EXAM 2: Prep U (CH 13, 14, ...)

17 - A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? "Client will list positive coping strategies and use them." "Client will learn to cope more effectively." "Client will identify one coping strategy to try by end of week." "Client tries using relaxation as a means to cope."

"Client will identify one coping strategy to try by end of week." *An appropriate outcome includes the client, an action verb, the circumstances by which the outcome is to be achieved, the performance criteria, and time frame. Identifying one coping strategy to try by the end of the week meets these criteria. The statement about the client learning to cope more effectively is not measurable. The statement about listing positive coping strategies and using them includes more than one behavior to evaluate, making it difficult to evaluate achievement. The statement about using relaxation is vague and not really measurable.

19 - When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate? "Extremely well-mannered" "Great response" "Inadequate skills" "Demonstrated steps"

"Demonstrated steps" *Written documentation of the subjective and objective data gathered and the judgment made about goal attainment is required on the client's health record. Judgments about goal attainment are written clearly and concisely. Avoid ambiguous terminology, such as "inadequate," "good," or "extremely well," which can be interpreted differently by different people.

3 - The nurse should identify the need for further teaching when the client with diabetes who is taking daily insulin and follows a strict diet makes which statement? "I cannot possibly ever be considered as healthy." "I can achieve a maximum level of functioning." "I have an illness, but I can feel as if I am healthy." "I can achieve a high quality of health and life."

"I cannot possibly ever be considered as healthy."

16 - A client is caring for their parent, an older adult who requires assistance with performing activities of daily living. Which statement by the client leads the nurse to identify the nursing concern of caregiver role strain? "My parent makes dinner on Tuesdays, and I cannot stand their cooking." "I feel great but wish that I could get more sleep." "My parent and I go for a walk daily." "I just do not have time to take a shower."

"I just do not have time to take a shower."

18 - The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? "I must conduct research to validate the usefulness of my nursing interventions." "I can learn about evidence-based practice by reading professional nursing journals." "Nursing interventions should be supported by a sound scientific rationale." "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."

"I must conduct research to validate the usefulness of my nursing interventions." *Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality.

18 - Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? "I provide a critical service that is necessary for financial reimbursement." "Even though I do not provide care to clients, my work is very important." "Moving away from client care is a necessary step to advancing my career." "I provide indirect care to my clients by coordinating their treatment with other disciplines."

"I provide indirect care to my clients by coordinating their treatment with other disciplines." *Nurses can provide direct, indirect, and collaborative care for their clients. A case manager directs interventions on behalf of the client away from the client's bedside. The most appropriate response is "I provide indirect care...". The case manager's response about the work being important does not adequately explain the role of the case manager. The case manager's role in facilitating financial reimbursement is critical, but does not address the nurse manager's role in client care. The case manager is still providing client care.

17 - The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? "I will take the medications until the inflammation goes away." "I will take my medications on an empty stomach for maximum effect." "I should increase water intake if I have dark bowel movements." "I should call my health care provider if I have a sore that won't heal."

"I should call my health care provider if I have a sore that won't heal." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration, storage, and conditions that require contact with the health care provider.

9 - The client reports to the clinic as ordered by the primary care provider for counseling on weight loss to improve overall health. The client received printed information in the mail to review before the session, and reports having read through it before the appointment. Which client statement alerts the nurse to a need for clarification and further education? "I can monitor my caloric intake by measuring portions." "Osteoarthritis in my knees may be because of my weight." "I can lower my blood pressure by losing weight." "I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."

"I will be doing well if I lose between 5 and 10 lb (2.3 and 4.5 kg) per week."

17 - The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? "I will take my medications between meals for maximum effect." "I will take insulin until my blood sugar levels are normal." "I will mix insulin glargine with insulin lispro at bedtime." "I will test my glucose level before meals and use sliding scale insulin."

"I will test my glucose level before meals and use sliding scale insulin." *The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration and storage and conditions that require contact with the health care provider. Diabetes mellitus is a chronic disease, so the client who takes insulin should not expect to ever achieve a normal blood glucose level without taking insulin. The client should test blood glucose level before, not between, meals. Mixing different types of insulin is not necessary.

14 -A group of student nurses has been encouraged by their instructors to be intentional and deliberate about applying clinical decision-making models to their practice. A student tells a colleague, "The model that makes the most sense to me is the information-processing model, because it seems the most straightforward." How should the colleague best respond to this student? "I agree. The model is elegant for its simplicity and has been clinically linked to better client outcomes." "That model was dominant in nursing for decades but has recently been replaced by more nuanced models." "It is definitely a clear model, but it does not really capture all of the complexities and the human element of nursing." "Absolutely. Many of the other models are evidence-based but excessively complex."

"It is definitely a clear model, but it does not really capture all of the complexities and the human element of nursing." The information-processing model is attractive by virtue of its simplicity and linear nature. However, there is no significant drive to apply this model to nursing practice, because nursing is psychosocially complex and cannot be reduced to a simple equation of input and output. For this reason, it has never been predominant in nursing, even in past decades. It has not been proven to achieve better client outcomes in the literature.

18 - An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status? "My daughter has been staying with me the past few weeks." "I sort my medication into an organizer every week." "I asked my neighbors to help me with my yard work." "My wife's been gone for about 7 months now."

"My wife's been gone for about 7 months now." *The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it.

16 - A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make? "Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions." "Nursing diagnoses are necessary to validate the medical diagnosis." "Nursing diagnoses are used to bill insurance for client care." "Nursing diagnoses are necessary to schedule the amount of care required by the client."

"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions."

17 - The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse? "Do you want to be discharged without treatment?" "Please tell me your thoughts about treating this diagnosis." "What are your plans after discharge?" "You need to stop smoking for us to effectively combat this disease."

"Please tell me your thoughts about treating this diagnosis." *In the planning stage of the nursing process, the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.

18 - When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? "It is a hospital policy to reduce the potential for errors." "We ask your name to ensure that we are treating the right client." "We ask your name to show that we respect your rights." "It is a habit that nurses develop in school."

"We ask your name to ensure that we are treating the right client." **The primary reason for asking the client to state the client's name is to ensure that the nurse is dealing with the correct client. Asking the client to state the client's name is a habit that should be developed in nursing school, but that is not the reason nurses ask clients for their names. It is not just a hospital-specific policy to ask the client for the client's name, but it is a step that is used in all client care situations. Respecting clients' rights is important but that is not why nurses ask for their names.

15 - The nurse auscultates the breath sounds of a 2-year-old child during an assessment and notes crackles over all lung fields. What will the nurse teach the parents about this finding? "Crackles indicate that your child may have an allergy." "This is a normal finding and nothing of concern." "We will share this assessment finding with the physical therapist." "We need to validate the information obtained in this assessment."

"We need to validate the information obtained in this assessment."

13 - The nurse is caring for a client who has been in the hospital for 7 days. When the nurse enters the room to perform the morning assessment, the client tells the nurse that the client can't wait to go home. Which statement by the nurse demonstrates that the nurse is skilled in developing caring relationships? "Maybe you will get to go home soon." "What do you miss most about being away from home?" "I am really busy this morning, but after my morning rounds I will come back and we can discuss how you feel." "Well, you only have 3 days left before you can go home."

"What do you miss most about being away from home?"

13 - A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask? "Were assumptions made correctly?" "How did the client perceive the event?" "How did the client value the experience?" "What happened?"

"What happened?"

14 - A nursing student observed a staff nurse change a client's IV dressing. During post-conference, the student remarked to a classmate, "The nurse did not even follow the process we learned in lab!" What is the classmate's most appropriate response? "Remember that the end result is the important thing, not the way that it's done." "It is well-known that nurses begin to 'cut corners' as soon as they graduate." "It is best to ignore what you see nurses do in practice and instead focus on what we learned." "You should consider some of the factors that might have influenced the nurse's action."

"You should consider some of the factors that might have influenced the nurse's action." **It is important to consider contextual factors and the underlying principles when reflecting on differences between what the student nurse learns and what the student nurse observes in practice. This does not entail ignoring what is seen in the clinical setting, but rather reflecting on it. It is an unfair characterization of nurses that they become sloppy after becoming licensed. Finally, the means and method by which nursing care is provided are important; the end result is not the sole consideration.

19 - An older adult client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. The client is tearful and reports feeling lonely and abandoned in the hospital unit. The family visits daily, and flowers and cards are in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Complete the following sentence(s). The nurse should immediately address the nursing concern of ____(a)____ - family process dysfunction - insufficient coping - altered walking - altered mobility ... with the outcome criteria ____(b)_____. - able to tie shoes - unilateral neglect - verbalizes support systems - family contact daily

(a) insufficient coping (b) verbalizes support systems *When considering appropriate evaluation criteria, the nurse needs to confirm they relate directly to the nursing concern and the nursing concern relates to the assessment data. There are no data to support unilateral neglect. Tying shoes evaluates a client's abilities, not mobility. The nurse assesses that the family visits daily, so the family process is functional. Insufficient coping is appropriately evaluated by identification of coping mechanisms, such as support systems.

18 - Structured Care Methodologies: Guideline

- Broad, research-based practice recommendations - May or may not have been tested in clinical practice - Practice resources helpful in construction of structured care methodologies - No mechanism for ensuring practice implementation

18 - Structured Care Methodologies: Order Set

- Preprinted provider orders used to expedite the order process after a practice standard has been validated through analytical research - Complements and increases compliance with existing practice standards - Can be used to represent the algorithm or protocol in order format

18 - Structured Care Methodologies: Protocol

- Prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients within the cohort - Multifaceted; may be used to drive practice for more than one discipline - Broader specificity than an algorithm - Allows for minimal provider flexibility by way of treatment options - May be "layered" on top of a pathway

18 - Structured Care Methodologies: Critical Pathway

- Represents a sequential, interdisciplinary, minimal practice standard for a specific patient population - Provides flexibility to alter care to meet individualized patient needs - Abbreviated format, broad perspective - Phase or episode driven - Ability to measure cause-and-effect relationship between pathway and patient outcomes prohibited by lack of control - Changes in patient outcomes directly attributable to the efforts of the collaborative practice team

18 - Structured Care Methodologies: Algorithm

- Useful in management of high-risk subgroups within the cohort - may be "layered" on top of a pathway to control care practices that are used to manage a specific problem - Binary decision trees that guide stepwise assessment and intervention - Intense specificity; no provider flexibility - May use analytical research methods to ensure cause and effect

18 - A nurse is confronted with a malnourished patient on a limited income who rents a single room in a boarding home. The nurse is preparing to educate the patient on the importance of including protein-rich foods within the diet. What are some psychosocial factors to consider when choosing an effective nursing intervention?

- does the patient have realistic access to better nutrition - can the patient afford better nutrition - does the patient value the intervention - is the patient willing to make necessary changes - is the patient familiar with the diet recommended - consider the cultural or economic reasons for the patients current diet

3 - Categories of Risk Factors (6) "Antelopes Gracefully Prance, Hiding from Lions' Eyes."

1) Age School-aged children are at high risk for communicable diseases. After menopause, females are more likely to develop cardiovascular disease. 2) Genetic factors A family history of cancer or diabetes predisposes a person to developing the disease. 3) Physiologic factors Obesity increases the possibility of heart disease. Pregnancy places increased risk on both the pregnant person and the developing fetus. 4) Health habits Smoking increases the probability of lung cancer. Poor nutrition can lead to a variety of health problems. 5) Lifestyle Multiple sexual relationships increase the risk for sexually transmitted infections (e.g., gonorrhea or AIDS). Events that increase stress (e.g., divorce, retirement, work-related pressure) may precipitate accidents or illness. 6) Environment Working and living environments (such as those where hazardous materials and poor sanitation are present) may contribute to disease.

18 - For possible nursing diagnoses/problems, interventions seek to: 1) Collect _______ ______ to _____ ___ or confirm the _________.

1) Collect additional data to rule out or confirm the diagnosis

19 - The following four steps are crucial in improving performance: DPICA 1) 2) 3) 4)

1) D iscover a problem 2) P lan a strategy using indicators 3) I mplement a C hange 4) A ssess the change; if the outcome is not met, plan a new strategy

3 -Suchman's stages of illness (4) cough, call off work, let doc treat, get better

1) Experiencing symptoms 2) Assuming the sick role 3) Assuming a dependent role 4) Achieving recovery & rehabilitation

18 - For collaborative problems, interventions seek to: 1) Monitor for ________ __ ______ 2) Manage ________ __ ______ with ________-________ and ________ _________ _______-________ interventions 3) Evaluate _____________

1) Monitor for changes in status 2) Manage changes in status with nurse-prescribed and health care provider-prescribed interventions 3) Evaluate response

17 - Maslow's Hierarchy of Human Needs means that basic needs must be met before a person can focus on higher ones. Explain how patient needs are prioritized according to Maslow's Hierarchy.

1) Physiologic needs 2) Safety needs 3) Love and belonging needs 4) Self-esteem needs 5) Self-actualization needs For example, a geriatric patient who is incontinent of urine and sitting in a wet disposable brief (physiologic need) will be unable to participate fully in a music therapy diversional activity (self-esteem need) until the more basic need is met.

18 - For actual nursing diagnoses/problems, interventions seek to: 1) Reduce or eliminate _______________ 2) Promote ______________ 3) _______ and ________ status

1) Reduce or eliminate contributing factors of the diagnosis or problem 2) Promote higher-level wellness 3) Monitor and evaluate status

18 - For risk nursing diagnoses/problems, interventions seek to: 1) Reduce or _______ ______ ________. 2) Prevent the ________. 3) _________ & ________ status

1) Reduce or eliminate risk factors 2) Prevent the problem 3) Monitor and evaluate status

19 - The American Association of Critical-Care Nurses Standards for Establishing and Sustaining Healthy Work Environments (6 - CCDMSRL) Careful Cats Dont MisS Retrieving Labradors 1) C 2) C 3) D M 4) S 5) R 6) L

1) Skilled communication. Nurses must be as proficient in communication skills as they are in clinical skills. 2) True collaboration. Nurses must be relentless in pursuing and fostering true collaboration. 3) Effective decision making. Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations. 4) Appropriate staffing. Staffing must ensure the effective match between patient needs and nurse competencies. 5) Meaningful recognition. Nurses must be recognized and must recognize others for the value each brings to the work of the organization. 6) Authentic leadership. Nurse leaders must fully embrace the imperativeness of a healthy work environment, authentically live it, and engage others in its achievement.

3 - The nurse is discharging several clients from an acute surgical unit on the same day. The nurse will prioritize discharge teaching based on how much time is required for each client. Place the clients in order, from the client requiring the longest teaching time to the shortest teaching time. Use all options. 1 - client who is learning to draw up and inject insulin for the first time 2 - client who indicates the live-in partner is a registered nurse 3 - client who is being discharged to a long-term care facility 4 - client who is being transferred to another unit in the hospital

1) client who is learning to draw up and inject insulin for the first time 2) client who indicates the live-in partner is a registered nurse 3) client who is being discharged to a long-term care facility 4) client who is being transferred to another unit in the hospital **Although having a family member who is a health care provider is a factor contributing to the client's ability to manage one's care, the client may take longer to learn how to care for oneself independently. For a client being transferred to long-term care facility, the care will be managed by a health care team. This client, however, will require enough time to ensure an understanding of what will ocur at the new facility

17 - Expected client outcomes must be ________, __________, _________, ________, _______, & ____________.

1) client-centered 2) specific 3) measurable 4) attainable 5) realistic 6) time-bound

17 - Common problems with planning nursing care include: (5)

1) failure to involve the client in the planning process 2) insufficient data collection 3) use of broadly stated outcomes 4) stating nursing orders that do not resolve the problem 5) failure to update the plan of care

18 What are the 4 intervention categories within the Omaha System (OS) "Intervention" step?

1) health teaching, guidance, & counseling 2) treatments & procedures 3) case management 4) surveillance

18 - What are some variables that influence the nurses ability to implement a care plan? (4)

1) level of expertise 2) creativity - ability to match patient needs with specific nursing strategies 3) willingness to provide care 4) available time

14 - The nurse is applying Tanner's Clinical Judgment Model in the care of a client. Building off the context and background information, place the components of the model in the correct sequence. (4) (nirr)

1) noticing 2) interpreting 3) responding 4) reflecting *Tanner's model represents an interactive process that generally follows the sequence of noticing, interpreting, responding and reflecting (both on-action and in-action).

14 - Tanner's Clinical Judgment Model (CJM) CORE ELEMENTS

1) noticing 2) interpreting 3) responding 4) reflecting This model is a go-to due to the first 3 components supported by reflection pg 385

18 - The Omaha System (OS) has 3 steps: _________, __________, & _________.

1) problem 2) intervention 3) outcome

14 - NCSBN Clinical Judgment Measurement Model (CJMM) - the result or observed outcome of critical thinking and decision making STEPS?

