ch 11,12,13,14
A nurse manager is implementing computerized care plans for the units of the hospital. Which of the following guidelines must be followed when writing care plans? (Select all that apply.) ______ Plans must be dated and signed. ______ Categories must have headings. ______ Plans must be specific. ______ Plans must include preventive and health maintenance. ______ Standardized or approved medical or English symbols may be used. ______ Plans must include interventions for ongoing assessment. ______ Plans are standardized and generalized for all clients.
Correct Answer: Plans must be dated and signed. Categories must have headings. Plans must be specific. Plans must include preventive and health maintenance. Standardized or approved medical or English symbols may be used. Plans must include interventions for ongoing assessment.
The nurse is reviewing the client's care plan and checking the quality of the nursing diagnosis statements. Criteria to use for guidelines in formulating nursing diagnoses include which of the following? (Select all that apply.) ______ Nonjudgmental statements ______ Stated in terms of a need ______ Must be legally advisable ______ Cause/effect are correctly stated ______ Use medical terminology to describe the cause ______ Word the diagnosis specifically and precisely
Nonjudgmental statements Must be legally advisable Cause/effect are correctly stated Word the diagnosis specifically and precisely
Nursing diagnoses are different from medical diagnoses and collaborative problems in ___________, ___________ , and ___________.
Orientation, duration, and nursing focus
A nurse is performing an initial assessment on a new admission. Which of the following is part of the database? (Select all that apply.) ______ Reports from physical therapy the client received as an outpatient ______ Documentation of the nurse's physical assessment ______ Physician's orders ______ A list of current medications ______ Information about the client's cultural preferences ______ Discharge instructions
Reports from physical therapy the client received as an outpatient Documentation of the nurse's physical assessment A list of current medications Information about the client's cultural preferences
The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions. Which of the following data would support this diagnosis? (Select all that apply.) ______ Skin is dry, cracked ______ One large with several smaller open, ulcerated areas on right leg ______ Client does not drive ______ Client states that does not use alcohol or drugs ______ Clothes are soiled ______ Client has obvious body odor
Skin is dry, cracked One large with several smaller open, ulcerated areas on right leg Clothes are soiled Client has obvious body odor
A nursing student is meeting an assigned client for the first time. In order to begin the establishment of rapport, the best statement by the student is:
1. "Hello, I'm your nursing student and I'll be helping to take care of you today."
The nurse is taking a health history from a client who has complications from chronic asthma. Which of the following is an example of an open-ended question?
1. "How would you describe your sleep pattern?"
The nurse has just completed an admission interview with a new client. Which response by the nurse is an example of a remark used during the closing phase of the interview?
1. "I'm going to set up your physical assessment now. Do you have any questions?"
One of the interventions for a client with a nursing diagnosis of Impaired Swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. The modifier in this intervention is which of the following?
1. 60 to 90 degrees during feeding times
The nurse understands that respect for the dignity of the client is extremely important in providing nursing care. Which of the following is an example of this aspect?
1. Allowing clients to complete their own hygienic cares when possible
On one of the first days working alone, the novice nurse must provide teaching on tracheostomy care to the client as well as the client's spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to:
1. Ask the nurse mentor to assist with the teaching after reviewing the procedure.
A nurse helping a client with care planning following a surgery which resulted in a permanent colostomy would consider a short-term goal requiring the client to:
1. Be able to state signs and symptoms of skin breakdown.
Nursing activities that represent the various characteristics of the nursing process includes the nurse's:1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature. 2. Advocating for a client who is mentally incapable of expressing her needs. 3. Deciding to increase a client's nasal oxygen based on his current pulse oxygenation levels. 4. Documenting all clients' pain level responses after the administration of pain medication. 5. Attending in-services on a new hydraulic lift to be used to support safe client care.
