the person as a whole.

The nurse describes behaviors of the transition stage of illness, which are: (Select all that apply.)

-awareness of vague symptoms. -denial of feeling ill. -resorts to self-medication.

The nurse clarifies that a person who is self-actualized would have the characteristics of: (Select all that apply.)

-having met all other need levels. -being certain of their beliefs and values.

The responses during the alarm stage of the general adaptation syndrome as defined by Hans Selye include: (Select all that apply.)..

-slight increase in body temperature. -decreased appetite. -hormones released for mobilization for defense.

The participants of the planning stage of the nursing process during which the health goals are defined include the

health team, the patient, and the patients family.

A nurse begins rounds on a medical surgical nursing unit. Review the following patients on her assignment. Prioritize the order in which the patients should be assessed, based on their descriptions. (Separate letters with a comma and space as follows: A, B, C, D.) A. A 22-year-old patient who is awakening from neck surgery. B. An 82-year-old patient who is blind and needs discharge instructions. C. A 44-year-old patient with dehydration from vomiting and diarrhea, who was admitted 3 days ago and who has an IV infusion of fluids. D. A 35-year-old patient admitted for an injury to his left femoral artery, which required surgical repair 8 hours ago following an ice-skating accident.

A, D, C, B

Which of the following items could be the responsibility of the LPN/LVN for a patient's plan of care? (Select all that apply.)

A. Collect data. B. Perform nursing interventions. C. Document nursing care.

Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select all that apply.)

A. determination of potential health problems. B. clustering of related assessments.

Activities considered to be aspects of the implementation step of the nursing process are: (Select all that apply.)

A. documentation of care given. B. assembly of supplies.

1. Conclusions that have been made based on observed data are __________.

ANS: inferences Inferences are conclusions made based on observed data.

21. Reginald is a nurse caring for a 56-year-old man who is admitted with an acute MI. As he completes the initial assessment, he knows that concerning the practice of nursing, the purpose of the assessment on admission is to: a. gather data so that the patient's response to the treatment can be evaluated. b. gather data for the health care provider, to make decisions based on the condition of the patient. c. establish rapport with the patient so that he/she can feel safe and secure in the acute health care setting. d. begin the care plan and set the patient on the road to recovery.

ANS: A The practice of nursing is concerned with how a patient responds, physiologically and psychologically, to their disease or disorder, to their treatment(s), their life situation and environment, etc. In order to determine this, a database containing information about the patient must be established. It is in this capacity that LPN/LVNs contribute, via data collection, to the assessment stage of the nursing process.

10. A patient has a nursing diagnosis of imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months. An appropriate short-term goal for this patient is to: a. eat 50% of six small meals every day by the end of 1 week. b. demonstrate progressive weight gain over 6 months. c. eat all of the meals prepared during admission. d. verbalize understanding of caloric needs and intention to eat.

ANS: A Short-term goals should be realistic and attainable and should have a timeline of 7 to 10 days before discharge.

14. A nursing care plan consists of: a. nursing orders for individualized interventions to assist the patient to meet expected outcomes. b. orders for diagnostic and therapeutic procedures such as laboratory tests or radiographs. c. the health care provider's history and physical examination, as well as medical diagnoses. d. laboratory and radiograph reports, pathology reports, and the medication record.

ANS: A The nursing care plan consists of the nursing orders for interventions to address problems and establish outcomes by which the plan can be evaluated.

3. An example of a structured format for gathering data that aids in forming a database is: a. North American Nursing Diagnosis Association-International (NANDA-I). b. Maslow's hierarchy. c. QSENl d. Gordon's 11 Health Patterns.

ANS: D Mary Gordon's assessment guide is a guided path to cover 11 health points. Although Maslow may be used, it is not structured.

8. An older adult patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she "can't breathe." Based on this information, an appropriately worded nursing diagnosis for this patient is: a. Airway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath. b. Pneumonia, cough, and shortness of breath related to chronic lung disease. c. Difficulty breathing not relieved by oxygen and evidenced by shortness of breath. d. Cough and shortness of breath caused by pneumonia, chronic lung disease, advanced age, and exhaustion.

