CLINICAL 3

Which of the following is an example of a direct, closed-ended question? A. "How many times in the last month have you slipped and fallen?" B. "Is there anything else you can tell me about this situation?" C. "Tell me about your balance issues." D. "You're losing your balance more often than before, right?"

"How many times in the last month have you slipped and fallen?" Rationale: "How many times in the last month have you slipped and fallen?" is an example of a direct, closed-ended question. "Is there anything else you can tell me about this situation?" is an example of a probing question. "Tell me about your balance issues." is an example of an open-ended question. "You're losing your balance more often than before, right?" is an example of a leading question.

The first step of the nursing process is assessment. What action do you perform during assessment? A. Acquire and validate information about the patient's health B. Collaborate with the patient and family to prioritize interventions C. Identify a pattern to reach a diagnostic conclusion D. Provide direct care

Acquire and validate information about the patient's health Rationale: During assessment you acquire and validate information about the patient's health. Collaborating with the patient and family to prioritize interventions is done during the planning stage. Identifying a pattern to reach a diagnostic conclusion is done during the diagnosis stage. Providing direct care is done during the implementation stage.

What action should you take if you have not used a particular piece of equipment before? A. Ask an experienced nurse to provide guidance B. Delegate the task to a more experienced nurse C. Guess at the equipment's operation D. Refuse to use the equipment

Ask an experienced nurse to provide guidance Rationale: If you have not used a particular piece of equipment before, research its operation first and seek out another nurse who has used the equipment correctly and safely to provide you with assistance and guidance. Do not delegate the task or guess at the equipment's operation. Do not refuse to use the equipment if knowledgeable assistance is available.

Which of these methods could be used to determine a patient's expectations of care? A. Asking the patient if she received all the information she needed to care for her surgery incision. B. Asking the patient to demonstrate how to perform wound care. C. Measuring the patient's wound and comparing it against previous measurements. D. Rating the patient's pain using an agency-approved pain scale and determining that the patient's pain was within the target parameters.

Asking the patient if she received all the information she needed to care for her surgery incision. rationale: Asking the patient is the best way to determine if the patient's expectations of care are being met. Asking the patient to demonstrate how to perform wound care is a way to verify patient understanding of wound care. Measuring the patient's wound and comparing it against previous measurements is a way to determine a pattern of improving or worsening health. Assessing that the patient's pain is within acceptable limits is a way of determining that a pain control goal or outcome is being met.

What is it called when you reinforce your interest in what a patient has to say by using active listening prompts such as "go on" or "uh-huh"? A. Back channeling B. Observation C. Leading questions D. Probing

Back channeling Rationale: Reinforcing your interest in what a patient has to say by using active listening prompts such as "go on" or "uh-huh" is called back channeling. With observation, you observe a patient's nonverbal communication to gain information about the patient's condition. Leading questions suggest a specific answer. This can be a risky interview tool because the patient may tell you what he or she thinks you want to hear. Probing is a technique that uses open-ended questions to prompt more complete answers.

What is an example of a document that provides standard interventions for common health care problems? A. Clinical practice guideline B. Healthcare provider-initiated actions C. Individualized nursing care plan D. NOC

Clinical practice guideline Rationale: Clinical practice guidelines are sets of statements about appropriate health care for specific health care problems or clinical situations. Health care provided-initiated interventions are dependent nursing interventions that require an order from a health care provider. An individualized nursing care plan has been customized for the patient's unique situation. NOC (Nursing Outcomes Classification) links outcomes to nursing diagnoses.

When formulating a nursing diagnosis, which of these should you do first? A. Cluster assessment data into meaningful patterns. B. Interpret assessment information. C. Find and select the specific diagnoses that fit your patient. D. Refer to the official ICNP® or NANDA-I list to verify accurate use of the nursing diagnostic label.

Cluster assessment data into meaningful patterns. Rationale: These steps should be completed in the following order: cluster your assessment data into meaningful patterns, interpret assessment information, find and select the specific diagnoses that fit your patient, and verify accurate use of the nursing diagnostic label.

1. The third step of the nursing process is planning. What action do you perform during planning? A. Acquire and validate information about the patient's health. B. Collaborate with the patient and family to prioritize interventions. C. Identify a pattern to reach a diagnostic conclusion. D. Provide direct care.

Collaborate with the patient and family to prioritize interventions. Rationale: Acquiring and validating information about the patient's health is done during assessment. Collaborating with the patient and family to prioritize interventions is done during the planning stage. Identifying a pattern to reach a diagnostic conclusion is done during the diagnosis stage. Providing direct care is done during the implementation stage.

