Fundamentals of Nursing 1 Chapter 13 PrepU & Rationales

The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds: a. "We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time." b. "You can expect your body temperature to drop about 3 degrees during your time at the bus stop." c. "When exposed to extreme cold, the body works hard to stay warm and may warm itself 1-2 degrees above normal during exposure." d. "Everyone is different so I cannot say how your body might react."

a. "We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time." Humans are warm-blooded creatures, which means they maintain a consistent internal body temperature independent of the outside environment. The body's surface or skin temperature can vary widely with environmental conditions and physical activity. Despite these fluctuations, the temperature inside the body, the core temperature, remains relatively constant, unless the client develops a febrile illness.

At 0730, the nurse notes that the client states that pain is a 7 on a scale of 0 to 10. Based on this assessment, the nurse administers pain medication to the client. At 0800, the nurse evaluates the client and finds that pain is a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment? a. 0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered. b. 0730: Client states that pain is severe. Pain medication administered. c. 0900: Client states pain from 0730 has decreased from a 7 to a 4 after medication was administered. d. 0800: Client states that pain has decreased.

a. 0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered. Documentation using the nursing process must be accurate, timely, and relevant. In the above example, documentation at 0730 for the initial assessment is timely, it is concise when assigning a number to the client's pain level, and it is relevant to the assessment at hand and the action that the nurse took based on the assessment: pain medication administration. Documenting the client's pain as severe or decreased is not concise; a pain scale should be used. Documenting at 0900 the evaluation of the assessment and intervention is not timely.

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? a. Activity and rest b. Health promotion c. Nutrition d. Self-perception

a. 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.

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 most appropriate nursing action? a. Assess the client's back visually. b. Document the rash in the client's chart. c. Establish a nursing diagnosis of Altered Skin Integrity. d. Report it to the health care provider.

a. 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 diagnosis.

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which action best demonstrates the nursing skill of caring in this situation? a. Assisting the client to sit up in a chair b. Assessing the abdominal incision c. Monitoring vital signs d. Notifying the health care provider of lab results

a. Assisting the client to sit up in a chair Caring skills are nursing interventions that restore or maintain a person's health and may involve actions as simple as assisting with activities of daily living--the acts that people normally do every day, such as bathing, grooming, dressing, toileting, and eating. Assisting the client to sit up in the chair is an example of this type of caring behavior. The other options are important nursing tasks, but they are not demonstrating the art of caring.

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill? a. Intellectual b. Technical c. Interpersonal d. Visual

a. Intellectual Teaching requires knowledge about teaching-learning principles to convey. The intellectual skills used in implementation include problem solving, decision making, and teaching.

Which are characteristics of critical thinking? Select all that apply. a. It requires a conscious and deliberate effort. b. It is a habit that most nurses have learned in their education. c. It forms the basis for interdependent but not independent decision making. d. It requires a systematic and logical approach e. It involves judgments based on evidence.

a. It requires a conscious and deliberate effort. d. It requires a systematic and logical approach. e. It involves judgments based on evidence. Critical thinking requires a conscious, deliberate effort. With repetition, critical thinking will become a habit, with nurses gaining expertise over time; it is typically not developed primarily during a nurse's formal education. Critical thinking also underlies independent and interdependent decision making and requires a systematic and logical approach, with judgments based on evidence.

What is the most beneficial use of the nursing process in addressing the needs of the client? a. Provides a universally applicable framework for nursing activities b. Allows the nurse to determine a medical diagnosis for the client c. Allows student nurses to work on assignments d. Targets desired outcomes for particular illnesses, procedures, or conditions

a. Provides a universally applicable framework for nursing activities The nursing process can be used with all clients, sick or well, of all ages and in all settings. The nursing process was not designed for use by students in their assignments. Critical pathways, not the nursing process, target desired outcomes for particular illnesses, procedures, or conditions. Medical diagnoses are determined by physicians.

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain? a. Repositioning the client b. Administering extra pain medication c. Documenting opioid dependence d. Administering a placebo

a. 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. Administering extra pain medication may only be done with a prescription from the health care provider. Documenting opioid dependence is inappropriate and not within the nurse's scope of practice. Administering a placebo is inappropriate and unethical.

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

b. Care provided during implementation should be documented in the client's chart. d. Implementation is the process of carrying out the plan of care. e. This phase promotes wellness and restores health. The implementation phase is the phase of the nursing process in which the plan of care is carried out. It is designed to promote wellness and restore health to clients through interventions that are collaborative and nursing driven. Not all interventions included in this phase have to be accompanied by a physician's order. Interventions are collaborative in that more than nursing professionals are involved in restoring health to the client.

The nurse is caring for a client with right-sided weakness after having a cerebrovascular accident (CVA). While conducting the head-to-toe assessment, the nurse notices the client has redness around the right elbow. When developing the client's care plan, which problem-focused nursing diagnosis will the nurse include? a. risk for impaired skin integrity related to immobility due to right-sided weakness b. impaired skin integrity of right elbow related to immobility due to right-sided weakness c. risk for impaired mobility due to pain from injury to elbow joint as evidenced by skin redness d. impaired mobility due to CVA-related right-sided weakness as evidenced by elbow joint skin redness

b. impaired skin integrity of right elbow related to immobility due to right-sided weakness A nursing diagnosis is a health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures. It is an exclusive nursing responsibility. Nursing diagnoses are categorized into four groups: problem-focused (formerly called actual); risk; syndrome; and health promotion. The client's elbow joint skin redness is considered an actual problem based on the various risk factors present. When developing a problem-focused nursing diagnosis, the nurse will indicate that skin integrity is actually impaired and this impairment is related to immobility leading to friction on the joint as a result of the client's right-sided weakness. Any nursing diagnosis with the terms "risk for" indicate that an actual problem does not yet exist but careful observation and monitoring using focused assessment must be carried out in order to prevent a problem for which risk factors are present. It is not within the nurse's scope of practice to state the medical diagnosis within the nursing diagnosis. Nurses develop problem-focused statements based on presenting signs and symptoms that can be addressed by employing nursing interventions.

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: a. acute observation ability. b. intuitive problem identification. c. illogical thinking. d. an assumption to guide practice.

b. 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.

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

c. 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.

A nurse is working with a group of staff members to address the needs of a client as they develop the client's interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group's thinking? a. "Could you elaborate on that point a bit more?" b. "How could we find out whether that is true?" c. "Could you be more specific in your observations?" d. "Is there another way to look at this situation?"

d. "Is there another way to look at this situation?" Breadth is demonstrated by asking whether there is another way to look at this situation. This question attempts to address other issues that may or may not be impacting the situation. Asking to elaborate demonstrates clarity; asking to find out if the issue is true reflects accuracy. The question about being more specific addresses precision.