1. Notifying the surgeon that a postoperative client is experiencing an increase in temperature. 2. Advocating for a client who is mentally incapable of expressing her needs. 3. Deciding to increase a client's nasal oxygen based on his current pulse oxygenation levels. 4. Documenting all clients' pain level responses after the administration of pain medication.
A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, the nurse should:
1. Sit next to the client, a few feet apart.
A client who has been in a wheelchair for several years is currently experiencing problems with skin breakdown and urinary retention in addition to depression. When formulating a nursing diagnosis, an appropriate selection would be which of the following?
1. Syndrome diagnosis
The student nurse must accurately perform a sterile dressing change before completing a unit of the course. This student is being evaluated on which of the following?
1. Technical skill
A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. The etiology of this diagnosis is which of the following?
1. Unfamiliarity of disease process
A client was admitted just prior to the shift change. The admitting nurse reported most of the information to oncoming staff, but did not have all of the client's past records. The second nurse is completing the assessment and database and continues to question the client about much of the same information as the previous nurse. The client says, "Why don't you people talk to each other and quit asking the same things over and over?" The best response of the nurse is:
2. "You're right. Let me know if there's anything you need right now."
A client has been admitted to the cardiac intensive care unit following an acute myocardial infarction. The nurse formulates the following nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing. Which of the following would be an example of a collaborative intervention?
2. Administer pain medication.
A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this client's interview?
2. After the client has settled in and been oriented to the room
The most appropriate manner in which to state an intervention directed towards assisting a client with ambulation is:
2. Ambulate with client, using a gait belt, twice daily for 15 minutes.
According to the care plan, the client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. When setting priorities, the home health nurse will:
2. Assist the client in finding an alternative plan for the achieving the therapy's outcomes
One of the clients assigned to the nurse's care is to receive a medication that the nurse is not familiar with and is not listed in the drug reference manual. The best action of the nurse is to:
2. Call the pharmacy and do further investigating before administering the medication.
Which of the following interventions appropriate for a client with Parkinson's disease who is working to improve fine motor skills would be considered a collaborative intervention?
2. Provide assistive devices and educate client to use grab bar and large handled utensils.
An experienced nurse has just walked into the room of a client to whom the nurse has been assigned for the shift. Which of the following might be a significant observation that could influence the inclusion of a new nursing diagnosis?
2. The client's skin is pale and mottled.
A nurse has been assigned a new client who cannot speak English. In order that the client receives accurate information, the nurse should:
2. Use the translation services supplied by the hospital.
When reviewing both the client's problem list against the various identified nursing diagnoses, both of which included client and family input, the nurse is utilizing of the following processes to minimize diagnostic error?
2. Verifying
A nurse is working in the operating room with a client just prior to the procedure. While setting up for the procedure, the nurse notices that the client has become unresponsive and respirations have become shallow. What type of assessment would be necessary in this situation?
3. Emergency assessment
The nurse makes the decision to look at alternatives for wound care with a client who has a stasis ulcer that has been treated over the past 2 weeks. The nurse was hopeful to see some improvement by this time. This represents which phase of the nursing process
3. Evaluation
ch13//The client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. While the admitting nurse will develop the initial plan of carewho will be involved with the ongoing planning of this client's care?
3. Everybody involved in this client's care
A client just had a baby following a long labor and difficult delivery. Which of the following nursing diagnoses is formulated correctly?
3. Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion
One of the diagnoses formulated for this client who recently experienced a CVA (cerebrovascular accident) is Risk for aspiration, related to neuromuscular dysfunction. Of the following interventions, which includes a rationale?
3. Keep client in low-Fowler's position to prevent reflux.
Nursing diagnoses are different from medical diagnoses and collaborative problems in areas that include:
3. Nursing care focus
The nurse is collecting information from a client's family. The client is confused and not able to contribute to the conversation. The spouse states, "This is not his normal behavior." The nurse documents this as which of the following?