ANS: A The nursing diagnosis from the NANDA list is complete with a cause and signs and symptoms.

20. A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is: a. Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. b. Airway clearance, ineffective, related to right lower lobe pneumonia as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. c. Right lower lobe pneumonia, related to airway clearance, ineffective, as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. d. Expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung related to right lower lobe pneumonia as evidenced by airway clearance.

ANS: A The nursing diagnosis is from the NANDA-I list and is complete with a cause and signs and symptoms. The other answers contain a medical diagnosis of pneumonia, which is inappropriate.

9. The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.) a. validate classification by field test. b. identify labels. c. provide language labels for desired outcomes. d. generate a readymade nursing care plan for a patient. e. identify patient outcomes and indicators.

ANS: A, B, C, E The purpose of NOC is to provide language labels to help identify and classify patient outcomes and validate classifications by field testing.

5. A nursing diagnosis identifies: (Select all that apply.) a. patient's response to illness. b. related signs and symptoms. c. underlying medical diagnosis. d. causative factors. e. potential risk for health problems.

ANS: A, B, D, E Defining characteristics of nursing diagnosis includes the patient's response to illness and the causative factors. Signs and symptoms must also be identified for a nurse to select an appropriate nursing diagnosis. Medical diagnoses label an illness; nursing diagnoses are independent of medical diagnoses.

3. Appropriate nursing roles in the initial assessment would include: (Select all that apply.) a. LPN obtains the vital signs of a new patient. b. RN performs a complete physical assessment. c. LPN organizes data into a database. d. RN reviews the patient's medical record for past medical/surgical history. e. LVN contributes ongoing assessments.

ANS: A, B, D, E The LPN/LVN, under the NFLPN standard, contributes assessments; the RN performs the physical assessment and medical records review and organizes the database.

2. A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurological impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.) a. Assist with range of motion exercises every 4 hours and as needed. b. Instruct patient to call for assistance when needing to get out of bed. c. Apply wrist and ankle restraints to promote safety and prevent falls. d. Teach about exercises that will strengthen muscles while lying in bed. e. Ambulate with physical therapy assistance at least three times a day.

ANS: A, B, D, E The nurse selects appropriate nursing interventions to alleviate the problems and assist the patient in achieving the expected outcomes. Consider all possible interventions for relief of the problems and then select those most likely to be effective.

8. The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.) a. community. b. health system. c. socioeconomic level. d. safety. e. behavioral.

ANS: A, B, D, E The seven domains of the NIC taxonomy are physiological: basic; physiological: complex; behavioral; safety; family; health system; and community.

1. The nurse understands that an expected outcome should be: (Select all that apply.) a. realistic. b. approved by the health care provider. c. attainable. d. within a defined time. e. included after patient collaboration.

ANS: A, C, D, E An expected outcome should be realistic and attainable and should have a defined time line after collaboration with the patient.

4. Aside from the information obtained from the patient (primary source) in the admission interview, the nurse will also access: (Select all that apply.) a. the patient's family. b. a reliable and up-to-date reference book. c. the admission note. d. the health care provider's history and physical. e. an observation of the patient for nonverbal clues.

ANS: A, C, D, E The nurse conducting the interview uses information from the patient's family, from the health care provider's s admission note and history and physical, and from personal observation of the patient.

7. A nursing diagnosis consists of: a. the health care provider's medical diagnosis listed as the nursing diagnosis. b. diagnostic labels formulated by the North American Nursing Diagnosis Association-International (NANDA-I). c. the patient's explanation of his or her "chief complaint" or "current complaint." d. the results of the nursing assessment without consideration of doctor's orders.

ANS: B NANDA-I has formulated an official list of nursing diagnoses to identify patient problems and problems that patients are at risk of developing. A nursing diagnosis is independent of a medical diagnosis.

13. The North American Nursing Diagnosis Association-I (NANDA-I) list is revised and updated every: a. year. b. 2 years. c. 3 years. d. 5 years.

