Ch 8, 13, 14, 15, 16

5. The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures.

Ans: A Feedback: An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the client's temperature. This should precede interventions such as blood work or even providing a warm blanket.

2. The nurse is caring for a client who speaks Chinese, and the nurse does not speak Chinese. An appropriate approach for communication with this client includes what? A) Using a caring voice and repeating messages frequently B) Speaking directly and loudly to the client C) Avoiding the use of gesture or play-acting D) Writing messages for the client and offering him a dictionary for translation.

Ans: A Feedback: Approaches to use when a client speaks a different language include speaking slowly and distinctly, and avoiding loud voices. Use a caring voice, keeping messages simple, and repeat messages frequently. The use of a language dictionary by the nurse is appropriate, but writing messages and asking the client to translate is not an appropriate approach. Gestures, pictures, and play-acting help the client understand.

6. A client comes to the emergency department complaining of severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? A) Assessing B) Diagnosing C) Planning D) Implementing

Ans: A Feedback: Assessing is the step in which nurses assess the client to determine the need for nursing care. When assessing, the nurse systematically collects client data.

17. What is a systematic way to form and shape one's thinking? A) Critical thinking B) Intuitive thinking C) Trial-and-error D) Interpersonal values

Ans: A Feedback: Critical thinking is defined as "a systematic way to form and shape one's thinking. It functions purposefully and exactingly. It is thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned" (Paul, 1993, p. 20).

1. Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients? A) "Assessment data about the client should be collected continuously." B) "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." C) "Assess your client at least hourly if the client's vital signs are unstable, and every two hours if the vital signs are stable." D) "Assessment data should be collected prior to the physician rounding on the unit."

Ans: A Feedback: Data about the client are collected continuously because the client's health status can change quickly.

25. An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The client's airway should be assessed. B) The nurse should determine the reason for admission. C) The nurse should review the client's medications. D) The client's past medical history is assessed.

Ans: A Feedback: Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Often, the client's difficulty involves airway, breathing, and circulatory problems.

3. The daughter of an older adult female client has asked the nurse why a urine specimen was collected from her mother earlier that morning. How can the nurse best respond to the daughter's query? A) "We want to test your mother's urine to make sure she doesn't have a urinary tract infection." B) "Your mother's doctor ordered a urine C&S to rule out a UTI." C) "We want to do everything we can to get your mother healthy again." D) "Sometimes sick urine can make the whole person sick, and this might be causing her fever."

Ans: A Feedback: In order to communicate effectively, the nurse needs to avoid the use of jargon or abbreviations ("C&S") that are unfamiliar to those outside the health care system. At the same time, accuracy is important, and vague and "dumbed-down" answers ("we want to do everything we can," "sick urine") are inappropriate.

21. A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information? A) Client'swife B) Medical documents C) Test results D) Assessment data

Ans: A Feedback: In this case, the primary source of information is the client's wife, as she can provide a detailed description of the incident as well as provide the medical history of the client. The medical files, test results, and assessment data are secondary sources of information.

27. After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data? A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach

Ans: A Feedback: Objective data include techniques of inspection, palpation, percussion, and auscultation. Symptoms, values, perceptions, feelings, beliefs, attitudes, and sensations are sources of subjective data.

26. The nurse observes the client as he walks into the room. What information will this provide the nurse? A) Information regarding the client's gait B) Information regarding the client's personality C) Information regarding the client's psychosocial status D) Information on the rate of recovery from surgery

Ans: A Feedback: Observation includes looking, watching, examining, scrutinizing, surveying, scanning, and appraising.

3. A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill? A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing B) Understanding the Rh system that underlies the client's blood type C) Ensuring that informed consent has been obtained and properly filed in the client's chart D) Explaining the process that will be involved in preparing and administering the transfusion

Ans: A Feedback: Performing tasks that require manual dexterity is a manifestation of technical skills. Explaining the transfusion process is largely dependent on interpersonal skills, while understanding the theory behind blood types is indicative of cognitive skills. Informed consent lies within the domain of legal/ethical skills.

2. A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following? A) Ethical/legal skills B) Technical skills C) Interpersonal skills D) Cognitive skills

Ans: A Feedback: Reporting problems and unacceptable practices is an aspect of ethical/legal skills. Technical skills enable the safe performance of kinesthetic tasks while interpersonal skills are the manifestations of caring. Cognitive skills encompass knowledge and critical thinking.

22. The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue? A) Sharp pain in the knee B) Small bloody drainage on dressing C) Temperature of 102 degrees F D) Pulse rate of 90 beats per minute

Ans: A Feedback: Sharp pain in the knee is an example of a subjective cue. Subjective cues are imperceptible, immeasurable, and abstract. Small bloody drainage on dressing, a temperature of 102 degrees F, and a pulse rate of 90 beats per minute are examples of objective cues.

6. The nurse has entered a client's room after receiving a morning report. The nurse rapidly assessed the client's airway, breathing, and circulation and greeted the client by saying "Good morning." The client has made no reciprocal response to the nurse. How should the nurse best respond to the client's silence? A) The nurse should ask appropriate questions to understand the reasons for the client's silence. B) The nurse should apologize for bothering the client, perform necessary assessments efficiently and leave the room. C) The nurse should document the client's withdrawal and diminished mood in the nurse's notes. D) The nurse should ask the client if he feels afraid or angry.

Ans: A Feedback: Silence can have many meanings, and the nurse should attempt to identify the meaning of the client's silence in a tactful manner. Directly asking if the client is angry or fearful is likely presumptuous and may harm rapport. The nurse should not make assumptions around the client's mood nor should the nurse cease to engage with the client.

10. What name is given to standardized plans of care? A) Critical pathways B) Computer databases C) Nursing problems D) Care plan templates

Ans: A Feedback: Standardized care plans include critical pathways, which target desired outcomes for particular illnesses, procedures, or conditions along a timeline. Critical pathways are used in many health care settings.

18. A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies. B) The nurse should modify data collection tool. C) The nurse should determine specific purpose of data collection. D) The nurse should update the database.

Ans: A Feedback: Strong interviewing skills are needed to obtain the necessary patient data. A common cause of data omission is the nurse's failure to know what information is wanted or not following up on client cues. The nurse only needs to modify the data collection tool if the database is inappropriately organized. If irrelevant or duplicate data is collected, the nurse should determine specific purpose of data collection. Data collection should be ongoing. If the nurse notices that data collection stopped after the initial assessment data were collected, the nurse should update the database.

4. When documenting subjective data, the nurse should do which of the following? A) Use the client's own words placed in quotation marks. B) Paraphrase the information stated by the client. C) Validate the information with the client's family prior to documentation. D) Record the information using nonspecific words.

Ans: A Feedback: Subjective data should be recorded using the client's own words, whenever possible. Quotation marks should be used around the client's statement. The tendency to use nonspecific terms that are subject to individual definition or interpretation should be avoided.

34. The nurse is providing care for a pediatric client on night shift. At 0400, the nurse notes that the child has a high fever but does not have an order for an antipyretic. What nursing action represents a good example of teamwork and collaboration as defined by the Quality and Safety Education for Nurses (QSEN) competencies? The nurse: A) calls the health care practitioner, reports her findings, and requests an order for an antipyretic. B) gives the child a common over-the-counter antipyretic based on dosing recommendations and reports this to the oncoming nurse. C) reports to the oncoming nurse at 0700 that the child has a fever so that when the healthcare provider comes in, she can obtain an order for an antipyretic. D) requests that the child 's mother give the child something for the fever that she brought from home.

Ans: A Feedback: Teamwork and collaboration as defined by QSEN indicates the need to recognize practice boundaries at the same time as functioning within the inter-professional team to accomplish shared decision making. It is the nurses responsibility to report altered client status that may require collaborative interventions, irregardless of time of day. For the nurse to administer a medication, there must be a written order for the medication, and it is outside of the scope of practice to prescribe medications. Waiting to report the assessment to an oncoming nurse may delay client care and effect client outcomes. It would be inappropriate to require the mother take care of this with medications brought from home.

28. When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using? A) Technical B) Therapeutic C) Interactional D) Adaptive

Ans: A Feedback: Technical skills are used to carry out treatments and procedures.

11. Which of the following groups developed standard language to increase the visibility of nursing's contribution to client care by continuing to develop, refine, and classify phenomena of concern to nurses? A) NANDA B) NIC C) NOC D) HHCC (now CCC)

Ans: A Feedback: The North American Nursing Diagnosis Association (NANDA) International increased the visibility of nursing's contribution to client care by continuing to develop, refine, and classify phenomena of concern to nurses. The Nursing Interventions Classification (NIC) works to identify, label, validate, and classify actions nurses perform, including direct and indirect care interventions. The Nursing-Sensitive Outcomes Classification (NOC) identifies, validates, and classifies nursing-sensitive client outcomes and indicators to evaluate the validity and usefulness of the classification. Home Health Care Classification (HHCC, now known as Clinical Care Classification (CCC) system) provides a structure for documenting and classifying home health and ambulatory care.

26. After completing an assessment of a client, the nurse uses critical thinking and clinical reasoning to prioritize the client's problems. Which of the following would the nurse determine is the highest priority? A) Severe bleeding from a wound B) History of asthma C) Diabetes D) Lack of family support

Ans: A Feedback: The client's problem is considered to be of high priority if it is life threatening, requires more intervention time, and has serious consequences. The severe bleeding from a wound would be the highest priority. The client's history of asthma, diabetes, and lack of family support may be important but the bleeding is the priority.