3. Objective data
An infant has been admitted to the pediatric unit. The parents are quite worried and upset, and the grandmother is also present. In this situation, what would be the best source of data?
3. Parents
A nurse is working with a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Of the following listed, which would be considered an observation intervention?
3. Provide ongoing assessment for skin breakdown every shift.
The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label?
3. Reports of fatigue
A client is admitted for a scheduled, elective hip replacement and will be cared for on a unit that specializes in such surgeries. The client's plan of care would most likely be taken from which of the following?
3. Standardized care plan
The student nurse understands that clustering data comes with experience and recognizing cues. The best way for this student to recognize patterns or cues in the data is to:
3. Take assessment notes and utilize information from textbooks for comparison.
When an ICU nurse consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension, this is an example of the nurse implementing which of the following?
4. A standing order
Which of the following is an example of a dependent nursing intervention?
4. Administering medications for pain
Which of the following would be a correctly formulated diagnosis for a client with a long, extensive history of psychiatric problems, beginning in childhood. that is being placed in a long-term, structured institutional environment?
4. Alteration in thought processes, related to complex factors
An appropriately written goal statement for the nursing diagnosis "Fluid volume deficit, related to active fluid loss, secondary to diarrhea" would be:
4. Client will have intake of at least 1000 mL within 24 hours.
ch14//The home health nurse must devise a way to administer IV antibiotics to a client who insists on being outside during the infusion. Using creativity and critical thinking, the nurse is able to meet the client's requests. This is an example of which of the following?
4. Cognitive skill
The nurse has completed the initial assessment of a client and has analyzed and clustered the data. The nurse's next step in the diagnostic process is to:
4. Identify the client's problem, health risks, and strengths.
The nurse makes this entry in the client's chart: "Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. However, is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse." This is an example of which method of data collection?
4. Observing
Upon entering the room, the client is found crying along with the client's spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of which of the following?
4. Reassessing the client
The nurse has correctly formatted a client's care when including: 1. Ineffective Coping related to drug abuse as evidenced by drug overdose. 2. The client will identify two healthy coping mechanisms by time of discharge. 3. The client has identified two health coping mechanisms to replace inappropriate drug use. 4. The client will be provided with guidance in identifying healthy coping mechanisms. 5. The client has apologized to his family for drug abuse behaviors.
Correct Answer: 1,2,3,4
A nurse manager is implementing computerized care plans for the units of the hospital. Which of the following guidelines must be followed when writing care plans?Select all that apply. 1. Plans must be dated and signed. 2. Categories must have headings. 3. Plans must be specific. 4. Plans must include preventive care and health maintenance. 5. Plans must include interventions for ongoing assessment. 6. Plans are standardized and generalized for all clients
Correct Answer: 1,2,3,4,5
A nurse is devising a care plan for a client with complex health issues and current acute health problems. Nursing interventions must meet which of the following criteria? (Select all that apply.) 1. Congruent with the client's values, beliefs, and culture 2. Within established standards of care 3. Based on scientific and medical knowledge 4. Achievable with the resources available
Correct Answer: 1,2,4
A nurse is devising a care plan for a client with complex health issues and current acute health problems. Nursing interventions must meet which of the following criteria? Select all that apply. 1. Congruent with the client's values, beliefs, and culture. 2. Within established standards of care. 3. Based on scientific and medical knowledge. 4. Achievable with the resources available. 5. Must be safe and appropriate for the client's age.
Correct Answer: 1,2,4,5
A nurse is performing an initial assessment on a new admission. Which of the following is part of the database? 1. Reports from physical therapy the client received as an outpatient. 2. Documentation of the nurse's physical assessment. 3. Physician's orders. 4. A list of current medications. 5. Information about the client's cultural preferences. 6. Discharge instructions.