1) recognizing cues 2) analyzing cues 3) prioritizing hypotheses 4) generating solutions 5) taking an action 6) evaluating outcomes

15 - A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply. Redness and blisters forming on both legs Crying and trying to scratch legs due to itching 4-year-old at 85 percentile of growth and development Stating "My legs feel like they are burning" Respirations 18 breath/min and regular

15 - A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply. Redness and blisters forming on both legs Crying and trying to scratch legs due to itching

16 - The nurse has been assigned to a group of clients. Which client should be the nurse's priority? A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue. A 48-year-old client with a hemoglobin of 9.5 g/dl (95 g/l) who is receiving ferrous sulfate supplements and is reporting feeling tired. *(ferrous sulfate is an iron supplement you may use to treat iron-deficiency anemia) An 82-year-old client with emphysema who is receiving 2 liters of oxygen and is concerned about a pulse oximetry reading of 91%. A 68-year-old client who had total hip replacement surgery 6 hours ago and is reporting moderate discomfort at the surgical site.

A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue. *The client receiving the intravenous antibiotic may be experiencing a possible airway obstruction secondary to an allergic reaction and should be the nurses first priority. Caring for a postoperative client reporting pain is important, but the client is not at risk of further deterioration if not cared for immediately. A client with an oxygen saturation of 91% is within normal limits and not the nurse's priority. A client with a low hemoglobin and symptoms of anemia is not in eminent danger and not the nurse's first priority.

13 - Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)? Grip weakness in the right hand A client report of shooting pain up the left leg Crackles in bilateral lung bases A blood glucose level of 108 mg/dL

A client report of shooting pain up the left leg

17 - guidelines

A guideline is a statement by which to determine a course of action.

16 - A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate? A risk nursing diagnosis A health promotion nursing diagnosis A possible nursing diagnosis An problem-focused nursing diagnosis

A health promotion nursing diagnosis *The client is seeking information related to healthy practices. Health promotion nursing diagnoses are formulated to assist the client to meet that need. The client has no health problem, risk of a health problem, or possible problem, so a problem-focused, risk, or possible nursing diagnosis would be inappropriate.

13 - When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply. Outcome setting allows for individualization of the plan of care. Outcomes can be short- and long-term. All plans of care are the same for clients with certain medical diagnoses. A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. Only the client is involved in outcome setting, not the family.

A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.

16 - Possible nursing diagnosis

A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information.

15 - Which statement is true regarding addressing a priority problem? Addressing priority problems involves skipping interventions. The priority of problems is established and continued according to the nursing plan of care. A priority problem requires a nursing intervention before another problem is addressed. Priority problems are identified at predetermined intervals throughout the shift.

A priority problem requires a nursing intervention before another problem is addressed.

16 - 3 parts of a problem-focused nursing diagnostic statement

A problem-focused nursing diagnostic statement contains three parts, sometimes referred to as "PES." P: Name of the health-related issue or problem as identified in the NANDA-I list. E: Etiology (the problem's cause). S: Signs and symptoms, also called defining characteristics. The name of the nursing diagnosis is linked to the etiology with the phrase "related to," and the signs and symptoms are identified with the phrase "as evidenced by."

16 - Risk nursing diagnosis

A risk nursing diagnosis is a clinical judgment that concludes that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation.

17 - A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using? A standardized care plan Guidelines An algorithm An order set

A standardized care plan *Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.

19 - _________ strives to provide safe work environments.

AACN - American Association of Critical-Care Nurses

16 - After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? Health promotion Actual Risk Possible

Actual

16 - After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? Health promotion Actual Possible Risk

Actual *"Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual nursing diagnosis, because it describes a human response to a health problem that is being manifested. A health promotion nursing diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information.

17 - A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I cannot do this any longer." What is the best action by the nurse to incorporate this information into the plan of care? Tell another nurse about this client statement. Add the nursing concern self-harm risk. Document that the depression has resolved. Encourage the client to join a therapy group.

Add the nursing concern self-harm risk.

13 - The nurse is caring for a client with a BMI of 18 and a new diagnosis of food allergy to wheat, rye, and oats. The nurse has identified the nursing concern of altered nutrition that is less than the amount required. What is the most appropriate intervention for this client? Administer a daily multivitamin. Administer a high-calorie diet, excluding wheat, rye, and oats. Monitor for allergies. Weigh client as needed.

Administer a high-calorie diet, excluding wheat, rye, and oats. **Because this client's BMI categorizes them as underweight and they have an allergy to wheat, rye, and oats; administering a high-calorie diet with no wheat, rye, or oats is the most appropriate intervention to meet the specific needs of this client. Administering a multivitamin, monitoring for allergies, and weighing the client as needed are generalized nursing measures and not specific to this client.

14 - A nurse has recommended a regimen of over-the-counter medications for a client who has seasonal allergies. A colleague contends that the nurse has exceeded the scope of nursing practice by recommending medications to a client. To resolve this difference of opinion, the nurses should consult resources from what organization? American Association of Colleges of Nursing National Council of State Boards of Nursing American Nurses Association National League for Nursing

American Nurses Association **While each of the listed organizations provides resources and information of different types, this dispute is directly related to scope of practice, which is delineated by the American Nurses Association's Nursing: Scope and Standards of Practice.

3 - What is the definition of wellness? Being without disease Maximizing the state in which you live An active state of being healthy A desire to be without disease

An active state of being healthy **Wellness, a reflection of health, is an active state of being healthy by living a lifestyle that promotes good physical, mental, and emotional health. It is not simply an absence of disease or a desire to be without disease, nor is it maximizing the state in which one lives.

16 - Actual nursing diagnosis

An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics.

19 - The Joint Commission

An independent nonprofit organization that evaluates and accredits health care organizations and programs in the United States.

17 - order set

An order set is a predetermined set of orders by a prescriber that dictates care of the client.

13 - The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? Analyze the data and create an individualized nursing concern for care planning. Identify outcomes for the client with the client's input. Follow up with the client later to determine whether the client's laboratory test results improve. Administer a prescribed medication to decrease the client's blood glucose level.

Analyze the data and create an individualized nursing concern for care planning.

13 - The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? Follow up with the client later to determine whether the client's laboratory test results improve. Identify outcomes for the client with the client's input. Analyze the data and create an individualized nursing concern for care planning. Administer a prescribed medication to decrease the client's blood glucose level.

Analyze the data and create an individualized nursing concern for care planning.

16 - A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis? Anxiety Physical immobility Compromised Overdistention

Anxiety

18 - The nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair and holds the client's hand while listening to the client's concerns. What additional type of nursing supportive intervention could the nurse provide? Arranging appointments with a specialist after the client is discharged Providing humor in conversation to assist in alleviating stress Teaching the client how to administer medications Arranging for clergy to visit with the client

Arranging for clergy to visit with the client **Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems and could include the use of humor. Coordinating interventions involve many different activities, such as acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care and would include medication administration.

19 - The nurse should evaluate client outcomes at which time? Several days after discharge Within 24 hours after identifying them The day of discharge As early as possible

As early as possible

18 - The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply. Counsel the client about making adjustments to a new medical condition. Demonstrate and teach new caregiving procedures to the family. Interview the client as part of the admission assessment. Orient the client and family to the room, including the call light button. Ask the client questions regarding personal care needs. Provide education to the client, including discharge instructions.

Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button. **Delegation to a UAP requires knowledge of the registered nurse (RN) role and what tasks can be legally delegated. The RN can delegate asking clients questions about personal care needs and orientation to the room (for example, the call light button). It is inappropriate to have the UAP interview the client as part of the admission assessment, provide education to the client or family, or counsel the client. Those duties are legally the role of the RN and would be most appropriately addressed with a the assistance of a professional interpreter.

19 - The nurse performs discharge teaching for a client. How will the nurse best evaluate the effectiveness of the discharge teaching? Ask the client to describe how care will be conducted at home. Review the content that was covered to see if all health care provider prescriptions were covered. Determine whether each aspect of critical pathways was completed. Ask if the client understands the teaching and offer to answer any questions.

Ask the client to describe how care will be conducted at home. *Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement. The best way to evaluate the effectiveness of discharge teaching is to have the client repeat back to the nurse how care will be conducted at home.

18 - A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action? Ask the gastroenterologist to explain the treatment plan to the client and family again. Ask the nutritionist to give the client strict meal plans to follow. Refer the client to available community resources and support groups. Ask the client to verbalize the medication regimen and diet modifications required.

Ask the client to verbalize the medication regimen and diet modifications required. *If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

18 - The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? Remind the client that the client is responsible for the client's own health care decisions. Ask the client whether the client is afraid that the spouse will be angry. Ask the surgeon to wait until the client has had a chance to talk to the spouse. Inform the surgeon that the nurse will not sign the informed consent form.

Ask the surgeon to wait until the client has had a chance to talk to the spouse. *It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

18 - One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action? Assess the client to determine the cause of the pain. Assist the client to reposition and splint the incision. Discuss the frequency of pain medication administration with the client. Consult with the health care provider for additional pain medication.

Assess the client to determine the cause of the pain. *One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new report of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision are interventions that the nurse might perform, but only after determining the cause of the pain.

13 - The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the next nursing action? Establish a nursing concern of altered skin integrity. Document the rash in the client's chart. Assess the client's back visually. Report the rash to the health care provider.

Assess the client's back visually. **Assessment is the first phase in the nursing process, so the nurse should perform a visual assessment of the client's rash before proceeding to activities that pertain to later phases, such as reporting or documenting the rash or formulating a nursing concern.

18 - The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? Ask the client to verbalize the purpose of the medication. Tell the client to report any side effects experienced. Assess the client's blood pressure to determine if the medication is indicated. Determine the client's reaction to the medication in the past.

Assess the client's blood pressure to determine if the medication is indicated. *Before initiating any intervention, the nurse must determine if the intervention is still necessary. Before administering blood pressure medication, the blood pressure must be assessed. The client's reaction to the medication previously does not indicate if the medication is indicated at this time. The client's ability to verbalize the purpose of the medication is important to promote self-care, but it is not important for the client's safety at this time. The client's report of side effects would indicate an adverse reaction after the medication is administered, but it would not protect the client's safety before the medication is given.

16 - When planning initial care for a 16-year-old postpartum client and the client's newborn, the nurse formulates a nursing concern of altered attachment risk. What action will the nurse appropriate action to take next? Assess the client's interactions with the newborn. Direct all education of newborn care to the client's parent. Initiate referrals to available community services. Develop a comprehensive education plan for newborn care.

Assess the client's interactions with the newborn. *To address a risk nursing concern, the nurse is required to collect additional data. Observing the client's interactions with the newborn would be the most effective way to evaluate attachment. It is inappropriate to assume that the client's parent will be doing all the newborn care, which would also be detrimental to the client's attachment to the newborn. It is premature to initiate referrals to community services until further data are collected. It is also premature to develop a comprehensive education plan until the needs of the client are known.

17 - In the nursing process, ___________ involves data collection.

Assessment

13 - A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process? Diagnosis Planning Implementation Assessment

Assessment **During assessment, the nurse recognizes the existence of cues and conducts a focused data collection. During diagnosis, the nurse clusters cues, interprets the clusters, and validates the diagnoses for accuracy. Planning involves preparing a client plan of care, which directs the activities of the nursing staff in the provision of care. Implementation is the action phase of the nursing process.

19 - The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome? At the client's direction On 3/3 At the completion of each meal On 3/2

At the completion of each meal *The nurse should collect data at the completion of each meal to ensure the accuracy of the data and to monitor the client's progress toward meeting the goal so that the nurse can make changes to the plan when the client fails to make sufficient progress or celebrate with the client when the client demonstrates success. Although the final evaluation of goal attainment must occur on or shortly after 3/2, data collection must begin far earlier than that. It would not be appropriate for the client to direct when data collection should occur.

14 - A nurse has just graduated and will be starting a new job in a clinical setting. The nurse states, "I want to be intentional about getting beyond being a novice and eventually progressing to be an expert nurse." Which action will support the nurse's goal? Become familiar with Benner's model of nurse development. Set a future goal for implementing the nursing process during client encounters. Gain knowledge within the QSEN competencies. Advocate publicly for increased visibility of the nursing profession.

Become familiar with Benner's model of nurse development. *Benner's novice-to-expert model specifically informs professional development along this continuum. Nurses of all levels of experience should be applying the nursing process in some form; this should not be characterized as a future goal. Advocacy is beneficial, but the act of advocating does not necessarily lead to professional development. Similarly, becoming familiar with the QSEN competencies will not necessarily help the nurse develop.

16 - A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination? Ulcerative Colitis Bowel Incontinence Irritable Bowel Syndrome Small Bowel Obstruction

Bowel Incontinence **Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses.

13 - Which activity is the clearest example of the evaluation step in the nursing process? Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading Checking the client's blood pressure 30 minutes after administering captopril Recognizing that the client's blood pressure of 172/101 is an abnormal finding Taking a client's blood pressure on both arms at the beginning of a shift

Checking the client's blood pressure 30 minutes after administering captopril

13 - While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking? Precision Clarity Relevance Accuracy

Clarity

17 - A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours? Client lipids are within range. Client is normotensive. Client is drowsy after lunch. Client reports no headache.

Client is normotensive.

17 - A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing concern of activity intolerance. Which expected client outcome directly demonstrates resolution of the problem? Client will use oxygen by nasal cannula when short of breath. Client will consistently perform pulmonary exercises. Client will alternate rest periods with exercise throughout the day. Client will increase protein intake in small frequent meals.

Client will alternate rest periods with exercise throughout the day. *Client outcomes are derived from the problem statement of the nursing concern. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. Although each of these outcomes will promote health in a client with chronic obstructive pulmonary disease (COPD), the most direct resolution of activity intolerance is for the client to pace activities by alternating rest with exercise throughout the day.

17 - Which is an appropriate expected outcome for a client? Client will perform complete ostomy care while bathing on the second postoperative day. Client will ambulate safely with walker in the room within 3 days of physical therapy. By the next clinic visit, client will report taking antihypertensive medication. After attending sibling classes, client will be happy about a new infant and demonstrate feeding.

Client will ambulate safely with walker in the room within 3 days of physical therapy. **Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy meets all of these criteria. "After attending sibling classes, client will be happy about a new infant and demonstrate feeding" includes more than one client behavior, one of which is not observable or measurable ("be happy"), does not include performance criteria related to how well the client is to demonstrate feeding, and has a vague time frame ("after attending sibling classes"). "By the next clinic visit, client will report taking antihypertensive medication" lacks specificity regarding how often the client should take the medication. "Client will perform complete ostomy care while bathing on the second postoperative day" is likely not attainable within the time frame specified and lacks specificity regarding care the client will provide, making it difficult for the nurse to measure the client's success.

17 - A client with food poisoning has the nursing concern of diarrhea. Which expected client outcome directly demonstrates resolution of the problem? Client will identify the food that caused the condition within 3 hours. Client will maintain adequate hydration within 2 days. Client will eat small meals of bland foods for 3 days. Client will have formed stools within 24 hours.

Client will have formed stools within 24 hours. *Client outcomes are derived from the problem statement of the nursing concern. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. Although each of the listed outcomes will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.

17 - The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome? Client will learn to cook foods that meet personal nutritional needs. Client will understand what inflammatory bowel disease is. Client will talk with campus cafeteria manager about identifying safe meals. Client will maintain nutritional intake without pain or diarrhea.

Client will maintain nutritional intake without pain or diarrhea. **The best long-term client outcome is to maintain nutritional intake without pain or diarrhea. The other outcomes are smaller increments that help the client reach the ultimate goal of controlling the disease. A formal plan of care allows the nurse to individualize care for maximal achievement of outcomes, set priorities, coordinate care, promote health care communication, and evaluate client response to care. The client understanding what inflammatory bowel disease is does not indicate a measurable goal.

17 - A client with a right facial droop and dysphagia after a stroke has the nursing concern of altered swallowing. Which client outcome will the nurse include because it describes the most effective action for the client's stated concern? Client will use chin tuck and double swallow for each bite. Client will sit in chair for all meals and snacks. Client will chew food well and use a tongue sweep. Client will avoid straws and drink thickened liquids.

Client will use chin tuck and double swallow for each bite. **Client outcomes are derived from the problem statement of the nursing concern. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. Although each of these actions will improve oral intake by the client with dysphagia, the most effective is a chin tuck and double swallow. These actions reduce the risk of aspiration and aid the movement of food down the esophagus.

18 - A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure. Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization.

Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization. **It is important to think about the environment for each intervention. Pay special attention to respecting the client's privacy and dignity; for example, close the door to the room or pull the drapes between the beds. To demonstrate respect, the procedure should be explained to the client and all areas except the sterile area should be covered to protect modesty and privacy. Asking another nurse to assist is helpful, but not required and may make the client feel awkward. There is no need to discuss with the family, because the client does not have any cognitive issues.

13 - The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm? Cognitive and technical skills Interpersonal and technical skills Interpersonal and ethical skills Cognitive and ethical skills

Cognitive and technical skills

18 - ___________ nursing interventions involve coordination and communication with health care professionals in other fields to meet the client's needs.

Collaborative

18 - _____________ orders may include suggested care strategies from other health care personnel such as the physical therapist.

Collaborative

16 - Collaborative nursing diagnoses.

Collaborative diagnoses are selected when the nurse needs to work with another member of the health care team to assist the client in resolving the health issue

16 - While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis? Perform a focused assessment related to the reason for admission. Establish short- and long-term client goals. Verify the primary care provider's written orders. Collect client subjective and objective data.

