Communication (Ch. 10-14) NUR 102

An element of quality improvement, rather than quality assurance, is which of the following? 1. focus is on individual outcomes 2. evaluates organizational structures 3. aims to confirm that quality exists. 4. plans corrective actions for problems

Answer: 4. Rationale: Quality improvement (QI) plans corrective actions for problems. QI focuses on process rather than outcomes (option1), client care rather than structure (option2), and aims for improvement rather than confirmation of quality (option3).

In the diagnostic statement "excess fluid volume related to decreased venous return as manifested by lower extremity edema (swelling)," the etiology of the problem is which of the following? 1. excess fluid volume 2. decreased venous return 3. edema 4. unknown

Answer: 2. Rationale: Because the venous return is impaired, fluid is static, resulting in swelling. Therefore, decreased venous return is the cause (etiology) of the problem. Excess Fluid Volume is the nursing diagnosis, and edema of the lower extremity is the sign/symptom or critical attribute. The cause is known.

Which of the following is likely to occur if a goal statement is poorly written? 1. there is no standard against which to compare outcomes. 2. the nursing diagnoses cannot be prioritized. 3. only dependent nursing interventions can be used. 4. it is difficult to determine which nursing interventions can be delegated.

Answer: 1. Rationale: Goal statements provide the standard against which outcomes are measured. Nursing diagnoses are prioritized before goals are written (option2). Both independent and dependent interventions may be appropriate for any goal (option3). Clarity of the goal does not influence delegation of the intervention (option4)

One of the discharge goals for a client is that they will have improved mobility. Which one of the following is an appropriately written desired outcome statement? 1. Client will ambulate without a walker by 6 weeks. 2. client will ambulate freely in the house 3. client will not fall 4. client will have freer movement in daily activities.

Answer 1. Rationale: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable.

When does the nurse show an understanding of the relationship of evaluation to the other phases of the nursing process? select all that apply. 1. being careful to effectively assess the client's needs 2. selecting the appropriate nursing diagnosis related to the client's needs 3. collecting client-focused data with a specific need in mind 4. evaluating by using assessment data to determine effective achievement of goals and outcome 5. basing evaluation on assessment data collected during the admission phase

Answer: 1,2,3,4. Rationale: Successful evaluation depends on the effectiveness of the steps that precede it. During the evaluation step, the nurse collects data for the purpose of comparing it with preselected goals/outcomes and judging the effectiveness of the nursing care. During the assessment phase, the nurse collects data for the purpose of making diagnoses.

A nurse shows an understanding of the reasons why critical thinking is so vital to today's nursing profession when stating which of the following? select all that apply. 1. "patient acuity is so much greater than it was even 10 years ago." 2. "Care delivery systems are only as good as the nurses delivering care.: 3. "Nurses have always relied on common sense thinking to provide quality, appropriate nursing care." 4. "With health care being so expensive, nursing has to take on responsibility in keeping the costs controlled." 5. "My practice involves caring for clients who require care that didn't even exist when I went to school."

Answer: 1,2,4,5. Rationale: While option 3 might be true, medicine and nursing have evolved tremendously, and so has the need for nurses to be critical thinkers. According to R. Alfaro LeFevre's Top 10 Reasons to Improve Thinking, patients are sicker, with multiple problems, and so nursing care requires a more critical form of thinking in order to meet their nursing needs; redesigning care delivery is useless if nurses don't have the thinking skills required to deal with today's world; consumers and payers demand to see evidence of benefits, efficiency, and results; and today's progress often creates new problems that can't be solved by old ways of thinking.

A nursing student is learning how to implement the nursing process in the clinical area. The purpose of the diagnosis phase includes which of the following? select all that apply 1. develop a list of problems 2. identify client strengths 3. develop a plan 4. specify goals and outcomes 5. identify problems that can be prevented

Answer: 1,2,5. Rationale: Diagnosing is analyzing and synthesizing data in order to identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions as well as developing a list of nursing and collaborative problems. Developing a plan and specifying goals and outcomes is part of the planning phase.

Which of the following would indicate a significant cue when comparing data to standards? Select all that apply. 1. The client has moved partway toward a set goal (e.g., weight lost). 2. The client's vision is within normal range only when wearing glasses. 3. A child is able to control bladder and bowels at age 18 months. 4. A recently widowed woman states she is "unable to cry." 5. A 16-year-old high school student reports spending 6hrs doing homework five nights per week.