Correct Answer: 1,2,4,5
Which of the following is true of the NANDA label? Select all that apply. 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medial diagnoses for nursing 4. Promotes a taxonomy of nursing 5. It contains the defining characteristics of the problem
Correct Answer: 1,2,4,5
A nursing student is learning how to implement the nursing process in the clinical area. The purpose of the diagnosis phase includes which of the following? (Select all that apply.) 1. Develop a list of problems. 2. Identify client strengths. 3. Develop a plan. 4. Specify goals and outcomes. 5. Identify problems that can be prevented.
Correct Answer: 1,2,5
The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions. Which of the following data would support this diagnosis? Select all that apply. 1. Skin is dry, cracked 2. One large with several smaller open, ulcerated areas on right leg 3. Client does not drive 4. Client states that does not use alcohol or drugs 5. Clothes are soiled 6. Client has obvious body odor
Correct Answer: 1,2,5,6
The nurse is reviewing the client's care plan and checking the quality of the nursing diagnosis statements. Criteria to use for guidelines in formulating nursing diagnoses include which of the following? Select all that apply. 1. Nonjudgmental statements 2. Stated in terms of a need 3. Must be legally advisable 4. Cause/effect are correctly stated 5. Use medical terminology to describe the cause 6. Word the diagnosis specifically and precisely
Correct Answer: 1,3,4,6
When discussing Nursing Intervention Classifications (NIC), the nurse shows an understanding of the role this tool plays in nursing care when stating:Select all that apply. 1. "I can look up interventions according to the nursing diagnosis that I've selected." 2. "The interventions connected to a diagnosis are appropriate for any client with that diagnosis." 3. "If there is a NANDA diagnosis, I should be able to find some appropriate interventions." 4. "Care plans are best written when the interventions are broad and flexible." 5. "I find NIC interventions a really good place to start when I'm working on client interventions."
Correct Answer: 1,3,5
A nursing diagnosis that was written according to the PES format model would include: Select all that apply. 1. Ineffective coping related to depression as evidenced by suicide attempt 2. Noncompliance (DASH diet) related to denial of having disease 3. Risk for infection related to recent surgery 4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds 5. Ineffective Breathing Pattern as evidenced by cyanotic lips
Correct Answer: 1,4
The nurse applies an actual nursing diagnoses when selecting: Select all that apply. 1. Ineffective Breathing Pattern 2. Risk of Infection 3. Readiness for Enhanced Nutrition 4. Readiness for Enhanced Family Coping 5. Anxiety
Correct Answer: 1,5
A nurse is just starting a job at a new hospital. As part of the orientation process, the nurse must review the hospital's policies and procedures for nursing care. Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff for which of the following reasons? (Select all that apply.) 1. Make sure all clients have the same types of care 2. Ensure that minimally accepted standards are met 3. Promote efficient use of the nurse's time 4. Eliminate care disparities among clients
Correct Answer: 2,3
Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff for which of the following reasons? Select all that apply. 1. To make sure all clients have the same type of care. 2. To ensure that minimally accepted standards of care are met. 3. To promote efficient use of the nurse's time. 4. To eliminate care disparities among clients. 5. Minimization of healthcare costs.
Correct Answer: 2,3
The nurse wishing to propose a new nursing diagnosis would initiate the process by:
Correct Answer: 3
A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority). Choice 1. Family is at bedside. Choice 2. The IV pump is running on battery. Choice 3. ECG monitor shows tachycardia. Choice 4. Client reports being restless. Choice 5. O2 tubing is not attached to wall regulator.
Correct Answer: 3,4,5,2,1
One of the discharge goals for a client is that they will have improved mobility. An appropriately written desired outcome statement is:
1. Client will ambulate without a walker by 6 weeks
A hospital is implementing the use of NIC (Nursing Interventions Classification) taxonomy. This taxonomy will:
2. Still require that the nurse use sound judgment and knowledge of the client
The nurse understands that the Nursing Outcomes Classification (NOC) taxonomy system can be compared to :
3. Goal statement of the traditional care plan
A client comes to the emergency department with injuries to her upper shoulders and back area. When questioned about how the injuries occurred, the client becomes less talkative and states that she "fell." The client has a history of frequent ED visits, always with believable excuses about how her injuries occurred. The nurse begins to suspect that this client is a victim of abuse. This is an example of the nurse making which of the following?
