Exam 2 PrepU
The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? "I will take insulin until my blood sugar levels are normal." "I will take my medications between meals for maximum effect." "I will mix insulin glargine with insulin lispro at bedtime." "I will test my glucose level before meals and use sliding scale insulin."
"I will test my glucose level before meals and use sliding scale insulin."
Which example of client care is not the responsibility of the nurse? Monitoring for changes in health status Promoting safety and preventing harm; detecting and controlling risks Tailoring treatment and medication regimens for each individual Confirming a medical diagnosis
Confirming a medical diagnosis
The nurse is assessing a client in the community. To obtain a relative estimate of the client's skeletal mass, the nurse will take which measurement? midarm circumference body mass index (BMI) triceps skinfold measurement abdominal circumference
midarm circumference
A client is caring for the client's mother-in-law, who is an older adult who requires assistance with performing activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain? "I just don't have time to take a shower." "I feel great but wish that I could get more sleep." "My mother-in-law and I go for a walk daily." "My mother-in-law makes dinner on Tuesdays, and I cannot stand her cooking."
"I just don't have time to take a shower."
The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met? "I take extra calcium to make my bones stronger." "I removed scatter rugs from my home." "I walk daily wearing low-heeled shoes." "I turn on lights at night so I won't fall."
"I walk daily wearing low-heeled shoes."
The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns? "Leaning forward may help you to breathe better." "Running short distances can help you breathe better." "Take short and shallow breaths instead of deep breathing." "Do not practice pursed lip breathing, as this is a contraindication."
"Leaning forward may help you to breathe better."
The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate? "Nursing interventions are selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." "The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions." "Nursing interventions should be consistent with standards of nursing care and research findings." "Nursing interventions are pretty much the same for clients that have the same medical diagnosis."
"Nursing interventions are pretty much the same for clients that have the same medical diagnosis."
The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse? "You need to stop smoking for us to effectively combat this disease." "Please tell me your thoughts about treating this diagnosis." "Do you want to be discharged without treatment?" "What are your plans after discharge?"
"Please tell me your thoughts about treating this diagnosis."
A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrointestinal symptoms or should be reported to the physician. Which action should the nurse perform next? Call the family. Consult with another nurse. Chart the information. Wait and see whether the pain subsides.
Consult with another nurse.
A nurse identifies the following nursing diagnosis for a client with an infected leg ulcer: "Deficient Knowledge related to diminished peripheral circulation and wound care as evidenced by recurrent infected leg ulcer." Which statement would the nurse identify as addressing a cognitive outcome? "The client states the reason for wound care measures." "The client demonstrates how to irrigate leg wound." "Client chooses correct size of dressing to cover the wound." "Client verbalizes being motivated to continue follow-up to prevent recurrence."
"The client states the reason for wound care measures."
Which statement by a nurse best indicates an accurate understanding of the different types of assessments? "It is up to the nurse to decide which assessment to perform." "How much time the nurse has and how the client is feeling determine which type of assessment to perform." "The purpose for the assessment offers guidance for which type and how much data to collect." "The physician informs the nurse of which type of assessment to perform for each client."
"The purpose for the assessment offers guidance for which type and how much data to collect."
The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding? "We need to validate the information obtained in this assessment." "Crackles indicate that your child may have an allergy." "We will share this assessment finding with the physical therapist." "This is a normal finding and nothing of concern."
"We need to validate the information obtained in this assessment."
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?" "Do you have any additional questions for me?" "Why do you feel that way about your cancer diagnosis?" "Have you ever heard the saying 'no pain no gain?'"
"When did you first notice the rash on your leg?"
The nurse is documenting morning care for a client with diabetes. Which documentation is most appropriate for this client? 8:00: Pt is resting in bed and appears to be comfortable. 0800: Resting in bed, eating some breakfast. Complains of headache. 0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10. 0800: Side rails up, call light in reach. Bed in high position.
0800: Consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.
