EAQ #2 Nursing Process

Which assessment data would cause the nurse to suspect that a toddler-age child is experiencing physical neglect?

Abdominal distention

Which organization provides scope and practice guidelines on the roles and responsibilities for nursing and nursing specialties?

American Nurses Association The American Nurses Association develops and publishes scope and standards of practice guidelines for nursing and nursing specialties.

The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client?

Assessment

The nurse is interviewing a client for admission to the hospital. Which phase of the nursing process is being used in this situation?

Assessment

Which skill in critical thinking requires the nurse to be orderly in data collection?

Interpretation

Which level of Maslow's hierarchy of needs is the nurse using when she teaches the client about the call light system?

Safety

Which related factor is appropriate for a nursing diagnosis?

Trauma of incision

The nurse has gathered data on a newly admitted client and is attempting to write the nursing diagnoses and develop a plan of care. Which would the nurse be aware of when using the problem, etiology, signs and symptoms (PES) format?

Nursing interventions are derived from the etiology statement

Which client assessment finding would the nurse document as subjective data?

Pain rating of 5

Which statement made by the client illustrates the love and belonging need based on Maslow's hierarchy of needs?

"I hardly speak to my children because they live in different countries."

Which statement of the client would illustrate the self-esteem need based on Maslow's hierarchy of needs?

"I tend to get worried about every little thing because I cannot do anything successfully."

Which situation would the nurse address first according to Maslow's hierarchy?

Complains of sleeplessness due to pain postsurgery

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

Planning

A client who was involved in an accident says, "I have a dream of conquering the world's highest mountain range." According to Maslow's hierarchy of needs, to which level of need does the given scenario refer?

Self-actualization needs The self-actualization need refers to self-fulfillment. Physiological needs refer to the need for clean air, water, and food. Self-esteem needs refer to self-confidence, usefulness, achievement, and self-worth. Safety and security needs refer to physical and psychological security.

The nurse creates a plan of care for a client with a risk of infection. Which is the desirable expected outcome for the client?

The client will be free of signs and symptoms of infection by discharge

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data?

The client's pain is 7 on a scale of 1 to 10.

A client says, "I feel frustrated because I do not spend enough time with my partner because of my job." According to Maslow's hierarchy of needs, which level of need does the given scenario refer?

Third level, which includes love and belonging needs The love and belonging need is the third level of need in the Maslow's hierarchy of needs. This includes maintaining friendships, social relationships, and intimate relationships. In the given scenario, the client demonstrates that he or she wants to spend more time with his or her partner. Thus this is an example of the third level of needs.

A group of individuals is working as a team in a rehabilitation program. Which nursing team member has the responsibility for acting as the team leader?

RN

Which definition is correct to explain the nursing process?

Sequence of steps used to meet the client's needs The nursing process is a step-by-step method that scientifically provides for a client's nursing needs. Procedures used to implement client care, activities employed to identify a client's problem, and mechanisms applied to determine nursing goals for the client are only steps in the nursing process.

Which step in the nursing process involves the nurse interviewing a client about a current health problem and taking the client's vital signs?

assessment