fundamentals test two

When developing a nursing diagnosis for a client, which should the nurse do first?

Identify the significant data

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. The client is consequently restless and can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document?

Impaired Verbal Communication related to the breathing problem

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis?

Ineffective Airway Clearance

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

Knowledge Deficit: Medications related to new medical diagnosis

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.

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?

Nursing diagnosis

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

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 diagnosis would be most appropriate for the nurse to select?

Readiness for Enhanced Knowledge: Childhood Immunizations

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature, paying close attention to technique

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

Reporting signs and symptoms related to the client's kidney failure

The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment?

Supplement the client's information by speaking with family or friends

The nurse is caring for a client who underwent surgery 1 day ago. Which client problem can be addressed by independent nursing diagnoses?

The client has diminished breath sounds.

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client?

The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal

When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind?

Validate inferences with the client

While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of:

an inference

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

bowel incontinence

A client comes to the emergency department with a stab wound and is bleeding profusely. Which type of assessment should the nurse perform on this client immediately?

emergency

A client is a poor historian of the client's past medical history. Whom should the nurse consult about the client's past history?

family

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?

over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse

The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?

pain

Which statement is true regarding addressing a priority problem?

priority problem requires a nursing intervention before another problem is addressed

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

When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:

the interventions planned must be within the nurse's scope of practice

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

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

time-lapse

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

time-lapsed assessment

What is the purpose of establishing a nursing diagnosis?

to describe a functional health problem

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused.

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate?

"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes."

The charge nurse identifies the need for further education when a new nurse makes which statement?

"Physical assessment is the examination of the client for subjective data."

A nurse manager identifies a need for further instruction when a new nurse makes which statement?

"The client is always the best source for collecting data."

A physical examination on a client should always include which components? Select all that apply.

- Appraisal of health status - Identification of health problems - Establishment of a database for interventions

A client has been admitted to a hospital due to an acute psychotic episode. Which assessment data would the nurse identify as this client's strengths? Select all that apply.

- The client has ample financial resources. - The client is willing to attend counseling sessions.

Which items reflect the assessment phase of the nursing process? Select all that apply.

- The nurse asks the client, "How would you rate your pain?" - The client's abdomen is firm and distended with hypoactive bowel sounds. - The client states, "I rarely sleep more than 6 hours."

The nurse identifies which types of data when performing an assessment? Select all that apply.

-Subjective -Objective

A nursing diagnosis of "Ineffective Coping" has been chosen for a client after receiving a diagnosis of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? Select all that apply.

-The client reports an inability to get adequate restful sleep. -The client has difficulty concentrating on the details of treatment options. -The client states, "I can't handle all of this."

Which are examples of subjective data? Select all that apply.

-anxiety -light-headedness -nausea

For which client would a standardized plan of care most likely be appropriate?

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia

A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client?

A focused assessment of the specific problems identified

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

A health promotion nursing diagnosis

Which client situation most likely warrants a time-lapse nursing assessment?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?

Assess blood pressure with a large cuff

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis?

Collect client subjective and objective data

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

The nurse is assessing a client who was just admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis?

Diminished breath sounds in left lower lobe

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'"

Which statement by a nurse best indicates an accurate understanding of the different types of assessments?

"The purpose for the assessment offers guidance for which type and how much data to collect."

Which are examples of subjective data? Select all that apply.

- A client describes pain as an 8 on the pain assessment scale. - A client feels nauseated after eating breakfast. - A client reports being cold and requests an extra blanket.

Which group of terms best defines assessing in the nursing process?

- problem-focused, time-lapsed, emergency-based -collection, validation, communication of client data -nurse-focused, establishing nursing goals -designing a plan of care, implementing nursing interventions answer: collection, validation, communication of client data

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply.

-The client has been accompanied by family members to every appointment. -The client states a belief in a reward in heaven after death. -The client has demonstrated effective coping skills in the past.

Which is the best source of information for the nurse when collecting data for an assessment?

-charge nurse -medical record -client -primary physician answer: client

Which are examples of objective data? Select all that apply.

-lab test results -breath sounds on auscultation -a client's temperature

A nurse is treating a client with congestive heart failure. The client reports having difficulty walking up the stairs at home and barely being able to walk to the store. Which is an accurate actual nursing diagnosis for this client?

Activity Intolerance related to congestive heart failure as evidenced by inability to walk up and down stairs

Which is the purpose of a focused assessment?

Adds depth to existing information

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation?

Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data.

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 unsafe home environment

When developing nursing diagnoses, the nurse should focus on which area?

Human responses to actual or potential health problems

Which best describes the purpose of nursing diagnoses?

Identification of client problems that nurses can treat independently

The care plan for a postoperative client includes a nursing diagnosis of "Risk for Urinary Retention." The nurse determines that the client has been voiding adequately. What is the nurse's most appropriate action?

Revise the nursing diagnosis because the client's status has changed.

Which is an accurately phrased risk nursing diagnosis?

Risk for Falls related to altered mobility

During admission, a teenage client who has a diagnosis of anorexia informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data?

Validate the weight loss with the client.

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?

actual

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?

actual nursing diagnosis

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 can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

add the nursing diagnosis: risk for self-harm

When collecting subjective and objective data for a database in a client's home, it is important to:

ask the client to turn off the television

A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrintestinal symptoms or should be reported to the physician. Which action should the nurse perform next?

consult with another nurse

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

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?

focused

Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight?

imbalanced nutrition: less than body requirements

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

The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next?

validate the data

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

"when did you first notice the rash on your leg?"

A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate?

Ask the client whether the heart rate is normal for the client.

When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?

Assess the client's interactions with the newborn

An older adult client's venous ulcer has become foul-smelling after the client began using strips of a sheet to dress the wound due to running out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances?

Risk for Infection related to knowledge deficit

Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease?

Risk for Injury

A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview?

The nurse assesses the client's comfort and ability to participate in the interview.

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by the client refusing to look at the surgical site and stating, "I'm ugly. My husband will no longer find me desirable." What is the etiology identified in this nursing diagnosis?

decreased ability to cope with surgical removal of right breast

A client has just given birth to the client's first baby. The client reports to the nurse not knowing very much about newborns because of limited exposure to them. Which is the priority nursing diagnosis for the nurse to address prior to discharge of this client?

deficient knowledge

A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?

disturbed body image related to loss of hair

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality

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 Powerlessness

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?

explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization

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?

focused

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

focused

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?

narcotic analgesic to treat pain

Which statement correctly describes a nurse-initiated intervention?

nurse-initiated interventions are derived from the nursing diagnosis

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

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

surveillance

The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase?

termination phase

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

verbally report the finding immediately to the client's physician

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

A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take?

the nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour

A client who gave birth yesterday refuses to eat the food provided by the hospital. The client reports needing special food brought from home by family. How would the nurse mostappropriately address this situation?

the nurse should not formulate a nursing diagnosis but should encourage the client to have family bring food from home