31. An older adult client who has had a colostomy for over 10 years states, "I won't need any teaching about colostomies. I understand how to change the bag and care for my colostomy, but I'm not sure how to best clean my stoma." What does this statement indicate? A) An incongruent relationship B) A confused relationship C) A non-therapeutic relationship D) An evaluative relationship

Ans: A Feedback: The client's two statements are incongruent with each other. This indicates the need for further education.

4. A nurse has drafted an SBAR communication before contacting the primary care provider of a client whose condition has worsened suddenly. How should the nurse best conclude this communication? A) Ask the care provider to come and assess the client. B) Provide the client's most recent vital signs. C) Ask the care provider if he or she is familiar with this client. D) Provide the most likely diagnosis of the problem.

Ans: A Feedback: The final phase of an SBAR communication involves making a recommendation. In the case of a client whose condition is worsening, this may entail recommending that the primary care provider come to assess the client. Asking the care provider if he or she is familiar with the client should be done early in the communication. Providing assessment data and possible diagnoses are addressed in the background and assessment sections of the tool.

35. Which of the following should the nurse first consider when attempting to become culturally competent? A) Personal cultural beliefs and prejudices B) Understanding the client's response C) Avoiding labeling clients D) Treating the client with dignity

Ans: A Feedback: The first step toward cultural competence requires becoming aware of your own personal cultural beliefs and prejudices.

14. Why is communication important to the "assessing" step of the nursing process? A) The major focus of assessing is to gather information. B) Assessing is primarily focused on physical findings. C) Assessing involves only nonverbal cues. D) Written information is rarely used in assessment.

Ans: A Feedback: The major focus of assessment is to gather information using both verbal and nonverbal communication forms. Nurses use the written word, the spoken word, and one-to-one communication with clients. Effective communication techniques, as well as observational skills, are used extensively during assessment.

3. A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation? A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward. B) Encourage the novice nurse to develop his or her own tool for data collection. C) Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation. D) Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.

Ans: A Feedback: The novice nurse can improve interpretation skills by independently observing the same situation with a peer, comparing notes afterward, and role-playing various validation techniques.

2. The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? A) Human Needs (Maslow) model B) Functional Health Patterns model C) Human Response Patterns model D) Body System model

Ans: A Feedback: The nurse is following the Human Needs model based on Maslow's Hierarchy of Human Needs. The Functional Health Patterns model was developed by Gordon and is a framework that identifies 11 functional health patterns and organizes data according to these patterns. The Body System model is often used by the medical community, and it organizes data according to organ and tissue function in various body systems. The Human Response Pattern model focuses on a unitary person.

26. A nurse pays a house visit to a client who is on total parenteral nutrition. The client expresses that he misses enjoying food with his family. What is the most appropriate response by the nurse? A) Tell me more about how it feels to eat with your family. B) You can sit with your family at meal times, even though you don't eat. C) In a few weeks you may be allowed to eat a little; you may enjoy then. D) I know that you must be missing your favorite foods.

Ans: A Feedback: The nurse should help the client to verbalize his feelings and cope with aspects of illness and treatment. Asking open-ended questions is most appropriate as the nurse encourages the client to express his feelings. The other options block communication and are not appropriate. Telling the client that he can sit with his family but avoid eating does not consider the client's feelings. Informing the client that he will be able to eat food in a few weeks changes the subject and stops communication. Stating that the client is missing his favorite dishes devalues the client's feelings.

24. A client age 50 years reports to a primary care unit with an open wound due to a fall in the bathroom. Which of the following nursing actions represents caring skills? A) The nurse cleans the wound and applies a dressing to it. B) The nurse inspects and examines the wound for swelling. C) The nurse tells the client to use caution while on slippery surfaces. D) The nurse informs the client that the wound is small and will heal easily.

Ans: A Feedback: The nursing action of cleaning the wound and applying a dressing indicates caring skills. The nurse implements assessment skills while inspecting and examining the wound. The nurse counsels the client to use caution when walking on slippery surfaces. By informing the client about the wound's condition, the nurse uses comforting skills.

18. Which of the nursing roles is primarily performed during the working phase of the helping relationship? A) Educator and counselor B) Provider of care C) Leader and manager D) Researcher

Ans: A Feedback: The nursing roles of educator and counselor are primarily performed during the working phase of the helping relationship. This is where the nurse's interpersonal skills are used to the fullest.

1. The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? A) Cognitive skill B) Technical skill C) Interpersonal skill D) Ethical/legal skill

Ans: A Feedback: The student is demonstrating the use of cognitive skills, which is characterized by identifying scientific rationales for the client's plan of care, selecting nursing interventions that are most likely to yield the desired outcomes, and using critical thinking to solve problems. Technical skills focus on manipulating equipment skillfully to produce a desired outcome. Interpersonal skills are used to establish and maintain a caring relationship. Ethically and legally skilled nurses conduct themselves in a manner consistent with their personal moral code and professional role responsibilities.

1. A group of nursing students is working together on a presentation for their clinical instructor. One student in the group participates by arguing and attempting to block each step of the process of this presentation. The student's behavior is causing frustration for the others and slowing their progress. Which of the following best describes the role this individual student is playing in relationship to the group dynamics? A) Self-serving B) Task-oriented C) Maintenance D) Group-building

Ans: A Feedback: The student's behavior is best described as self-serving. Self-serving roles advance the needs of individual members at the group's expense. Task-oriented roles focus on the work to be completed. Group-building or maintenance roles focus on the well-being of the people doing the work.

20. A student is asked to perform a skill for which he is not prepared. When using the method of critical thinking, what would be the first step to resolve the situation? A) Purpose of thinking B) Adequacy of knowledge C) Potential problems D) Helpful resources

Ans: A Feedback: The student's first step when thinking critically about a situation is to identify the purpose or goal of the thinking. This helps to discipline thinking by directing all thoughts toward the goal.

5. The nurse has entered a client's room and observes that the client is hunched over and appears to be breathing rapidly. What type of question should the nurse first implement in this interaction? A) A yes/no question B) A directing question C) An open-ended question D) A reflective question

Ans: A Feedback: There are times when yes/no questions are appropriate. In this case, the nurse may want to ask, "Do you feel short of breath?" or something similar. Directing questions and reflective questions follow up on earlier communication. An open-ended question may elicit the necessary assessment data, but a yes/no question accomplishes this goal more directly.

4. In which of the following situations would the nurse be most justified in implementing trial-and-error problem solving? A) The nurse is attempting to landmark an obese client's apical pulse. B) The nurse is attempting to determine the range of motion of a client's hip joint following hip surgery. C) The nurse is attempting to determine which PRN (as needed) analgesic to offer a client who is in pain. D) The nurse is attempting to determine whether a poststroke client has a swallowing deficit.

Ans: A Feedback: Trial-and-error problem solving can be dangerous to the client. Testing range of motion by trial-and-error could result in dislocation; trial-and-error drug administration could result in over- or under-medicating; trial-and-error assessment of a potential swallowing deficit could result in aspiration. Each of these situations warrants more systematic problem solving. Trial-and-error landmarking of an anatomically difficult point, such as the apex of an obese client's heart, does not pose a threat to the client and a reasonable amount of "hunting" for the apical pulse may be necessary.

8. A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) To identify a life-threatening problem B) To establish a database for medical care C) To practice respiratory assessment skills D) To facilitate the resident's ability to breathe

Ans: A Feedback: When a life-threatening physiologic or psychological crisis occurs, the nurse performs an emergency assessment to identify life-threatening problems. Emergency assessments are not used to establish a database for medical care, practice assessment skills, or help a physiologic process (such as breathing).

8. A nurse is educating a home care client on how to administer a topical medication. The client is watching television while the nurse is talking. What might be the result of this interaction? A) The message will likely be misunderstood. B) The stimulus for communication is unclear. C) The receiver will accurately interpret the message. D) The communication will be reciprocal.

Ans: A Noise, which is a factor that distorts the quality of a message, can interfere with communication at any point in the process. If the client is watching television, it is likely that the message from the nurse will be misunderstood.

30. Which of the following examples of client data needs to be validated? Select all that apply. A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall. C) A nurse examining a client with a respiratory infection documents fever and chills. D) A client in a nursing home states that she is unable to eat the food being served. E) A pregnant client is experiencing contractions that are two minutes apart.

Ans: A, B Feedback: Because validation of all data is neither possible nor necessary, nurses need to decide which items need verification. For example, data need to be verified when there are discrepancies: A patient tells the nurse he is fine and has no concerns, but the nurse notes that he demonstrates tense body musculature and seems curt in his responses. When there is a discrepancy between what the person is saying and what the nurse is observing, validation is necessary to determine accuracy. Data also need verification when they lack objectivity.

29. Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply. A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. D) It is driven by the nurse's need to document competent, efficient care. E) It calls for strategies that make the most of human potential.

Ans: A, B, C, E Feedback: Critical thinking is guided by standards, policies and procedures, ethics codes, and laws; is based on principles of nursing process, problem solving, and the scientific method; and carefully identifies the key problems, issues, and risks involved. It is driven by client, family, and community needs, as well as nurses' needs to give competent, efficient care (e.g., streamlining paperwork to free nurses for client care). It calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve.

31. Which of the following is an essential feature of professional nursing? Select all that apply. A) Providing a caring relationship to facilitate health and healing B) Attention to a range of human experiences and responses to health and illness C) Use of objective data to negate the client's subjective experience D) Use of judgment and critical thinking to form a medical diagnosis E) Advancement of professional nursing knowledge through scholarly inquiry

Ans: A, B, E Feedback: As the role has changed, definitions of nursing have evolved to acknowledge the following essential features of professional nursing: (1) providing a caring relationship that facilitates health and healing, (2) attention to the range of human experiences and responses to health and illness within the physical and social environments, (3) integration of objective data with knowledge gained from an appreciation of the client's or group's subjective experience, (4) application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking, (5) advancement of professional nursing knowledge through scholarly inquiry, and (6) influence on social and public policy to promote social justice.