Answer: 1,4,5. Rationale: A client's movement toward a goal (option1) or whose behavior is inconsistent with population norms (option4 & 5) represents a cue that further analysis toward creating a nursing diagnosis is required. Corrected vision (option 2) and bladder and bowel control at age 18 months (option 3) are consistent with population norms.

Which of the following demonstrates appropriate use of guidelines in implementing nursing interventions? Select all that apply. 1. no interventions should be carried out without the nurse having clear rationales. 2. Always follow the primary care provider's orders exactly, without variation. 3. encourage all clients to be as dependent as desired and allow the nurse to perform care for them. 4. When possible, give the client options in how interventions will be implemented. 5. each intervention should be accompanied by client teaching.

Answer: 1,4,5. Rationale: Nurses should always have clear rationales for their actions, clients should be given options whenever possible, and client teaching is a constant, integral part of implementing. Primary care provider orders must be critically evaluated and modified to meet individual client needs (option2). Clients may have nurses provide needed care but should take care of themselves whenever possible since dependency has its own complications (option3).

A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis 1. if both medical and nursing interventions are required to treat the problem. 2. When independent nursing actions can be utilized to treat the problem. 3. In cases where nursing interventions are the primary actions required to treat the problem. 4. When no medical diagnosis (disease) can be determined.

Answer: 1. Rationale: A collaborative (multidisciplinary) problem is indicated when both medical and nursing interventions are needed to prevent or treat the problem. If nursing care alone (whether that care involves independent or dependent nursing actions) can treat the problem, a nursing diagnosis is indicated. If medical care alone can treat the problem, a medical diagnosis is indicated.

A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. When formulating a nursing diagnosis, an appropriate selection would be which of the following? 1. Syndrome diagnosis 2. Risk nursing diagnosis 3. Actual diagnosis 4. Wellness diagnosis

Answer: 1. Rationale: A syndrome diagnosis is associated with a cluster of other diagnoses (in this situation, urinary elimination alteration, impaired skin integrity, and powerlessness). Currently, there are six syndrome diagnoses on the NANDA International list. The others are incorrect options.

The nurse is teaching a client about wound care during a follow-up visit in the client's home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence-based practice when the client states, " I just don't know how I can afford these dressings"? 1. integrity 2. intellectual humility 3. confidence 4. independence

Answer: 1. Rationale: By reconsidering the type of dressing used based on research, the nurse is using integrity. Options 2 and 3 are critical thinking attitudes characterized by an awareness of the limits of one's own knowledge, and being trustworthy. Option 4 indicates an attitude of not being easily swayed by the opinions of others

The care plan calls for administration of a medication plus client education on diet and exercise for high BP. The nurse finds the BP extremely elevated. The client is very distressed with this finding. Which nursing skill of implementing would be needed most? 1. cognitive 2. intellectual 3. interpersonal 4. psychomotor

Answer: 3. Rationale: This client needs psychosocial support rather than skills related to knowledge (options 1&2) or hands on activity (option4)

Which of the following principles does the nurse use in selecting interventions for the care plan? 1. actions should address the etiology of the nursing diagnosis. 2. always select independent interventions when possible 3. there is one best intervention for each goal/outcome 4. interventions should be "doing," not just "monitoring."

Answer: 1. Rationale: Interventions should address the etiology of the nursing diagnosis. Both independent and dependent interventions should be selected if appropriate (option2) and several interventions may be needed for a single outcome (option3). Both action and assessment-type interventions can be used (option4).

Which of the following nursing diagnoses contains the proper components? 1. Risk for Caregiver Role Strain related to unpredictable illness course 2. Risk for Falls related to tendency to collapse when having difficulty breathing 3. Impaired Communication related to stroke 4. Sleep Deprivation secondary to fatigue and a noisy environment

Answer: 1. Rationale: States the relationship between the stem (caregiver role strain) and the cause of the problem. Option 2: The diagnostic statement says the same thing as the related factor (falls and collapse). OPtion3: It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement. Option 4 is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep deprivation and does not direct intervention).

A client reports feeling hungry, but does not eat when food is served. Using clinical reasoning skills, the nurse should perform which of the following? 1. assess why the client is not ingesting the food provided. 2. Continue to leave the food at the bedside until the client is hungry enough to eat. 3. Notify the primary care provider that tube feeding may be indicated soon. 4. Believe the client is not really hungry.