3. Inference
A client has just given birth to a premature infant via emergency C-section. Which of the following nursing diagnoses would receive the lowest priority for the new mother?
4. Risk for infection, related to surgical incision
The written goal statement in a client's care plan is: Client will have clear lung sounds bilaterally within 3 days. One of the interventions to meet this goal is that the nurse will teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the client's lungs are indeed clear. In order to relate the intervention to the outcome, the nurse should:
1. Ask how many times per day the client practiced the coughing and deep breathing exercises.
The nurse has formulated a diagnosis of Activity intolerance related to decreased airway capacity for a client with chronic asthma. In looking at the client's coping skills, the nurse realizes that the client has a vast knowledge about the disease and what exacerbates symptoms in particular situations. The nurse will utilize this information because:
1. Strengths can be an aid to mobilizing health and the healing process.
A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. The nurse should:
2. Document that the problem has been resolved and discontinue the care for the problem.
A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month. The client however, has fallen several times. In this situation, the nurse should do which of the following?
2. Investigate whether the best nursing interventions were selected.
The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted, premature infant. The nurse finds these actions in what type of document?
2. Protocol
A nursing unit has been short staffed for the past month with a heavy client load and high acuity. The nurses on this unit have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. This unit should be evaluated at which level?
2. Structure
The nurse, after formulating several diagnoses for a client, does not understand the reason for some of the discrepancies in the client's lab values and diagnostic tests, when comparing to norms and standards. Which of the following is the best action of the nurse?
3. Consult other professionals and colleagues.
A nurse has provided routine morning cares to a client, including all the medications and scheduled treatments. The most appropriate action after this is completed is for the nurse to:
3. Document all cares in the progress notes.
A client comes into the emergency department with a non-life-threatening wound to the hand that will require stitches. The department is quite busy with other clients, their families, and other people in the waiting room. The best way for the nurse to conduct an interview with this client is to:
3. Draw curtains around the client and nurse to provide as much privacy as possible.
The goal statement for a client's care plan read as follows: Client will be able to state two positive aspects of rehab therapy by the end of the week. Which of the following is an appropriately written evaluation statement?
3. Goal met, client able to state two positive aspects of therapy by week's end.
A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. The quality assurance officer is evaluating this unit, paying particular attention to which of the components of care?
3. Process
A nurse is working on a medical unit, and assigns a nurse's aide to take vital signs for several clients. The aide completes this task and documents them accordingly. One of the clients had a blood pressure reading of 180/110, and it wasn't until the end of the shift that the nurse was apprised of this value. The physician was notified, and orders were received for treatment, but not until much later in the shift. Which responsibility of delegation did the nurse fail to carry out?
4. Appropriately supervising care.
A nurse has taken a position with an insurance company to review clients' records and the care they received while they were inpatient status. Part of the job description requires the nurse to make sure the client (and insurance company) were billed for services and treatment/therapies rendered and that there were no errors in billing. This type of audit is which of the following?
4. Retrospective
After implementing interventions and reassessing the client's response, the nurse completes the process by evaluating. Evaluation includes which of the following attributes?Select all that apply. 1. Purposeful activity. 2. Nursing accountability. 3. Continuous. 4. Judgments. 5. Opinion.
Correct Answer: 1,2,3,4
The nurse shows an understanding of the relationship of evaluation to the other phases of the nursing process when:: Select all that apply. 1. Being careful to effectively assess the client's needs. 2. Selecting the appropriate nursing diagnosis related to the client's needs. 3. Collecting client-focused data with a specific need in mind. 4. Evaluating by using assessment data to determine effective achievement of goals and outcomes.