32. Which of the following statements accurately describes the relationship between therapeutic communication and the nursing process? Select all that apply. A) Effective communication techniques, as well as observational skills, are used extensively during the assessment step. B) Only the written word in the form of a medical record is used during the diagnosing step of the nursing process. C) The implementing step requires communication among the client, nurse, and other team members to develop interventions and outcomes. D) Verbal and nonverbal communication are used to educate, counsel, and support clients and their families during the implementation phase. E) Nurses rely on the verbal and nonverbal cues they receive from their clients to evaluate whether client objectives have been achieved.

Ans: A, D, E Feedback: Effective communication techniques, as well as observational skills, are used extensively during the assessment phase, since the major focus of assessment is to gather information in both verbal and nonverbal communication forms. Following the formulation of the nursing diagnoses, the nurse communicates findings to other nursing professionals through the use of the written and spoken word. The planning step requires communication among the client, nurse, and other team members, as mutually agreed-upon outcomes are developed and interventions are determined. Verbal and nonverbal communication are employed to enhance basic caregiving measures and to educate, counsel, and support clients and their families during the implementation phase. Nurses often rely on the verbal and nonverbal cues they receive from their clients to verify whether client objectives have been achieved. Because one nurse cannot provide 24-hour coverage for clients, significant information must be passed on to others through nursing progress notes and care plans (documentation).

29. Which of the following data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply. A) The client's chemotherapy causes him nausea and loss of appetite. B) The client became teary when his daughter from out of state came to the bedside. C) The client's ileostomy put out 125 mL of effluent in the past four hours. D) The patient is unwilling to manipulate or empty his ostomy bag. E) The patient has been experiencing fatigue in recent weeks.

Ans: A, E Feedback: Reports of nausea, anorexia, and fatigue are subjective data that depend on the client's self-report. Weeping, ostomy output, and an inability to perform a kinesthetic task are observable assessment findings that would be characterized as objective.

7. A client comes to her health care 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? A) Initial assessment B) Focused assessment C) Emergency assessment D) Time-lapsed assessment

Ans: B Feedback: A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.

7. A nurse is examining a child two years of age. Based on her findings, she initiates a care plan for a potential problem with normal growth and development. Which step of the nursing process identifies actual and potential problems? A) Assessing B) Diagnosing C) Planning D) Implementing

Ans: B Feedback: After assessing the need for nursing care, the nurse clearly identifies client strengths, and actual and potential problems in diagnoses.

13. A nurse interviews a pregnant teenager and documents her answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and maternity care. This scenario is an example of which of the descriptors of the nursing process? A) Systematic B) Dynamic C) Outcome oriented D) Universally applicable

Ans: B Feedback: Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. No one step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously.

5. What nursing organization first legitimized the use of the nursing process? A) National League for Nursing B) American Nurses Association C) International Council of Nursing D) State Board of Nursing

Ans: B Feedback: Although the term "nursing process" was first used by Lydia Hall in 1955 and nursing theorists delineated specific steps in a process approach to nursing, use of the nursing process was legitimized in 1973, when the American Nurses Association's Congress for Nursing Practice developed Standards of Practice to guide nursing performance.

18. What step in the nursing process is most closely associated with cognitively skilled nurses? A) Assessing B) Planning C) Implementing D) Evaluating

Ans: B Feedback: Cognitively skilled nurses are critical thinkers and are able to select those nursing interventions that are most likely to yield the desired outcomes.

30. When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is which of the following? A) Legal representation to care B) Conveyance of information C) Assisting in organization of care D) Noting the client's response to interventions

Ans: B Feedback: Documentation of care in the client's record is most important for communicating with other health care team members that are involved in the care of the patient.

8. A home health nurse reviews the nursing care with the client and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating? A) Diagnosing B) Planning C) Implementing D) Evaluating

Ans: B Feedback: During the planning step, the nurse identifies expected outcomes of the plan of care. The plan of care should be holistic and individualized, specify desired client goals and related outcomes, and identify the nursing interventions most likely to meet those expected outcomes.

13. A nurse is sitting near a client while conducting a health history. The client keeps edging away from the nurse. What might this mean in terms of personal space? A) The nurse is outside the client's personal space. B) The nurse is in the client's personal space. C) The client does not like the nurse. D) The client has concerns about the questions.

Ans: B Feedback: Each person has a sense of how much personal or private space is needed and what distance between individuals is optimum. It is best to take cues from the client; a client moving backward indicates discomfort with invasion of his or her personal space.

24. When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focused C) General D) Time-lapse

Ans: B Feedback: In focused assessments, the nurse determines whether the problem still exists and whether the status of the problem has changed.

17. What action by the nurse will facilitate the helping relationship during the orientation phase? A) Providing assistance to meet activities of daily living B) Introducing oneself to the client by name C) Designing a specific teaching plan of care D) Preparing for termination of the relationship

Ans: B Feedback: In the orientation phase of the helping relationship, the nurse and patient meet and learn to identify each other by name. It is especially important that the nurse introduce herself or himself to the patient during this phase.

9. The family of a client in a burn unit asks the nurse for information. The nurse sits with the family and discusses their concerns. What type of communication is this? A) Intrapersonal B) Interpersonal C) Organizational D) Focused

Ans: B Feedback: Interpersonal communication occurs among two or more people with a goal to exchange messages. Nurses spend most of their day communicating with clients, family members, and health care team members.

19. A nurse asks a multidisciplinary team to collaborate in developing the most appropriate plan of care to meet the needs of an adolescent with a severe head injury. Which of the blended skills essential to nursing practice is the nurse using? A) Cognitive skills B) Interpersonal skills C) Technical skills D) Ethical/legal skills

Ans: B Feedback: Interpersonally skilled nurses establish and maintain caring relationships that facilitate the achievement of valued goals, and simultaneously affirm the worth of those in the relationship. They are, among other things, able to work collaboratively with the health care team to reach valued goals.

14. An experienced ICU nurse is mentoring a student. The nurse tells the student, "I think something is going wrong with your client." What type of clinical decision making is the experienced nurse demonstrating? A) Trial-and-error problem solving B) Intuitive thinking C) Scientific problem solving D) Methodical reasoning

Ans: B Feedback: Nurses today acknowledge the role of intuitive thinking in clinical decision making. Many veteran nurses can describe situations in which an "inner prompting" led to a quick nursing intervention that saved a client's life. However, intuitive problem solving comes with years of practice and observation.

32. Self-evaluation is a method that nurses use to promote their own development, and to grow in confidence in their nursing roles. This process is referred to as what? A) Promoting the nurse's self-esteem. B) Reflective practice. C) Assessment of oneself. D) Learning from mistakes.

Ans: B Feedback: Reflective practice is the use of self-evaluation by nurses committed to quality nursing practice. The others may be additional gains but are not descriptive of self-evaluation.

15. A nurse uses the SBAR method to hand off the communication to the health care team. Which of the following might be listed under the "B" of the acronym? A) Vital signs B) Mental status C) Client request D) Further testing

Ans: B Feedback: SBAR stands for Situation, Background, Assessment, and Recommendations, and provides a consistent method for hand-off communication that is clear, structured, and easy to use. Vital signs would fall under the category of situation; mental status: background; client request: assessment; further testing: recommendations.

15. A nurse is caring for a client in the ER who was injured in a snowmobile accident. The nurse documents the following client data: uncontrollable shivering, weakness, pale and cold skin. Th nurse suspects the client is experiencing hypothermia. Upon further assessment, the nurse notes a heart rate of 53 BPM and core internal temperature of 90°F, which confirms the initial diagnosis. The nurse then devises a plan of care and continues to monitor the client to evaluate the outcomes. This nurse is using which of the following types of problem solving in her care of this client? A) Trial-and-error B) Scientific C) Intuitive D) Critical thinking

Ans: B Feedback: Scientific problem solving is a systematic, seven-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the study. This method is used most correctly in a controlled laboratory setting but is closely related to the more general problem-solving processes commonly used by health care professionals as they work with clients, such as the nursing process.

20. A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data? A) Blood pressure B) Nausea C) Heart rate D) Respiratory rate

Ans: B Feedback: Subjective data are those which the client can feel and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data.

21. Which of the following is an example of a closed-ended question or statement? A) "How did that make you feel?" B) "Did you take those drugs?" C) "What medications do you take at home?" D) "Describe the type of pain you have."

Ans: B Feedback: The closed-ended question or statement provides the receiver with limited choices of possible responses and might often be answered by one or two words, such as "yes" or "no." When not used appropriately, closed-ended questions are a barrier to effective communication.

25. The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process? A) Planning B) Diagnosis C) Implementation D) Outcome identification

Ans: B Feedback: The diagnosis phase involves the analysis of information and deriving the meaning from the analysis. The planning phase involves preparing a care plan and directing the nursing staff in providing care. The implementation phase involves initiation, evaluation of response to the plan, record of nursing actions, and client response to actions. Outcome identification involves formulating and documenting measurable, realistic, client-focused goals.

23. A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A) Initial assessment B) Focused assessment C) Time-lapsed reassessment D) Emergency assessment

Ans: B Feedback: The nurse is performing a focused assessment to determine whether the problem still exists, and whether the status of the problem has changed. An initial or admission assessment is the initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. Time-lapsed reassessment is performed after the initial assessment when substantial periods of time have elapsed between assessments. An emergency assessment is performed any time a physiologic, psychological, or emotional crisis occurs.