The nurse is performing an admission assessment. Which are considered objective data? Select all that apply. 38-year-old man Height: 6 ft (1.82 m) Weight: 195 lb (89 kg) "My leg hurts." "I am afraid something serious is wrong."
38-year-old man Height: 6 ft (1.82 m) Weight: 195 lb (89 kg)
The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. What type of data should the nurse review prior to caring for this client? Select all that apply. Consultations Lab reports Medical history Progress notes Financial history X-ray reports
Consultations Lab reports Medical history Progress notes X-ray reports
The nurse has been assigned to a group of clients. Which client should be the nurse's priority? A 68-year-old client who had total hip replacement surgery 6 hours ago and is reporting moderate discomfort at the surgical site. A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue. An 82-year-old client with emphysema who is receiving 2 liters of oxygen and is concerned about a pulse oximetry reading of 91%. A 48-year-old client with a hemoglobin of 9.5 g/dl (95 g/l) who is receiving ferrous sulfate supplements and is reporting feeling tired.
A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue.
For which client would a standardized plan of care most likely be appropriate? A client who was admitted for shortness of breath and who has been diagnosed with pneumonia A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident
A client who was admitted for shortness of breath and who has been diagnosed with pneumonia
A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? A client with a high fever receiving intravenous fluids, antibiotics, and oxygen An older adult with pneumonia who is being discharged to the son's home tomorrow A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall An adult client who is being treated for kidney stones
A client with a high fever receiving intravenous fluids, antibiotics, and oxygen
A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client? A full assessment of the urinary system A focused assessment of the specific problems identified Obtaining a detailed assessment of the client's sexual history Conducting a thorough systems review to validate data on the client's record
A focused assessment of the specific problems identified
A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? A plan designed to support the client physically A plan derived from a consensus of opinions of all staff members A plan with problems that are easily solved A plan made in conjunction with the hospital's ethics committee
A plan designed to support the client physically
A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using? A standardized care plan An order set Guidelines An algorithm
A standardized care plan
Which is the priority question for the nurse to consider before implementing a new intervention? Does this treatment make sense for this client? How much experience do I have with this treatment? What equipment do I need? Will I need someone to assist me?
Does this treatment make sense for this client?
A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing, for which the nurse identifies several nursing diagnostic labels, including Ineffective Breathing Pattern and Impaired Gas Exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern? Activity-exercise Nutritional-metabolic Coping-stress tolerance Cognitive-perceptual
Activity-exercise
After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? Health promotion Actual Risk Possible
Actual
A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care? Add the nursing diagnosis: Risk for Self-Harm. Tell another nurse about this client statement. Encourage the client to join a therapy group. Document that the depression has resolved.
Add the nursing diagnosis: Risk for Self-Harm.
The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview? Inform the client that the interview must proceed before getting anything that will alter sensorium. Administer prescribed pain medication prior to conducting the interview. Document that the client refused the interview. Use the information that is on the electronic health record and eliminate the need for the interview.
Administer prescribed pain medication prior to conducting the interview.
Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training? Validation is an important part of assessment. Validation helps to keep data as free from error as possible. All data collected need to be validated. Validation is the act of confirming or verifying.
All data collected need to be validated.
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? Interrupted Breastfeeding Ineffective Thermoregulation Altered Gas Exchange Impaired Parenting
Altered Gas Exchange
The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply. Interview the client as part of the admission assessment. Provide education to the client, including discharge instructions. Ask the client questions regarding personal care needs. Demonstrate and teach new caregiving procedures to the family. Counsel the client about making adjustments to a new medical condition. Orient the client and family to the room, including the call light button.
Ask the client questions regarding personal care needs. Orient the client and family to the room, including the call light button.
A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate? Ask the client whether the heart rate is normal for the client. Compare the client's heart rate to that another teenaged client. Have another nurse reassess the heart rate for accuracy. Determine whether the client has any risk factors for cardiac disease.
Ask the client whether the heart rate is normal for the client.