Answer: 1. Rationale: The nurse recognizes that many assumptions (beliefs) could interfere with the client eating—such as that the food presented is not culturally appropriate. These assumptions must be clarified. Options 2 and 3 reach conclusions not supported by the facts. In option 4, the nurse has made a judgment or has an opinion that may not be accurate. Also, the nurse is acting without assessment. Implementation should be preceded by assessment.

A major characteristic of the nursing process is which of the following? 1. a focus on client needs 2. its static nature 3. an emphasis on physiology and illness 4. its exclusive use by and with nurses

Answer: 1. Rationale: The nursing process focuses on client needs. It is dynamic rather than static (option2), emphasizes client responses rather than physiology and illness (option 3), and is collaborative rather than used exclusively by nurses (option 4).

The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. What decision is the nurse engaging in? 1. the research method 2. the trial-and-error method 3. intuition 4. the nursing process

Answer: 1. Rationale: The research method uses a research study-based approach to problem solving. Trial and error (option 2) and intuition (option 3) would involve unstructured approaches resulting in less predictable results. The nursing process generally uses application of known interventions, previously determined by the scientific (research) process (option4).

Which of the following is the purpose of assessing? 1. establish a database of client responses to his or her health status 2. Identify client strengths and problems. 3. develop an individualized plan of care. 4. implement care, prevent illness, and promote wellness

Answer: 1. Rationale: assessing provides a database of the client's physiological and psychosocial responses to his or her health status. Client strengths and problems (option 2) are identified in the diagnosing phase of the nursing process, a care plan is established (option 3) in the planning phase, and care, prevention, and wellness promotion (option 4) are part of the implementing phase.

The student nurse is learning the Taxonomy II nursing diagnoses system. This system is coded according to which of the following axes? select all that apply. 1. Gordon's health pattern groupings 2. age 3. time 4.. health status 5. gender 6. unit of care

Answer: 2,3,4,6. Rationale: The Taxonomy II system codes diagnoses according to seven axes that includes age, time, health status, and unit of care. Health patterns and gender are not axes upon which diagnoses are coded.

During the process of implementing care and treatments for a client, the nurse realizes there are several entities include in which phase? select all that apply. 1. evaluating the outcome of the interventions 2. reassessing the client 3. documenting the history and physical 4. supervising delegated care 5. implementing the nursing intervention

Answer: 2,4,5. Rationale: Evaluating the outcome of the interventions I part of the evaluation phase (option 1). Documentation of the history and physical is part of the initial assessment (option3).

Which of the following represent effective planning of the interview setting? Select all that apply. 1. keep the lighting dimmed so as not to stress the client's eyes. 2. ensure that no one can overhear the interview conversation. 3. stand near the client's head while he or she is in the bed or chair. 4. keep approximately 3 ft from the client during the interview. 5. use a standard form to be sure all relevant data are covered in the interview.

Answer: 2,4,5. Rationale; The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to respect the client's personal space is about 3 ft. Using a standard form will help ensure the nurse doesn't omit gathering any vital information. Lighting should be at a normal level - neither bright nor dim (option1). The nurse should be at the same height as the client, usually sitting, at approximately a 45 degree angle facing the client. The nurse standing over the client creates an uncomfortable atmosphere for an interview (option3)

Nurses must use critical thinking in their day-to-day practice, especially in circumstances surrounding client care and wise use of resources. In which of the following situations would critical thinking be most beneficial? 1. administering IV push meds to critically ill clients 2. educating a home health client about treatment options 3. teaching new parents car seat safety 4. assisting an orthopedic client with the proper use of crutches

Answer: 2. Rationale: All other options have standard procedures to follow.

If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to a client need reported over the intercom system on each shift, which process does this reflect? 1. structure evaluation 2. process evaluation 3. outcome evaluation 4. audit

Answer: 2. Rationale: Because this assessment focuses on how care is provided, it is a process evaluation. A structure evaluation (option 1) would focus on the setting (e.g., how well equipment functions), and outcome evaluations (option3) focus on changes in client status (e.g., whether reported satisfaction levels vary with type of person who answers the call light). An audit (option4) would be chart or document review.

Which of the following represents application of the components of evaluating? 1. goal achievement must be written as either completely met or unmet. 2. data related to expected outcomes must be collected. 3. if the outcome was achieved, conclude that the plan was effective. 4. after determining that the outcome was not met, start over with a new nursing care plan.

Answer: 2. Rationale: Evaluating requires that client behavior be compared to expected outcomes. Goals may be partially met in addition to completely met or unmet (option 1). An outcome may be achieved by not be a direct result of the plan or interventions (option3). A care plan should be continued, modified, or terminated based on achievement of outcomes (option 4).