13. A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? A) Number of rooms in the house B) Safety of the immediate environment C) Frequency of home visits to be made D) Friendliness of the client and family

Ans: B Feedback: The nurse should also observe the safety of the immediate environment. Observation is the conscious and deliberate use of the five senses to gather data. Each time a client is observed, the nurse observes current responses, ability to provide self-care, the immediate environment, and the larger environment.

25. A client has been recently diagnosed with diabetes. He is seen in the emergency room every day with high blood sugar. The client apologizes to the nurse for bothering them every day, but he cannot give himself insulin injections. What should the nurse's response be? A) "I myself cannot take insulin injections." B) "Has someone taught you how to take them?" C) "You should learn to take injections yourself." D) "Ask the doctor to change the medications."

Ans: B Feedback: The nurse should assess whether the client has a knowledge deficit regarding self-injection. If there is a knowledge deficit, the nurse should educate the client in the correct method of taking insulin injections. Answer A is a negative reinforcement and is therefore inappropriate. Demanding that the client learn injection administration is also inappropriate. Answer D is inappropriate, because the nurse should not offer a change that cannot be carried out.

16. Which of the following questions or statements would be an appropriate termination of the health history interview? A) "Well, I can't think of anything else to ask you right now." B) "Can you think of anything else you would like to tell me?" C) "I wish you could have remembered more about your illness." D) "Perhaps we can talk again sometime. Goodbye."

Ans: B Feedback: The successful interview is concluded carefully. After summarizing the data, it is helpful to ask the client if he or she has anything else to tell the nurse. This gives the client the chance to add data the nurse did not think to include.

23. A nurse tells a client, "Aren't you going to get out of bed or are you just going to sleep all day and night?" This is an example of which of the following barriers to communication? A) Using comments that give advice B) Using judgmental or belittling language C) Using leading questions D) Using probing questions

Ans: B Feedback: Using judgmental comments tends to impose the nurse's standards on the client. In this case, the nurse judges the client as being lazy and the nurse's apparent hostility could end effective communication.

30. Nurses make decisions in their practice every day. Which of the following are potential errors in this decision-making process? Select all that apply. A) Placing emphasis on the last data received B) Avoiding information contrary to one's opinion C) Selecting alternatives to maintain status quo D) Being predisposed to multiple solutions E) Prioritizing problems in order of importance

Ans: B, C Feedback: Potential errors in decision making include bias: placing emphasis on the first data received, avoiding information contrary to one's opinion, selecting alternatives to maintain status quo, and being predisposed to a single solution. Failure to prioritize problems in order of importance is failure to consider the total situation. Failure to use appropriate resources is impatience. All these actions can lead to errors in decision making (Lipe & Beasley, 2004.)

29. A client comes to the clinic complaining of abdominal pain. Which first question would be most appropriate for the nurse to ask to facilitate the assessment? A) "Do you have sharp, stabbing pain?" B) "Is the pain associated with meals?" C) "What activities exaggerate the pain?" D) "Does the pain increase on palpation?"

Ans: C Feedback: "What activities exaggerate the pain?" is an open-ended question, because it gives the client an opportunity to express feelings and describe the pain. "Do you have sharp, stabbing pain?"; "Is the pain associated with meals?"; and "Does the pain increase on palpation?" are questions that can be answered with "Yes" or "No." These questions would be helpful later in the assessment to help focus on the client's statements.

16. What is the goal of the nurse in a helping relationship with a client? A) To provide hands-on physical care B) To ensure safety while caring for the client C) To assist the client to identify and achieve goals D) To facilitate the client's interactions with others

Ans: C Feedback: A helping relationship exists among people who provide and receive assistance in meeting human needs. When a nurse and a client are involved in a helping relationship, the nurse assists the client to identify and achieve goals that allow the client's human needs to be met.

17. A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A) "Do you have a family history of chest problems?" B) "Why don't you use a laxative every night?" C) "Do you take anything to help your constipation?" D) "Everyone who ages has bowel problems."

Ans: C Feedback: A possible cause of omission of pertinent data is failing to follow up on cues during data collection. The nurse should ask about what the client uses to self-treat her constipation in order to identify further important information. It is not correct to ignore the statement, ask "why" questions, or make assumptions.

15. Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview? A) "Why didn't you go to the doctor when you began to have this pain?" B) "Are you feeling better now than you did during the night?" C) "Tell me more about what caused your pain." D) "If I were you, I would not wait to get medical help next time."

Ans: C Feedback: Avoid questions that impede communication during the interview, including those that can be answered by yes or no, why or how questions, and giving advice.

22. As a beginning student in nursing, what is essential to the mastery of technical skills, such as giving an injection? A) Read the steps of the procedure before clinical assignments. B) Even if you do not know how to give an injection, act as if you do. C) Practice giving injections in the learning laboratory until you feel comfortable. D) Tell your instructor that you don't think you can ever give an injection.

Ans: C Feedback: Before attempting to perform a technical skill with or on a patient, it is necessary for the nurse to practice that skill until he or she feels confident in doing it.

12. A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual? A) "Can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."

Ans: C Feedback: Clients such as older adults with dementia, and their children, cannot be relied on to report accurately. However, they should be encouraged to respond to interview questions as best as they can. Bypassing the client communicates that the nurse does not have time or has doubts in the client's ability to communicate.

20. What is the primary focus of communication during the nurse-client relationship? A) Time available to the nurse B) Nursing activity to be performed C) Client and client needs D) Environment of the client

Ans: C Feedback: Communication in the nurse-client relationship should focus on the client and patient needs, not on the nurse or an activity in which the nurse is engaged.

12. Which of the following statements is true of factors that influence communication? A) Nurses provide the same information to all clients, regardless of age. B) Men and women have similar communication styles. C) Culture and lifestyle influence the communication process. D) Distance from a client has little effect on a nurse's message.

Ans: C Feedback: Culture and lifestyle do influence the communication process; understanding a client's culture assists nurses in understanding nonverbal communication and enables the nurse to deliver accurate care.

A nurse is caring for a client who is visually impaired. Which of the following is a recommended guideline for communication with this client? A) Ease into the room without acknowledging presence until the client can be touched. B) Speak in a louder tone of voice to make up for lack of visual cues. C) Explain reason for touching client before doing so. D) Keep communication simple and concrete.

Ans: C Feedback: For clients who are visually impaired, the nurse should acknowledge his or her presence in the client's room, identify self by name, speak in a normal tone of voice, explain the reason for touching the client before doing so, and indicate to the client when the conversation has ended and when leaving the room.

27. When the nurse is administering Lasix 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent? A) Assessment B) Planning C) Implementation D) Evaluation

Ans: C Feedback: Implementation refers to the action phase of the nursing process, in which nursing care is provided.

12. Legally speaking, how would the nurse ensure that care was not negligent? A) Verbally reporting assessments to the client's physician B) Keeping private notes about the care given to each assigned client C) Documenting the nursing actions in the client's record D) Tape recording complete information for each oncoming shift

Ans: C Feedback: Legally speaking, a nursing action not documented in the client's record is a nursing action not performed. Unless the record contains written (not verbal, tape-recorded, or in private notes) documentation of care provided, the court would have no reason to accept a nurse's claim that the care was given.

10. Which of the following is an example of nonverbal communication? A) A nurse says, "I am going to help you walk now." B) A nurse presents information to a group of clients. C) A client's face is contorted with pain. D) A client asks the nurse for a pain shot.

Ans: C Feedback: Nonverbal communication is the transmission of information without the use of words. In this situation, the facial contortion is a nonverbal message of pain.

10. Of the following information collected during a nursing assessment, which are subjective data? A) vomiting, pulse 96 B) respirations 22, blood pressure 130/80 C) nausea, abdominal pain D) pale skin, thick toenails

Ans: C Feedback: Subjective data are information perceived only by the affected person. They cannot be perceived or verified by another person. Other terms for subjective data are symptoms or covert data.

27. A nurse is caring for a client with myasthenia gravis. The client is having difficulty forming words and his tone is nasal. Which of the following is an effective communication strategy for this client? A) Engage the client in a lengthy discussion to strengthen his voice. B) Encourage the client to speak quickly while talking. C) Repeat what the client has said to verify the meaning. D) Nod continuously when the client is talking.

Ans: C Feedback: The client is having a problem forming words and has a nasal tone due to a nerve involvement that controls speech. For effective communication, the nurse should repeat and verify whatever the client says. The nurse should ask those questions which can be answered in a yes or no form. Lengthy discussions may tire the client. Encouraging the client to speak quickly is inappropriate. Nodding continuously when the client is talking would not facilitate an effective communication strategy.

35. Which of the following group of terms best describes the nursing process? A) nursing goals, medical terminology, linear B) nurse-centered, single focus, blended skills C) patient-centered, systematic, outcomes-oriented D) family-centered, single point in time, intuitive

Ans: C Feedback: The nursing process is a patient-centered, systematic, outcomes-oriented method of caring that provides a framework for nursing practice. It is nursing practice in action.

9. A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment? A) Comprehensive B) Focused C) Time-lapsed D) Emergency

Ans: C Feedback: The time-lapsed assessment is scheduled to compare a client's current status to baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess health status and to make necessary revisions in the plan of care.

34. A nurse tells a client that she will come back in 10 minutes to re-assess the client's pain. When the nurse returns in 10 minutes, which aspect of the therapeutic relationship is the nurse developing? A) Empathy B) Sympathy C) Trust D) Closure

Ans: C Feedback: When a nurse repeatedly upholds commitments made to a client, it fosters foundational trust within the therapeutic relationship. The other options may be part of the therapeutic relationship, but in this case the nurse's behavior will instill trust.