ANS: B NANDA-I meets every 2 years to revise and update the list.

15. In an acute care facility, a nursing care plan is usually reviewed and updated: a. every shift. b. every 24 hours. c. once every 3 days. d. on admission and discharge.

ANS: B Ongoing assessment, intervention, and evaluation lead to attainment or modification of the original plan for the patient who is acutely ill. The nursing care plan must be updated every day to reflect these changes.

12. A patient with visual impairment is identified as at-risk for falls related to blindness. An appropriate intervention would be: a. assist the patient with feeding herself at the end of the meal. b. arrange furnishings in room to provide clear pathways and orient the patient to these. c. take the patient's blood pressure before she gets up in the morning. d. report any falls immediately to the charge nurse and the doctor.

ANS: B Providing clear pathways directly reduces the risk of patient falls.

19. Standardized Nursing Care Plans can: a. be documented without alteration. b. have items altered or deleted. c. become part of the record without documentation. d. help the family understand the concept of Nursing Care Plans.

ANS: B Standardized Nursing Care Plans are generic and need to be altered to become individualized. They must be documented.

7. The nurse should make a point when closing the initial interview to: (Select all that apply.) a. develop rapport. b. summarize the problems discussed. c. thank the patient for his or her time. d. discuss the nursing goals associated with nursing diagnoses. e. give a copy of the nursing care plan to the patient.

ANS: B, C The nurse should summarize the problems discussed, thank the patient for his or her time, and explain what happens next and when the nurse will return.

6. The statements that are correctly stated as expected outcomes are: (Select all that apply.) a. patient will be able to void in the bathroom independently. b. patient will be able to ambulate using a walker independently within 3 days. c. the nurse will assist the patient to the bathroom three times a day. d. patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours. e. the family will bring food from home to improve patient appetite.

ANS: B, D Expected outcomes need to have a time frame and be measurable. Ambulating with a walker within 3 days and performing ROM independently for 4 hours are both measurable outcomes with clear time frames. The outcome of voiding independently does not have a time frame. Assisting the patient to the bathroom is a nursing intervention.

22. Theresa is a nurse caring for a 14-year-old girl who is admitted with an asthma attack. When she writes the nursing diagnosis statement she includes? a. Two statements; the problem and the signs and/or the symptoms. b. The medical diagnosis. c. Her clinical judgment regarding the patient's response to the problem. d. Uses the NANDA-I as the stem and the medical diagnosis as the conclusion.

ANS: C Most care facilities use a problem statement in care planning that may (or may not) conform to the NANDA-I terminology. Whatever the terminology used, the nursing diagnosis reflects the nurse's clinical judgment regarding the patient's response to an actual or potential health problem, and is the basis for the nurse's plan of care for the patient.

9. If a patient has several nursing diagnoses, the nurse will first: a. consult with the doctor regarding which diagnosis is most important. b. devise nursing interventions for the most quickly solved problems. c. prioritize the nursing problems according to Maslow's hierarchy of needs. d. review the patient's medical prescriptions and other drugs being taken.

ANS: C Nursing diagnoses (and thus their interventions) must be prioritized to identify the order of importance based on Maslow's hierarchy.

17. The nurse clarifies that nursing orders are also called: a. goals. b. qualifiers. c. interventions. d. measurement criteria.

ANS: C Nursing orders are also called nursing interventions and follow the same requirements when placed in a nursing care plan.

16. The nurse takes into consideration that the difference between a sign and a symptom is that a sign is: a. subjective data. b. unreliable because it depends on translation. c. can be verified by examination. d. something a patient reports that is verified by a relative.

ANS: C Signs are objective data that can be confirmed by examination, assessment, or observation. Signs are reliable research-based data.

1. When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _______ data. a. objective b. medical c. subjective d. adjunct

ANS: C Subjective data are symptoms that only the patient can identify.