Collect client subjective and objective data. *Nursing diagnoses are developed as the second step of the nursing process. The first step is to collect all assessment data so that appropriate actual or potential nursing problems can be selected and addressed in the client's plan of care. Nursing diagnoses are not related to the medical diagnosis or the specific written orders from the primary care provider. Goals can only be established after the problem is identified. Although assessment--collecting subjective and objective client data--is necessary before developing nursing diagnoses, this assessment does not necessarily have to be a focused assessment.

19 - Which statement related to the evaluation of outcome attainment for a client is correct? The nurse should initially evaluate the plan of care at the time of the client's discharge. Celebrating outcome achievement with a client often interferes with attainment of future goals. Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. Evaluation of the client's attainment of outcome goals is determined by the nurse and health care provider.

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. *In addition to knowing what type of data to collect to determine outcome achievement, it is important to know when to collect the data based upon established time criteria. It is important for the nurse to evaluate client outcome achievement as early as possible and not wait until discharge, when the plan of care cannot be modified. Evaluation of the client's attainment of outcome goals is determined by the nurse, client, and the client's family. Celebrating outcome attainment with the client usually helps encourage the client and leads to further outcome achievement.

15 - Which group of terms best defines assessing in the nursing process? Designing a plan of care, implementing nursing interventions Collection, validation, communication of client data Nurse-focused, establishing nursing goals Problem-focused, time-lapsed, emergency-based

Collection, validation, communication of client data *Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem-focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse-focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.

17 - comprehensive planning

Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning

16 - Which example of client care is not the responsibility of the nurse? Monitoring for changes in health status Promoting safety and preventing harm; detecting and controlling risks Confirming a medical diagnosis Tailoring treatment and medication regimens for each individual

Confirming a medical diagnosis

16 - A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem? Readiness for Enhanced Nutrition related to constipation Constipation related to irregular evacuation patterns Bowel incontinence related to depressive state Diarrhea related to client report of small, loose stools

Constipation related to irregular evacuation patterns

16 - A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? Continue to collect assessment data. Contact the client's health care provider. Consult with a more experienced nurse. Document the data for future reference.

Consult with a more experienced nurse.

9 - When deciding what information the client needs to meet the learner objectives successfully, the nurse is formulating which part of the teaching plan? Learning activities Content Learning domains Teaching strategies

Content **The nurse is planning the content when the nurse decides what information the client needs to meet the learner objectives successfully. To ensure the teaching was effective, the nurse would include teaching strategies. The learning activities would be designed by the nurse to meet the needs of the client. Learning domains—including cognitive, affective, psychomotor—are the different types of learning. Psychomotor is physical or kinesthetic based. Cognitive is knowledge based. Affective is feeling or emotion based.

18 - _________ interventions involve many different activities, such as acting as a client advocate and making referrals for follow-up care.

Coordinating

- comes from data analysis & interpretation - come from assessment - any significant data that raises "red flag" - cues - RN looking for actual or potential nursing problem diagnosis - While determining what is going on with the patient, you need to have strong interpersonal and communication skills. Gain their trust so they can tell you "their story".

Criteria for Nursing Dx

13 - A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. Which behavior is the nurse demonstrating in the care of the client? Reflection in action Critical reflectivity Thoughtful practice Reflective skepticism

Critical reflectivity Critical reflectivity (becoming aware of one's awareness and critiquing it) occurs when a person questions judgments and considers other ways of thinking about the situation. Thoughtful practice is caregiving to promote the humanity, dignity, and well-being of the client. Reflection in action requires the person to engage in exploring experiences to lead to new understandings and appreciations during the situation or during clinical practice. Reflective skepticism involves adopting an attitude of doubt about supposed truths.

19 - Which statement regarding the difference between data collected for assessment and data collected for evaluation is correct? Data collected for assessment are part of the client's health record but are not further used for client care. There is no difference between data collected for assessment and data collected for evaluation. Data collected for assessment identify client health issues, whereas data collected for evaluation determine whether client outcomes are being achieved. Data collected for assessment relate to the client health history, whereas data collected for evaluation identify the actions of health care provider orders.

Data collected for assessment identify client health issues, whereas data collected for evaluation determine whether client outcomes are being achieved. *Data collected for assessment and evaluation are used for different purposes. Data collected for evaluation are used to determine whether client goals are being met, and data for assessment are used in an ongoing manner as they relate to the health issues identified.

17 - Which guideline should the nurse follow when including interventions in a plan of care? Date the nursing interventions when written and when the plan of care is reviewed. Make sure each nursing intervention does not describe the action the nurse should perform. Make sure the attending health care provider approves of and signs the nursing interventions. Make sure the nursing interventions are unrelated to the original outcomes.

Date the nursing interventions when written and when the plan of care is reviewed. *Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The health care provider does not approve and sign the interventions, because they are nursing interventions.

13 - Which action exemplifies the purpose of evaluation in the nursing process? Determine the client's health status, self-care ability, and need for nursing. Decide whether to continue, modify, or terminate client care. Develop an individualized plan of client care. Develop a prioritized list of nursing concerns.

Decide whether to continue, modify, or terminate client care.

18 - The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do? Delay the instruction until the visitors leave. Leave written information for the client to read later. Give the visitors instructions to leave in 10 minutes. Ask the client if the client has any questions.

Delay the instruction until the visitors leave. **The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is an adolescent and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors leave. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

16 - Dependent nursing diagnosis

Dependent nursing diagnoses require a specific written order from the primary health care provider for a nurse to address

13 - A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? (ADPIE) Determine whether the prescribed treatment was effective. Formulate a plan of care based on risk for dehydration. Check the client's skin turgor. Administer an additional liter of intravenous fluids.

Determine whether the prescribed treatment was effective. **The sequence of the nursing process is assessment, diagnosis, planning, implementation, and evaluation. Checking skin turgor is an assessment. Formulating a care plan is part of planning. Administration of additional fluid occurs during implementation. The nurse evaluates whether the intervention was effective, as demonstrated by a rise in blood pressure and a decline in pulse rate.

16 - Which describes the best approach for the development of nursing diagnoses? Develop each nursing diagnosis based on a single cue. Collaborate with the health care provider in the formation of nursing diagnoses. Develop nursing diagnoses from clusters of significant data. Collaborate with the multidisciplinary team in the formation of nursing diagnoses.

Develop nursing diagnoses from clusters of significant data.

16 - Which describes the best approach for the development of nursing diagnoses? Develop nursing diagnoses from clusters of significant data. Develop each nursing diagnosis based on a single cue. Collaborate with the multidisciplinary team in the formation of nursing diagnoses. Collaborate with the health care provider in the formation of nursing diagnoses.

Develop nursing diagnoses from clusters of significant data. *Nursing diagnoses should always be derived from clusters of significant data, rather than from a single cue. Nursing diagnoses describe client problems that nurses can treat independently and do not require collaboration with other members of the health care team. Therefore, nurses can develop nursing diagnoses without collaborating with health care providers or other health care team members.

17 - A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome? Failing to update the written plan of care Developing the plan without client input Choosing actions that do not solve the problem Beginning the plan without family to help

Developing the plan without client input *Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. There is no indication that the nurse included strategies in the plan of care that did not solve the client's problem. There is no evidence that the care plan needed to be updated or that the nurse failed to do so. Although family support can be important to achieving client outcomes, not every client outcome requires family support.

13 - Which action should the nurse associate with outcome identification and planning in the nursing process? Develops a prioritized list of problem-based nursing concerns. Decides whether to continue, modify, or terminate nursing care. Develops an individualized plan of nursing care. Determines the client's health status, self-care ability, and need for nursing.

Develops an individualized plan of nursing care. **In the process of outcome identification and planning, the nurse adapts the identified nursing concern to address the client's strengths, thereby individualizing the plan of care.ssessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.

18 - The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? Continue the education and remind the client that it is essential to learn self-care. Discontinue the education and ask the client for permission to teach a family member. Discontinue the education and attempt at another time. Medicate the client for anxiety and continue the education later.

Discontinue the education and attempt at another time. *The nurse should always perform client education when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the education because the client is not ready to learn.

19 - The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating? Discovering a problem Implementing a change Assessing the change Planning a strategy using indicators

Discovering a problem *Discovering the problem by detecting that there are several readmissions with heart failure is the first step in the process of performance improvement. The next step would be to plan a strategy using indicators, which includes calling an interdisciplinary meeting. The team would then implement a change and, lastly, assess whether the change was effective.

18 - A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? Discuss the risks and benefits of a blood transfusion with the client. Discuss the client's refusal with hospital risk managers. Discuss possible alternatives to a blood transfusion with the health care provider. Discuss the client's options with other church members.

Discuss possible alternatives to a blood transfusion with the health care provider. *As coordinator of the client's care, the nurse functions as an intermediary between the health care provider and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the health care provider to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

19 - A nurse overhears a coworker telling a somewhat offensive joke to a client. Which nursing action is indicated? Investigate whether the coworker and client have a previous relationship. Discuss the occurrence with the coworker. Report what was overheard to the charge nurse. Apologize to the client for the coworker's behavior.

Discuss the occurrence with the coworker. *The first step is to confront the coworker. If the behavior continues or the nurse does not seem to understand the gravity of the mistake, it would be appropriate to discuss the situation with the charge nurse. It makes no difference if the client and coworker have a previous relationship or not, given the unprofessional nature of the incident. The client-nurse boundary should be protected. Apologizing to the client may draw attention to the issue.

18 - The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? Discuss with the client the reasons for declining surgery. Review with the client the risks and benefits of surgery. Ask the client to discuss the decision with family members. Notify the health care provider of the client's refusal.

Discuss with the client the reasons for declining surgery. *The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the health care provider until the assessment is complete.

19 - Which action should the nurse take during the evaluation phase of the nursing process? Discontinue the indwelling urinary catheter per the provider's order. Have the client give input into plan of care upon admission. Provide the client with a follow-up appointment after discharge. Document reassessment of pain after medication administration.

Document reassessment of pain after medication administration.

13 - A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment? Do not document this assessment because the client could be using a wireless device to talk to family. Document this assessment based on the client's behaviors. Do not document this assessment because it is subjective. Document that the client is talking back to the voices in the client's head.

Document this assessment based on the client's behaviors.

13 - Which action is performed in the implementation step in the nursing process? Selecting nursing interventions Documenting the plan of care Identifying measurable outcomes Documenting the nursing care and client responses

Documenting the nursing care and client responses **The implementation step in the nursing process involves documenting the nursing care and client responses. Planning involves selecting nursing interventions, documenting the plan of care, and identifying measurable outcomes.

18 - Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? How can I explain the task to the UAP? What is the client's condition? Does this task fall within the scope of a UAP? How can I supervise the completion of this task?

Does this task fall within the scope of a UAP?

18 - Which action is a nursing intervention that facilitates lifespan care? Educate family members about normal growth and development patterns. Explore factors that could motivate adolescent members of the family to engage in risky behaviors. Teach contraceptive options for planned pregnancy. Identify coping strategies for the family that have worked in the past.

Educate family members about normal growth and development patterns. *Knowledge of normal growth and development is essential for family members to promote their own health and welfare throughout the lifespan, and to facilitate family functioning. Childbearing care includes interventions to assist in understanding and coping with psychological and physiologic changes during the childbearing period. Coping assistance includes interventions to assist the client in building on his or her strengths, to adapt to a change in function, or to achieve a higher level of function. Risk management includes interventions to initiate risk reduction activities.

17 - A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? Provide oral pain medication before ambulation. Encourage hourly use of the incentive spirometer. Reassess in 4 hours and document the findings. Promote oral fluid intake between meals.

Encourage hourly use of the incentive spirometer. *Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions.

18 - The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? Encourage the client to provide as much self-care as possible. Teach the family to anticipate the client's needs to care for the client. Perform all care activities for the client to facilitate rest. Arrange with the nurse case manager for an early discharge.

Encourage the client to provide as much self-care as possible. *The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

3 - Risk factors for illness are divided into six categories. Working with carcinogenic chemicals is an example of which type of risk factor? Environmental risk factor Health habits risk factor Physiologic risk factor Lifestyle risk factor

Environmental risk factor

19 - The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan? Provide additional relief with non-pharmacologic measures. Evaluate the use of current pain relief measures. Create a new nursing diagnosis to reflect new goals. Request a stronger analgesic from the provider.

Evaluate the use of current pain relief measures. *Prior to proceeding with any changes in the plan of care, the nurse must first perform evaluation of the client's current pain relief measures. Once this has been performed, it might be appropriate to request a stronger analgesic or reinforce education for nonpharmacologic pain relief measures. Creating a new nursing diagnosis and goals would come after evaluating the current pain relief measures.

13 - A nurse administers medications to a client. Which step of the nursing process would the nurse perform next? Planning Diagnosing Assessing Evaluating

Evaluating

17 - Nursing __________ are assessments of the effectiveness of interventions in resolving clients' health problems.

Evaluations

13 - Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing? Person-centered care Informatics Evidence-based practice Teamwork and collaboration

Evidence-based practice

17 - ________ ______ _________ are specific, measurable, realistic statements of a client's goal attainment.

Expected client outcomes

19 - Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? Finances of the client The client's condition Time and resources Feedback from the family

Finances of the client *The client's condition, time and resources, and feedback or input from the family are all of great value when the nurse is prioritizing the client's nursing diagnoses. The client's finances, however, should not influence the nurse's priority setting. The nursing code of ethics states that clients should receive the same treatment regardless of their ability to pay.

19 - Quality improvement in care delivery requires which components? Select all that apply. Continuous improvement Leadership commitment Total client care by the nursing unit Focus on the mission of the organization Focus on data collection

Focus on data collection Focus on the mission of the organization Leadership commitment Continuous improvement **When performing quality improvement the nurse should be collaborating with other departments rather than maintaining total client care by the nurses. All of the other choices are part of the quality improvement process. Quality improvement the commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes—also known as continuous quality improvement (CQI) or total quality management (TQM)

3 - When caring for a client who has just been diagnosed with a chronic illness, the nurse understands the importance of promoting health by highlighting which concept? Focus on the altered functioning. Focus on what can no longer be. Focus on why the client has the illness. Focus on what is possible.

Focus on what is possible. *When a client has a chronic illness, the nurse needs to make every effort to promote health with a focus of care that emphasizes what is possible rather than what can no longer be.

15 - A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? Time-lapse Emergency Focused Initial

Focused

15 - A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? Time-lapse Head-to-toe Focused Emergency

Focused **In a focused assessment, the nurse gathers information about a specific problem that has already been identified. A head-to-toe assessment is an initial, complete assessment, typically to assess for any problems that have not been identified yet. An emergency assessment is used to identify a life-threatening problem. A time-lapse reassessment is scheduled to compare current status with the baseline obtained earlier.

1) Problem—identifies what is unhealthy about patient 2) Etiology—identifies factors maintaining the unhealthy state 3) Defining characteristics—identify the subjective and objective data that signal the existence of a problem

Formulating a nursing Dx

14 - An experienced nurse has received a new client and will apply the principles of inductive reasoning in the care-planning process. What action will the nurse perform first when applying this form of clinical reasoning? Identify a respected nursing theory to inform care. Hypothesize the client's most likely diagnoses and challenges. Select the principles that relate most closely to the client's admitting diagnosis. Gather objective and subjective assessment data

Gather objective and subjective assessment data **Inductive reasoning requires observing, then drawing conclusions. That is, the process begins with data (such as assessment findings) and then progresses to identification of patterns or explanations. Presupposing the client's challenges or diagnoses would be contrary to this linear process. Beginning with a principle or theory is consistent with deductive reasoning.

18 - During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? Instruct the client in nonpharmacologic pain management. Determine the frequency of pain medication. Go to the client and assess the client's pain. Medicate the client with the ordered pain medication.

Go to the client and assess the client's pain. **The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.

19 - ___________ measures client satisfaction with health care.

HCAHPS - Hospital Consumer Assessment of Healthcare Providers and Systems

3 - When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. The nurse is demonstrating an understanding of which health model? Holistic health model High-level wellness model Health belief model Clinical model

Health belief model

3 - Which is the most accurate definition of health? Health is a lack of disease. Health is a reflection of wellness and requires a conscious and deliberate effort to maintain. Health is a state of maximal wellness. Health is a state of complete physical, mental, and social well-being.

Health is a state of complete physical, mental, and social well-being. *Health is viewed as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. The other options would not be the best definition of health.

16 - A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis? Syndrome Health promotion Problem-focused Risk

Health promotion

16 - Health promotion nursing diagnosis

Health promotion - behavior of an individual motivated by a personal desire to increase well-being and health potential A health promotion nursing diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state Health promotion nursing diagnoses are formulated to assist the client to meet that need.

16 - The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? Health promotion nursing diagnosis Actual nursing diagnosis Risk nursing diagnosis Syndrome nursing diagnosis

Health promotion nursing diagnosis *Readiness for Enhanced Coping is an example of a health promotion nursing diagnosis. Two cues must be present for a valid health promotion nursing diagnosis: a desire for a higher level of wellness and an effective present status or function.