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 cholesterol levels. Obtain an electrocardiogram daily. Assess blood pressure with a large cuff. Begin client education regarding a low-fat diet.
Assess blood pressure with a large cuff.
When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next? Assess the client's interactions with the newborn. Direct all education of infant care to the client's mother. Initiate referrals to available community services. Develop a comprehensive education plan for infant care.
Assess the client's interactions with the newborn.
For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment? Focused Psychosocial Physical Initial
Initial
A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing Inadequate Hygiene related to homelessness as evidenced by client's stink Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing
Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor
A nurse has selected a nursing diagnosis and is preparing to validate it. With whom would the nurse do this? Another staff nurse Client's health care provider Client The unit's nurse manager
Client
A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem? Client will alternate rest periods with exercise throughout the day. Client will increase protein intake in small frequent meals. Client will use oxygen by nasal cannula when short of breath. Client will consistently perform pulmonary exercises.
Client will alternate rest periods with exercise throughout the day.
A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective? Client will use chin tuck and double swallow for each bite. Client will avoid straws and drink thickened liquids. Client will sit in chair for all meals and snacks. Client will chew food well and use a tongue sweep.
Client will use chin tuck and double swallow for each bite.
Nurses on an orthopedic nursing unit use standardized care plans that incorporate nursing, physical therapy, occupational therapy, and case management actions for clients who experience a particular surgery. Which type of care plan do these nurses use? Clinical pathway Computer database Nursing diagnosis Concept map
Clinical pathway
While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis? Collect client subjective and objective data. Establish short- and long-term client goals. Perform a focused assessment related to the reason for admission. Verify the primary care provider's written orders.
Collect client subjective and objective data.
Which guideline should the nurse follow when including interventions in a plan of care? Make sure the nursing interventions are unrelated to the original outcomes. Date the nursing interventions when written and when the plan of care is reviewed. Make sure the attending physician approves of and signs the nursing interventions. Make sure each nursing intervention does not describe the action the nurse should perform.
Date the nursing interventions when written and when the plan of care is reviewed.
The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? Continue the education and remind the client that it is essential to learn self-care. Medicate the client for anxiety and continue the education later. Discontinue the education and attempt at another time. Discontinue the education and ask the client for permission to teach a family member.
Discontinue the education and attempt at another time.
After a client has a myocardial infarction, the nurse formulates a possible nursing diagnosis of "Powerlessness." To determine the accuracy of the diagnosis, what would be the nurse's most appropriate action? Determine the extent of cardiac tissue damage. Discuss the client's health condition with the client. Assess the client's knowledge of risk factors. Identify the client's support systems.
Discuss the client's health condition with the client.
A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem? Disturbed Body Image related to breast cancer Disturbed Body Image related to loss of hair Disturbed Body Image as evidenced by client's refusal to look at self Disturbed Body Image as evidenced by client's negative comments
Disturbed Body Image related to loss of hair
A nursing unit was recently audited. Which findings would indicate to the nursing supervisor that the nurses are adhering to the principles of defensible charting? Select all that apply. Documenting entries that have unidentifiable writers' names and titles Documenting entries that are up to date and comprehensive Recording the date and time of all entries Documenting entries that are subjective Using approved agency abbreviations
Documenting entries that are up to date and comprehensive Recording the date and time of all entries Using approved agency abbreviations
A 24-year-old client presents to the emergency department with signs and symptoms of a sickle cell crisis. The nurse quickly obtains the necessary laboratory tests to assist with the assessment, as well as conducts an assessment of the client to determine the proper nursing care the client will require. Which type of assessment did the nurse perform in this situation? Emergency Focused Initial Comprehensive
Emergency
A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? Head-to-toe Focused Emergency Time-lapse
Focused
Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? Initial Focused Emergency Time-lapse
