NUR Exam #1

A student is ambulating a patient for the first time after surfery. What would the student do to anticipate and plan for an unexpected outcome?

ask another student to help with ambulation

a nurse is preparing to insert an IV and begin administering IV fluid. The patient has visitors in the room what should the nurse do?

ask the patient if visitors should remain in the room

Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the patients sutuation

concept map care plan

The staff in a long term care facility often plays loud rock music on the radio and designs childrens games as exercise. What is the staff doing in this situation?

ignoring the developmental needs of older adults

A nurse is formulating a nursing diagnosis for a patient with respiratory disease. Which of the following would be correct?

ineffective airway clearance related to thick mucus

Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process?

keep an open mind and trust your intuition when formulation diagnosis

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

collection, validation, communication of patient data

Of the following information collected during a nursing assessment, which are subjective data?

nausea and abdominal pain

A nurse writes the following diagnosis for a patient with Alzheimers: Disturbed Thought Processes related to Alzheimers disease as evidenced by incoherent language which part of this diagnosis is considered the problem statement?

Disturbed Thought Processes

A nurse is reviewing the health history and physical assessment findings for a patient who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem?

I get out of breath when I walk a few steps

critical thinking is an essentia; component in all phases of the nursing process. What question might be used to facilitate critical thining during outcome identification and planning?

What problems require my immediate attention or that of the team

Which of the following is categorized as a psychomotor outcome?

Within 2 days of teaching, the patients wife will demonstrate abdominal dressing change.

which of the following examples of nursing actions involve direct care of the pateint?

a nurse massages the back of a patient while permorming a skin assessment, a nurse helps a patient in hospice fill out a living will form, a nurse councils a young family who is interested in natural family planning, a nurse arranges PT for a patient who had a stroke

Which of the following are examples of common factors that may influence assessment priorities? Select all that apply.

a patient's developmental stage need for nursing diet and exercise program standing in the community

A nurse writes down the following outcome for a depressed patient: "By 6/9/12, the patient wi;; state 3 positive benefits of recieving counseling." This is an example of which of the following types of outcomes?

affective

A student is reviewing a patient's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis?

appendicitis

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?

actual nursing diagnosis

Which of the following statements accurately describe a recommended guideling for implementation? select all that apply

before implementing any nursing action, reassess the pateint to determine whether the action is still needed, consult colleagues and the nursing and related literature to see if other approaches might be more successful, check to make sure that the nursing interventions selected are consistent with standards of care/

Which of the following would not be part of the nurse's decision about care after evaluating the pateints responses to the plan of care?

begin the plan of care

a nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards, what must the nurse do next

collect data about patient responses

a nurse is catheterizing a patient. what action illustrates respect for the patients privacy?

closing the door to the room

A fatgher runs into the emergenct room with his 18-month olf son in his arms. The father screams, "HELP HE IS NOT BREATHING!" the nursing diagnosis of impared gas exchange is what lecel of prioritty diagnosis

high priority

Which of the following are verbs that are helpful in writing measurable outcomes? select all that apply

define, verbalize, list

In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is "presence of large scar over left side of face"?

etiology

What type of patient record data would the nurse find in the medical history and progress notes?

findings of the physician's assessment and treatment

Mrs. James comes to her healthcare provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?

focused assessment

A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing health habits. What conclusion did the nurse reach after interpreting and analyzing the data?

no problem

Which of the following outcomes is correctly written?

on discharge, pateint will be able to list five symptoms of infection

a Nurse assess the vital signs of a patient who is one day post surgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of vare. What are these actions considered

on-going planning

which of the following illustrates a common error whem writing pateint outcomes?

patient will be less anxious and fearful before and after surgery

what activity is carried out during the implementing step of the nursing process?

planned nursing actions (interventions) are carried out

A nurse caring for an elderly patient in a long-term care facility notices that the bedding is wet when the patient gets up in the morning. The nurse collects for data to form a conclusion. What type of problem is involved in this scenario?

possible problem

A nurse documents the following diagnosis for a hospitalized patient: Risk for imbalenced nutrition: More than body requirements. What is the major goal of interventions for a risk diagnosis

prevent the problem

After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a patient. What are the nursing diagnoses used for?

selecting nursing interventions to meet expected outcomes

each time a nurse administers an insulin injection to a patient with diabetes, she tells the patient what she is doing and demonstrats each step of preparing and giving the injection. What is the nurse promoting

self care

A nurse is preparing to conduct a health history for a patient who is confined to bed. How should the nurse position herself?

sitting at a 45 degree angle to the bed

A resident of long tem care facility refuses to eat until she has had her hair combed and her make-up appplied. In this care, what patient need should havve priority?

the need to feel good about oneself

Which of the following best summarizees the evaluating step of the nursing process?

the nurse and patient measure achievement of planned outcomes of care

Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis?

the nursing diagnosis is based on the patient's response to the medical diagnosis

A nurse performs an assessment of a patient in a long-term care facility and records baseline data. The nurse reassesses the patient a month later and makes revisions in the plan of care. What type of assessment in the second assessment?

time-lapsed

What is the primary purpose of the outcome identification and planning step of the nursing process?

to design a plan of care for and with the patient

The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?

to establish a database to identify problems and strengths

A nurse performing triage in an emergency room makes assessments of patients using critical thinking skills? Select all that apply.

using the nursing process to diagnose a blocked airway privately interviewing a patient suspected of being a victim of abuse checking the data supplied by a patient with dementia with the family te