A nurse enters the room of a critically ill child and has a sense that "something" isn't right. After performing an initial physical assessment and finding that the child is stable, the nurse continues to perform a check of all the lines and equipment in the room and finds that the last IV solution hung by the previous nurse was not the correct solution. This nurse was utilizing which method of problem solving? 1. Trial and error 2. intuition 3. Judgment 4. Scientific method

Answer: 2. Rationale: Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as sixth sense, hunch, instinct, feeling, or suspicion. Clinical experience allows the nurse to recognize cues and patterns and begin to reach correct conclusions using intuition. Finding no cause for concern in the physical assessment of the client, the nurse is not satisfied and continues to assess the client's surroundings, finding the error. Trial and error is solving problems through a number of approaches until a solution is found (option1). Judgment is not part of problem solving (option 3). The scientific method requires that the nurse evaluate potential solutions to a given problem in an organized, formal, and systematic approach (option 4).

The nurse assess a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked 2 on a scale of 0-10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? 1. pain 2. nausea 3. constipation 4. potential for wound infection

Answer: 2. Rationale: More detailed assessment data and consultation with the client would be needed to absolutely confirm the priority. Postoperative nausea to the level of inhibiting oral intake has the greatest likelihood of leading to complications and requires nursing intervention now. The client's pain level is not extreme considering the recency of the surgery, and pain intervention can be assumed to be effective (option1). Although the constipation is probably bordering on abnormal, a nursing intervention would most likely begin with oral treatment, which is not possible due to the nausea. More invasive interventions such as an enema or suppository would not be commonly administered the first day postoperative (option3). Wound infection can occur, but there are no data to indicate that this requires a change in the current plan (option4).

Which of the following elements is best categorized as secondary subjective data? 1. the nurse measures a weight loss of 10 lbs since the last clinic visit. 2. Spouse states the client has lost all appetite. 3. The nurse palpates edema in lower extremities. 4. client states severe pain when walking up stairs.

Answer: 2. Rationale: Primary data come from the client (option 4), whereas secondary data come from any other source (chart, family). Subjective data are covert (reported or an opinion), whereas objective data can be measured or validated (weight -option 2, edema - option 3). If the spouse had stated that the client had eaten only toast and tea, this would be secondary objective (measured) data.

A client complains of shortness of breath. During assessment the nurse observes that the client has edema of the left leg only. The nurse reviews evidence-based practice literature and reflects on a previous client with the same clinical manifestations. What do these actions represent? 1. clinical judgment 2. clinical reasoning 3. reflecting 4. Intuition

Answer: 2. Rationale: Reviewing evidence-based literature and identifying similarities in the clinical manifestations of symptoms is an act of clinical reasoning. Past experiences in care enhance the nurse's ability to recognize and respond in the delivery of client-centered care. Clinical judgment in nursing is a decision-making process to ascertain the right action to implement at the appropriate time during client care (option 1). Reflection is the nurse's review of the care provided to determine strategies to improve future care (option 3), Intuition is a problem-solving approach that relies on a nurse's inner sense (option 4).

According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. Which of the following will the home health nurse do when setting priorities? 1. make sure that he or she is able to get to the client's home. 2. assist the client in finding an alternative plan for achieving the therapy's outcomes. 3. tell the client that this therapy will be impossible to receive. 4. make arrangements to have the client moved to a long-term care facility.

Answer: 2. Rationale: The nurse must consider a variety of factors when assigning priorities, including resources available to the nurse and client. Factors in this case include the distance between the client's home and the hospital and the fact that therapy is ordered on a twice daily basis. Driving 80 miles two times a day may not be feasible, but perhaps there are other alternative that could be considered (e.g., a neighbor who might be willing to drive the client, or someone in the area who may be able to assist with the therapy)

When written properly, NOC outcomes and indicators 1. do not require customization. 2. address several nursing diagnoses. 3. are broad statements of desired end points 4. reflect both the nurse's and the client's values

Answer: 4. NOC outcomes should reflect both the nurse's and the client's values of what is trying to be achieved. The outcomes still must be customized (option1), but address only one nursing diagnosis at a time (option2). Outcomes are narrow/specific end points, not broad (option3).

