Exam Review Questions
In order that they are clear and easily understood by other members of the health care team, the nurse recognizes that client goals or outcomes should be documented according to specific criterion. Of the following, the outcome statement that best meets the established criteria is: A. "Client will describe activity restrictions." B. "Client will verbalize understanding of treatments." C. "Client will be ambulated in hallway 3 times each day." D. "Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24
"Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24"
What patient statement provides subjective data? A. "I'm not sure that I am going to be able to manage at home by myself" B. "I can call a home-care agency if I feel I need help at home" C. "What should I do if I have uncontrollable pain at home?" D. "Will a home health aide help me with my care at home?"
"I'm not sure that I am going to be able to manage at home by myself"
A nurse responds to a patient's call bell. Which patient statement is subjective data? A. "I just went in the urinal and it needs to be emptied" B. "My pain feels like a 5 on a scale of 0 to 5" C. "The physician said I can go home today" D. "I ate only 50% of my breakfast"
"My pain feels like a 5 on a scale of 0 to 5"
A nurse is caring for a patient with a urinary elimination problem. Which is most accurately stated goal? "The patient will: A. Be taught how to use a bedpan when on bed rest" B. Experience fewer incontinence episodes at night" C. Transfer independently and safely to a toilet before discharge" D. Be assisted to the commode every two hours and whenever necessary"
"Transfer independently and safely to a toilet before discharge"
A patient with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died! I've always been a failure. Nothing ever goes right for me." Which response demonstrates therapeutic communication? A. "You have everything to live for." B. "Why do you see yourself as a failure?" C. "Feeling like this is all part of being depressed." D. "You've been feeling like a failure for a while?"
"You've been feeling like a failure for a while?"
When the community health nurse visits a patient at home, the patient states, "I haven't slept the last couple of nights." Which response by the nurse illustrates a therapeutic communication response to this patient? A. "I see." B. "Really?" C. "You've having difficulty sleeping?" D. "Sometimes, I have trouble sleeping too."
"You've having difficulty sleeping?"
What is the primary goal of the Assessment phase of the Nursing Process? A. Build trust B. Collect data C. Establish goals D. Validate the medical diagnosis
Collect data
A nurse determines that the appropriateness of a Nursing diagnosis is supported by its: A. Defining characteristics B. Planned interventions C. Diagnostic statement D. Related risk factors
Defining characteristics
A nurse evaluates a patient's response to a nursing intervention. To which aspect of the nursing process is this evaluation most directly related? A. Goal B. Problem C. Etiology D. Implementation
Goal
A nurse teaches a patient to use visualization to cope with chronic pain. Which step of the Nursing Process is associated with this nursing intervention? A. Planning B. Analysis C. Evaluation D. Implementation
Implementation
The nurse assesses a patient and collects a variety of data. Identify the human responses that are subjective data. (Select all that apply.) A. Nausea B. Jaundice C. Dizziness D. Diaphoresis E. Hypotension
Nausea, Dizziness
A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English." Which is the best action for the nurse to take? A. Have one of the client's family members interpret. B. Have the Spanish-speaking triage receptionist interpret C. Page an interpreter from the hospital's interpreter service D. Obtain a Spanish-English dictionary and attempt to triage the client.
Page an interpreter from the hospital's interpreter service
Determining what nursing actions will be employed occurs in which step of the Nursing Process? A. Implementation B. Assessment C. Planning D. Analysis
Planning
What word is most closely associated with scientific principles? A. Data B. Problem C. Rationale D. Evaluation
Rationale
The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, "I am too afraid I will fall." The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis
Reexamine the nursing orders
Which nurse is demonstrating the assessment phase of the nursing process? A. The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals
The nurse who ask the client how much lunch he or she ate.