2. The major goal of the admission interview (usually performed by the RN) is to: a. establish rapport. b. help the patient understands the objectives of care. c. identify the patient's major complaints. d. initiate nursing care plan forms.

ANS: C The interview is used as part of the assessment process to elicit information about the patient's physical, emotional, and spiritual health.

6. The nurse performing an admission interview on an older adult person should: a. rush through the interview to avoid tiring the patient. b. direct questions to the family rather than the patient. c. allow more time for a response to questions. d. prompt the patient to speed recall.

ANS: C When interviewing an older adult person, allow more time because the person will probably have a more extensive history and may take a little longer to recall the needed information.

11. The nursing diagnoses that has the highest priority is: a. Mobility, impaired physical, related to muscular weakness as evidenced by the inability to walk without assistance. b. Communication, impaired verbal, related to neuromuscular weakness as evidenced by facial weakness and inability to speak. c. Imbalanced nutrition: less than body requirements, related to difficulty swallowing and inadequate food intake as evidenced by weight loss of 10 pounds. d. Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.

ANS: D Choking and aspiration are life-threatening events and take priority over problems such as weakness, inability to speak, or weight loss.

4. During the assessment phase of the nursing process, the nurse: a. develops a care plan to meet the patient's nursing needs. b. begins to formulate plans for providing nursing intervention. c. establishes a nursing diagnosis for the nursing care plan. d. gathers, organizes, and documents data in a logical database.

ANS: D Gathering and organizing data is the first step in the assessment phase of the nursing process.

18. The nurse designs the goals for patients in long-term facilities to be: a. conditional. b. open ended. c. based on behavioral norms. d. long term.

ANS: D Long-term goals are more appropriate for patients in long-term facilities because they will be there for an extended period and many of their health problems are chronic.

5. After the admission assessment is completed, on subsequent shifts or days, the nurse: a. does not assess the patient again unless the condition changes. b. refers only to the admission assessment during the hospitalization. c. performs a complete physical examination every day. d. assesses the patient briefly in the first hour of the shift.

ANS: D The patient should be briefly assessed at the beginning of each shift and more thoroughly if his or her condition changes or as per the plan of care.

Sickle cell anemia is an example of a biological trait found primarily in:

African population

Place the steps of the problem-solving approach in the appropriate order. (Separate letters with a comma and space as follows: A, B, C, D, E.) A. Predict the likelihood of each outcome occurring. B. Choose the alternative with the best chance of success. C. Consider all possible alternatives as the solution to the problem. D. Identify the problem. E. Examine possible outcomes of each alternative.

D, C, E, A, B

The nurse assesses a terminal illness in:

a 43-year-old with Lou Gehrig's disease who is refusing food and fluid.

The nurse clarifies to a patient who now has an abscess following a ruptured appendix that the abscess is considered to be:

a secondary illness.

Homeostasis can be described as

a tendency of biological systems toward stability of the internal environment by continuously adjusting to survive..

A nurse practicing a holistic approach to nursing care must.

recognize that a change in one aspect of the person's life can alter the whole of that person's life..

The nurse explains defense mechanisms as a patient's attempt to:

reduce anxiety

When a young family man hospitalized after breaking his leg confides to the nurse that he is concerned about the well-being of his family and financial stress, the nurse can best support his sense of security by::

actively listening to his concerns...

The nurse who uses the nursing process will

approach the patients disorder in a step-by-step method.

A nurse clarifies that methods of tertiary prevention are designed for:

rehabilitation

Once the nursing plan has been initiated, the nursing care plan will

change as the patient's condition changes.

The activity that is implementation in nursing care is

changing the patient's surgical dressing.

Critical thinking is considered to be the keystone and foundation of the development of _________.

clinical judgment

In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is to

collect data of health status.

An emergency room nurse will give first priority to the patient with the most critical need, which is the patient who

complains of severe chest pain.

The tasks of synthesizing data and linking nursing interventions with patient health problems are enhanced by the process of ________.

concept mapping

When a nurse prioritizes the patient care, consideration is given to

considering situations that may result in an alteration of health.