One of the patient's goals is for her surgery incision to remain free of infection. At her follow up, the wound looks good but has not completely healed yet. As a result, the goal of remaining free of infection should be ___________ on the care plan. A. Continued B. Deleted C. Discontinued D. Revised

Continued Rationale: The goal of remaining free from infection should be continued on the care plan until the wound is healed. The goal of remaining free from infection should not be discontinued, deleted, or revised until the wound is healed.

The fifth step of the nursing process is evaluation. What action do you perform during evaluation? A. Collaborate with the patient and family to prioritize interventions. B. Determine whether goals and outcomes have been achieved. C. Identify a pattern to reach a diagnostic conclusion. D. Provide direct or indirect care.

Determine whether goals and outcomes have been achieved. Rationale: Determining whether goals and outcomes have been achieved is done during the evaluation stage. Collaborating with the patient and family to prioritize interventions is done during the planning stage. Identifying a pattern to reach a diagnostic conclusion is done during the diagnosis stage. Providing direct or indirect care is done during the implementation stage.

Changing the bandage on a patient's wound is an example of which type of care? A. Direct care B. Indirect care C. Patient-centered goal D. Patient-centered outcome

Direct care Rationale: Direct care actions are those that the nurse provides directly to the patient (such as wound care). Indirect care actions are those that are provided indirectly but are still done on the patient's behalf (such as a consultation with another health care provider). A goal describes the change you are striving to achieve. An expected outcome is the change that must be achieved in order to meet a goal.

3. What type of nursing diagnosis applies when a patient has an interest in improving his or her health status by making behavioral changes? A. Health promotion nursing diagnosis B. Medical diagnosis C. Problem-focused nursing diagnosis D. Risk nursing diagnosis

Health promotion nursing diagnosis Rationale: Health promotion nursing diagnoses identify a patient's desire or motivation to improve health status through a change in the patient's behavior. A medical diagnosis is not a nursing diagnosis. Problem-focused nursing diagnoses identify an undesirable human response to a patient's existing problems or concerns. Risk nursing diagnoses apply when a patient has an increased likelihood of developing a problem or complication.

The second step of the nursing process is diagnosis. What action do you perform during diagnosis? A. Acquire and validate information about the patient's health. B. Collaborate with the patient and family to prioritize interventions. C. Identify a pattern to reach a diagnostic conclusion. D. Provide direct care.

Identify a pattern to reach a diagnostic conclusion. Rationale: Identifying a pattern to reach a diagnostic conclusion is done during the diagnosis stage. Acquiring and validating information about the patient's health is done during assessment, not diagnosis. Collaborating with the patient and family to prioritize interventions is done during the planning stage. Providing direct care is done during the implementation stage.

During the patient interview, the patient shows signs of acute respiratory distress. What should you do next? A. Continue the interview so you can get the whole picture before taking action. B. Immediately assess the affected body system. C. Reassure the patient that everything will be all right. D. Refer the patient to his or her primary health care provider.

Immediately assess the affected body system. Rationale: If a patient experiences acute distress, stop the interview and immediately assess the affected body system. Notify the practitioner. Take action immediately, rather than refer a patient in acute distress to his or her primary health care provider. Do not continue the interview or general assessment until the acute symptoms are resolved. Do not provide false reassurance.

Which of the following is an example of a problem-focused nursing diagnostic statement? A. Chronic obstructive pulmonary disease. B. Impaired nutritional status: deficient food intake related to inability to absorb nutrients. C. Readiness for enhanced knowledge of smoking cessation. D. Risk for fall related to generalized weakness.

Impaired nutritional status: deficient food intake related to inability to absorb nutrients. C. Readiness for enhanced knowledge of smoking cessation. Rationale: Impaired nutritional status: deficient food intake related to inability to absorb nutrients is an example of a problem-focused nursing diagnostic statement. Chronic obstructive pulmonary disease is an example of a medical diagnosis, not a nursing diagnosis. Readiness for enhanced knowledge of smoking cessation is an example of a health promotion diagnosis. Risk for fall related to generalized weakness is an example of a risk diagnosis.

Two nurses work together to reposition a patient in bed to aid to facilitate pressure injury prevention. This is an example of which kind of intervention? A. Collaborative nursing intervention B. Dependent nursing intervention C. Independent nursing intervention D. Interdependent nursing intervention

Independent nursing intervention Rationale: This is an example of an independent nursing intervention. Independent nursing interventions are that the nurse completes autonomously. Dependent nursing interventions require an order from a health care provider. Other provider interventions are interdependent(also called collaborative) interventions that require the combined knowledge, skill, and expertise of other or multiple health care providers.

Consulting with another health care provider about patient care is an example of which type of care? A. Direct care B. Indirect care C. Patient-centered goal D. Patient-centered outcome

Indirect care Rationale: Indirect care actions are those that are provided indirectly but are still done on the patient's behalf (such as a consultation with another health care provider). Direct care actions are those that the nurse provides directly to the patient (such as wound care). A goal describes the change you are striving to achieve. An expected outcome is the change that must be achieved in order to meet a goal.