Focused
Which piece of client information is subjective? A temperature of 102°F (38.9°C) Leukoplakia on the client's oral mucosa Generalized myalgia or muscle pain Alert and oriented to person and place but not time or situation Ptosis, a drooping of the eyelid, on the right side
Generalized myalgia or muscle pain
A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? High Risk for Injury related to abusive parents High Risk for Injury related to impaired home management Child Abuse related to unsafe home environment High Risk for Injury related to unsafe home environment
High Risk for Injury related to unsafe home environment
A nurse is caring for a marathon runner who collapsed while running in extremely warm weather. Upon admission, the client's temperature is 102°F (38.9°C). What is the most appropriate nursing diagnosis? Dehydration Hyperthermia Heat Exhaustion Electrolyte Imbalance
Hyperthermia
The sclerae of a 3-day-old infant have a yellowish tint, and the nurse has just received an order to initiate phototherapy. Which nursing diagnosis should the nurse use to plan care for this client? Risk for Neonatal Jaundice Neonatal Jaundice Risk for Visual Deficit Visual Deficit
Neonatal Jaundice
Which best describes the purpose of nursing diagnoses? Identification of client problems that nurses can treat independently Identification of signs and symptoms that identify diseases Identification of client problems that require collaboration with other health care professionals to treat Identification of actual client problems, not including potential problems
Identification of client problems that nurses can treat independently
A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information? If the client is in bed, the nurse stands at the foot of the bed. If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. If the client is in bed, the nurse stands at the side of the bed.
If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.
Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight? Anorexia Nervosa Lack of Adequate Nutrition Weight Loss Imbalanced Nutrition: Less than Body Requirements
Imbalanced Nutrition: Less than Body Requirements
These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 2Fluid Volume Deficit 3Risk for Impaired Skin Integrity 1Impaired Swallowing 4Altered Body Image
Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image
The client is admitted to the surgical unit following an exploratory laparotomy. Which nursing diagnosis is the priority? Deficient knowledge Impaired skin integrity Risk for imbalanced body temperature Fear/anxiety
Impaired skin integrity
A nursing diagnosis of Ineffective Airway Clearance has been chosen by the nurse caring for a client with respiratory problems. Which assessment data would be appropriate evidence of this diagnosis? Select all that apply. Ineffective cough Wheezes auscultated over all lung fields Labored respirations Viral pneumonia Oxygen at 3 L/min per nasal cannula
Ineffective cough Wheezes auscultated over all lung fields Labored respirations
A teenager on life support after a diving accident has no brain wave activity. The parents tell the nurse they are sure their child will wake up soon. Which nursing diagnosis would the nurse identify to assist the parents of the child? Interrupted Family Processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon Interrupted Family Processes related to brain death of their child as evidenced by parents' refusal to accept the inevitable Death Anxiety related to anticipated death of child as evidenced by child having no brain wave activity Death Anxiety related to dysfunctional family processes as evidenced by parents' refusal to acknowledge the child's condition
Interrupted Family Processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon
The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing? Nursing diagnoses remain the same for as long as the disease is present. Nurses formulate nursing diagnoses to identify diseases. Nurses write nursing diagnoses to describe client problems that nurses can treat. Nursing diagnoses focus on identifying healthy responses to health and illness.
Nurses write nursing diagnoses to describe client problems that nurses can treat.
A computerized information system developed to classify client outcomes is the: NANDA-International list Nursing Outcome Classification system International Classification of Diseases Clinical Care Classification System
Nursing Outcome Classification system
The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? Registered nurse Nursing assistant A senior nursing student present for clinical Licensed practical nurse
Nursing assistant
The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? Registered nurse Nursing assistant who is a nursing student A senior nursing student present for clinical Licensed practical nurse
Nursing assistant who is a nursing student
Which are criticisms that have been made of the use of nursing diagnoses in nursing practice? Select all that apply. Nursing diagnoses apply limits to nursing practice. Nursing diagnoses discourage innovative thinking. Nursing diagnoses focus on negative client factors. Nursing diagnoses promote a paternalistic attitude in health care providers. Nursing diagnoses are confused with medical diagnoses in the health care community.