18 - The nurse is proceeding through the nursing process in the care of a new client. During the implementation phase, the nurse will likely accomplish what task? Identify a need for collaborative consults. Help the client achieve optimal levels of health. Establish trust and rapport with the client. Implement the critical pathway for the client.

Help the client achieve optimal levels of health. **The purpose of the nursing implementation phase is to help the client achieve an optimal level of health. Implementing the critical pathway for the client is too narrow to represent the purpose of the implementation phase, although this may be the purpose of specific interventions that would be implemented during this phase. Identifying the need for collaborative consults is an action the nurse would perform in the planning phase of the nursing process. Establishing trust happens earlier in the nursing process.

18 - Which is an independent (nurse-initiated) action? Executing health care provider orders for a catheter Administering medication to a client Helping to allay a client's fears about surgery Meeting with other health care professionals to discuss a client

Helping to allay a client's fears about surgery *An independent (nurse-initiated) action is one that a nurse may initiate and carry out independently, without an order from any other health care provider. Helping the client decrease fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Interventions that involve executing a health care provider's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care.

16 - A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? High Risk for Injury related to impaired home management High Risk for Injury related to abusive parents High Risk for Injury related to unsafe home environment Child Abuse related to unsafe home environment

High Risk for Injury related to unsafe home environment

3 - A nurse evaluates whether a middle-age client with chronic back pain has been performing the different exercises and physiotherapy procedures recommended by the health care provider. What would the nurse most likely use to evaluate the client? Written test Return demonstration Oral test Simulation

High-level wellness model

19 - One of the first national, standardized, publicly reported surveys of patients perspectives of hospital care.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

17 - Which action should the nurse perform during the planning phase of the nursing process? Assess the client's overall health. Identify the client's health-related problems. Analyze the client's response to medicines. Identify measurable goals or outcomes.

Identify measurable goals or outcomes. *In the planning phase of the nursing process, the nurse identifies measurable goals or outcomes, prioritizes nursing diagnoses and collaborative problems, selects appropriate interventions, and documents the plan of care. The nurse assesses the client's overall health during the assessment step of the nursing process, not during the planning step. The nurse identifies the client's health-related problems during diagnosis and analyzes the client's response to medicines during the evaluation process.

16 - A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client? Disturbed Body Image Activity Intolerance Disturbed Sleep Pattern Impaired Comfort

Impaired Comfort

16 - A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis will the nurse use to address this concern? decreased community health associated with chemical plant lack of knowledge regarding effects of chemical plant pollution community contamination risk associated with possible environmental pollution infection risk associated with community contamination

Impaired Physical Mobility related to pain

16 - The nurse is caring for a client who is postoperative day 2 after a total knee replacement. The client refuses to ambulate when the physiotherapist arrives at the unit. The client states, "It is too soon to get up and walk. I am worried my incision will tear open." The nurse correctly documents the problem-focused nursing diagnosis using which statement? Risk for postoperative complications due to disturbed body image. Anxiety related to knowledge deficit regarding normal postoperative activities. Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. Risk for anxiety related to fear of ambulating postoperatively.

Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. **A problem-focused nursing diagnostic statement contains three parts, sometimes referred to as "PES." P: Name of the health-related issue or problem as identified in the NANDA-I list. E: Etiology (the problem's cause). S: Signs and symptoms, also called defining characteristics. The name of the nursing diagnosis is linked to the etiology with the phrase "related to," and the signs and symptoms are identified with the phrase "as evidenced by." The client's ability to ambulate when expected postoperatively is impaired by anxiety related to fear of postoperative complications. A statement regarding an actual client problem must include what the problem is related to and what evidence the nurse has to indicate that there is a problem. The client is having actually anxiety and is not at risk for it. Beginning the statement with "at risk for" would make the statement inaccurate. The client has not demonstrated a knowledge deficit about normal postoperative activities. The barrier to ambulating is fear and anxiety. There is no evidence to indicate that the client has a disturbed body image. The nurse would have to assess further to confirm this is accurate and include this as evidence in the problem-focused statement.

13 - Which statements are true about the implementation phase of the nursing process? Select all that apply. Care provided during implementation should be documented in the client's chart. This phase promotes wellness and restores health. All interventions carried out during this phase must be accompanied by a health care provider's order. Implementation is the process of carrying out the plan of care. Implementation is only carried out by nursing professionals.

Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health. Care provided during implementation should be documented in the client's chart.

3 - A hospital nurse assesses clients in various stages of illness. Which statements accurately describe client responses to illness based on Suchman's stages of illness? Select all that apply. When help from a health care provider is sought, the person becomes a client and enters stage 3, assuming a dependent role. In stage 2, most people focus on their symptoms and bodily functions. When a client decides to accept a diagnosis and follow a prescribed treatment plan, he or she is in stage 4, achieving recovery and rehabilitation. In stage 1, pain is the most significant symptom indicating illness, although other symptoms, such as a rash, fever, bleeding, or cough, may be present. Most clients complete the final stage of illness behavior in the hospital or a long-term care setting.

In stage 1, pain is the most significant symptom indicating illness, although other symptoms, such as a rash, fever, bleeding, or cough, may be present. In stage 2, most people focus on their symptoms and bodily functions. When help from a health care provider is sought, the person becomes a client and enters stage 3, assuming a dependent role. Most clients complete the final stage of illness behavior in the hospital or a long-term care setting.

14 - Define inductive reasoning.

Inductive reasoning - cognitive process in which one identifies a specific idea or action and then makes conclusions about general ideas

16 - A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis? Infection (Pulmonary) Altered Airway Impaired Respiration Ineffective Airway Clearance

Ineffective Airway Clearance **Ineffective Airway Clearance is a plausible nursing diagnosis for a client with pneumonia. The other listed options are not recognized NANDA nursing diagnoses.

15 - During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, what action will the nurse take? Assess personal feelings regarding similar clinical situations. Review literature pertinent to the client's attributes. Implement supportive nursing interventions. Inform the client of the maintenance of confidentiality.

Inform the client of the maintenance of confidentiality. **During the introductory phase, the nurse should inform the client how the information will be used and that confidentiality will be maintained. The alternate responses are not associated with this specific phase.

18 - The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client? Instruct the client and family in wound care. Teach the client about dietary restrictions during recovery. Inform the client what to expect after the surgery. Discuss discharge plans with the client.

Inform the client what to expect after the surgery. *If the surgery is an emergency, the highest priority is to meet the client's immediate needs. The nurse should inform the client about what to expect after surgery. Discussing discharge plans, instructing in wound care, and teaching about dietary restrictions are important, but not necessary before the surgery.

17 - initial planning

Initial planning is done at time of admission based on the nurse's admission assessment.

18 - Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Ask another UAP to observe and assist the UAP in performing the task. Inform the UAP of the importance of following each step listed in the procedure manual. Request that the UAP place the steps of the task in the framework of the nursing process.

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. *Instruct the UAP to repeat the nurse's instructions to be sure the nurse has communicated them clearly. The UAP must be clear on the difference between nursing tasks and the nursing process, as the nursing process structures care delivered by the registered nurse. Although it is important for the UAP to follow procedure manuals, it is important that the registered nurse is clear on the UAP's understanding of the steps through direct observation or discussions. It is not correct to ask another UAP to observe and assist the UAP in performing the task.

14 - The nurse is participating in a client conference for a client who has complex health needs. The client's psychiatrist, occupational therapist, and social worker are also participating in the conference. The nurse is most clearly demonstrating the values of what organization? The Joint Commission National Council of State Boards of Nursing Interprofessional Education Collaborative National League for Nursing

Interprofessional Education Collaborative **Active collaboration between health professions is the cornerstone of the Interprofessional Education Collaborative (IPEC) competencies. The actions are wholly consistent with the values of the other listed organizations, but the interdisciplinary nature of this action is a direct and practical example of IPEC competencies.

14 - A skilled nurse is providing care for a client with mental health needs who is recovering from a stroke. The client is experiencing dysphagia (difficulty swallowing), so the nurse is working together with the speech-language pathologist (SLP) to ensure the client's cooperation with a swallowing assessment. This nurse's action best demonstrates: the American Nurses Association (ANA) Nursing: Scope and Standards of Practice. Rest's model of moral reasoning. reflection-in-action. Interprofessional Education Collaborative (IPEC) core competencies.

Interprofessional Education Collaborative (IPEC) core competencies. *Interprofessional Education Collaborative (IPEC) core competencies emphasize the need for interdisciplinary teamwork and collaboration, as demonstrated by working directly with a member of another health discipline. Reflection-in-action is a form of introspection and analysis within Tanner's model of clinical judgment, but there is no obvious indication that the nurse is doing this. The nurse's action is consistent with Rest's framework but this framework focuses on moral action, which is not described in the scenario. The nurse's action is well within the ANA Scope of Practice, but the focus on collaboration and teamwork is a more clear and apparent function.

3 - A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease? It takes a long time to cure. It has a gradual onset and lasts for a long time. It is a sequela of acute illness. It persists for a long time.

It has a gradual onset and lasts for a long time. **Chronic illness has a gradual onset and lasts for a long time. It is usually seen in old age. It may or may not be due to acute illness. Chronic diseases are a major cause of morbidity in the population.

13 - Which is a characteristic of person-centered care? It is a framework for providing care. It involves general care for all clients. It can be used in hospital settings. It is independent of other disciplines.

It is a framework for providing care.

13 - Which statement regarding critical thinking in nursing is true? It shows trends and patterns in client status. It is a systematic way of thinking. It makes judgments based on conjecture. It supplies validation for reimbursement.

It is a systematic way of thinking.

3 - What do the 4 assumptions below indicate? (1) As people mature, their self-concept is likely to move from dependence to independence. (2) The previous experience of the adult is a rich resource for learning. (3) An adult's readiness to learn is often related to a developmental task or a social role. (4) Most adults' orientation to learning is that material should be useful immediately, rather than at some time in the future.

Knowles (1990) four assumptions about adult learners

14 - NCSBN Clinical Judgment Measurement Model (CJMM)

Layers 0-2 - emphasize how CJ informs the clinical decisions made to address the client's needs P 388

18 - _____________ nursing interventions involve the nurse assisting the client with performing routine activities of daily living.

Maintenance

18 - The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem? Provide information to the client on the benefits of complying with the plan of care. Make changes in the plan of care based upon assessment data. Discuss the desired outcomes with the client and the importance of the outcomes. Ask the client's family to assist the client in following the plan of care.

Make changes in the plan of care based upon assessment data. **A plan of care that is inappropriate for the client requires a change in the plan of care, not a change in the client. In situations when the plan of care is appropriate, the nurse must evaluate factors that contribute to the client's failure to comply. Such factors include lack of family support, lack of understanding of the benefits of compliance, low value attached to the outcomes and related interventions, and adverse or emotional effects of treatment.

18 - The health care provider has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action? Emphasize to the client the importance of following the treatment plan. Ambulate the client and medicate later. Explain to the client the benefits of ambulation. Medicate the client and wait to ambulate later.

Medicate the client and wait to ambulate later. *It is most appropriate to manage the client's pain first. The client will be able to ambulate more easily and it is not necessary to cause the client further pain. Ambulating first considers the needs of the nurse, not the client. The client has not indicated misunderstanding of benefits or the importance of ambulation.

13 - The nurse is caring for a client with an identified nursing concern of fluid volume deficiency. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of fluid volume deficiency. What should the nurse do next? Modify the plan of care and interventions to meet the client's needs. Reassess the client for more symptoms of fluid volume deficiency. Develop an additional nursing concern to meet the client's health needs. Change the nursing concern, because the client's problem was falsely identified.

Modify the plan of care and interventions to meet the client's needs. **The nurse should review the plan of care and its implementation periodically and, as needed based on evaluation, modify them to meet the client's needs. Because this client continues to exhibit symptoms identified by the nursing concern, the implementation should be modified to better meet the client's needs and outcomes. Because the original nursing concern appears to be accurate, there is no indication that it falsely identifies the client's problem or that another one is needed. There is no need to reassess the client for more symptoms of fluid volume deficiency, because it is evident that the client has this problem.

13 - The nurse enters the room of an adult client who reports postoperative abdominal pain. The client states that the pain is severe but is relieved some when getting up to go the bathroom. Which is the nurse's best determination based on this assessment? The client should not be ambulating with pain. The client's pain is really not that bad because the client can ambulate. More assessment would be beneficial to determine whether pain medication is desirable. Even with pain, the client is ambulatory and therefore ready for discharge.

More assessment would be beneficial to determine whether pain medication is desirable. Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. More assessment is needed about this client's pain to determine the status and the need for intervention. There is not enough information to determine whether the client is ready for discharge. The health care provider should not question a client's report of pain. Clients may ambulate with pain.

16 - What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses? The Canadian Nurses Association (CNA) NANDA-International (NANDA-I) The National League for Nursing (NLN) The Canadian Medical Association (CMA)

NANDA-International (NANDA-I)

14 - A nursing student is excited to begin the first semester of the program and has learned that the competencies embedded in the program include human flourishing, nursing judgment, professional identity, and spirit of inquiry. What is the source of these competencies? Department of Health and Human Services National League for Nursing Centers for Disease Control and Prevention American Association of Colleges and Universities

National League for Nursing The competencies identified by the National League for Nursing include human flourishing, nursing judgment, professional identity, and spirit of inquiry. None of the other listed organizations share this particular taxonomy of competencies.

18 - A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? Health care provider Insurance company Nurse case manager Nurse manager

Nurse case manager *The nurse case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The health care provider is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage.

17 - Which statement correctly describes a nurse-initiated intervention? Nurse-initiated interventions are derived from the nursing diagnosis. Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. Nurse-initiated interventions are actions performed to diagnose a medical problem. Nurse-initiated interventions require a health care provider's order.

Nurse-initiated interventions are derived from the nursing diagnosis. *Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a health care provider's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome.

17 - What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)? Nurses do carry out interventions in response to a health care provider's order. Nurses do not carry out health care provider-initiated interventions. Nurses are responsible for reminding health care providers to implement orders. Nurses are not legally responsible for these interventions.

Nurses do carry out interventions in response to a health care provider's order. *A health care provider-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the health care provider and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding health care providers to implement orders, nurses may request a health care provider to implement an order or question an existing order by the health care provider if the nurse believes it is in the client's best interests.

16 - The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing? Nurses write nursing diagnoses to describe client problems that nurses can treat. Nursing diagnoses focus on identifying healthy responses to health and illness. Nursing diagnoses remain the same for as long as the disease is present. Nurses formulate nursing diagnoses to identify diseases

Nurses write nursing diagnoses to describe client problems that nurses can treat. *Data collection leads the nurse to identifying client problems that the nurse is able to treat with planned nursing interventions, which is the focus of nursing diagnoses. Nursing diagnoses change as client goals are met or as new problems develop. Medical diagnoses identify disease processes.

16 - Nursing diagnosis

Nursing diagnoses describe client problems that nurses can treat independently and do not require collaboration with other members of the health care team.

16 - A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care? Medical diagnosis Collaborative problem Nursing assessment Nursing diagnosis

Nursing diagnosis **The nursing diagnosis statement is worded by stating the client problem (using NANDA-I approved diagnoses) that the nurse is able to treat followed by the etiology of the problem. Nursing assessment refers to the collection of data. A medical diagnosis identifies diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Nurses cannot treat medical diagnoses independently. Collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines.

18 - _________ ____________ refer to care administered by the nurse and can be dependent or independent in nature.

Nursing interventions

17 - Nursing interventions include:

Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should: 1) include the dates - should be dated both when written and when the care plan is reviewed. 2) include a verb (action to be performed) 3) include the subject (who is to do it) 4) include a descriptive phrase (how, when, where, how often, how long, or how much) 5) directly relate to the outcomes.

13 - A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care? Reflection Experience Clinical reasoning Nursing process

Nursing process

9 - Which nursing action is applicable to the psychomotor domain of learning when conducting a teaching session for parents who are breastfeeding/chestfeeding? Advising parents to avoid taking over-the-counter drugs while breastfeeding/chestfeeding Showing charts that illustrate the types of human milk Observing human milk being expressed by someone Advising the parents to drink plenty of water while breastfeeding/chestfeeding

Observing human milk being expressed by someone *Observing is one of the levels of psychomotor skills, which involves watching an experienced person perform a physical skill. Telling, showing, and advising are examples of addressing the cognitive domain, which helps the individuals process information by listening or reading facts.

15 - The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case? Obtaining data regarding the amount and frequency of drinking Asking the client to discuss social functioning Performing an abdominal assessment Interviewing friends to ascertain the client's exercise habits

Obtaining data regarding the amount and frequency of drinking

17 - A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? On the client's admission to the hospital Once the client has received a discharge order Once the client is admitted to the nursing unit from postanesthetic recovery As soon as possible after the client's surgery

On the client's admission to the hospital **Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.

17 - ongoing planning

Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.

17 - A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? Opioid analgesic to treat pain Septic workup due to blood pressure and heart rate elevation Isolation for suspected respiratory illness Acetaminophen to treat pain and fever

Opioid analgesic to treat pain *A sickle cell crisis is an extremely painful event. Most clients with sickle cell disease have an individualized opioid plan that will help them to receive opioids in an expedited manner when they present in crisis. The slight elevations in the client's blood pressure and heart rate are likely secondary to pain, not sepsis. There is no evidence of respiratory illness based on the information given. Acetaminophen is not strong enough to treat this client's pain; furthermore, the client does not have a fever.