The nurse takes into consideration that in the stage of resistance in Selye's GAS, the patient:

continues to battle for equilibrium.

The nurse uses a diagram to demonstrate how Dunn's theory of health and illness can be compared with a:

continuum, with peak wellness and death at opposite ends; the person moves back and forth in a dynamic state of change.

When the nurse constructs a nursing approach after careful judgment and sound reasoning, the nurse has used a system of __________.

critical thinking

The nurse is aware that any description of health would include the concept that:

culture, education, and socioeconomic status influence one's definition of health or illness.

A patient states, "I am not obese. My entire family is large." The nurse assesses that the patient is using the defense mechanism of:

denial

A patient has been advised by the primary care provider to take medication for high cholesterol and to change eating habits after discharge home. The home health nurse discovered that the patient refused to follow the medical and nutritional directions. The nurse's best initial response to this situation is to

determine whether any cultural, socioeconomic, or religious values conflict, thus interfering with the patient's compliance..

According to Hans Selye's general adaptation syndrome (GAS), a person who has experienced excessive and prolonged stress is likely to:

develop an illness or disease such as allergy, arthritis, or asthma.

A child who has just been scolded by her mother proceeds to hit her doll with a hairbrush. The nurse recognizes the child's actions are characteristics of:

displacement

Exercise can reduce stress and anxiety by the release of _____________.

endorphins

When the nurse checks to see whether a patient has had relief 45 minutes after administering pain medication, the nurse is performing a(n)

evaluation.

The nurse instructs a patient that according to Selye's GAS theory, when stress is strong enough and occurs over a long enough period, the patient will enter the stage of:

exhaustion

Adequate _____________ is necessary in the communication between nurse and patient in order to meet the higher basic needs of security, love, belonging, and self-esteem.

feedback

When a patient states, I can't walk very well, the first problem-solving step would be to

find out what the problem is, such as weakness or poor balance.

The nurse completing morning assessments on a patient who is sitting up in bed is told by the patient, Im having trouble breathing I can't seem to get enough air. The best nursing response is to

finish the vital signs for the assigned patients, and then notify the charge nurse.

The effect of using a scientific problem-solving approach in nursing care will cause decision making to be

improved nursing care outcomes.

The nurse is aware that a stressor as experienced by an individual is usually perceived:

in different ways based on previous experience and personality traits

The nurse assesses successful adaptation in a post stroke patient when the patient:

learns to walk and maintain balance with the aid of a walker.

A student nurse can begin to develop critical thinking skills by means of

listening attentively and focusing on the speakers words and meaning.

The factors involved in assessing the importance the patient attaches to the relief of a particular deficit include:

needs that the nurse must assess to prioritize care, because they may be different from person to person.

The nurse takes into consideration that the patient with an admitting diagnosis of Type 2 diabetes mellitus and influenza is described as having;

one chronic and one acute illness.

The nurse encourages a patient to participate in health maintenance by maintaining an ideal body weight as a method of:

primary prevention

Included in Maslow's hierarchy, physiological needs are those that:

protect from harm

The nurse believes that patient teaching of how to give insulin and monitor blood glucose levels will improve the level of the patient's

self-esteem, by promoting independence and learning.

In 1946, the World Health Organization redefined health as the:

state of complete physical, mental, and social well-being.

When a new admission to an extended care facility wanders about listlessly, eats only a small amount of each meal, and keeps himself isolated, the nurse can intervene by:

supporting him to interact with an exercise group.

A patient admitted for diagnostic tests is frightened of hospital procedures and is nervous about the possible outcome of the tests. She states that her mouth is dry and her heart is pounding. Her blood pressure is 168/78 mm Hg (her usual blood pressure is 140/80 mm Hg), pulse is 112 beats/min, and respirations are 22 breaths/min. The nurse will recognize that these signs and symptoms are::

the effects of the sympathetic nervous system that can negatively affect the patient's health...

Constant nursing assessments and evaluations of the patient will most likely result in

the nursing care plan changing to reflect appropriate priorities.