A patient experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the use to encourage that patient to eat? A. Using open-ended questions and silence B. Sharing personal preference regarding food choices C. Documenting reasons why the patient does not want to eat D. Offering opinions about the necessity of adequate nutrition
Using open-ended questions and silence
The nurse is caring for a client admitted to the hospital with severe left-sided flank pain and hematuria. Diagnostic tests indicate a kidney stone partially obstructing the left ureter. Which of the following outcomes is the most important for this client? A. Verbalizes understanding of the disease process B. Pain controlled with medication C. Tolerates diet without nausea and vomiting D. Adequate urinary elimination is maintained
Adequate urinary elimination is maintained
Which word best describes the role of the nurse when using the Nursing Process to meet the needs of the patient holistically? A. Teacher B. Advocate C. Surrogate D. Counselor
Advocate
The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein diet C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness
Risk for impaired skin integrity related to malnutrition
A nurse collects data about a patient. What should the nurse do next? A. Plan nursing interventions B. Write patient-centered goals C. Formulate nursing diagnoses D. Determine significance of the information
Determine significance of the information
During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved? A. Implementation B. Evaluation C. Planning D. Analysis
Evaluation
Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation
Evaluation
The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible evaluation statement would be: A. Goal met; client able to state three symptoms B. Goal not met; client able to list three symptoms C. Goal not met; client unable to list five symptoms D. Goal partially met; client able to state three symptoms
Goal partially met; client able to state three symptoms
What is the primary reason why a nurse performs as admission assessment of a newly admitted patient? A. Diagnose if the patient is at risk for falling B. Ensure that the patient's skin is intact C. Establish a therapeutic relationship D. Identify important data
Identify important data
In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens
Include the client and family when setting goals and formulating the plan of care
Of the following statements, which one is an example of an example of an appropriately written nursing diagnosis? A. Risk for change in body image related to cancer B. Cardiac output decreased related to motor vehicle accident C. Ineffective airway clearance related to increased secretions D. Potential for injury related to improper teaching in the use of crutches
Ineffective airway clearance related to increased secretions
The nurse has determined the following outcome for a client with a skin impairment. "Erythema will be reduced in 3 days." Evaluation will specifically focus on: A. Selection of appropriate wound care B. Notation of the odor and color of the drainage C. Inspection of the color and condition of the area D. Measurement of the diameter of the ulceration daily
Inspection of the color and condition of the area
Which human response identified by the nurse is an example of objective data? A. Irregular radial pulse of 50 beats per minute B. Pain rated as 5 on a 0-10 pain scale C. Shortness of breath D. Dizziness
Irregular radial pulse of 50 beats per minute
The concept that is the cornerstone of the Nursing Process is that it: A. Is dynamic rather than static B. Focuses on the role of the nurse C. Moves from a simple to the complex D. Is based on the patient's medical problem
Is dynamic rather than static
A nurse is caring for a patient with a fever. Which is a well-designed goal for this patient? "The patient will: A. Have a lower temperature B. Be taught how to take an accurate temperature C. Maintain fluid intake sufficient to prevent dehydration D. Be given aspirin every eight hours whenever necessary
Maintain fluid intake sufficient to prevent dehydration
The nurse in the emergency department cares for a patient diagnosed with a possible cervical spinal cord injury. It is most important for the nurse to assess for which of the following? A. How the accident occurred B. Status of neurological functioning C. Respiration and heart rate D. Pre-existing medical conditions
Respiration and heart rate
The nurse in the mental health unit recognizes which of the following as therapeutic communication techniques? Select all that apply. A. Restating B. Listening C. Asking the patient "Why?" D. Maintaining neutral responses E. Providing acknowledgment and feedback F. Giving advice and approval or disapproval
Restating, Listening, Maintaining neutral responses, Providing acknowledgment and feedback
What should the nurse do during the Evaluation step of the nursing process? A. Establish outcomes B. Determine priorities C. Revise a plan of care D. Set the time frames for goals
Revise a plan of care
The nurse finds a visitor slumped over on the floor of a patient's room during visiting hours at the hospital. Initially, the nurse should take which of the following actions? A. Start rescue breathing and chest compressions B. Call for help C. Shake the patient and shout, "Are you all right?" D. Listen for breath sounds
Shake the patient and shout, "Are you all right?"