19 - The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? Structure Process Outcome Cost-effectiveness

Outcome *Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association

17 - A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? The nurse will help the client ambulate the length of the hallway once a day. Offer to help the client walk the length of the hallway each day. The client will become mobile within a 24-hour period. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. *Goals must be client-centered, specific, measurable, attainable, realistic, and time bound. "Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse" has all of these characteristics. "The nurse will help the client ambulate the length of the hallway once a day" is not specific in whether assistance is required, is not timebound, and is not client-centered, in that the nurse is the subject of the sentence, not the client. "Offer to help the client walk the length of the hallway each day" is a nursing intervention, not a client outcome. "The client will become mobile within a 24-hour period" is not specific or measurable.

16 - A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address? PC: altered body image associated with decreased activity tolerance PC: activity intolerance associated with decreased oxygenation capacity PC: fear associated with new diagnosis of myocardial infarction PC: decreased cardiac output associated with cardiac tissue damage

PC: decreased cardiac output associated with cardiac tissue damage PC = collaborative problem *All these collaborative problems may be indicated for a client with a recent myocardial infarction; however, priority must be given to life-threatening issues. Decreased cardiac output is the only life-threatening problem, so it must be the priority for care planning.

19 - A new parent is having difficulty breastfeeding a newborn. A goal was established stating that the newborn would be nursing every 2 to 3 hours by age 1 week. The parent presents to the follow-up clinic at 1 week and reports having discontinued breastfeeding 4 days ago. How will the nurse characterize the original goal? unmet partially met abandoned inappropriately chosen for this client

Peer review

19 - A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed: Quality and Safety Education for Nurses (QSEN) American Association of Critical-Care Nurses (AACN) Peer review Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

Peer review *Peer review is a process by which one nurse evaluates the performance of another to improve professional performance. QSEN has as its goal the preparation of nurses with the knowledge, skills, and attitudes necessary to improve the quality and safety of health care systems. AACN strives to provide safe work environments. HCAHPS measures client satisfaction with health care.

13 - A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process? Evaluation Diagnosis Planning Implementation

Planning During the planning phase, the nurse examines alternatives and judges the worth of evidence using this information to develop the plan of care for the client. During diagnosis, the nurse analyzes the assessment information to identify actual or potential responses to health problems. During implementation, the nurse carries out the plan of care. During evaluation, the nurse determines outcome attainment, revises plans, and identifies a client's perception of results.

13 - The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated? Assessing; diagnosing Planning; implementing Implementing; evaluation Diagnosing; implementing

Planning; implementing

13 - A nurse has developed a plan of care for an adult client. What nursing function is important when using the identified nursing concerns to guide the care of this client? Add a new nursing concern in the nurse's own words to individualize the plan of care. Keep resolved nursing concerns as part of the plan of care in case the related problems return. Do not allow the client to review the nursing concerns identified for them. Prioritize the nursing concerns.

Prioritize the nursing concerns. **After performing a nursing assessment, data should be analyzed and compiled into actual and potential health problems and documented as nursing concerns. It is the nurse's responsibility to prioritize the nursing concerns, thereby prioritizing the care of the client. Resolved nursing concerns should be deleted from the plan of care as soon as they are resolved and replaced with new ones when appropriate. Nursing concerns should be written in a nonjudgmental way and in legally advisable terms, not in the nurse's own words. The plan of care is individualized for each client; therefore, the client should be aware of what is included.

LP 8 - Anxiety related to situational crisis and stress (related factors such as loss of employment) as evidenced by restlessness, insomnia, anguish and anorexia (defining characteristics).

Problem-Focused Diagnosis Example

18 - __________ are written plans that detail the nursing activities to be executed in specific situations; these include routine nursing care and standing orders.

Protocols

18 - Which task is appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Reassess the client's sacrum for redness when doing a bed bath. Assess an IV site for possible infiltration. Provide the client with assistance in transferring to the bedside commode. Retrieve a unit of blood from the blood bank.

Provide the client with assistance in transferring to the bedside commode. *Assisting with toileting is one of the tasks the state board of nursing permits unlicensed assistive personnel (UAPs) to perform. UAPs commonly performed this task in health facilities. Each of the other responses demands a level of responsibility that the nurse cannot legally delegate to a UAP.

19 - Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement? Psychomotor Physical changes Affective Cognitive

Psychomotor

19 - "The client will demonstrate cast care prior to discharge" is which type of evaluative statement? Physical changes Psychomotor Cognitive Affective

Psychomotor *This is an example of a psychomotor evaluative statement. Psychomotor outcomes are those that are related to new skill attainment.

18 - ___________ interventions focus on resolving emotional, psychological, or social problems. These interventions should consider and respect the patient's socioeconomic background and culture.

Psychosocial

19 - ___________ has as its goal the preparation of nurses with the knowledge, skills, and attitudes necessary to improve the quality and safety of health care systems.

Quality and Safety Education for Nurses (QSEN)

19 - The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted? Quality improvement Peer review Magnet status Quality assurance

Quality assurance *Accreditation by the Joint Commission evaluates quality assurance. Quality assurance is an externally driven process, demonstrating nursing excellence by meeting professional standards of care. Quality improvement is an internally driven, continuous process focusing on the processes of client care. Peer review is a process whereby individual nurses improve their professional performance through the evaluation of one staff member by another staff member on the same level of the hierarchy. Magnet status is awarded by the American Nurses Credentialing Center, recognizing health care organizations for their excellence in nursing.

18 - A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? Notify the health care provider that the client has required pain medications. Reassess the client to determine the effectiveness of the interventions. Perform additional non-pharmacological pain interventions. Instruct the client that pain medication is available at regular intervals.

Reassess the client to determine the effectiveness of the interventions. *After implementing any interventions (such as pain medication or any nonpharmacological pain control method, such as splinting the incision), the nurse must always reassess the client to determine the effectiveness of the interventions. It is more likely that the pain medication is available on an as-needed basis rather than at regular intervals; in any case, informing the client of the availability of pain medication is of lower priority than reassessing the client to determine the effectiveness of the interventions performed. There is no need to inform the health care provider that the client has required pain medication; the health care provider anticipated the client needing pain medication, which is why the health care provider ordered the medication for the client to begin with. After evaluating the effectiveness of the implemented interventions, if the nurse finds that they have been ineffective, then the nurse would then revise the plan and include additional interventions, including, possibly, other nonpharmacological pain interventions.

13 - Which is the best example of person-centered care provided by a registered nurse? Insertion of a nasogastric tube for gastric decompression Administration of pain medication every 4 hours to a client who is postoperative Development of a plan of care for a new admission Reassuring a client who is anxious about a procedure

Reassuring a client who is anxious about a procedure **Person-centered care involves consideration of a client holistically by incorporating an awareness of the client's feelings into the provision of care. Person-centered care is different from task-oriented care in that the task-oriented nurse is only focused on completing tasks in a timely manner. Reassuring a client who is anxious about a procedure shows caring in that the nurse considers the client's feelings about the procedure and does not focus only on the procedure as a task in and of itself. Administering pain medicine, development of the plan of care, and insertion of a nasogastric tube are all important tasks but are not the best example of person-centered care.

14 - An experienced nurse uses cognitive continuum theory (CCT) to inform interactions with clients and families. To optimize the component of intuition in this theoretical framework, the nurse will perform what action? Prioritize feelings over facts to enhance intuition. Participate in interprofessional education whenever possible. Explain the rationale for each nursing action to clients. Reflect carefully to uncover personal biases.

Reflect carefully to uncover personal biases. **The use of intuition requires a close examination of bias, both known and unconscious. Explaining actions to clients and participating in interprofessional education is helpful and respectful, but this act does not necessarily increase the nurse's intuition. Intuition does not consist of prioritizing feelings and downplaying facts; rather, it integrates the two.

13 - The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action? Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. The nurse decides to turn the client every 4 hours because everyone is too busy to help. After turning the client alone, the nurse realizes that the nurse should have insisted on having help. During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.

9 - Which strategy should the nurse use when providing education to the older adult client? Remain calm and conduct the teaching session in a quiet environment. Avoid the use of colorful materials and keep the session short. Teach from books only and remain calm. Teach in a monotone voice in a quiet environment.

Remain calm and conduct the teaching session in a quiet environment.

15 - Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. Number of years in profession Respect for client Caring Competence Professionalism

Respect for client Caring Competence Professionalism

16 - After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first? Review the client's recent food and fluid intake. Provide teaching about the prevention of constipation. Encourage the client to drink more fluids and eat more fiber. Prepare the client for administration of laxative medication.

Review the client's recent food and fluid intake.

18 - Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? Revise the care plan to allow the client to ambulate to the bathroom independently. Instruct the client's family to assist the client to ambulate to the bathroom. Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability.

Revise the care plan to allow the client to ambulate to the bathroom independently. **The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.

16 - The nurse has assessed a client and drafted a nursing diagnosis that is outside the nurse's scope of practice. Which action will the nurse take? Have the interdisciplinary team validate the nursing diagnosis. Revise the diagnosis so it is in the nurse's scope of practice. Collaborate with the primary care provider to address the diagnosis. Document the fact that the diagnosis is out of the nurse's scope.

Revise the diagnosis so it is in the nurse's scope of practice. A nursing diagnosis must be within a nurse's legal scope of practice. If this is not the case, the diagnosis must be rejected or revised and should not be entered into documentation. Interdisciplinary collaboration is important but cannot compensate for an inappropriate diagnosis.

Risk for infection as evidenced by inadequate vaccination and immunosuppression (risk factors).

Risk Diagnosis Example

- There are no related factors (etiological factors), since we are identifying a vulnerability in a patient for a potential problem; the problem is not yet present. Therefore, we identify the risk factors that predispose the individual to a potential problem.

Risk Nursing Dx: They are more likely to develop this problem. Doesn't currently have it, but is at a higher risk than others.

18 - The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? The cellular metabolism of glucose Medications used to treat diabetes mellitus The severity of the client's disease Risk factors for and prevention of diabetes mellitus

Risk factors for and prevention of diabetes mellitus *An important nursing function is to enable clients to prevent illness. Because a member of the family has developed diabetes, the other family members are also at risk. The nurse would most appropriately educate the family about the risk factors for and prevention of diabetes mellitus.

16 - A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan? Anxiety related to surgical procedure Knowledge Deficit related to surgical procedure Risk for Injury related to latex allergy Risk for Allergy Response related to latex allergy

Risk for Allergy Response related to latex allergy

16 - A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern? Risk for Suicide Impaired Comfort Disturbed Body Image Risk for Powerlessness

Risk for Powerlessness *The most appropriate nursing diagnosis for the client is the Risk for Powerlessness. The client feels that the disease is not under the client's control and any personal efforts will not affect outcome. Disturbed Body Image is not an appropriate answer because the client does not seem to be concerned about the appearance of the body. Impaired Comfort is also not an appropriate nursing diagnosis because the client does not demonstrate any sign of discomfort. There is not enough indication that the client is at risk for suicide.

13 - The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? Risk for falls Hypertension Congestive heart failure Pneumonia

Risk for falls

17 - A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care? Set priorities using client care standards. Follow institutional guidelines. Consult with another nurse. Seek research about the disorder.

Seek research about the disorder. *While each option is appropriate, it is crucial to find research to support the plan before establishing priorities. The nurse planning care uses clinical reasoning to set priorities that incorporate standards and agency policies, identify and record expected client outcomes, select evidence-based nursing interventions, and record the plan of care.

17 - Which action should the nurse perform during the planning step of the nursing process? Identifies client strengths and weaknesses Interprets and analyzes the client data Selects nursing measures, including client education Establishes a database for the client

Selects nursing measures, including client education

13 - Which are characteristics of one who has developed critical thinking skills? Resilient, authoritative, reactive, and private Curious, other-directed, fallible, and humble Creative, oriented to success, self-determined, and perfectionistic Self-aware, honest, persistent, and authentic

Self-aware, honest, persistent, and authentic

18 - As part of a client's plan of care, a nurse teaches a client's spouse how to perform a dressing change to the client's abdominal wound. Which method would be most effective to determine whether the spouse has mastered the skill? Spouse shows the nurse what supplies are needed. Spouse lists the signs of healing. Spouse performs the steps of the dressing change correctly. Spouse identifies the steps for the dressing change.

Spouse performs the steps of the dressing change correctly. *The only way to be sure that clients or family caregivers have mastered a skill is watching them perform it. Once the nurse observes them doing a procedure correctly, the nurse can be confident that learning—as well as teaching—has occurred. The other answer options only demonstrate that the spouse has learned the cognitive aspects to related to the skill; the spouse can only demonstrate full, effective knowledge of the skill by performing it.

17 - standardized care plan

Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem

17 - The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs? Ask the client's learning style, then teach diet information using that style. Present the client with videos and books about diet changes that reduce inflammation. Answer the client's questions about diet alterations, and then evaluate understanding. Start from client's knowledge, teach about diet modifications, and check for learning.

Start from client's knowledge, teach about diet modifications, and check for learning. *The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made and what nursing interventions, including teaching, counseling, and advocacy, need to be done. They should also include evaluation of the outcome of the intervention. "Start from client's knowledge, teach about diet modifications, and check for learning" provides the most comprehensive intervention for this client, as it includes assessment of the client's current level of knowledge, teaching, and evaluation of the teaching. None of the other answer options includes all three of these elements.

19 - A nurse is working as part of a quality assurance team that uses the American Nurses Association model. The team is evaluating the resources of the facility as well as the physical facilities and equipment. Which type of evaluation is the team engaged in? Outcome evaluation Structure evaluation Process evaluation Quality by inspection

Structure evaluation

18 - The Omaha System (OS) is one of the oldest of the ANA-recognized standardized terminologies describing and measuring the impact of health care services. It is a research-based, comprehensive, standardized taxonomy or classification that exists in the public domain. The OS has these 3 aspects:

Structure: characteristics of the care providers, their tools and resources, and the physical/organizational setting) Process: both interpersonal and technical aspects of the treatment process Outcome: change in the patient's symptoms and functioning

Purpose of identifying the etiology in a nursing Dx

Suggests the appropriate nursing measures *Fears of falling in the tub & obesity --> as evidence by (AEB)

Purpose of identifying the problem in a nursing Dx

Suggests the pt outcomes (expectations for change)

18 - __________ interventions refer to overseeing the client's overall health care and would include medication administration.

Supervisory

17 - A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? Supportive Psychosocial Supervisory Coordinating

Supportive

18 - _________ interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors.

Supportive

18 - _____________ nursing measures involve providing basic comfort and emotional care to the client.

Supportive

18 - _____________ or ____________ nursing interventions include detecting changes from baseline data and recognizing abnormal responses.

Surveillance or monitoring

16 - Syndrome nursing diganosis

Syndrome nursing diagnoses address a cluster of actual or risk diagnoses that are predicted to be present as a result of a certain event or situation.

14 - The public health nurse is performing a postpartum home visit to a first-time parent who describes themselves as "awfully anxious." In alignment with Tanner's model of clinical judgment, the nurse has taken notice of the subjective and objective data that are relevant to the client's state of mind. Before responding by providing interventions, which action will the nurse take? Corroborate the assessment findings with the client. Systematically interpret the meaning of the assessment data. Perform reflection on-action to better prepare for arranging supports for the client. Elicit guidance from an expert nurse in light of the psychosocial nature of the client's challenges

Systematically interpret the meaning of the assessment data. **Within Tanner's model, the stage of "noticing" is followed by "interpreting," in which meaning is assigned to the various cues. Reflection on-action takes place after the clinical encounter in Tanner's model. The model does not explicitly identify the need for expert guidance, and it is not necessary or practical to corroborate each assessment datum with the client.

14 - A nurse has entered a client's home and noticed the client's disheveled state and several fall risks in the home. The nurse has interpreted these data as indications of a need for increased home support for the client and responded by arranging for care. The nurse reflected on the client's response to this suggestion, as well as reflected on the course of this interaction after the fact. The nurse has most clearly exemplified what model? California Critical Thinking Disposition Inventory (CCTDI) Tanner's clinical judgment model Developing Nurses' Thinking (DNT) model The Lasater clinical judgment rubric

Tanner's clinical judgment model **Although the nurse's actions are not inconsistent with any of the listed models, the integration of the specific steps of noticing, interpreting, responding, and reflecting demonstrates Tanner's clinical judgment model.

14 - A nurse has entered a client's home and noticed the client's disheveled state and several fall risks in the home. The nurse has interpreted these data as indications of a need for increased home support for the client and responded by arranging for care. The nurse reflected on the client's response to this suggestion, as well as reflected on the course of this interaction after the fact. The nurse has most clearly exemplified what model? Developing Nurses' Thinking (DNT) model Tanner's clinical judgment model California Critical Thinking Disposition Inventory (CCTDI) The Lasater clinical judgment rubric

Tanner's clinical judgment model **Although the nurse's actions are not inconsistent with any of the listed models, the integration of the specific steps of noticing, interpreting, responding, and reflecting demonstrates Tanner's clinical judgment model.