A client in a cardiac rehabilitation program says to the nurse, "I have to eat a low-sodium diet for the rest of my life, and I hate it!" Which is the most appropriate response by the nurse? 1. " I will get a dietary consult to talk to you before next week." 2. "what do you think is so difficult about following a low-sodium diet?" 3. "At least you survived a heart attack and are able to return to work." 4. "you may not need to follow a low-sodium diet for as long as you think."

Answer: 2. Rationale: The nurse recognizes the need to obtain further information from the client in order to respond directly to the client's statement. Option 1 passes off the client's educational needs to another practitioner. Options 3 and 4 are nontherapeutic.

The nurse is concerned about a client who begins to breathe very rapidly. Which action by the nurse reflects clinical reasoning? 1. notify the primary care provider. 2. obtain vital signs and oxygen saturation 3. request a chest x-ray 4. call the rapid response team

Answer: 2. Rationale: The nurse's intuition is like a sixth sense that allows the nurse to recognize cues and patterns to reach correct conclusions. The nurse appropriately obtains vital signs and an oxygen saturation to assess the client's clinical picture more fully. Option 1 supports appropriate nursing actions, but the client's respiratory status should be assessed first. Usually, a physician must order a chest x-ray (option 2). the rapid response team (option 4) may be needed if the client's condition becomes more critical.

The client has a high-priority nursing diagnosis of risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following? 1. delete the diagnosis since the problem has not occurred. 2. keep the diagnosis since the risk factors are still present. 3. modify the nursing diagnosis to Impaired Mobility 4. Demote the nursing diagnosis to a lower priority.

Answer: 2. Rationale: There is no reason to delete (option1) or modify (option3) the nursing diagnosis or demote its priority (option 4) because the risk factors that prompted it are still present.

During an initial interview, the client makes this statement: "I don't understand why I have to have surgery, I'm really not that sick or in pain right now." What is the nurse's best response? 1. "it's okay to be worried. Surgery is a big step." 2. "What kind of questions do you have about your surgery?" 3. "I think these are things you should be asking your doctor." 4. "Have you had surgery before?"

Answer: 2. Rationale: the nurse should use a combination of directive and nondirective approaches during the interview to determine areas of concern for the client. Simply noting this concern, without dealing with it, or passing questions off to the doctor can leave the impression that the nurse does not care about the client's concerns or dismisses them as unimportant (options 1 and 3). A closed question (option 4) does not allow the client to offer much information, besides yes/no or one word answers.

Place the following activities of planning in the correct order of their use. 1. establish goals/outcomes. 2. write the care plan 3. set priorities. 4. choose interventions

Answer: 3,1,4,2. Rationale: In planning, first the nurse sets priorities and then writes goals/outcomes, selects interventions, and then writes the nursing care plan.

The care plan includes a nursing intervention "4/2/15 measure client's fluid intake and output. F. Jenkins, RN." What element of a proper nursing intervention has been omitted? 1. action verb 2. content 3. time 4. none

Answer: 3. Rationale: Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done "routinely" or at specific intervals (e.g., q4h). The nurse is also aware, however, that critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings.

When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes that part of the purpose of the nursing process is to do which of the following? 1. deliver care to a client in an organized way 2. implement a plan that is close to the medical model 3. identify client needs and deliver care to meet those needs 4. make sure that standardized care is available to clients

Answer: 3. Rationale: Delivery or organized care is not part of the nursing process, though each phase is interrelated (option 1). The nursing process is not part of the medical model as nurses treat the client's response to the disease or problem (option 2). The nursing process is individualized for each client's care plan. It is not about standardizing care (option 4)

Which of the following is true regarding the state of the science in regards to nursing diagnosis? 1. The original taxonomy has proven to be adequate in scope. 2. The organizing framework of the taxonomy is based on the work of Florence Nightingale. 3. More research is needed to validate and refine the diagnostic labels. 4. New diagnostic labels are approved by means of a vote of registered nurses.

Answer: 3. Rationale: Diagnostic labels are continuously reviewed and revised as indicated by research - much more of which is needed. The original taxonomy has been replaced by Taxonomy II and is no longer based on a nurse theorist (options 1 & 2). new diagnoses are approved by NANDA International's Diagnostic Review Committee, not by a vote of nurses (option 4).

In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following? 1. collects subjective data. 2. applies a framework to the collected data. 3. confirms data are complete and accurate. 4. records data in the client record

Answer: 3. Rationale: In validating, the nurse confirms that data is complete and accurate. Subjective data is collected in the collecting activity (option1), a framework is applied to the data in the organizing activity (option2), and data is recorded in the documenting activity (option4).

