Fund. Ch.13 PrepU
An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will:
create an exercise plan that is realistic and valued.
A nurse is working with a group of staff members to address the needs of a client as they develop the client's interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group's thinking?
"Is there another way to look at this situation?"
The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds:
"We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time."
A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask?
"What happened?"
Which are characteristics of reasoning? Select all that apply.
*Is based on assumptions *Has a purpose *Contains inferences *Has implications
Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)?
A client report of shooting pain up the left leg
A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which action best demonstrates the nursing skill of caring in this situation?
Assisting the client to sit up in a chair
The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client?
Administer a high-calorie diet, excluding wheat, rye, and oats.
The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?
Analyze the data and create an individualized nursing diagnosis.
To implement the most effective care for clients in an acute care facility, which is the most appropriate action for a new nurse to take?
Apply theoretical knowledge to present clinical situations
A nurse technician is assigned to take clients' vital signs. When making rounds, the nurse notices that one client's vital signs are very different from what they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings?
Assess the client's vital signs again.
A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?
Assessment
Which step of the nursing process involves reporting or analysis of data to identify and define health problems?
Diagnosis
The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying?
Developing accountability
Which action should the nurse associate with outcome identification and planning in the nursing process?
Develops an individualized plan of nursing care
A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process?
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 reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?
Document this assessment based on the client's behaviors.
Which is an important element of implementation?
Documentation
The nurse assesses a client's blood pressure, which is 160/90 mm Hg. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure, finding it to be 140/78 mm Hg. Which action has the nurse implemented?
Evaluating
Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill?
Intellectual
Which statement best conveys the role of intuition in nurses' problem solving?
Intuition can be a clinically useful adjunct to logical problem solving.
client is admitted to the hospital with an abscess on the leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and intravenous antibiotics. The nurse begins to prepare for this admission. What type of problem solving does this exhibit?
Intuitive
Which is a characteristic of person-centered care?
It is a framework for providing care.
A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?
Nursing process
A nurse is evaluating a client's care. During this phase of the nursing process, which behavior by the nurse indicates critical thinking?
Outcome attainment
Which are characteristics of one who has developed critical thinking skills?
Self-aware, honest, persistent, and authentic
A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?
Planning
The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?
Planning; implementing
What is the most beneficial use of the nursing process in addressing the needs of the client?
Provides a universally applicable framework for nursing activities
The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action?
Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.
Which is the best example of person-centered care provided by a registered nurse?
Reassuring a client who is anxious about a procedure
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.
In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged?
Reevaluating experience in light of ideas
Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?
Reflection
The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis?
Risk for falls
Which statement is true of the nursing process?
Scientific problem solving can occur within the nursing process.
The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?
Show respect for the client, and engage in open communication in getting to know the client.
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).
What is the purpose of the diagnosis phase of the nursing process?
To develop a prioritized list of client-centered problems
Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:
uses critical thinking to direct care for the individual client.
Which statements are true about the implementation phase of the nursing process? Select all that apply.
*Care provided during implementation should be documented in the client's chart. *Implementation is the process of carrying out the plan of care. *This phase promotes wellness and restores health.
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 evaluates the client and finds that pain is a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment?
0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered.
A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented?
Clinical reasoning
The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?
Modify the plan of care and interventions to meet the client's needs.
The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time?
Terminate the plan of care because evaluation reveals that the outcome has been met.
The nurse is caring for a pediatric client with respiratory distress. Upon assessment the client has increased respirations and work of breathing (WOB). Breath sounds are adventitious and the client has thick yellow/green drainage coming from the nose. Based on these findings, the nurse determines that this client has an ineffective airway clearance related to copious amounts of thick secretions and proceeds to perform nasopharyngeal suctioning to relieve some of the secretions. If the nurse were documenting the evaluation of this intervention, what would be documented?
The amount and type of drainage suctioned from the nares, and the client's response
After analyzing the assessment data of a morbidly obese client, the nurse includes the nursing diagnosis of Altered nutrition: more than body requirements in the client's plan of care. Which is the best example of outcome identification and planning for this client using the nursing process?
The nurse involves the client in developing a comprehensive and individualized plan of care with specific outcomes.
A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is 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 the 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 identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified:
outcome.
Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. This process is referred to as:
reflective practice
The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply
*Evaluation is the last part of the nursing process. *Evaluations should be documented daily in the client's record. *The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.
A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply.
*Impaired mobility *Imbalanced nutrition *Ineffective coping
A nurse is engaged in the assessment phase of the nursing process. When completing the physical exam, which techniques would the nurse likely use? Select all that apply.
*Inspecting *Auscultating *Percussing *Palpating
Which statements are true about informatics in nursing practice? Select all that apply.
*Nurses should value technologies that support error prevention and care coordination. *The use of informatics can help manage knowledge and mitigate error. *Utilization of information services helps to support decision making.
Which statements describe the common use of problem solving in the nursing process? Select all that apply.
*The scientific problem-solving method is closely related to the more general problem-solving process (the nursing process) commonly used by health care professionals as they work with clients. *Today, nurses acknowledge the positive role of intuitive thinking in clinical decision-making. *Critical thinking in nursing can be intuitive or logical or a combination of both.
Put the phases of the nursing process in the correct order. Use all options.
*assessment *diagnosis *planning *implementation *evaluation
The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm?
Cognitive and technical skills
Which activity is the clearest example of the evaluation step in the nursing process?
Checking the client's blood pressure 30 minutes after administering captopril
A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:
complete the postoperative assessment.
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.
The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?
involving the client with all the steps of the process in care development
What result is the most appropriate outcome for the nursing diagnosis of Impaired Urinary Elimination? The client will:
maintain urine output of 30 mL/hr.