17 - Which is an example of a nurse-initiated intervention? Teach the client how to splint an abdominal incision when coughing and deep breathing. Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. Administer a 1000-mL soap suds enema. Administer oxygen at 4 L/min per nasal cannula.

Teach the client how to splint an abdominal incision when coughing and deep breathing. **A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a health care provider's order. A health care provider's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

3 - The nurse is caring for a client with a diagnosis of heart failure. This admission is the client's third admission within 90 days. The nurse educates the client with the goal of preventing readmission. Which nursing activity for this client would represent tertiary level prevention? Assessing for risk factors for heart disease Teaching about adhering to a low-sodium diet Screening for breast cancer every 5 years Screening for tuberculosis

Teaching about adhering to a low-sodium diet *Tertiary health promotion and illness prevention begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate the client to a maximum level of functioning. Nursing activities on a tertiary level include teaching a client with heart failure the importance of adhering to a low-sodium diet.

19 - A client with a new diagnosis of diabetes will be discharged on insulin therapy. Which client psychomotor outcome does the nurse expect after client education? The client identifies signs and symptoms of hypoglycemia. The client demonstrates administration of insulin. The client reports testing blood sugar before meals. The client identifies correct insulin injection sites.

The client demonstrates administration of insulin. *Psychomotor outcomes describe the client's achievement of new skills, such as demonstration of administration of insulin.

18 - What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session. The client verbalizes understanding of the instructions. The client tells the nurse that the client's spouse will handle the care. The client asks the nurse to repeat the instructions.

The client discusses the specifics of what was taught during the session. The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. *After an intervention is implemented, the nurse must assess the effectiveness of the intervention. The client stating an understanding of the instructions gives the nurse an indication that learning has taken place. Asking the client questions and receiving the correct answers is an excellent way to judge the client's knowledge. The client asking for the nurse to repeat the instructions shows that the client does not have a clear understanding. The client's statement that the spouse will handle the care signals that the client is not ready to learn at this time. The client's ability to discuss the specifics of the material suggests that learning has taken place.

18 - The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? The parents have comprehensive insurance coverage for their family's medical care. The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. The client expresses a desire to learn how to manage the medication regime. The parents verbalize acceptance of the need to closely monitor their child's condition.

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. **If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.

19 - A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem? The client is able to explain when and why the client needs to check the blood glucose level. The client expresses a desire to change the way that the client eats and exercises. The client has maintained blood glucose levels within acceptable range in the days prior to discharge. The client can demonstrate the correct technique for using a new glucometer.

The client is able to explain when and why the client needs to check the blood glucose level. *The ability to describe the rationale and technique for blood glucose monitoring indicates that the client has achieved a cognitive outcome. Demonstration of the technique constitutes a psychomotor outcome, whereas the expression of a desire for change is an affective outcome. The maintenance of healthy blood glucose levels is a physiologic outcome.

18 - The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. The client denies the need for education. The client is male. The client is married. The client is blind. The client is an architect.

The client is blind. The client denies the need for education. *The client's blindness will require the nurse to alter the education plan to fit the client's needs. The education might also require teaching another person to perform the wound care. If the client denies the need for education, attempting to teach the client at this time will be ineffective. The nurse will need to determine why the client denies the need for teaching and address that issue first. The facts that the client is male, married, and an architect do not have any bearing on the instruction.

19 - Which are cognitive client outcomes? Select all that apply. The client reports cycling 30 minutes three times each week. The client describes how to perform progressive muscle relaxation. The client correctly ambulates with a walker. The client lists the side effects of digoxin. The client identifies signs and symptoms of hypoglycemia.

The client lists the side effects of digoxin. The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia. *Cognitive outcomes demonstrate increases in client knowledge, such as listing side effects of medications, identifying signs and symptoms of hypoglycemia, and describing progressive muscle relaxation.

16 - The nurse has identified the nursing concern of complex grieving for a client whose spouse died 1 year ago. What assessment data are appropriate evidence to justify this diagnosis? Select all that apply. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything." The client keeps a picture of the client's spouse at the bedside. The client states, "I miss my spouse every day." The client no longer indulges in usual activities.

The client no longer indulges in usual activities. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything."

16 - A client diagnosed with advanced lung cancer has a nursing concern of insufficient coping. What assessment data provide evidence to the nurse for this diagnosis? The client states, "I am sure the doctors have misdiagnosed me." The client makes funeral plans. The client asks about hospice services. The client states, "I hope that I am able to attend my child's wedding."

The client states, "I am sure the doctors have misdiagnosed me."

16 - The nurse has identified a nursing concern of altered parenting risk for a client who has recently learned of being pregnant. What assessment data are appropriate to lead the nurse to select this concern for care planning? The client states, "I do not plan to tell my family about my pregnancy right away." The client states, "I am shocked to find out that I am pregnant." The client states, "I do not know how to take care of an infant." The client states, "I know that I will have to make some changes in my life."

The client states, "I do not know how to take care of an infant."

17 - A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client? The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day. The client will perform range of motion exercises 3 times per day. The client performed active range of motion exercises only twice today but states a goal of 3 times per day tomorrow. Passive abduction with assistance

The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day. **Documentation should be specific. The evaluation is a form of communication with the multidisciplinary health care team that indicates how the client is progressing in meeting expected outcomes. The most detailed documentation of evaluation is the one that provides a numerical measure of the client's range of motion, along with the specific plan for continued evaluation. The remaining options are too general and vague while lacking accountability and stemming from the client perspective.

17 - Which outcome for a client with a new colostomy is written correctly? The client will demonstrate proper care of the stoma by 3/29/20. The client will know how to care for the stoma by 3/29/20. The client will be able to care for stoma and cope with psychological loss by 3/29/20. Explain to the client the proper care of the stoma by 3/29/20.

The client will demonstrate proper care of the stoma by 3/29/20. **Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.

17 - The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision? By 8/02, the client will state when to notify the health care provider after discharge By 08/02, the client will state three therapeutic methods of reducing stress. The client will understand the effects of smoking related to heart disease. By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet.

The client will understand the effects of smoking related to heart disease. *Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that the nurse will be unable to measure.

18 - The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? The client with continuous pulse oximetry who requires pharyngeal suctioning. The client who needs vital signs taken following infusion of packed red blood cells. The client who requires assistance dressing in preparation for discharge. The client who is pleasantly confused and requires assistance to the bathroom.

The client with continuous pulse oximetry who requires pharyngeal suctioning. *The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.

18 - The client is having difficulty breathing. The respiratory rate is 44 breaths/min and the oxygen saturation is 89% (0.89). The nurse raises the head of the bed and applies oxygen at 3 L/min via nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. The client is watching television. The client states, "I can breathe easier now." The client's family asks if the client is going to be okay. The client's oxygen saturation level increases. The client's respiratory rate decreases.

The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases. *When reassessing the client after implementing interventions to increase oxygenation, the nurse would look for a decrease in respiratory rate to a more normal rate and an increase in the oxygen saturation level. The client's subjective statement of breathing easier would also indicate effectiveness. The client watching television and the client's family's statement do not indicate anything about oxygenation status.

15 - A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments? The nurse The case manager The nursing supervisor The health care provider

The nurse

19 - Which of the following best summarizes the evaluation step of the nursing process? The nurse and client identify nursing diagnoses and appropriate interventions. The nurse completes a health assessment to establish a database. The nurse and client measure achievement of planned outcomes of care. The client and family have met health care goals and no longer need care.

The nurse and client measure achievement of planned outcomes of care. *In evaluation, which is the fifth step of the nursing process, the nurse and client together measure how well the client has achieved the outcomes specified in the plan of care.

9 - When a nurse is planning for learning, who must decide who should be included in the learning sessions? The client and the client's family The nurse and the client The health care team The doctor and nurse

The nurse and the client **The nurse and the client should be the individuals who decide who should be included in the learning sessions. The nurse cannot assume that family members are wanted by the client to be included. The client must always be included in the learning session.

19 - Which characteristic is the most important indicator of high-quality nursing practice? The nurse takes measures to ensure accurate medication administration. The nurse follows the policies and procedures of the institution. The nurse is organized and efficient in client care. The nurse considers the individual needs of clients.

The nurse considers the individual needs of clients. *The personal, compassionate, caring side of a nurse is the most important indicator of quality nursing care. Considering the individual needs of the clients demonstrates the nurse's belief in the importance of the client. Being organized and efficient, following policies and procedures, and ensuring accurate medication administration are important parts of nursing care but are mainly task oriented.

18 - The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up? The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine. The nurse encourages the client to participate in all treatment decisions as the center of the health care team. The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend. The nurse explains each procedure twice to prevent client questions from wasting time.

The nurse encourages the client to participate in all treatment decisions as the center of the health care team. **TJC encourages clients to become active, involved, and informed participants on the health care team. By becoming involved and "speaking up" research shows that clients who take part in decisions about their health care are more likely to have better outcomes. The nurse should never want to prevent client questions. While clients are encouraged to be independent, trusted family members and friends can be an asset to the client's care. The nurse should investigate the possibility of an error if the client questions the nurse about a medication.

14 - Which description clearly indicates that the nurse is applying Tanner's Clinical Judgment Model (CJM) in clinical practice? The nurse demonstrates situational awareness by reconciling competing demands according to risk and immediacy. The nurse prioritizes the needs of the client, followed by the family, the support network, and the community. The nurse consistently follows a sequence of assessing, diagnosing, intervening, and evaluating. The nurse engages in a near-constant cycle of noticing, interpreting, and reflecting.

The nurse engages in a near-constant cycle of noticing, interpreting, and reflecting. *Tanner's Clinical Judgment Model (CJM) is a cyclical, iterative process that encompasses the domains of noticing, interpreting, and reflecting. Situational awareness is consistent with the use of a CJM but does not directly suggest the use of this particular CJM. The use of the nursing process is consistent with the CJM, but it is possible to follow the nursing process without applying Tanner's CJM. Similarly, it is possible to prioritize client needs and assign importance to other groups on a stepwise basis without implementing Tanner's CJM.

14 - A novice nurse has been growing in skill, largely as a result of experiential learning in the clinical setting. Within the model of experiential learning, what outcome would most clearly indicate that the nurse has achieved the stage of transformation? The nurse integrates experience and reflections into new forms of practice. The nurse influences the ways that care is organized and provided. The nurse's awareness of ethical and moral issues in nursing becomes heightened. The nurse's actions influence other nurses and nursing students who are less skilled.

The nurse integrates experience and reflections into new forms of practice. *Transformation encompasses meaningful change that results from integrating new experiences with reflections. This may result in practice improvements, increased awareness of ethics, or influence on others, but it is the convergence of experience and reflection that most clearly indicates personal transformation.

14 - In which clinical scenario(s) has the nurse likely applied inductive reasoning? Select all that apply. The nurse integrates the gate-control theory when addressing clients' reports of pain. The nurse has crafted a theory of parental-infant attachment after many years of seeing new parents interact with their infants. The nurse conscientiously applies critical thinking to complex practice situations. The nurse has proposed a model for shift handoff after participating in thousands of handoffs over the years. The nurse applies Erikson's model of growth and development when choosing interventions.

The nurse integrates the gate-control theory when addressing clients' reports of pain. The nurse has proposed a model for shift handoff after participating in thousands of handoffs over the years. **Inductive reasoning requires observing, then drawing conclusions; this is referred to as forward reasoning. Inductive reasoning processes require the ability to recognize patterns and connections and form hypotheses and theories. Applying preexisting theories to particular situations exemplifies deductive reasoning. Critical thinking applies to all nursing actions and interactions and is not limited to situations involving inductive reasoning.

14 - A community health nurse has a reputation that is described as "stellar" by peers and colleagues. Apart from the nurse's years of experience, the nurse's skillfulness is the attribute most described by others. According to cognitive continuum theory (CCT), what characteristic of the nurse suggests that the nurse has achieved the highest level of competence? The nurse is able to apply intuition to complex clinical scenarios. The nurse is highly regarded by peers and colleagues. The nurse has been providing care for over 10 years in the same setting. The nurse readily accepts the most complex client assignments.

The nurse is able to apply intuition to complex clinical scenarios. **Cognitive continuum theory (CCT) acknowledges and integrates both intuitive and analytical cognitive characteristics. These values supersede years of service, reputation, or willingness to take on difficult work.

14 - A novice nurse is being mentored by a more experienced nurse who is able to recognize small but significant client cues and process large amounts of data in a short time. What conclusion(s) should the novice nurse draw about the more experienced nurse's practice? Select all that apply. The nurse has a high capacity for cognitive load. The nurse is able to apply the steps of the Clinical Judgment and Measurement Model (CJMM) simultaneously. The nurse is able to rely on reflection-in-action rather than reflection-on-action. The nurse is able to rely on intuition more than critical thinking. The nurse has well-developed situational awareness.

The nurse is able to rely on intuition more than critical thinking. *Cognitive continuum theory (CCT) acknowledges and integrates both intuitive and analytical cognitive characteristics. These values supersede years of service, reputation, or willingness to take on difficult work.

14 - For which scenario will the nurse consult resources from the American Nurses Association? The nurse is seeking guidance on QSEN competencies. *Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work. The nurse is unsure whether a particular intervention is in the nursing scope of practice. The nurse is unsure how to frame feedback to a preceptor student. The nurse needs to provide updated NCLEX information to a group of students.

The nurse is unsure whether a particular intervention is in the nursing scope of practice. **The American Nurses Association (ANA) produces Nursing: Scope and Standards of Practice. The National Council of State Boards of Nursing (NCSBN) administers the NCLEX. Quality and Safety Education in Nursing (QSEN) competencies are not within the purview of the ANA. Various organizations provide information and guidance on working with students, but this is not specific to the ANA.

9 - When teaching an adult client how to control stress through relaxation techniques, the nurse should proceed on the basis of which assumption concerning adult learners? As an adult matures, self-concept becomes more dependent; therefore, this client must be made aware of the importance of reducing stress. The adult learner is not as concerned with the immediate usefulness of the material being taught as with the quality of the material. As clients, adults are the least likely to resist learning because of preconceived ideas about the teaching-learning process. The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction.

The nurse should be able to draw from the previous experience of the client to emphasize the importance of stress reduction. **Knowles (1990) listed the following four assumptions about adult learners: (1) As people mature, their self-concept is likely to move from dependence to independence. (2) The previous experience of the adult is a rich resource for learning. (3) An adult's readiness to learn is often related to a developmental task or a social role. (4) Most adults' orientation to learning is that material should be useful immediately, rather than at some time in the future. With this in mind, adult learners would appreciate the nurse being able to draw from previous experiences of the client to emphasize the importance of stress reduction. The other options do not apply to Knowles's assumptions about adult learners.

19 - Which statements are true of factors that influence client responses and outcome achievement and of how the nurse should use them? Select all that apply. The nurse should identify which factors are helpful to attaining outcomes and manipulate them to achieve goals. A client's strong motivation to learn appropriate health behaviors is an example of a positive factor. The nurse should reinforce negative behaviors to achieve desired outcomes. A nurse uses only positive factors to manipulate client outcomes. The nurse should draw on positive factors to deal with other variables in the future.

The nurse should draw on positive factors to deal with other variables in the future. A client's strong motivation to learn appropriate health behaviors is an example of a positive factor. The nurse should identify which factors are helpful to attaining outcomes and manipulate them to achieve goals. **The nurse should reinforce positive, not negative, behaviors to achieve the outcomes for the client. The nurse can manipulate both positive and negative factors to improve client outcomes. The other choices are all true regarding positive factors.

18 - A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? The nurse should ask another nurse who was previously assigned to the client for instruction. The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. The nurse should request that the blood transfusions be delayed until the next shift. The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability.

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. **The nurse should recognize that the nurse lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.

16 - During a home health care visit, the nurse identifies a nursing concern of caregiver strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data support the concern? The parent states, "A member of my faith group gives me a break twice a week." The parent states, "I cannot allow anyone else to help because they will not do it right." The parent states, "I attend support group meetings when I am able to go." The parent states, "I make sure that I get regular exercise."

The parent states, "I cannot allow anyone else to help because they will not do it right."

15 - Which is an example of objective data? A client receiving chemotherapy reports nausea. The skin of a client who has liver failure has a yellowish tint. A client reports feeling very anxious about tests the client is undergoing. A client with inner ear infections reports dizziness.

The skin of a client who has liver failure has a yellowish tint.

14 - A nurse is distraught that she failed to intervene promptly in a situation where a client's status declined sharply. The client was becoming agitated and aggressive. The nurse states, "There was just too much going on, all at once, and I basically froze and then panicked." What interpretation of this event is most accurate? The speed and complexity of the situation overwhelmed the nurse's cognitive load. The nurse failed to understand the importance of clinical judgment and clinical reasoning. The nurse applied inductive reasoning at a time when deductive reasoning would have been preferable. The nurse's situational awareness increased throughout the event.

The speed and complexity of the situation overwhelmed the nurse's cognitive load. *Overstimulation in this case overwhelmed the nurse's cognitive load, leading to a failure to recognize, process, and act upon information. This is unrelated to the differences between inductive and deductive reasoning. The nurse's situational awareness decreased once overwhelmed, not increased. It is unlikely that this nurse's response was related to a lack of understanding that clinical judgment and clinical reasoning are important.

