fundamental quiz 2
Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients? A) "Assessment data about the client should be collected continuously." B) "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." C)stable." "Assess your client at least hourly if the client's vital signs are unstable, and every two hours if the vital signs are D) "Assessment data should be collected prior to the physician rounding on the unit."
A) "Assessment data about the client should be collected continuously."
Which of the following examples of client data needs to be validated? Select all that apply. A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall. C) A nurse examining a client with a respiratory infection documents fever and chills. D) A client in a nursing home states that she is unable to eat the food being served. E) A pregnant client is experiencing contractions that are two minutes apart.
A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis? A) A cluster of several significant cues of data that suggest a particular health problem B) A single, definitive cue that is closely associated with a common diagnosis C) A cue that can be verified by objective, medical data D) A group of related nursing diagnoses that exist within the same NANDA-approved domain
A) A cluster of several significant cues of data that suggest a particular health problem
After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data? A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach
A) Auscultation of the lungs
The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? A) Clarify discrepancies of assessment data with the client. B) Validate client data with members of the health care team. C) Document all data collected in the nursing history and physical examination. D) Seek input from family members regarding the client's breathing at home.
A) Clarify discrepancies of assessment data with the client.
A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information? A) Client'swife B) Medical documents C) Test results D) Assessment data
A) Client'swife
Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply. A) Diet and exercise program B) Standing in the community C) Ability to pay for services D) Developmental stage E) Need for nursing
A) Diet and exercise program D) Developmental stage E) Need for nursing
In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is "presence of large scar over left side of face"? A) Etiology B) Problem C) Defining characteristics D) Client need
A) Etiology
The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? A) Human Needs (Maslow) model B) Functional Health Patterns model C) Human Response Patterns model D) Body System model
A) Human Needs (Maslow) model
After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? A) Impaired urinary elimination B) Readiness for enhanced sleep C) Risk for infection D) Possible impaired adjustment
A) Impaired urinary elimination
In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis? A) Ineffective airway clearance as evidenced by inability to clear secretions B) Ineffective health maintenance as evidenced by unhealthy habits C) Ineffective breathing pattern related to pneumonia D) Ineffective therapeutic regimen management due to smoking
A) Ineffective airway clearance as evidenced by inability to clear secretions
The nurse observes the client as he walks into the room. What information will this provide the nurse? A) Information regarding the client's gait B) Information regarding the client's personality C) Information regarding the client's psychosocial status D) Information on the rate of recovery from surgery
A) Information regarding the client's gait
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis? A) Is written as a two-part statement B) Describes human response to a health problem C) Describes potential for enhancement to a higher state D) Made when not enough evidence supports the problem
A) Is written as a two-part statement
The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures
A) Measure the client's oral temperature.
The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures.
A) Measure the client's oral temperature.
A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing good health habits. What conclusion did the nurse reach after interpreting and analyzing the data? A) No problem B) Possible problem C) Actual problem D) Clinical problem
A) No problem
Which of the following is a correct guideline to follow when composing a nursing diagnosis statement? A) Place defining characteristics after the etiology and link them by the phrase "as evidenced by." B) Phrase the nursing diagnosis as a client need. C) Place the etiology prior to the client problem and linked by the phrase "related to." D) Incorporate subjective and judgmental terminology.
A) Place defining characteristics after the etiology and link them by the phrase "as evidenced by."
A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he "can't live with this fear." Which of the following diagnoses for this client is correctly written? A) Post-trauma syndrome related to being attacked B) Psychological overreaction related to being attacked C) Needs assistance coping with attack D) Mental distress related to being attacked
A) Post-trauma syndrome related to being attacked
A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the 4. client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? A) Presuming to know the factors contributing to the problem B) Identifying a problem that cannot be changed C) Identifying a problem without corroborating evidence in the statement D) Neglecting to identify potential complications related to the problem
A) Presuming to know the factors contributing to the problem
After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. what are the nursing diagnoses used? A) Selecting nursing interventions to meet expected outcomes B) Establishing a database of information for future comparison C) Mutually establishing desired outcomes of the plan of care D) Evaluating the effectiveness of the established plan of care
A) Selecting nursing interventions to meet expected outcomes
The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue? A) Sharp pain in the knee B) Small bloody drainage on dressing C) Temperature of 102 degrees F D) Pulse rate of 90 beats per minute
A) Sharp pain in the knee
The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following? A) The client is more vulnerable to certain problems than other individuals would be. B) The diagnoses present significant risks for the development of medical diagnoses. C) The data necessary to make a definitive nursing diagnosis is absent. D) The diagnosis has yet to be confirmed by another practitioner.