You are assessing a patient's pain-relief goal. The patient self-reports his pain as a 1 on a scale of 0 to 10. You note that the patient is grimacing, bracing his incision site, and is reluctant to move. Additional pain medication is available on request, but the patient has not requested it. What is your next step? A. Ask the patient's wife if the patient is in more pain than he is admitting. B. Bring the patient the additional pain medication he has not requested. C. Consider his goal as being met and accept that his pain is under control, based on the patient's self-report. D. Investigate his obvious discomfort.

Investigate his obvious discomfort. Rationale: Investigate the patient's obvious discomfort. Understand the patient's situation, reflect on the situation, and correct any identified errors. The patient is the best source of information on his level of pain. Do not bring the patient the additional pain medication. Do not consider his pain control goal as met until you have investigated his nonverbal behavior.

In which order should nursing diagnoses be listed in the patient's record? A. List nursing diagnoses by how quickly each condition can be resolved. B. List nursing diagnoses solely in alphabetical order. C. List nursing diagnoses from highest priority to lowest priority, and in chronological order. D. List nursing diagnoses from lowest priority to highest priority, in alphabetical order.

List nursing diagnoses from highest priority to lowest priority, and in chronological order. Rationale: List nursing diagnoses from highest priority to lowest priority, and in chronological order. Do not list nursing diagnoses in alphabetical order, or by how quickly each condition can be resolved.

An intervention that addresses a patient's long-term health care needs, rather than a specific illness, would generally be assigned which priority? A. High B. Intermediate C. Low D. It would not be assigned a priority

Low Rationale: Nursing diagnoses that focus on a patient's long-term health care needs, rather than a specific illness, are assigned a low priority. In general, high-priority nursing diagnoses are those that sustain life and preserve function. Intermediate-priority nursing diagnoses are those that are not life-threatening, but are still illness-related (such as infection prevention). All patient health care needs are assigned a priority.

What do standing orders include? A. Assistance in selecting a nursing diagnosis B. Equipment operation instructions C. Medical orders for routine therapies D. The interprofessional care plan

Medical orders for routine therapies Rationale: A standing order is a preprinted document containing medical orders for routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. After completing a standing order, the nurse notifies the health care provider. A standing order does not help you select a nursing diagnosis or aid in the operation of equipment. Interprofessional care plans are patient care plans that include contributions from all of the disciplines involved in a patient's care, rather than standing orders.

The fourth step of the nursing process is implementation. What action do you perform during implementation? A. Acquire and validate information about the patient's health. B. Collaborate with the patient and family to prioritize interventions. C. Identify a pattern to reach a diagnostic conclusion. D. Provide direct or indirect care.

Provide direct or indirect care. Rationale: Acquiring and validating information about the patient's health is done during the assessment stage. Providing direct or indirect care is done during the implementation stage. Collaborating with the patient and family to prioritize interventions is done during the planning stage. Identifying a pattern to reach a diagnostic conclusion is done during the diagnosis stage.

What type of nursing diagnosis applies when a patient has an increased likelihood of developing a problem or complication? A. Health promotion nursing diagnosis B. Medical diagnosis C. Problem-focused nursing diagnosis D. Risk nursing diagnosis

Risk nursing diagnosis Rationale: Risk nursing diagnoses apply when a patient has an increased likelihood of developing a problem or complication. Health promotion nursing diagnoses identify a patient's desire or motivation to improve health status through a change in the patient's behavior. A medical diagnosis is not a nursing diagnosis. Problem-focused nursing diagnoses identify an undesirable human response to a patient's existing problems or concerns.

During the interview, the patient provides information about his or her symptoms and health status. What is this data called? A. Invalid data B. Objective data C. Perceptual data D. Subjective data

Subjective data Rationale: Subjective data is the patient's account of his or her feelings, perceptions or health problem, in the patient's own words. Objective data include verifiable, concrete observations and measurements of a patient's health status. Invalid data refers to data element values that are outside of the range of allowable values or are presented in an incorrect format, such as when entering information into a computer program. Perceptual data is data perceived via sensory input.

You determine that a patient is not meeting a nutritional goal because he is not following the mutually agreed-upon dietary plan. What is your next step? A. Ask the nutritionist to speak with the patient B. Emphasize the importance of following the dietary plan C. Label the patient noncompliant and discontinue that part of the plan D. Understand why the patient is not following the plan

Understand why the patient is not following the plan Rationale: Understand why the patient is not following the plan. Simply emphasizing the importance of the plan is unlikely to yield different results. Avoid labeling a patient as noncompliant and before asking a nutritionist to speak with the patient, first understand why the patient is not following the plan. Many factors can impact dietary compliance including religion, culture, language and learning considerations.