Nursing diagnoses apply limits to nursing practice. Nursing diagnoses discourage innovative thinking. Nursing diagnoses focus on negative client factors. Nursing diagnoses promote a paternalistic attitude in health care providers.
The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case? Obtaining data regarding the amount and frequency of drinking Interviewing friends to ascertain the client's exercise habits Asking the client to discuss social functioning Performing an abdominal assessment
Obtaining data regarding the amount and frequency of drinking
The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. Which is most likely the cause of this action by the client? Hunger Low anxiety Pain Sleepiness
Pain
Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? Revise the care plan to allow the client to ambulate to the bathroom independently. Continue assisting the client to the bathroom to ensure the client's safety. Consult with the physical therapist to determine the client's ability. Instruct the client's family to assist the client to ambulate to the bathroom.
Revise the care plan to allow the client to ambulate to the bathroom independently.
When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform hand-washing. What is the nurse's most appropriate action? Inform the client that it is not necessary to wash hands before vital signs. Reassure the client that the nurse knows when to perform hand hygiene. Praise the client for taking an active role in the client's care. Tell the client that gloves are required for this procedure
Praise the client for taking an active role in the client's care.
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? Maintenance Surveillance Psychomotor Psychosocial
Psychomotor
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? Cover the infant. Ask the parent whether the child has been exposed to cold temperatures. Assess the skin for signs of cyanosis. Recheck the temperature, paying close attention to technique.
Recheck the temperature, paying close attention to technique.
Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure? Reporting signs and symptoms related to the client's kidney failure Independently managing the client's kidney failure Coordinating the treatment of the client's kidney failure Choosing interventions to resolve the client's kidney failure
Reporting signs and symptoms related to the client's kidney failure
A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement? Adjust expected outcome to have client ambulate a shorter distance. Return the client to bed and provide pain relief measures. Ask the client to describe a personal walking goal. Review evidence-based interventions for the client's pain.
Return the client to bed and provide pain relief measures.
What should the nurse do prior to performing an initial assessment on a newly admitted client? Introduce the members of the health care team to the client. Review the records available on the client. Report to the charge nurse what needs to be done for the client. Tell the client that the nurse will do an assessment only if it's convenient.
Review the records available on the client.
Which is an accurately phrased risk nursing diagnosis? Risk for Impaired Coping as evidenced by client crying Risk for Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda Risk for Pain After Surgery Risk for Falls related to altered mobility
Risk for Falls related to altered mobility
Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease? Impaired Physical Mobility Risk for Injury Self-Care Deficit Impaired Memory
Risk for Injury
A nursing student is writing a student care plan for an assigned client. When identifying specific interventions to be used, which aspect would the student need to include with the interventions? Scientific rationales Outcome criteria Goals Nursing orders
Scientific rationales
A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care? Consult with another nurse. Seek research about the disorder. Follow institutional guidelines. Set priorities using client care standards.
Seek research about the disorder.
Which action should the nurse perform during the planning step of the nursing process? Interprets and analyzes the client data Establishes a database for the client Identifies client strengths and weaknesses Selects nursing measures, including client education
Selects nursing measures, including client education
A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply. 4-year-old at 85 percentile of growth and development Stating "My legs feel like they are burning" Redness and blisters forming on both legs Respirations 18 breath/min and regular Crying and trying to scratch legs due to itching
Stating "My legs feel like they are burning" Redness and blisters forming on both legs Crying and trying to scratch legs due to itching
Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal? Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. Assist the client to put on the clothing that goes over the operated leg. Tell the client's family to bring in clothes a size larger to make dressing easier. Arrange for the social worker to schedule home health care with discharge planning.
Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.
When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate? The outcome is not observable or measurable. The outcome is not related to an independent nursing action. The outcome does not specify the conditions in which it will be achieved. The statement expresses a client outcome as a nursing intervention.
The outcome is not observable or measurable.
The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment? Supplement the client's information by speaking with family or friends. Limit the assessment to objective data. Obtain the client's records from admissions to other institutions. Perform the assessment in several short episodes rather than at one sitting.