16. Which of the following is one example of a client benefit of using the nursing process? A) Greater personal satisfaction B) Decreased reliance on the nursing staff C) Continuity of care D) Decreased incidence of medical errors

Ans: C Feedback: When used well, the nursing process achieves for the client scientifically based, holistic, individualized care; the opportunity to work collaboratively with nurses; and continuity of care.

28. A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply. A) Carrying out a physician's order to intubate a client B) Educating a novice nurse on the principles of triage C) Using the nursing process to diagnose a blocked airway D) Interviewing privately a client suspected of being a victim of abuse E) Checking with the family about the data supplied by a client suffering from dementia

Ans: C, D, E Feedback: Since the entire nursing process rests on the initial and ongoing assessment of the client, it is imperative to use excellent critical thinking skills when gathering, validating, analyzing, and communicating data. The nurse using critical thinking skills assesses information systematically using the nursing process, detects biases, makes judgments about the significance of data, and identifies assumptions and inconsistencies. Carrying out physician's orders and educating a novice nurse involve the implementation stage of the nursing process.

22. A client tells the nurse that he is very worried about his surgery. Which of the following responses by the nurse is a cliché? A) "Tell me what you are worried about." B) "Have you spoken to your family about your concerns?" C) "Do you want to cancel your surgery?" D) "Don't worry, everything will be fine."

Ans: D Feedback: A cliché is a stereotypical, trite, or pat answer. Most health care clichés suggest there is no cause for concern, or they often offer false assurance. Their use tends to be interpreted as a lack of real interest in what has been said.

21. Members of the staff on a hospital unit are critical of a client's family, who has different cultural beliefs about health and illness. A student assigned to the patient does not agree,based on her care of the client and family. What critical thinking attitude is the student demonstrating? A) Being curious and persevering B) Being creative C) Demonstrating confidence D) Thinking independently

Ans: D Feedback: Although all the attitudes listed are components of critical thinking, the student is thinking independently. Nurses who are independent thinkers are careful not to let the status quo or a persuasive individual control their thinking.

6. The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? A) To gather data about a specific and current health problem B) To identify life-threatening problems that require immediate attention C) To compare and contrast current health status to baseline data D) To establish a database to identify problems and strengths

Ans: D Feedback: An initial assessment is performed shortly after the client is admitted to a health care agency or service. The purpose of the initial assessment is to establish a complete database for problem identification and care planning.

23. Which of the following interpersonal skills is essential to the practice of nursing? A) Performing technical skills knowledgeably and safely B) Maintaining emotional distance from clients and families C) Keeping personal information among shared clients confidential D) Promoting the dignity and respect of patients as people

Ans: D Feedback: Characteristics of interpersonal caring that are essential to the practice of nursing include promoting the dignity and respect of clients as people, the centrality of the caring relationship, and a mutual enrichment of both participants in the nurse-client relationship.

19. Which term describes a nurse who is sensitive to the client's feelings, but remains objective enough to help the client achieve positive outcomes? A) Competent B) Caring C) Honest D) Empathic

Ans: D Feedback: Empathy is identifying with the way another person feels. An empathic nurse is sensitive to the client's feelings and problems, but remains objective enough to help the client work to attain positive outcomes.

14. A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself? A) Standing at the end of the bed B) Standing at the side of the bed C) Sitting at least six feet from the beside D) sitting at a 45-degree angle to the bed

Ans: D Feedback: If the patient is in bed, placing a chair at a 45-degree angle is helpful in facilitating an easy exchange of information. If the nurse stands at the side or foot of the bed and physically looks down at the client, a superior-inferior relationship is communicated and can negatively affect the interview.

11. A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A) "My leg hurts so bad. I can't stand it." B) "Appears anxious and frightened." C) "I am so sick; I am about to throw up." D) "Unable to palpate femoral pulse in left leg."

Ans: D Feedback: Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Objective data are also called signs or overt data. The only objective data in this question would be that the nurse is unable to palpate a femoral pulse.

11. A nursing student caring for an unconscious client knows that communication is important even if the client does not respond. Which nonverbal action by the nursing student would communicate caring? A) Making constant eye contact with the client B) Waving to the client when entering the room C) Sighing frequently while providing care D) Holding the client's hand while talking

Ans: D Feedback: Tactile sense is a form of nonverbal communication and is viewed as one of the most effective nonverbal ways to express feelings of comfort.

33. Nursing is a profession in a rapidly changing health care environment. What is the most important reason for the nurse to develop critical thinking and clinical reasoning? A) To be able to employ the nursing process in client care. B) The licensing examination requires nurses to be adept at critical thinking. C) Because clients deserve experts who know how to care for them. D) To provide quality care with nursing ability and knowledge.

Ans: D Feedback: The goal of all nursing is to meet the standard of quality care. Clinical reasoning and critical thinking may be applied in all of the answers but the most important goal in health care is to provide quality nursing care to clients.

28. The nurse has engaged the services of an interpreter when interviewing a client who speaks a language that the nurse does not understand. The interpreter is functioning in which role during the communication process? A) Sender B) Encoder C) Receiver D) Communication channel

Ans: D Feedback: The interpreter's role is that of a communication channel. A communication channel is the medium, the carrier of the message. The interpreter conveys the message sent by the client to the nurse. The client is the sender and the encoder of the message. The nurse is the receiver of the message.

7. A nurse touches a client's hand to indicate caring and support. What channel of communication is the nurse using? A) Auditory B) Visual C) Olfactory D) Kinesthetic

Ans: D Feedback: The nurse is using a kinesthetic channel of communication. The channel of communication is the medium the sender has selected to send the message. The channel might target any of the receiver's senses. The channels are auditory (spoken words and cues), visual (sight, observations, and perceptions), and kinesthetic (touch).

19. What is the primary purpose of validation as a part of assessment? A) To identify data to be validated B) To establish an effective nurse-client communication C) To maintain effective relationships with coworkers D) To plan appropriate nursing care

Ans: D Feedback: Validation is the act of confirming or verifying to plan appropriate nursing care. Validation is an important part of assessment because invalid information can lead to inappropriate nursing care. Validation does not identify data to be validated, nor does it establish effective nurse-client communication or relationships with coworkers.

33. A nurse who is discharging a client is terminating the helping relationship. Which of the following actions might the nurse perform in this phase? Select all that apply. A) Making formal introductions B) Making a contract regarding the relationship C) Providing assistance to achieve goals D) Helping client perform activities of daily living E) Examining goals of the relationship to determine their achievement

Ans: E Feedback: In the termination phase, the nurse examines with the client the goals of the helping relationship for indications of their attainment, or for evidence of progress toward them. If goals were not attained, the nurse should help the client establish a relationship with the new nurse. Answers A and B occur in the orientation phase, and answers C and D occur in the working phase.

2. Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes? A) The nurse expresses the client outcome as a nursing intervention. B) The nurse develops measurable outcomes using verbs that are observable. C) The nurse develops a target time when the client is expected to achieve that outcome. D) The outcome should include a subject, verb, conditions, performance criteria, and target time.

Ans: A Feedback: A common error made when writing client outcomes includes the nurse expressing the client outcome as a nursing intervention. The other mentioned criteria for writing client outcomes are correct.

6. Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis? A) A cluster of several significant cues of data that suggest a particular health problem B) A single, definitive cue that is closely associated with a common diagnosis C) A cue that can be verified by objective, medical data D) A group of related nursing diagnoses that exist within the same NANDA-approved domain

Ans: A Feedback: A data cluster is a grouping of client data or cues that points to the existence of a client health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. Medical corroboration is not always possible or necessary. The presence of multiple nursing diagnoses within one domain does not necessarily validate further diagnoses in that same domain.

5. The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis? A) Validate the nursing diagnosis B) Identify potential complications C) Cross-reference the nursing diagnosis with medical diagnoses D) Modify interventions based on the diagnosis

Ans: A Feedback: After writing a nursing diagnosis, it is important to verify and validate the diagnosis. This action should precede the modification of the client's care. Nursing diagnoses do not always correlate with medical diagnoses and not every nursing diagnosis is accompanied by potential complications.

1. The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal? A) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. B) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma. C) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased. D) Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear.

Ans: A Feedback: An example of a long-term outcome is "Patient returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack." The other three examples are short-term outcomes that focus on short-term goals related to the period of time during hospitalization.

35. The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures

Ans: A Feedback: An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the client's temperature. This should precede interventions such as blood work or even providing a warm blanket.

10. The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs? A) Physiologic B) Safety C) Love and belonging D) Self-actualization

Ans: A Feedback: Because basic human needs must be met before a person can focus on higher-level needs, client needs may be prioritized according to Maslow's hierarchy. Physiologic needs, including the need for oxygen, are the most basic and have the highest priority.

30. Which intervention does the nurse recognize as a collaborative intervention? A) Teach the client how to walk with a three-point crutch gait. B) Administer spironolactone (Aldactone). C) Perform tracheostomy care every eight hours. D) Straight catheterize every six hours.

Ans: A Feedback: Collaborative interventions are treatments initiated by other providers, such as pharmacists, respiratory therapists, physical therapists, and other members of the health care team. Teaching the client how to walk with crutches would be a collaborative intervention. Administering medications, performing tracheostomy care, and catheterizing a client require a physician's order and are physician-initiated interventions.

1. Which of the following is a correct guideline to follow when composing a nursing diagnosis statement? A) Place defining characteristics after the etiology and link them by the phrase "as evidenced by." B) Phrase the nursing diagnosis as a client need. C) Place the etiology prior to the client problem and linked by the phrase "related to." D) Incorporate subjective and judgmental terminology.