The student nurse understands that clustering data comes with experience and by recognizing cues. What is the best way for this student to recognize patterns or cues in the data? 1. depend on knowledge gained from peers' experiences 2. work with seasoned and experienced nurses and learn from them 3. take assessment notes and utilize information from textbooks for comparison 4. know that this will take time, and experience is the best teacher

Answer: 3. Rationale: Learning from peers and seasoned nurses is helpful, but does not take the place of didactic information (options 1&2). Experience teaches much information, but it never takes the place of concrete, scientific theory (option4).

Which reasoning process describes the nurse's actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcomes? 1. intuition 2. research process 3. trial and error 4. problem solving

Answer: 4. Rationale: A nurse thinks critically, evaluates possible solutions, and uses problem solving. Intuition (option 1) is not a sufficient basis for implementing wound care when significant data on alternative care strategies are available. Research (option2) is a more comprehensive rigorous process and not typically implemented while caring for an infected wound. Trial and error (option 3) is unsafe and inappropriate for care of an infected wound.

A client is admitted for complications following a routine diagnostic procedure of the colon. Which is the type of care plan that will most likely be implemented for this client? 1. informal nursing care plan 2. formal nursing care plan 3. standardized care plan 4. individualized care plan

Answer: 4. Rationale: An individualized care plan is tailored to meet the unique needs of a specific client, needs that are not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine procedure, something that is unplanned and a rare occurrence and must fit with the needs of the client.

The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1. correlation of the data with other members of the health care team 2. demonstration of cost-effective care 3. utilization of creativity and intuition in creating a plan of care 4. collection of all necessary information for a thorough appraisal

Answer: 4. Rationale: Frameworks help the nurse be systematic in data collection. Other members of the health care team may use very different conceptual organizing frameworks so data may not correlate (option1). Cost-effective care (option2) is more likely to occur with systematic application of the nursing process, but use of a framework for assessment alone may not accomplish this goal. Because the framework is structured and because of the nature of the client needs/problems, creativity and intuition in care planning are not assured (option 3)

Which of the following would be true regarding use of the observing method of data collection? 1. when observing, the nurse uses only the visual sense. 2. observing is done only when no other nursing interventions are being performed at the same time. 3. data should be gathered as it occurs, rather than in any particular order. 4. observed data should be interpreted in relation to other sources of collected data.

Answer: 4. Rationale: Interpreting collected data is necessary to help validate its accuracy. Observing includes the senses of smell, hearing, and touch in addition to vision (option1). Using priority setting, observing must often be performed simultaneously with other activities (option2). A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most important data first (option4.)

Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out? 1. when the activity is routine (e.g., raising the bed rails) 2. when the activity occurs at regular intervals (e.g., turning the client in bed) 3. when the activity is to be carried out immediately (e.g., a stat medication) 4. it is never acceptable.

Answer: 4. Rationale: It is never acceptable practice for the nurse to document a nursing activity before it is carried out. This would be very unsafe because many things can cause an activity to be postponed or canceled and prior charting would be inaccurate, misleading , and potentially dangerous. In a few situations, it may be permissible to chart frequent or routine activities some time following the activities such as at the end of a shift or after a particular interval (e.g., every 4 hours) rather than immediately following the activity.

After being admitted directly to the surgery unit, a 75-yr-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? 1. initial 2. ongoing 3. discharge 4. strategic

Answer: 4. Rationale: Strategic planning is an ongoing process focused on organizational change rather than individual clients so it is least useful and not relevant in this case. The client requires initial planning because he has just arrived on the orthopedic unit for the first time (option1). Of the 3 types of planning that need to be done at this time, initial is the highest priority since he has just had surgery. The client also requires the ongoing type of planning necessary to determine the care appropriate for this shift (option2). Discharge planning need to start on admission to ensure adequate client preparation for management of health needs outside the health agency (option3).

In order to differentiate between evaluation and assessment, the student should remember that 1. assessment is done at the beginning of the process. 2. evaluation is completed at the end of the process. 3. they are the same and there is no need to differentiate. 4. the difference is in how the data are used.

Answer: 4. Rationale: Though assessment is the first phase of the nursing process it is carried out during all phases (option 1). Evaluation is continuous (option2). Inoption3, though the two processes overlap, there is a difference between the data collected. Assessment data are collected for the nurse to make a diagnosis and evaluate desired outcomes. Evaluation data are collected for the purpose of comparing them to prescribed goals and judging the effectiveness of the nursing care.