Correct Answer: 1,2,3,4
A nurse implementing effective communication guidelines during an assessment interview when: Select all that apply. 1. Looking directly at the client to ensure good eye contact. 2. Managing the conversation to avoid periods of silence. 3. Providing personal experiences to help the client focus. 4. Sitting in a chair next to the client who is in bed. 5. Keeping arms unfolded and in a relaxed position.
Correct Answer: 1,4,5
When assessment data show a change in the client's condition, the nurse—before changing the care plan—asks: Select all that apply.1. How difficult will it be to change the care plan? 2. Are the new data complete? 3. Are the new data accurate? 4. Do the new data require a change in the care plan? 5. Will the primary medical provider agree with the need to alter the care plan?
Correct Answer: 2,3,4
A nurse manager has been charged with implementing a quality assurance program at the hospital. Quality assurance requires evaluation of several components of care. Select those that apply: 1. Methods 2. Structure 3. Finances 4. Process 5. Outcome
Correct Answer: 2,4,5
During the process of implementing care and treatments for a client, the nurse realizes there are several entities included in which phase?Select all that apply. 1. Evaluating the outcome of the interventions. 2. Reassessing the client. 3. Documenting the history and physical. 4. Supervising delegated care. 5. Implementing the nursing intervention.
Correct Answer: 2,4,5
During the process of implementing cares and treatments for a client, the nurse realizes there are several entities included in this phase. (Select all that apply): 1. Evaluating the outcome of the interventions 2. Reassessing the client 3. Documenting the history and physical 4. Supervising delegated care 5. Implementing the nursing interventions
Correct Answer: 2,4,5
A nurse is working on a medical unit and assigns a nurse's aide to take vital signs for several clients. The aide completes this task and documents them accordingly. One of the clients had a blood pressure reading of 180/110, and it wasn't until the end of the shift that the nurse realized this value. The physician was notified and orders were received for treatment, but not until much later in the shift. Which of the two responsibilities of delegation did the nurse fail to carry out?
Correct Answer: adequate supervision
A nurse is providing a back rub to a client just after administering a pain medication, with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing?
3. Implementation
The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process?
1. Assessment
A teenage client has been having problems with peer support, school performance, and parental expectations, all of which have led to an eating disorder. After gathering this assessment data, the nurse formulate the diagnosis Activity Intolerance related to weakness. After evaluating this information, the nurse should realize which of the following?
4. The data are not sufficient enough to support this diagnosis.
In order to differentiate between evaluation and assessment, the student should remember that:
4. The difference is in how the data are used.
A nursing diagnosis of Enhanced readiness for spiritual well-being has been formulated for a particular family. Which of the following data clusters would support this diagnosis?
A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. The data cluster that describes the questioning, searching, and reflecting would support an attitude of readiness
ch12/A nursing student is learning the application of the nursing process to client care. When questioned by the student about the reason for implementing a nursing diagnosis, the nursing professor responds: "The nursing diagnosis statement:
. "Describes client problems that nurses are licensed to treat."
The student nurse is learning the Taxonomy II nursing diagnoses system. This system is coded according to which of the following axes? Select all that apply. 1. Gordon's health pattern groupings 2. Age 3. Time 4. Health status 5. Gender 6. Unit of care
Correct Answer: 2,3,4,6
A nursing unit's records of client care have been reviewed for accuracy in documentation. This type of review is which of the following?
1. Nursing audit
A nurse has delegated to a nurse's aide to obtain vital signs for a newly admitted client. The aide reports the following: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. To validate the data, the best action by the nurse is:
1. Retake the vital signs.
The nurse is taking information for the client's database. The client is not very talkative; is pale, diaphoretic, and restless in the bed; and tells the nurse to just "leave me alone." Which of the following is an example of subjective data regarding this client?
2. "Leave me alone"
A client had an outcome goal stated as follows: Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic. Which statement by the client will the nurse use to evaluate this goal?