14 - A student nurse has been challenged to apply the principles of critical thinking during laboratory simulations. What characteristic of the student nurse's actions suggests that the student nurse engaged in critical thinking? The student nurse respectfully criticized the actions of student nurses who did not choose the recommended approach. The student nurse thought systematically and reflectively before deciding what to do. The student nurse identified every available option before choosing an action. The student nurse adopted a position of likely being wrong rather than expecting to be right.

The student nurse thought systematically and reflectively before deciding what to do. *Although there are many definitions of what constitutes critical thinking, there is broad agreement that the process involves intentional, reflective thinking to inform an action. This approach does not presume that one will likely be wrong. It often leads to an examination of various options, but it is not realistic to identify every possible option. Critical thinking is not synonymous with criticizing others.

16 - Assessment of a client with difficulty breathing reveals that the client has thick, tenacious secretions in the trachea and bronchi and excessive sputum with coughing. The respiratory rate is slightly increased. When developing this client's plan of care, which intervention would the nurse include? Mechanical ventilation Limit fluids to 1,000 ml per day Assisted ambulation Tracheobronchial suctioning

Tracheobronchial suctioning

13 - The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use? Critical thinking Scientific problem solving Trial-and-error problem solving Intuitive thinking

Trial-and-error problem solving

17 - A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client? Adding the diagnosis "Altered Nutrition, Less Than Required" Updating the diet orders in the client's plan of care Posting the sign "NPO after midnight" over the bed Obtaining written consent for the diagnostic procedure

Updating the diet orders in the client's plan of care **The plan of care communicates three different types of nursing care: care related to meeting basic human needs, care related to nursing diagnoses, and care that must be coordinated with medical and interdisciplinary providers. Nutrition is a basic human need. The temporary need to withhold food and fluid should be documented in the record. The other options are not the best, most direct methods for conveying this information to all who may need it.

3 - The nurse is addressing primary prevention with a group of college students. Which promotional statement by the nurse would be the best example of a developmentally appropriate discussion? Annual Papanicolaou test can detect cancer earlier. HIV screening should be done on an annual basis if you are sexually active. Use of condoms can help prevent sexually transmitted infections and unwanted pregnancy. Testicular examinations for male students can detect early stages of cancer.

Use of condoms can help prevent sexually transmitted infections and unwanted pregnancy.

16 - The electronic health record enables the nurse to facilitate which nursing actions related to diagnosing? Select all that apply. Deciding on and documenting new nursing diagnoses Preparing a client for discharge from a health care facility Making decisions about mutual client goals and interventions Determining and documenting when the nursing diagnoses are resolved Viewing the client's ongoing risks Facilitating communication of the client's actual problems

Viewing the client's ongoing risks Deciding on and documenting new nursing diagnoses Facilitating communication of the client's actual problems Making decisions about mutual client goals and interventions Determining and documenting when the nursing diagnoses are resolved

16 - When used in a nursing diagnosis, the descriptor "impaired" has which meaning? Lack of proportion or relation between corresponding things Late, slow, or postponed Consisting of many interconnecting parts or elements Weakened or damaged

Weakened or damaged

18 - The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's best response? Work with the evening shift to possibly reschedule. Inform the client the evening shift will not have time to give baths. Ask the client for permission to give the bath in the morning. Tell the client that the health care provider has prescribed sleep medication if necessary.

Work with the evening shift to possibly reschedule. *The client's preferences are a primary consideration in scheduling interventions. The client's preference to have a bath at night requires a change in scheduling and the nurse should discuss the issue with the evening shift to determine if rescheduling is possible. Asking for permission to give the bath in the morning does not address the client's preference. The schedule of the nurses should not take priority over client desires. Informing the client about sleep medication does not address the client's preference. To just brush off the client's desires is not showing holistic nursing care.

19 - The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: a psychomotor outcome. a physiologic outcome. a cognitive outcome. an affective outcome.

a cognitive outcome. **Cognitive outcomes demonstrate increases in client knowledge, such as strategies for minimizing leakage of an ileostomy bag.

15 - A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: factual. complete. purposeful. able to prioritize.

able to prioritize. **It is essential to get the most important information first when doing an assessment. This is prioritizing. Being purposeful is when a nurse completes a task that has meaning for the client. Complete means that the information obtained is comprehensive. Factual is concerned with what is actually the case rather than interpretations of or reactions to a situation (for example, a diagnosis as opposed to a hunch).

13 - The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? self-perception nutrition activity and rest health promotion

activity and rest **A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertinent for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.

16 - The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called: actual or potential nursing diagnoses. collaborative nursing diagnoses. syndrome nursing diagnoses. dependent nursing diagnoses.

actual or potential nursing diagnoses. *Nursing diagnoses are established based on actual or potential health problems that are identified by the nurse and can be independently addressed.

19 - An _________ outcome involves changes in the client's values, beliefs, feelings, and attitudes, such as testing blood sugar before meals.

affective

17 - The nurse is selecting interventions after gathering and analyzing client data. Interventions that the nurse includes will meet what criterion? time-specific based on collaboration with the care provider multidisciplinary aligned with a goal

aligned with a goal *Nursing interventions must be specifically designed to meet the identified goal. These are grounded in the scope of nursing practice so they may not require collaboration with other disciplines. Goals and outcomes should be time-specific but interventions may not always be.

13 - A nurse has completed a client assessment and is preparing to identify appropriate nursing concerns. Which area(s) will the nurse likely address in the nursing concern? Select all that apply. ineffective coping heart failure pneumonia altered mobility altered nutrition

altered mobility altered nutrition ineffective coping

15 - The nurse is caring for a 14-year-old client who has just gave birth. The client reports living with an aunt and having no other family around. The birth was uncomplicated, and the newborn is healthy. Which is the primary nursing concern the nurse will identify for this client's care planning? ineffective breastfeeding acute pain loneliness risk altered parenting risk ineffective feeding pattern in the newborn

altered parenting risk

17 - algorithm

an algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions.

18 - With which nursing action is the nurse performing a surveillance or monitoring intervention? providing assistance with hygiene administering a paracetamol tablet applying therapeutic communication skills auscultating bilateral lung sounds

auscultating bilateral lung sounds **Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone; detecting odors and comparing them with past experience and knowledge of specific problems; and using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the health care provider to minimize problems. Providing hygiene and administering a paracetamol tablet are examples of maintenance nursing interventions. Use of therapeutic communication skills is an example of a supportive nursing intervention.

16 - A client experiencing homelessness presents to health clinic and has a strong body odor and is wearing clothes that are visibly soiled. What nursing concern will the nurse to identify to plan care? bathing/hygiene ADL deficit associated with lack of access to bathing facilities as evidenced by a strong body odor *adl = activities of daily living homelessness syndrome associated with lack of housing as evidenced by visibly soiled clothing altered impulse control associated with poor socioeconomic conditions as evidenced by visibly soiled clothing inadequate hygiene associated with homelessness as evidenced by client's stink

bathing/hygiene ADL deficit associated with lack of access to bathing facilities as evidenced by a strong body odor

14 - A nursing student is moving through a curriculum that emphasizes the value of experiential learning. The nursing student is consciously linking previous experiences with new and transformative practices. How will the nursing student link experiences with transformative behaviors? by eliciting input from a trusted professional mentor by gaining the widest possible variety of learning experiences by reducing the amount of time elapsed from previous experiences to new experiences by engaging in frequent and thoughtful reflection

by engaging in frequent and thoughtful reflection *In experiential learning, there is a progression from experiences to reflection to transformation. Without reflection, new learning cannot be gleaned from experiences and used to inform future actions. Simply increasing the pace or quantity of learning is not sufficient, nor can a mentor's guidance replace this vital step.

19 - __________ outcomes are related to achieving greater knowledge, such as the client knowing the signs and symptoms of hypoglycemia and correct injection sites.

cognitive

14 - principles of inductive reasoning

cognitive process in which one identifies a specific idea or action and then makes conclusions about general ideas

16 - The nurse is caring for a client whose health problem requires both health care provider- and nurse-prescribed actions to address. What type of problem is being addressed for this client? collaborative health problem independent health problem interdisciplinary health problem health care provider-developed problem

collaborative health problem

16 - A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis will the nurse use to address this concern? lack of knowledge regarding effects of chemical plant pollution decreased community health associated with chemical plant community contamination risk associated with possible environmental pollution infection risk associated with community contamination

community contamination risk associated with possible environmental pollution

14 - A nursing student has been providing care for several clients in both community and hospital settings. For which client will the nurse use a concept map when planning and providing care? client who has presented to the clinic for a scheduled immunization client who has just been admitted to the emergency department with shortness of breath community-dwelling client with complex physical and psychosocial needs client who requires discharge teaching related to surgical wound care

community-dwelling client with complex physical and psychosocial needs *Although concept maps can inform care in a wide variety of circumstances, they are especially helpful when planning care for clients who have longstanding, complex needs. Concept maps have less utility in time-dependent circumstances like emergencies or in clients whose needs are more finite, such as clients needing specific teaching or a single immunization.

18 - A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention? technical surveillance assertive coordinating

coordinating *Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other health care team members, and ensuring that the client's schedule is therapeutic. This is not a surveillance or technical type of intervention. The nurse is being supportive of the client, but this is not characterized as an "assertive" intervention.

14 - What action by the nurse in a hospital setting best exemplifies the goals of the Interprofessional Education Collaborative (IPEC) core competencies? reporting a sudden decline in a client's status to the health care provider taking a course about intimate partner violence that was created by a social worker coordinating with the physical therapist to amend a client's activity orders in the plan of care administering a medication that was just prescribed by a health care provider

coordinating with the physical therapist to amend a client's activity orders in the plan of care *Interprofessional Education Collaborative (IPEC) competencies go beyond carrying out orders from another profession, reporting to a member of another profession, or one-way learning from another profession. Active collaboration on client care, such as working together on activity orders, demonstrates the participatory nature of the competencies.

16 - After meeting with a client and their family, the nurse has identified a nursing diagnosis of Effective Family Coping. In this diagnosis, the term "Effective" constitutes what part of the nursing diagnosis? qualifier amendment composition descriptor

descriptor

17 - Nursing __________ are statements describing a client's actual or potential health problems that the nurse can treat independently using nursing interventions.

diagnoses

17 - In the nursing process, __________ involves identifying client problems.

diagnosis

16 - While caring for a client admitted with a Clostridioides difficile infection, the nurse notes that the client has had 3 loose bowel movements in 3 hours. What would be the most appropriate nursing concern to plan care for this health problem? excess fluid volume associated with diarrhea as evidenced by 3 loose bowel movements in 3 hours injury risk associated with urgent need for bowel evacuation diarrhea associated with infectious process as evidenced by 3 loose bowel movements in 3 hours infection transmission risk associated with high potential for communicability

diarrhea associated with infectious process as evidenced by 3 loose bowel movements in 3 hours **The assessment data point to the nursing concern of diarrhea. The other three concerns may be part of the care plan for Clostridioides difficile, but the assessment data do not provide evidence for them. The client would be at greater risk for a fluid volume deficit rather than a fluid volume excess.

17 - The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: initial planning discharge planning comprehensive planning ongoing planning

discharge planning **Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.

18 - A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize: environment and client. logistics and planning. equipment and personnel. skills and assistance.

equipment and personnel. *A key component of the organizing interventions is to ensure adequate equipment (extra supplies) and sufficient personnel to assist with more complex tasks. Skills are first learned in nursing school but then validated with policies and procedures of the institution. Assistance is necessary to assist with the skill but is not the main issue in this scenario. Environment would be related to the lighting and space. Client issues would be the correct response if the client was cognitively aware and not confused. Logistics and planning may be related to other issues such as making sure all the elements such as personnel, client, environment, and assistance are all present.

13 - The nurse assesses a client's blood pressure, which is 160/90 mm Hg. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure, finding it to be 140/78 mm Hg. What has the nurse implemented with the second action? appraising planning implementing evaluating

evaluating

14 - The nurse has provided analgesia to a client who was reporting pain, and the nurse used the NCSBN Clinical Judgment Measurement Model (CJMM) to inform the process. What action by the nurse represents the final step in this model? documenting the administration of the analgesia evaluating the client's pain 30 minutes after administering the analgesia reflecting on the decision-making process modifying the nursing care plan to prioritize the client's risk for pain

evaluating the client's pain 30 minutes after administering the analgesia **Evaluating outcomes is the final step in the CJMM. All of the actions listed are appropriate, but evaluation is the most direct indication of this sixth and final step.

14 - The nurse has provided analgesia to a client who was reporting pain, and the nurse used the NCSBN Clinical Judgment Measurement Model (CJMM) to inform the process. What action by the nurse represents the final step in this model? reflecting on the decision-making process modifying the nursing care plan to prioritize the client's risk for pain evaluating the client's pain 30 minutes after administering the analgesia documenting the administration of the analgesia

evaluating the client's pain 30 minutes after administering the analgesia Evaluating outcomes is the final step in the CJMM. All of the actions listed are appropriate, but evaluation is the most direct indication of this sixth and final step.

19 - _________ is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses.

evaluation

16 - A nurse documents the following nursing concern on a client's plan of care: deficient fluid volume associated with gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past 3 days, slow skin turgor, and weight loss. The nurse identifies which part of the statement as the etiology? vomiting gastrointestinal upset from food poisoning deficient fluid volume slow skin turgor

gastrointestinal upset from food poisoning

14 - The nurse applies Tanner's Clinical Judgment Model while providing care on a busy medical unit. Which of the nurse's actions demonstrates reflection-in-action? debriefing with the care team following a code blue that resulted in a client's death gauging the effectiveness of a teaching session by monitoring the client's changing body language journaling about a client's family conflict that the nurse observed participating in an in-service focused on building empathic listening skills

gauging the effectiveness of a teaching session by monitoring the client's changing body language **Reflection-in-action occurs when actively engaged in the situation and during ongoing monitoring and assessment; reflection-on-action, which mirrors a debrief or post-conference, occurs after the situation and drives clinical learning. Journaling also exemplifies reflection-on-action. In-service learning equips the nurse to provide better care but does not have the immediacy of reflection-in-action.

16 - A client recently diagnosed with pancreatic cancer tells the nurse, "I do not see any hope for my future." What nursing concern will the nurse formulate to plan care for this client? altered self-concept associated with pancreatic cancer diagnosis hopelessness associated with difficulty coping secondary to pancreatic cancer diagnosis lack of knowledge regarding cancer treatment options related to new diagnosis insufficient health maintenance associated with being overwhelmed by cancer diagnosis

hopelessness associated with difficulty coping secondary to pancreatic cancer diagnosis

17 - In the nursing process, __________ involves putting the plan of care into action.

implementation

19 - Identifying the kind and amount of nursing services required is a possible solution for: nurses frustrated with substandard care. inadequate staffing. clients who fail to communicate their needs. nurses who are bored.

inadequate staffing.

14 - The nurse is describing a clinical encounter, stating, "I entered the room, gathered assessment data, and then provided the interventions specified in standard operating procedures." The nurse is applying which conceptualization of clinical decision-making? cognitive continuum theory information-processing model humanistic-intuitive approach Rest framework

information-processing model **The rote, linear approach to addressing issues that disregard client complexities is the information-processing model. Each of the other listed models integrates the complex, human realities of nursing practice.

14 - The nurse is describing a clinical encounter, stating, "I entered the room, gathered assessment data, and then provided the interventions specified in standard operating procedures." The nurse is applying which conceptualization of clinical decision-making? information-processing model humanistic-intuitive approach Rest framework cognitive continuum theory

information-processing model *The rote, linear approach to addressing issues that disregard client complexities is the information-processing model. Each of the other listed models integrates the complex, human realities of nursing practice.

16 - A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I do not really have diabetes. My doctor overreacts." What is the most appropriate concern to plan care for this client's health problem? unstable blood glucose risk associated with client's reluctance to manage the diabetes regimen insufficient coping associated with client's inability to manage the diabetes regimen insufficient health maintenance associated with client's denial of illness injury risk associated with client's mismanagement of disease

insufficient health maintenance associated with client's denial of illness

17 - Nursing __________ are the actions nurses take to treat the client's health problems.

interventions

13 - The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using: acute observation ability. illogical thinking. an assumption to guide practice. intuitive problem identification.

intuitive problem identification. **Experienced nurses are able to make clinical decisions based on intuition, or an "inner prompting or hunch" that can lead to early and life-saving interventions. Intuitive problem solving is based on a background of experience, knowledge, and skill. Acute observation ability is using skills to determine the extent of the issue using observation. Logical fallacies (illogical thinking) are used to describe faults in logic that result in false conclusions. Assumption a thing that is accepted as true or as certain to happen, without proof.