Ans: A Feedback: Defining characteristics should follow the etiology and be linked by the phrase "as evidenced by" when included in the nursing diagnosis. The nursing diagnosis should be phrased as a client problem or alteration in health state, rather than as a client need. The client problem precedes the etiology and is linked by the phrase "related to." Avoid using judgmental language and write in legally advisable terms.

32. The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? A) Clarify discrepancies of assessment data with the client. B) Validate client data with members of the health care team. C) Document all data collected in the nursing history and physical examination. D) Seek input from family members regarding the client's breathing at home.

Ans: A Feedback: First, the nurse needs to validate the data with the client, who is the primary source. The nurse can validate data with the health care provider but consulting with the client is the best option. The client must give permission for family members to participate in the health history. Ultimately, the nurse documents all assessment data, both from the history and the physical exam.

31. After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? A) Impaired urinary elimination B) Readiness for enhanced sleep C) Risk for infection D) Possible impaired adjustment

Ans: A Feedback: Impaired urinary elimination is an actual nursing diagnosis because it describes a human response to a health problem that is being manifested. Readiness for enhanced sleep is a wellness diagnosis. Risk for infection is a risk diagnosis, and possible impaired adjustment is a possible nursing diagnosis.

6. A male client is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: "After attending an educational session, client will demonstrate correct technique for applying his prosthesis." Which of this client's following statements would signal a need to amend this outcome? A) "I'm not interested one bit in wearing an artificial hand." B) "I'm worried that I'm going to get some really strange looks when I wear this thing." C) "I don't have a clue how this thing goes on and comes off." D) "I don't understand the technology that's used in this artificial hand."

Ans: A Feedback: It is imperative that interventions and outcomes be valued by the client. The client's resistance to using a prosthesis likely invalidates the outcome that addresses his technique for its use. The other statements express cognitive and affective learning needs that would need to be addressed, but none of those precludes his eventual mastery of the prosthesis.

4. A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? A) Presuming to know the factors contributing to the problem B) Identifying a problem that cannot be changed C) Identifying a problem without corroborating evidence in the statement D) Neglecting to identify potential complications related to the problem

Ans: A Feedback: Multiple factors may underlie the client's response to education in a complex and emotionally charged situation, such as receiving a new ostomy. As a result, it is likely presumptuous to ascribe the client's response to hostility. The problem is likely modifiable with a correct approach; the evidence underlying a nursing diagnosis is not normally explicit in the statement itself. The existence of potential complications is not central to the psychosocial nature of this client's situation.

22. What common problem is related to outcome identification and planning? A) Failing to involve the client in the planning process B) Collecting sufficient data to establish a database C) Stating specific and measurable outcomes based on nursing diagnoses D) Writing nursing orders that are clear and resolve the problem

Ans: A Feedback: One of the most important considerations in outcome achievement is to encourage the client and family to be as involved in goal development as their abilities and interest permit. The more involved they are, the greater the probability that the outcomes will be achieved.

21. A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he "can't live with this fear." Which of the following diagnoses for this client is correctly written? A) Post-trauma syndrome related to being attacked B) Psychological overreaction related to being attacked C) Needs assistance coping with attack D) Mental distress related to being attacked

Ans: A Feedback: Post-trauma syndrome is a NANDA-approved problem statement and being attacked is the correct etiology. Overreaction and mental distress implies a value judgment by the nurse. Needs assistance addresses the need of the client.

4. The nurse is planning the care of a male client who is receiving treatment for acute renal failure and who has begun dialysis three times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of his arteriovenous fistula." This outcome is classified as which of the following? A) Psychomotor B) Affective C) Cognitive D) Holistic

Ans: A Feedback: Psychomotor outcomes describe the client's achievement of new skills, such as the safe and aseptic care of a new fistula. Cognitive outcomes are focused on knowledge and effective outcomes address values, beliefs, and attitudes. Outcomes are not classified as holistic.

35. Which of the following reflects the diagnosis phase? A) The nurse identifies that the client does not tolerate activity. B) The nurse performs wound care using sterile technique. C) The nurse sets a tolerable pain rating with the client. D) The nurse documents the client's response to pain medication.

Ans: A Feedback: Recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as activity intolerance, is the focus of diagnosing. Performing wound care is an example of implementation. Setting a tolerable pain rating with the client is an example of planning. Documenting the client's response to pain medication is an example of evaluation.

3. The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following? A) The client is more vulnerable to certain problems than other individuals would be. B) The diagnoses present significant risks for the development of medical diagnoses. C) The data necessary to make a definitive nursing diagnosis is absent. D) The diagnosis has yet to be confirmed by another practitioner.

Ans: A Feedback: Risk nursing diagnoses are clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. They do not denote a particular link to medical diagnoses nor do they require independent confirmation. Missing data is associated with possible nursing diagnoses.

2. In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis? A) Ineffective airway clearance as evidenced by inability to clear secretions B) Ineffective health maintenance as evidenced by unhealthy habits C) Ineffective breathing pattern related to pneumonia D) Ineffective therapeutic regimen management due to smoking

Ans: A Feedback: The appropriately written nursing diagnosis is "ineffective airway clearance related to inability to clear secretions." "Ineffective health maintenance related to unhealthy habits" is incorrect because it shows value judgments by the nurse. "Ineffective breathing pattern related to pneumonia" is incorrectly written because it includes a medical diagnosis. "Ineffective therapeutic regimen management due to smoking" is incorrect because the clause "due to" implies a direct cause-and-effect relationship.

3. Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following? A) Reduction in the time spent on care planning B) Increased autonomy related to the nursing care planning process C) Enhanced individualization of a care plan D) Increased nursing expertise in care planning

Ans: A Feedback: The benefits of using computerized plans include ready access to a large knowledge base; improved record keeping, with resultant improvement in audits and quality assurance; documentation by all members of the health care team; and reduced time spent on paperwork. Research cautions that computerized systems for client care planning contribute to loss of autonomy, loss of individualization of care, and loss of nursing expertise.

5. The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation? A) Record an evaluative statement in the client's plan of care. B) Remove the outcome from the client's care plan. C) Ask the nurse who wrote the plan of care to document this development. D) Reassess the client's psychomotor skills at dinner time.

Ans: A Feedback: The client has successfully met this outcome, and the nurse should note the time and date that it was achieved in the client's plan of care. The outcome should not be removed from the plan of care and it is unnecessary to have the original author of the plan update it. Further observation may or may not be necessary at dinner time, but an evaluative statement should nonetheless be recorded at the present time.

24. 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"? A) Etiology B) Problem C) Defining characteristics D) Client need

Ans: A Feedback: The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. The etiology directs nursing interventions.

9. After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used? A) Selecting nursing interventions to meet expected outcomes B) Establishing a database of information for future comparison C) Mutually establishing desired outcomes of the plan of care D) Evaluating the effectiveness of the established plan of care

Ans: A Feedback: The nurse formulates, validates, and lists nursing diagnoses for each client. Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued client outcomes for which the nurse is responsible.

17. A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing good health habits. What conclusion did the nurse reach after interpreting and analyzing the data? A) No problem B) Possible problem C) Actual problem D) Clinical problem

Ans: A Feedback: The nurse reaches one of four basic conclusions after interpreting and analyzing the client data. Different nursing responses are possible for each conclusion. In this case, the nurse would most likely conclude there was no problem and reinforce the client's health habits.

23. A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using which of the following? A) Assessment skills B) Nursing books C) Client's records D) Supervisor's advice

Ans: A Feedback: The nurse should use assessment skills to determine the priority of nursing care for the client. Books on nursing can give only the theoretical aspect of nursing care. Client's records reveal information about the client's condition but do not convey the client's needs. Advice from supervisors can be taken if confronted with a problem.

20. A nurse writes the following nursing diagnosis for a client with Alzheimer's disease: Disturbed Thought Processes related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement? A) disturbed thought processes B) related to C) Alzheimer's disease D) incoherent language

Ans: A Feedback: The purpose of the problem statement is to describe the health state or health problem of the client as clearly and concisely as possible. Because this section of the nursing diagnosis identifies what is unhealthy about the client and what the client would like to change in his or her health status, it suggests client outcomes. NANDA recommends the use of quantifiers or descriptors to limit or specify the meaning of a problem statement. Disturbed thought processes is a NANDA-approved descriptor for this client problem. The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor, and in this case is Alzheimer's disease. Incoherent language is considered a defining characteristic or subjective/objective data signaling the existence of an actual or potential health problem.

30. A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis? A) Is written as a two-part statement B) Describes human response to a health problem C) Describes potential for enhancement to a higher state D) Made when not enough evidence supports the problem

Ans: A Feedback: The risk diagnoses are written as two-part statements because they do not include defining characteristics. An actual nursing diagnosis describes human response to a health problem. Wellness diagnoses describe potential for enhancement to a higher state. A possible nursing diagnosis is made when not enough evidence supports the problem.

28. Which of the following statements accurately describes the impact on nursing of using NIC/NOC standardized languages? Select all that apply. A) They demonstrate the impact that nurses have on the system of health care delivery. B) They standardize and define the knowledge base for nursing curricula and practice. C) They limit the number of appropriate nursing interventions to be selected. D) They hinder the teaching of clinical decision making to novice nurses. E) They enable researchers to examine the effectiveness and cost of nursing care.

Ans: A, B, E Feedback: Using NIC/NOC standardized language demonstrates the impact that nurses have on the system of health care delivery; standardizes and defines the knowledge base for nursing curricula and practice; facilitates the selection of appropriate nursing interventions; facilitates the teaching of clinical decision making to novice nurses; enables researchers to examine the effectiveness and cost of nursing care; assists educators to develop curricula that better articulate with clinical practice; assists administrators in planning more effectively for staff and equipment needs; promotes the development and use of nursing information systems; and communicates the nature of nursing to the public.