Supplement the client's information by speaking with family or friends.
During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to: body systems. functional health patterns. human response patterns. human needs.
body systems.
Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply. The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse. The nurse seeks input from the UAP in planning the client's care for the shift. The UAP evaluates the client's response after implementing the task and then reports findings to the nurse.
The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse.
A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply. The client states, "I miss my wife every day." The client no longer indulges in usual activities. The client attempted suicide 1 month ago. The client keeps a picture of the client's wife at the bedside. The client states, "I have no interest in doing anything."
The client no longer indulges in usual activities. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything."
A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client? The client will perform range of motion exercises 3 times per day. Passive abduction with assistance The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day. The client performed active range of motion exercises only twice today but states a goal of 3 times per day tomorrow.
The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day.
Which outcome for a client with a new colostomy is written correctly? Explain to the client the proper care of the stoma by 3/29/20. The client will know how to care for the stoma by 3/29/20. The client will demonstrate proper care of the stoma by 3/29/20. The client will be able to care for stoma and cope with psychological loss by 3/29/20.
The client will demonstrate proper care of the stoma by 3/29/20.
A nurse is beginning the preparatory phase of the nursing interview for a client who fractured the left leg in a fall. Which nursing actions occur in this phase of the nursing interview? Select all that apply. The nurse ensures that the interview environment is private and comfortable. The nurse initiates the interview by stating the nurse's name and status. The nurse recapitulates the interview, highlighting key points. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. The nurse prepares to meet the client by reading current and past records and reports.
The nurse ensures that the interview environment is private and comfortable. The nurse arranges the seating in the interview room to facilitate an easy exchange of information. The nurse prepares to meet the client by reading current and past records and reports.
Which factor is most likely to contribute to the nurse making a diagnostic error? The client withholds information during the client assessment. The client's subjective and objective data are congruent. The subjective and objective data point to a specific health issue. The client expands on information previously provided.
The client withholds information during the client assessment.
The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases. The client is watching television. The client's family asks if the client is going to be okay.
The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases
A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? The nurse assesses the client's comfort and ability to participate in the interview. The nurse recapitulates the interview, highlighting important points. The nurse asks the client if there is anything else that needs to be divulged The nurse gathers all the information needed to form the subjective database.
The nurse assesses the client's comfort and ability to participate in the interview.
A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client? Posting the sign "NPO after midnight" over the bed Updating the diet orders in the client's plan of care Obtaining written consent for the diagnostic procedure Adding the diagnosis "Altered Nutrition, Less Than Required"
Updating the diet orders in the client's plan of care
The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next? Chart the data. Validate the data. Ignore the client's answer. Ignore the client's nonverbal behavior.
Validate the data.
While planning care for a client immediately after surgery, the nurse formulates a nursing diagnosis of "Risk for Injury." Which assessment data would be appropriate for the nurse to identify as possible etiologies for the diagnosis? Select all that apply. Visual deficit Effects of pain medications Impaired mobility Unfamiliarity with the hospital environment Two side rails up at all times
Visual deficit Effects of pain medications Impaired mobility Unfamiliarity with the hospital environment
A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements? a client who is homebound and needs skilled nursing care a client whose rehabilitation potential is not good a client whose status is stabilized a client who is not making progress in expected outcomes of care
a client who is homebound and needs skilled nursing care
A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: a guideline. an algorithm. a critical pathway. an order set.
a guideline.
A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease and their families. Providing this information is an example of: a referral. a consultation. conferring. reporting.
a referral.
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: a cue. an inference. duplicate data. erroneous data.
an inference.
The primary purpose of nursing implementation is to: improve the client's postoperative status. identify a need for collaborative consults. help the client achieve optimal levels of health. implement the critical pathway for the client.
help the client achieve optimal levels of health.
A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of: inconsistent cues. premature closure. clustering of cues. cluster interpretation.
premature closure.
