Exam 1

The novice nurse demonstrates proper understanding of collaborative problems by making which statement?

"A medical diagnosis of heart failure with the possible consequence of fluid in the lungs could lead to the collaborative problem of pulmonary edema."

The nurse has arranged to start an IV line for a client with pancreatitis. The nurse notes that the client appears anxious about the procedure. What is the most appropriate response by the nurse to decrease the client's anxiety?

"I will start an IV that will add fluids directly to the blood stream."

The nursing student is learning about the different types of assessments, when each type is used, and exactly how much information should be collected each time. Which of the following statements made by the nursing student indicates an understanding of the different types of assessments?

"The purpose for the assessment offers guidance for which type and how much data to collect."

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

"When did you first notice the rash on your leg?"

A nurse is collecting a health history on a client. When asked about alcohol, tobacco, and drug use, the client states, "I quit smoking 10 years ago." However, the nurse observes an open package of cigarettes in the client's shirt pocket. What is the most appropriate response by the nurse?

"You said that you do not smoke, but you have an open package of cigarettes in your pocket."

At 0730, the nurse notes that the client states that pain is a 7 on a scale of 0 to 10. Based on this assessment the nurse administers pain medication to the client. At 0800, the nurse evaluated the client and found that pain was a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment?

0730: Client's reports pain is a 7 on a scale of 0-10, Morpine sulfate 2 mg. IV administered.

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?

Assess blood pressure with a large cuff.

The nurse is communicating with a client who begins to cry. The nurse places a hand on the client's arm and sits quietly at the client's beside. What mode of communication is the nurse using to offer caring and comfort for the client?

Kinesthetic

The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?

Nurses write nursing diagnoses to describe client problems that nurses can treat.

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select?

Readiness for enhanced knowledge: childhood immunizations

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature paying close attention to technique

An older adult client's venous ulcer has become foul-smelling after she began using strips of a sheet to dress the wound when she ran out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances?

Risk for Infection related to knowledge deficit

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

Personal characteristics demonstrate that one has developed critical thinking. Characteristics of critical thinking include:

Self-aware, honest, persistent, and authentic.

the nurse is preparing to document the nursing diagnoses for a client. What is the most appropriate outcome for the nursing diagnosis of impaired gas exchange?

The client will maintain a pulse oximeter reading of greater than 94% (0.94 L).

Which of the following errors has the nurse made in formulating the nursing diagnosis: Pain related to nurse failing to administer pain med in a timely manner AEB client pain rating of 7 out of 10, client guarding abdominal incision, client ambulates slowly.

Used legally inadvisable terms

What information provides the nurse with accuracy when developing a nursing diagnosis?

a set of clinical cues

While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of which of the following?

an interference

A nurse is on his lunch break in the hospital cafeteria and sits at a table near a group of physicians eating their lunch. The nurse recognizes one of the physicians as being in charge of his clients. The nurse witnesses the physician point at the nurse and state, "That guy needs to get fired." The best response by the nurse would be to:

ask to speak to the physician in private and address any disrespectful remarks or behaviors.

The Canadian Nurses Association (CNA) has published the standards of care for which the nurse is responsible. The Standards of Practice are:

assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this?

client

A nursing student is learning about how to perform a thorough assessment in a health assessment class. Which of the following is the best source of information for the student to learn data collection for an assessment? You Selected:

client

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?

clinical reasoning

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization, or:

clustering

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client reports cramping pain in left foot. The nurse is doing what?

clustering significant data cues

When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is:

conveying information.

The nurse analyzes client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve. Which step of the nursing process is the nurse performing?

diagnosing

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

diagnosis

A nurse should have critical thinking attitudes to develop critical thinking skills. One attitude the nurse should possess is orderly thinking to do what is best. Which term best suits this attitude description?

discipline

A client is a poor historian of his past medical history. Whom should the nurse consult about the client's past history?

family

The nurse is caring for a patient with an IV infusion and notes an elevated BP, increased pulse and respirations, dyspnea, crackles, and neck vein distention. Based on the assessment, the nurse suspects:

fluid overload

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

ineffective airway clearance

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill?

intellectual

In order for a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?

intial

A nurse is performing a wet to dry dressing change on a client's lower abdomen. The nurse should be aware that which zone is the nurse encroaching on?

intimate

The nurse observing an interaction between a mother and her daughter appropriately identifies the interaction as which communication zone?

intimate

The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using:

intuitive problem identification.

A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is a newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in this client? The client will:

maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L).

A nurse suspects that a patient has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this patient?

possible

The nurse is reporting to an oncoming nurse about the care of a client using the SBAR format. The nurse informs the oncoming nurse that the client should continue to have neurolgoical checks every 2 hours and the nurse should report any alterations to the health care provider. In which section should this information be relayed?

recommendation

When writing an actual nursing diagnosis, the nurse includes the etiology that contributes to the current situation. This would be identified as: defining characteristics or related to factors?

related to factors

The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate?

risk nursing diagnoses

The client recently immigrated from Mumbai, India. The client was just admitted to the nurse's unit postoperatively following gallstone removal. The client does not speak the dominant language. When using the hospital's interpretive services, which is most important?

speak directly to the client

A nurse is developing a plan of care for a client with a chronic respiratory problem. When developing appropriate nursing diagnoses for this client, the nurse needs to keep in mind that:

the interventions planned must be within the nurse's scope of practice.

The nurse is developing and documenting a nursing diagnosis for a client. When formulating the nursing diagnosis, what guidelines should the nurse follow?

use accepted terms for the specific facility.