27. In which of the following clients has the order of priorities for nursing diagnoses changed? Select all that apply. A) A client in a long-term care facility who had a stroke B) A client who is recovering from a broken leg C) A client who insists on using the bathroom instead of a bedpan D) A client who appears confused after taking pain medication E) A pregnant client whose contractions are progressing as anticipated

Ans: A, C, D Feedback: The work of setting priorities demands careful critical thinking. When planning nursing care, the nurse should consider the following: Have changes in the client's health status influenced the priority of nursing diagnoses? Have changes in the way the client is responding to health and illness (or the plan of care) affected those nursing diagnoses that can be realistically addressed? Are there relationships among diagnoses that require that one be worked on before another can be resolved? Do several client problems need to be dealt with together.

29. Which of the following is a correctly written client goal? Select all that apply. A) The client will identify five low-sodium foods by October 9. B) The client will know the signs and symptoms of infection. C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. D) The client will understand the side effects of digoxin (Lanoxin). E) The client will eat at least 75% of all meals by May 5.

Ans: A, C, E Feedback: Outcomes are client-centered, use action verbs, identify measurable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (eat), how well (75%) under what circumstances (not always included), and by when (May 5). Understand and know are vague and are not action-oriented.

31. Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply. A) Diet and exercise program B) Standing in the community C) Ability to pay for services D) Developmental stage E) Need for nursing

Ans: A, D, E Feedback: The purpose for which the assessment is being performed offers the best guideline about what type and how much data to collect. Assessment priorities are influenced by the client's health orientation, developmental stage, culture, and need for nursing. After the comprehensive nursing assessment has been completed, client health problems dictate assessment priorities for future nurse-client interactions.

16. Which of the following groups of terms best describes a nurse-initiated intervention? A) Dependent, physician-ordered, recovery B) Autonomous, clinical judgment, client outcomes C) Medical diagnosis, medication administration D) Other health care providers, skill acquisition

Ans: B Feedback: A nursing intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. Nurse-initiated interventions are autonomous (independently performed).

32. The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention? A) Teach client how to transfer from bed to chair and chair to bed. B) Administer oxygen 4 L/min per nasal cannula. C) Assist the client with coughing and deep breathing every hour. D) Monitor intake and output every 2 hours.

Ans: B Feedback: A physician-initiated intervention is an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a physician's order. A physician's order is required for the nurse to administer drugs, such as oxygen. 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. Nursing-initiated interventions, such as teaching client how to transfer, assisting with coughing and deep breathing, and monitoring intake and output do not require a physician's order.

24. A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? A) Evaluate the need for antibiotics. B) Resolve the client's anxiety. C) Provide preoperative education. D) Prepare the client for surgery.

Ans: B Feedback: A priority is something that takes precedence in position, deemed the most important among several items. The client's preparation for surgery is important, but to have a successful outcome, the nurse must address the psychosocial issues related to anxiety.

22. Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Possible nursing diagnosis D) Wellness diagnosis

Ans: B Feedback: Actual nursing diagnoses represent problems that have been validated by the presence of major defining characteristics. An actual nursing diagnosis has four components: label, definition, defining characteristics, and related factors.

19. A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? A) Continue to follow the written plan of care. B) Make recommendations for revising the plan of care. C) Ask another health care professional to design a plan of care. D) State "goal will be met at a later date."

Ans: B Feedback: Client outcomes are meaningless unless the nurse evaluates the client's progress toward their achievement. If the plan is not achieved (not met), recommendations for revising the plan of care are included in the evaluative statement.

9. A nurse is discharging a client from the hospital. When should discharge planning be initiated? A) At the time of discharge from an acute health care setting B) At the time of admission to an acute health care setting C) Before admission to an acute health care setting D) When the client is at home after acute care

Ans: B Feedback: Discharge planning is best carried out by the nurse who worked most closely with the client and family. In acute care settings, comprehensive discharge planning begins when the client is admitted for treatment.

34. Which of the following is not appropriate in writing client-centered measurable outcomes? A) The client or a part of the client B) A flexible time frame C) Observable, measurable terms D) The action the client will perform

Ans: B Feedback: In writing client-centered measurable outcomes, a target time is required. This target time specifies when the client is expected to be able to achieve the outcome. The other options given (the client or part of the client; observable and measurable terms; the action the patient will perform) are all part of client-centered measurable outcomes.

8. Which of the following client care concerns is clearly a nursing responsibility? A) Prescribing medications B) Monitoring health status changes C) Ordering diagnostic examinations D) Performing surgical procedures

Ans: B Feedback: Monitoring for health status changes is clearly a nursing responsibility. The other options are medical responsibilities, although in some instances an advanced practice nurse practitioner may be responsible for A and C.

21. Which of the following is an example of a well-stated nursing intervention? A) Client will drink 100 mL of water every 2 hours while awake. B) Offer client 100 mL of water every 2 hours while awake. C) Offer client water when he complains of thirst. D) Client will continue to increase oral intake when awake.

Ans: B Feedback: Nursing interventions describe in writing the specific nursing care to be implemented for the client. They include information that answers the questions who, what, where, when, and how.

13. A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have? A) The written outcomes are designed to meet nursing goals B) To encourage the client and family to be involved C) To discourage additions by other healthcare providers D) Why the nurse believes the outcome is important

Ans: B Feedback: One of the most important considerations in writing outcomes is to encourage the client and family to be involved in goal development as their abilities and interest permit. The more involved they are, the greater the probability the goals will be achieved.

8. Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning? A) "How do I best cluster these data and cues to identify problems?" B) "What problems require my immediate attention or that of the team?" C) "What major defining characteristics are present for a nursing diagnosis?" D) "How do I document care accurately and legally?"

Ans: B Feedback: Questions to facilitate critical thinking during outcome identification and planning include those related to setting priorities, such as "Which problems require my immediate attention or that of the team?" and "Which problems are most important to the client?"

35. While developing the plan of care for a new client on the unit the nurse must identify expected outcomes that are appropriate for the new client. What is a resource for identifying these appropriate outcomes? A) Community Specific Outcomes Classification (CSO) B) The Nursing-Sensitive Outcomes Classification (NOC) C) State Specific Nursing Outcomes Classification (SSNOC) D) Department of Health and Human Resources Outcomes Classification (HHROC)

Ans: B Feedback: Resources for identifying appropriate expected outcomes include the Nursing-Sensitive Outcomes Classification (NOC) (Chart 3-6) and standard outcome criteria established by health care agencies for people with specific health problems. The other options are incorrect because they do not exist.

32. What is the nurse accountable for, according to the state nurse practice act? A) Continuing education B) Nursing diagnoses C) Prescribing medications D) Mentoring other nurses

Ans: B Feedback: State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held accountable.

25. Which of the following client outcomes best describes the parameters for achieving the outcome? A) The client will eat a well-balanced diet. B) The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow. C) The client will cleanse his wound with soap and water and apply a dry sterile dressing. D) The client will be without pain in 24 hours.

Ans: B Feedback: The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow possesses all parameters for achieving the outcome.

28. A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern? A) Impaired physical mobility B) Disturbed body image C) Risk for infection D) Risk for social isolation

Ans: B Feedback: The diagnosis of disturbed body image is appropriate for the client because he is worried about the appearance of his legs due to swelling and the external fixation device. There is no mention about impaired physical mobility or risk for social isolation in the client's concern. There may be a risk of infection, but the client does not mention it.

18. A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario? A) No problem B) Possible problem C) Actual problem D) Clinical problem

Ans: B Feedback: The nurse reaches one of four basic conclusions after interpreting and analyzing the client data: no problem, possible problem, actual or potential problem, or clinical problem. When dealing with a possible problem, the nurse must collect more data to confirm or disprove a suspected problem.

14. What is the focus of a diagnostic statement for a collaborative problem? A) The client problem B) The potential complication C) The nursing diagnosis D) The medical diagnosis

Ans: B Feedback: To write a diagnostic statement for a collaborative problem, the nurse should focus on the potential complications of the problem and use "PC" (for potential complication), followed by a colon, and list the complications that might occur. For clarity, the nurse should link the potential complications and the collaborative problem by using "related to."

11. A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority? A) The need to have nutrition B) The need to feel good about oneself C) The need to live in a safe environment D) The need for love from others

Ans: B Feedback: When setting priorities, it is best to first meet the needs that the client believes are most important. In this situation, the woman is not refusing food altogether; rather, she wants to feel good about herself (self-esteem) when she does eat.

34. The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply. A) Dysphagia B) Bowel Incontinence C) Impaired Swallowing D) Impaired Physical Mobility E) Risk for Hemiparesis

Ans: B, C, D Feedback: Bowel Incontinence, Impaired Swallowing, and Impaired Physical Mobility are all health problems that can be independently prevented or resolved by nursing practice. Dysphagia and hemiparesis are medical diagnoses.

26. Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply. A) Professional physicians' organizations B) State Nurse Practice Acts C) The Joint Commission D) The Agency for Health Care Research and Quality E) The Patient Health Partnership

Ans: B, C, D Feedback: To plan health care correctly, the nurse must be familiar with standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. These standards include the law, national practice standards, specialty professional nursing organizations, The Joint Commission, the Agency for Health Care Research and Quality, and employers.

26. Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses? A) Defining the domain of nursing practice B) Informing patients of their care C) Improving communication among nurses D) Structuring curricular content

Ans: C Feedback: Although all the choices are correct, improved communication among nurses and other health care professionals is probably the most important benefit that accurate, up-to-date nursing diagnoses offer nurses.