2. "My pain is a 4."
During an initial interview, the client makes this statement: "I don't understand why I have to have surgery, I'm really not that sick or in pain right now." The nurse's best response is:
2. "What kind of questions do you have about your surgery?"
A nurse works in an acute psychiatric setting and sees clients as they are admitted for inpatient psychiatric care. Many of the clients exhibit paranoid behavior. The most important skill this nurse can utilize for these clients is which of the following?
2. Interpersonal skill
A client has been having pain without any clear pathology for cause. The most appropriately written nursing diagnosis for this client would be which of the following?
2. Pain related to unknown etiology
Wanting to know more about the client's pain experience, the nurse continues to explore different questioning techniques. Which of the following is the best example of an open-ended question for this situation?
3. "How has the pain impacted your life?"
A child is admitted to the hospital for complications from diabetes. Which of the following nursing diagnoses will the nurse focus on as priority?
3. Altered nutrition, less than body requirements, related to inability to maintain glucose level
A client has been seeing a nurse practitioner for counseling following a rape. A long-term goal for this client would be which of the following?
3. Client will return to level of purpose and functioning as before the rape.
ch11/When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes that part of the purpose of the nursing process is to:
3. Identify client needs and deliver care to meet those needs.
An action that allows new parents to feel in control when being taught how to bath their infants would be when the nurse:
3. Lets the parents bathe the baby with direction and guidance from the nurse.
A 2-year-old has been admitted to the pediatric unit with a 2-day history of vomiting and diarrhea. Which of the following would be a cue the nurse identifies as being outside the normal standard?
3. The child is not able to stand alone.
A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan?
3. The goal is unrealistic.
A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. The most appropriate diagnosis for this client is which of the following?
3. Wellness diagnosis
A nurse has worked in the trauma critical care area for several years. Which of the following noises may become indiscriminate for this particular nurse?
3. Whirring of ventilators
A nurse has just been informed that a new admission is coming to the unit. According to the 2005 JCAHO requirements, how long does the nurse have to complete a physical assessment and have a documented history and physical on the chart?
4. 24 hours
An appropriate, realistic short-term goal for a client with beginning stages of Alzheimer's disease who is being admitted to an assisted living facility includes:
4. Client will be oriented to the surroundings.
. The nurse makes sure that the client learning how to administer insulin understands how to activate the safety mechanism on the syringe to prevent needlestick injuries. This is an example of which of the guidelines for implementing interventions?
4. Implement safe care.
A client is admitted for complications following a routine diagnostic procedure of the colon. The type of care plan that will most likely be implemented for this client is the:
4. Individualized care plan
A client is diagnosed with pneumonia and has been hospitalized for several days. A priority nursing diagnosis for this client is which of the following?
4. Ineffective airway clearance, related to increased secretions
During an assessment interview, the nurse understands that the client has decided not to take the physician's advice about an elective surgical procedure. The client shares that this is "just not part of what I have in mind for my life's goals." This would fall into which of Gordon's functional health patterns?
4. Value/belief pattern
After implementing interventions and reassessing the client's response, the nurse completes the process by evaluating. Evaluation includes which of the following? (Select all that apply.) 1. Purposeful activity 2. Nursing accountability 3. Continuous 4. Judgments 5. Opinions
Correct Answer: 1,2,3,4
Which of the following is true of the NANDA label? (Select all that apply.) 1. Must contain three components 2. Describes the health problem for which nursing therapy is given 3. Helps define medical diagnoses for nursing 4. Promotes a taxonomy of nursing
Correct Answer: 1,2,4
The student nurse is learning the Taxonomy II nursing diagnoses system. This system is coded according to which of the following axes? (Select all that apply.) ______ Gordon's health pattern groupings ______ Age ______ Time ______ Health status ______ Gender ______ Unit of care
Correct Answer: Age Time Health status Unit of care