13 - The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse? implementing the standard plan of care for all clients with diabetes mellitus involving the client with all the steps of the process in care development ensuring the client is informed after decisions are made with care delivery requiring the client to evaluate the plan of care after implementation

involving the client with all the steps of the process in care development

13 - The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse? involving the client with all the steps of the process in care development ensuring the client is informed after decisions are made with care delivery requiring the client to evaluate the plan of care after implementation implementing the standard plan of care for all clients with diabetes mellitus

involving the client with all the steps of the process in care development

18 - Reading professional nursing journals, attending continuing education workshops/conferences, researching online using sites such as The Agency for Healthcare Research and Quality, and American Association of Critical-Care nurses (AACN) Practice Alerts These are all examples of the ways in which a nurse can _____________________.

learn about evidence-based practice

16 - The nurse has completed a comprehensive assessment of a client and is considering possible nursing concerns for care planning. To be selected for the care plan, the nurse must ensure the nursing concern meets what criterion? corroborated by the primary care provider legally treatable by a nurse consequence of a medical diagnosis linked to the client's pathophysiology

legally treatable by a nurse *The scope of practice of the nurse determines what interventions a nurse is permitted to perform. Because nurses are responsible for addressing any problems they identify in their nursing concerns, they may only include in their nursing concerns problems that they may address using interventions that are within their scope of practice to perform. Nursing concerns may not be established by a health care provider or other nonnurse professional. Many nursing concerns are not rooted in pathophysiology or medical diagnoses, such as the diagnosis of effective family coping.

13 - A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in the client? The client will: maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). maintain a normal HgbA1C. log all meals in a diary for the next 6 weeks. not exhibit signs and symptoms of hypoglycemia/hyperglycemia.

maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). **Outcomes can be short- or long-term, and short-term outcomes should describe a single, observable, and measurable behavior. Maintaining a blood sugar between 70 and 110 mg/dL (3.89 and 6.11 mmol/L) is short-term and is a single, observable, measurable outcome. Logging meals for 6 weeks and maintaining a normal HgbA1C are more long-term goals. Not exhibiting signs and symptoms of hypoglycemia/hyperglycemia is not as measurable/observable as monitoring the blood sugar.

15 - While performing the nursing history, the nurse notes that the client reports having very little pain but is occasionally grimacing and rubbing one shoulder throughout the interview. The nurse acknowledges this behavior, questions the client, and then proceeds with other phases of the interview. This action takes place during which phase of the nursing interview? concluding maintenance preparatory introductory

maintenance

17 - In the planning phase of the nursing process, the nurse identifies _________ or _________, prioritizes __________ __________ and ________ __________ selects ________ ________, and documents the ______ __ ____.

measurable goals or outcomes nursing diagnoses and collaborative problems appropriate interventions plan of care

14 - The nurse is applying the Clinical Judgment Measurement Model (CJMM) to the care of a client who has been expressing anxiety. The nurse has recognized and analyzed the various cues that the client is exhibiting, has prioritized hypotheses that may explain the client's anxiety, and is now generating possible solutions. In this particular stage of the CJMM, the nurse is demonstrating which component of Rest's framework of moral reasoning? moral judgment/reasoning moral sensitivity moral character moral motivation/focus

moral judgment/reasoning **Moral judgment/reasoning involves consideration of several courses of action to account for the potential impact on those involved. This is tantamount to generating solutions. Moral sensitivity involves awareness of ethics. Moral motivation is the cognitive process of decision-making. Moral character is the actual implementation of a plan.

14 - A nurse is applying Tanner's clinical judgment model in the care of a postpartum client. Which action by the nurse will constitute the first step in this process? prioritizing hypotheses that may explain the client's condition noticing the significant aspects of the client's condition engaging in reflection engaging in reflection establishing trust and rapport with the client

noticing the significant aspects of the client's condition *Tanner's iterative model begins with noticing; this takes place on the basis of the nurse's initial grasp of the situation and precedes hypothesizing. Reflection takes place during and after interactions but after the initial step of noticing. Trust and rapport are key aspects of care but do not represent the initial stage of Tanner's model.

14 - A nurse is applying Tanner's clinical judgment model to the care they provide. What action characterizes the first step in this process? speculating about the likely causes for the client's health challenges clustering data into meaningful groups partnering with the client and with other members of the care team noticing what is significant about the client's status and circumstances

noticing what is significant about the client's status and circumstances *While Tanner's model is cyclical, a common starting point is characterized as "noticing" (i.e., recognizing cues, which may often be subtle). This must precede any subsequent actions such as analyzing or clustering data, or hypothesizing issues and causes. Partnering with the client and the care team is important, but this is not an explicit component of Tanner's model.

19 - Deciding whether a client has met their goals of care is an __________ evaluation.

outcome

19 - While the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in patient health status. What type of evaluation is being described?

outcome evaluation

19 - ___________ evaluation focuses on measurable changes in the health status of the patient, or the end results of nursing care. While the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in patient health status.

outcome evaluation

17 - The nurse is working through the nursing process with a new client to the facility. In which phase of the nursing process will the nurse establish priorities? outcome identification implementation diagnosis assessment

outcome identification *During outcome identification and planning, the nurse establishes priorities as well as client goals and outcomes. During this phase, the nurse also plans nursing interventions and writes the plan of care. Assessment involves data collection; diagnosis involves identifying client problems. Implementation involves putting the plan of care into action.

13 - A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified: objective data. intervention. outcome. nursing diagnosis.

outcome.

17 - When planning a client's care, the nurse has drafted specific, measurable and realistic statements of goal attainment. What component of the care planning process has the nurse included? evaluations nursing diagnoses outcomes nursing interventions

outcomes *Expected client outcomes are specific, measurable, realistic statements of a client's goal attainment. Nursing diagnoses, interventions, and evaluation do not apply to outcomes or goals of nursing care. Nursing diagnoses are statements describing a client's actual or potential health problems that the nurse can treat independently using nursing interventions. Nursing interventions are the actions nurses take to treat the client's health problems. Evaluations are assessments of the effectiveness of interventions in resolving clients' health problems.

13 - Which is the most appropriate example of the assessment phase of the nursing process? including a nursing concern of acute pain in the client's plan of care palpating a mass in the right lower quadrant of the abdomen evaluating the temperature of a client given medication for a fever documenting the administration of a medication provided for pain

palpating a mass in the right lower quadrant of the abdomen

19 - _______ _________ is a process whereby individual nurses improve their professional performance through the evaluation of one staff member by another staff member on the same level of the hierarchy

peer review

17 - A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? plan made in conjunction with the hospital's ethics committee plan designed to support the client physically plan derived from a consensus of opinions of all staff members plan focusing on problems that are easily solved

plan designed to support the client physically **An unconscious client who is unable to provide input into outcome identification depends on the nurse to make informed choices to support the client physically. This care plan would treat any life-threatening situations and act to prevent the development of unhealthy physical consequences. The nurse is in the best position to determine client needs and would not seek the opinion of all staff members or the ethics committee. The care plan would deal with all problems, not just those that are easily solved.

9 - Transtheoretical Model of Change

precontemplation stage - the client is not even thinking about or considering making a change. contemplation stage - the client is considering making a change. preparation stage - the client has decided to make a change and is preparing for it. maintenance stage - the client attempts to maintain the change in lifestyle begun in an earlier stage.

16 - A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of: premature closure. inconsistent cues. clustering of cues. cluster interpretation.

premature closure. *Premature closure is when the nurse selects a nursing diagnosis before analyzing all of the pertinent information in the client's case. The nurse did not investigate any other information in this case before making a diagnosis. Inconsistent cues occur when the meaning attached to one cue may be altered based on another cue. The nurse in this case only considered one cue, so inconsistent cues could not be the correct answer. Clustering of cues is a clustering of data; this nurse has only one cue, so the nurse cannot cluster data or interpret data clusters.

3 - directed toward promoting health and preventing the development of disease processes or injury

primary prevention

16 - The nurse identifies the nursing concern of acute pain associated with instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure and client description of experience as "stabbing." This is an example of which type of nursing diagnosis? *During peritoneal dialysis, a cleansing fluid called dialysate passes through a catheter tube into part of the abdomen known as the peritoneal cavity. The dialysate absorbs waste products from blood vessels in the lining of the abdomen, called the peritoneum. Then the fluid is drawn back out of the body and discarded. health promotion nursing diagnosis potential nursing diagnosis problem-focused (actual) nursing diagnosis risk nursing diagnosis

problem-focused (actual) nursing diagnosis

19 - Determining the accuracy of a client's nursing diagnoses and a student's ability are _________ evaluations.

process

19 - The focus of a __________ evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process

process

19 - In this type of evaluation, the criteria make explicit acceptable levels of performance for nursing actions related to patient assessment, diagnosis, planning, implementation, and evaluation. (ADPIE)

process evaluation

19 - The focus of a _________ evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. Criteria make explicit acceptable levels of performance for nursing actions related to patient assessment, diagnosis, planning, implementation, and evaluation.

process evaluation

17 - When a nurse documents an intervention involving a one-person assist of a client to the chair, which type of nursing intervention does this represent? psychosocial psychomotor maintenance surveillance

psychomotor **Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring interventions.

19 - ________ ________ is an externally driven process, demonstrating nursing excellence by meeting professional standards of care.

quality assurance

19 - _______ ________ is an internally driven, continuous process focusing on the processes of client care

quality improvement

19 - ___________ ______________the commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceed- ing customer expectations and outcomes—also known as (CQI) or (TQM)

quality improvement continuous quality improvement (CQI) total quality management (TQM)

16 - A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing concern is most appropriate for the nurse to select? infection transmission risk associated with lack of immunizations ineffective health maintenance associated with lack of knowledge of childhood immunizations ready to learn about childhood immunizations complication risk associated with childhood illnesses

ready to learn about childhood immunizations *The community group is asking for information to enhance their health care habits. A health promotion nursing concern of ready to learn is indicated. There is no evidence of ineffective health maintenance practices. There is no evidence that the clients lack immunizations. Complication risk might result from a lack of immunizations, but that is not the issue being addressed in the program.

13 - The nurse is deliberately engaged in a purposeful activity that leads to action, improvement of practice, and better client outcomes. What activity is the nurse likely performing? memorization reflection data collection assessment

reflection **Reflection is defined as a purposeful activity that leads to action, improvement of practice, and better client outcomes. Memorization is strict learning of material for recall. Assessment and data collection involve careful observation and evaluation of a client's health status but without subsequent action, these activities on their own do not lead to the nurse's growth and the client's benefit.

13 - The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain? expressing empathy documenting opioid dependence repositioning the client reassessing the client's pain

repositioning the client **The nursing process focuses on the client's unique problems, setting priorities, developing goals and outcome criteria, and selecting nursing interventions. Repositioning the client is a nursing intervention; it is nonpharmacologic and does not require a prescription from the health care provider and can assist with pain relief. Documenting opioid dependence is inappropriate and not within the nurse's scope of practice. Reassessing and expressing empathy are not considered to be interventions.

18 - A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a health care provider is termed: standing orders. collaborative orders. protocols. nursing interventions.

standing orders. *Standing orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider, such as pain medication administration based on specific criteria.

19 - A _________ evaluation or audit focuses on the environment in which care is provided.

structure

19 - Availability of equipment, layout of physical facilities, nurse-client ratios, administrative support, and maintenance of nursing staff competence are some areas of concern for _________ evaluation.

structure

19 - A ________ evaluation or audit focuses on the environment in which care is provided. Standards describe physical facilities and equipment; organizational characteristics, policies, and procedures; fiscal resources; and personnel resources.

structure evaluation

19 - In this type of evaluation, standards describe physical facilities and equipment; organizational characteristics, policies, and procedures; fiscal resources; and personnel resources.

structure evaluation

13 - What type of intervention is the nurse performing when the nurse observes the spouse of a postoperative client performing the client's dressing change? technical maintenance surveillance supervisory

supervisory The term "supervisory intervention" is applied in the context of overseeing a client's overall care.

18 - The nurse has assessed a client and determined that the client has abnormal breath sounds and a low oxygen saturation level. The nurse is performing what type of nursing intervention? surveillance maintenance collaborative supportive

surveillance Surveillance or monitoring nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes: - observing the appearance and characteristics of clients - hearing by auscultation, pitch, and tone - detecting odors and comparing them with past experience and knowledge of specific problems - using touch to assess body temperature, skin condition, clamminess, or diaphoresis. Nurses use all of these surveillance or monitoring activities to determine the current status of clients and changes from previous states. Nurses often detect subtle changes in a client's condition and communicate them to the health care provider to minimize problems.

14 - A nurse is navigating a busy morning on a hospital unit and is struggling to finish the necessary tasks in the time available. In response, the nurse has assigned morning hygiene tasks for two clients to an unlicensed assistive personnel (UAP). What QSEN competency is this nurse exemplifying? teamwork and collaboration quality improvement evidence-based practice informatics safety client-centered care

teamwork and collaboration **Although this action is consistent with all the QSEN competencies, delegation is a practical example of the competency of collaboration and teamwork in the clinical setting.

19 - In the United States, regulatory facilities such as State Boards of Nursing, ____ ________ __________ and the Professional Standards Review Organization, along with the National Health Planning and Resources Development Act of 1975, require nurses to document that nursing standards are being implemented and maintained. Each of these facilities is concerned with quality care and quality control.

the Joint Commission

19 - One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated? when the client is discharged during the first home health care visit once the primary care health care provider has written a discharge order throughout the client's hospital admission

throughout the client's hospital admission **It is important to evaluate client outcomes early and frequently. Reserving evaluation for the time of discharge or after discharge is inappropriate, even if the designated time criteria for the outcome specifies "by time of discharge."

15 - A nurse is providing care to a client with a history of intimate partner violence. During the last visit, the client stated an intent to leave the spouse. In this visit, the nurse reassesses the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing? focused complete time-lapse emergency

time-lapse

18 - The nurse is discussing dietary options with a client who is disappointed due to not being able to have foods the client previously enjoyed. The nurse states, "You may not be able to have steak at this point, but you can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving the client an option? to help the client adhere to the care plan to model the practice of making healthy food choice to give the client the opportunity to actively participate in care to distract the client from their dietary restrictions

to give the client the opportunity to actively participate in care *Giving clients options allows them to actively participate in their own care, which is empowering. Although giving the client options might improve the client's adherence to the plan, this is not the primary purpose. The purpose of giving the client options is not to distract, because the nurse is still addressing the client's dietary restrictions. The nurse is encouraging the client's choice, not modeling a choice by making the decision for the client.

18 - What is the purpose of the nursing implementation phase?

to help the client achieve an optimal level of health

19 - The nurse has performed multiple evaluations on the hospital unit. What evaluation does the nurse identify as a structure evaluation? determining the accuracy of a client's nursing diagnoses tracking nurse-client ratios on various shifts deciding whether a client has met their goals of care evaluating the technical skill of a nursing student

tracking nurse-client ratios on various shifts *Availability of equipment, layout of physical facilities, nurse-client ratios, administrative support, and maintenance of nursing staff competence are some areas of concern for structure evaluation. Deciding whether a client has met their goals of care is an outcome evaluation. Determining the accuracy of a client's nursing diagnoses and a student's ability are process evaluations.

18 - The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? unlicensed assistive personnel senior student in nursing school who is present for clinical registered nurse licensed practical/vocational nurse

unlicensed assistive personnel

18 - The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? senior student in nursing school who is present for clinical licensed practical/vocational nurse registered nurse unlicensed assistive personnel who is in nursing school

unlicensed assistive personnel who is in nursing school *The nurse should avoid delegating this client to the unlicensed assistive personnel who is in nursing school. Suctioning and the associated evaluation of the client is within the scope of practice of the registered nurse, licensed practical/vocational nurse, and the senior student in nursing school who is present for clinical.

19 - A new parent is having difficulty breastfeeding a newborn. A goal was established stating that the newborn would be nursing every 2 to 3 hours by age 1 week. The parent presents to the follow-up clinic at 1 week and reports having discontinued breastfeeding 4 days ago. How will the nurse characterize the original goal? abandoned partially met unmet inappropriately chosen for this client

unmet **After collecting data and evaluating the client's behavioral responses, the nurse makes a judgment about goal attainment by comparing the client's actual behavioral responses with the predicted responses or predetermined outcome criteria developed in the planning phase. In this case, the parent ceased breastfeeding, which represents an unmet goal. If the parent reported breastfeeding the newborn every 4 to 5 hours, the nurse could consider the goal partially met. There is no evidence that the goal was inappropriately chosen for the parent, despite it being unachieved. Goals are not typically described as being "abandoned."

15 - A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: uses broad, open statements to communicate with the client. agrees with each of the client's statements. reassures the client of good outcomes. attempts to write down everything the client says.

uses broad, open statements to communicate with the client.

13 - Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: uses critical thinking to direct care for the individual client. uses scientific problem solving to meet client problems. employs communication to meet the client's needs. applies intuition and routine care for clients.

uses critical thinking to direct care for the individual client.

13 - Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: uses scientific problem solving to meet client problems. applies intuition and routine care for clients. employs communication to meet the client's needs. uses critical thinking to direct care for the individual client.

uses critical thinking to direct care for the individual client. The nursing process requires blended skills and critical thinking. Critical thinkers think systematically about the nursing process and apply it for the individual client. Communication is important but not sufficient to meet client needs, and scientific problem solving is used in the laboratory setting, not nursing.

13 - What action will allow the nursing student to learn and improve skills while best minimizing risk for clients? advocating for low nurse-client ratios using simulation laboratories obtaining mentorship focusing on stable clients

using simulation laboratories