18. What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system? A) Kardex care plans B) Computerized plans of care C) Clinical pathways D) Student care plans

Ans: C Feedback: Clinical pathways (critical pathways, CareMaps) are tools used to communicate the standardized interdisciplinary plan of care for clients. The emphasis in case management is on clearly stating expected client outcomes and the specific times targeted to achieve these outcomes.

12. A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client's physiologic response. This action is known as a: A) medical diagnosis. B) nursing diagnosis. C) collaborative problem. D) goal for care.

Ans: C Feedback: Collaborative problems are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems by using physician-prescribed and nursing-prescribed interventions to minimize the complications of the event.

15. Which of the following illustrates a common error when writing client outcomes? A) Client will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m. B) Client will demonstrate correct sequence of exercises by next office visit. C) Client will be less anxious and fearful before and after surgery. D) On discharge, client will list five symptoms of infection to report.

Ans: C Feedback: Common errors when writing client outcomes include expressing the outcome as a nursing intervention, using verbs that are not observable and measurable (as is done here), and writing vague outcomes (also done here).

9. Based on an established plan of care, a nurse turns a client every two hours. What part of the nursing process is the nurse using? A) Assessing B) Planning C) Implementing D) Evaluating

Ans: C Feedback: During the implementing step of the nursing process, the nurse carries out interventions that were developed during the planning step.

17. What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care? A) Problem statement B) Defining characteristics C) Etiology of the problem D) Outcomes criteria

Ans: C Feedback: In contrast to the client goals, which are suggested by the problem statement of the diagnosis, it is the cause of the problem (etiology) that suggests the nursing interventions. Effective nurses select nursing interventions that specifically address factors that cause, or contribute to, the client's problem.

19. A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct? A) "needs nasal oxygen to improve breathing" B) "cough related to ineffective airway clearance" C) "ineffective airway clearance related to thick mucus" D) "refuses to cough and expectorate thick mucus"

Ans: C Feedback: It is important to use guidelines to formulate correctly written nursing diagnoses. The nurse would not use client needs, put defining characteristics before the diagnoses, or judge the willingness of the client to cough.

33. The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse recognizes this information is an example of what? A) Subjective data B) A data cue C) An inference D) Primary data

Ans: C Feedback: Making a judgment that the client is confused is an inference. An inference must be validated with subjective and/or objective data cues. Sources of data cues can be primary or secondary.

11. A student is reviewing a client'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? A) Neither appendicitis nor acute pain B) Both appendicitis and acute pain C) Appendicitis D) Acute pain

Ans: C Feedback: Medical diagnoses identify diseases (in this case, appendicitis). Nursing diagnoses describe problems treated by the nurse within the scope of independent nursing practice.

13. A nurse is reviewing the health history and physical assessment findings for a client 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? A) "I often have diarrhea after I eat spicy foods." B) "My skin is so dry I just can't keep from scratching." C) "I get out of breath when I walk a few steps." D) "I just feel so bad about myself these days."

Ans: C Feedback: Most experienced nurses begin the work of interpreting and analyzing data while they are still collecting it. The term cue is often used to denote significant data, which "raises a red flag" to look for patterns or clusters of data that signal a nursing diagnosis. In this instance, the client's statement of getting out of breath when walking would be a cue to assess other subjective and objective data related to the respiratory system.

31. Which of the following is a correctly written client goal? A) The client will eliminate a soft formed stool. B) The client understands what foods are low in sodium. C) The client will ambulate 10 feet with a walker by October 12. D) The client correctly self-administers the morning dose of insulin.

Ans: C Feedback: Outcomes are client-centered, use action verbs, identify measureable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (ambulate), how well (10 feet), under what circumstances (with a walker), and by when (October 12). Understand is vague and not action-oriented. The outcomes regarding eliminating a stool and self-administering insulin are missing the time frame.

12. During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived? A) The defining characteristics B) The related factors C) The problem statement D) The database Ans: C Feedback: Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement.

Ans: C Feedback: Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement.

29. A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan? A) Risk for impaired physical mobility due to surgery B) Ineffective denial related to poor coping mechanisms C) Disturbed body image related to the incision scar D) Risk of injury related to surgical outcomes

Ans: C Feedback: The client is concerned about the surgery scar on his neck, which would disturb his body image; therefore, the appropriate diagnosis should be disturbed body image related to the incision scar. Risk for impaired physical mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, ineffective denial related to poor coping mechanisms, and injury related to surgical outcomes are also not related to the client's concern.

34. While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing? A) The nurse bathing the client B) The nurse documenting the incident C) The nurse asking if the client is having pain D) The nurse removing the wash basin

Ans: C Feedback: The nurse asking if the client is having pain clearly demonstrates assessing. Bathing the client and removing the wash basin demonstrate implementation. Documentation is part of every step of nursing process.

7. In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process? A) To collect information about subjective and objective data B) To correlate nursing and medical diagnostic criteria C) To identify etiologies of health problems D) To evaluate mutually developed expected outcomes

Ans: C Feedback: The purpose of diagnosing, the second step in the nursing process, is to identify how an individual, a group, or a community responds to actual or potential health and life processes; to identify etiologies (factors that contribute to or cause health problems); and to identify resources or strengths that the individual, group, or community can draw on to prevent or resolve problems.

10. Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client? A) The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client. B) The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the client. C) The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it. D) The health care facility directs the nursing diagnosis in order to receive payment for services performed.

Ans: C Feedback: The term diagnosis means there is a problem requiring qualified treatment. The nurse must decide if he or she is qualified to make the diagnosis and will be able to treat it. If not, the nurse must refer the client to a qualified person for treatment.

14. Which of the following outcomes is correctly written? A) Abdominal incision will show no signs of infection. B) On discharge, client will be free of infection. C) On discharge, client will be able to list five symptoms of infection. D) During home care, nurse will not observe symptoms of infection.

Ans: C Feedback: To be measurable, outcomes should have a subject (client or part of the client), verb (action to be performed), conditions (not always included), performance criteria (observable, measurable), and target time (to achieve the outcome).

33. The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made? A) Expressed the client outcomes as a nursing intervention B) Wrote vague outcomes that will confuse other nurses C) Included more than one client behavior in the outcome D) Used verbs that are not observable and measurable

Ans: C Feedback: Two client behaviors have been included in the outcome statement: drawing up insulin and identifying four signs and symptoms.

20. Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client's situation? A) Kardex B) Case management C) Critical pathways D) Concept map care plan

Ans: D Feedback: A concept map care plan is a diagram of client problems and interventions. The nurse's ideas about client problems and treatments are the "concepts" that are diagrammed. These maps are used to organize client data, analyze relationships in the data, and enable the nurse to take a holistic view of the client's situation (Schuster, 2002).

16. A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the baby's strengths? A) Nothing; this observation is not important. B) The mother is just behaving as all mothers do. C) A baby is not capable of having strengths. D) Nurturing is a strength for developing infants.

Ans: D Feedback: A strength, as assessed by the nurse during data interpretation and analysis, contributes to a client's level of wellness. In this case, the obvious love of the mother for her baby indicates a significant strength in the normal growth and development of the baby.

25. A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem? A) "I have assessed you and find you are fatigued." B) "I analyzed and interpreted your information as fatigue." C) "Why are you so tired all the time?" D) "I think fatigue is a problem for you. Do you agree?"

Ans: D Feedback: After a tentative nursing diagnosis is made, it should be validated. Clients who are able to participate in decision making should be encouraged to validate the diagnosis.

27. According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? A) Ineffective airway clearance B) Ineffective coping C) Impaired urinary elimination D) Risk for body image disturbance

Ans: D Feedback: Risk for disturbed body image is the least priority among all the nursing diagnoses mentioned, according to the Maslow's hierarchy. Body image disturbance is not vital for life. Secondly, it is a potential diagnosis, not an actual diagnosis. The other options could be an actual diagnosis present in the client. Ineffective airway clearance is the most important diagnosis because it is vital to life. Impaired urinary elimination is the next most important diagnosis because it is a physiological need. Ineffective coping is a social need, followed by the least important diagnosis of disturbed body image.

7. What is the primary purpose of the outcome identification and planning step of the nursing process? A) To collect and analyze data to establish a database B) To interpret and analyze data so as to identify health problems C) To write appropriate client-centered nursing diagnoses D) To design a plan of care for and with the client

Ans: D Feedback: The primary purpose of outcome identification and planning is to design a plan of care for (and with) the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.

23. A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase "Disturbed Self-Esteem" identify? A) The expected outcome of the plan of care B) A cue to determining a health problem C) The major defining characteristic of a health problem D) The health state or problem of the client

Ans: D Feedback: The problem, a part of a nursing diagnosis, describes the health state or health problem of the client as clearly and concisely as possible. It identifies what is unhealthy about the client and what the client would like to change. It also suggests client outcomes but is not an outcomes statement.

15. 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? A) Trust clinical judgment and experience over asking for help. B) Respect clinical intuition, but never allow it to determine a diagnosis. C) Recognize personal biases as a strength in formulating diagnoses. D) Keep an open mind and trust your intuition when formulating diagnoses.

Ans: D Feedback: To correctly diagnose health problems, the nurse must be familiar with nursing diagnoses and other health problems; read professional literature and keep reference guides handy; trust clinical experience and judgment but be willing to ask for help when the situation demands more than his or her qualifications and experience can provide; respect clinical intuitions, but before writing a diagnosis without evidence, increase the frequency of observations and continue to search for clues to verify intuition. The nurse must also recognize personal biases and keep an open mind.

33. A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ... A) Categorizing B) Diagnosing C) Grouping D) Clustering

Ans: D Feedback:Cue clustering brings together cues that if viewed separately would not convey the same meaning.