A) The client is more vulnerable to certain problems than other individuals would be.
An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The client's airway should be assessed. B) The nurse should determine the reason for admission. C) The nurse should review the client's medications. D) The client's past medical history is assessed.
A) The client's airway should be assessed.
Which of the following data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply. A) The client's chemotherapy causes him nausea and loss of appetite. B) The client became teary when his daughter from out of state came to the bedside. C) The client's ileostomy put out 125 mL of effluent in the past four hours. D) The patient is unwilling to manipulate or empty his ostomy bag. E) The patient has been experiencing fatigue in recent weeks.
A) The client's chemotherapy causes him nausea and loss of appetite. E) The patient has been experiencing fatigue in recent weeks.
Which of the following reflects the diagnosis phase? A) The nurse identifies that the client does not tolerate activity. B) The nurse performs wound care using sterile technique. C) The nurse sets a tolerable pain rating with the client. D) The nurse documents the client's response to pain medication.
A) The nurse identifies that the client does not tolerate activity.
A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies. B) The nurse should modify data collection tool. C) The nurse should determine specific purpose of data collection. D) The nurse should update the database.
A) The nurse should practice interviewing strategies.
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) To identify a life-threatening problem B) To establish a database for medical care C) To practice respiratory assessment skills D) To facilitate the resident's ability to breathe
A) To identify a life-threatening problem
When documenting subjective data, the nurse should do which of the following? A) Use the client's own words placed in quotation marks. B) Paraphrase the information stated by the client. C) Validate the information with the client's family prior to documentation. D) Record the information using nonspecific words.
A) Use the client's own words placed in quotation marks.
The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis? A) V alidate the nursing diagnosis B) Identify potential complications C) Cross-reference the nursing diagnosis with medical diagnoses D) Modify interventions based on the diagnosis
A) V alidate the nursing diagnosis
A nurse writes the following nursing diagnosis for a client with Alzheimer's disease: Disturbed Thought Processes related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement? A) disturbed thought processes B) related to C) Alzheimer's disease D) incoherent language
A) disturbed thought processes
A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation? Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the A) situation afterward. B) Encourage the novice nurse to develop his or her own tool for data collection. Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the C) correct interpretation. Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for D) communication skills.
A.) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward.
Which of the following questions or statements would be an appropriate termination of the health history interview? A) "Well, I can't think of anything else to ask you right now." B) "Can you think of anything else you would like to tell me?" C) "I wish you could have remembered more about your illness." D) "Perhaps we can talk again sometime. Goodbye."
B) "Can you think of anything else you would like to tell me?"
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Possible nursing diagnosis D) Wellness diagnosis
B) Actual nursing diagnosis
The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply. A) Dysphagia B) Bowel Incontinence C) Impaired Swallowing D) Impaired Physical Mobility E) Risk for Hemiparesis
B) Bowel Incontinence C) Impaired Swallowing D) Impaired Physical Mobility
A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern? A) Impaired physical mobility B) Disturbed body image C) Risk for infection D) Risk for social isolation
B) Disturbed body image
When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focused C) General D) Time-lapse
B) Focused
A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do? A) Initial assessment B) Focused assessment C) Emergency assessment D) Time-lapsed assessment
B) Focused assessment
A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A) Initial assessment B) Focused assessment C) Time-lapsed reassessment D) Emergency assessment
B) Focused assessment
Which of the following client care concerns is clearly a nursing responsibility? A) Prescribing medications B) Monitoring health status changes C) Ordering diagnostic examinations D) Performing surgical procedures
B) Monitoring health status changes
A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital 20. signs. Which of the following data collected can be classified as subjective data? A) Blood pressure B) Nausea C) Heart rate D) Respiratory rate
B) Nausea
What is the nurse accountable for, according to the state nurse practice act? A) Continuing education B) Nursing diagnoses C) Prescribing medications D) Mentoring other nurses
B) Nursing diagnoses
A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario? A) No problem B) Possible problem C) Actual problem D) Clinical problem
B) Possible problem
A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? A) Number of rooms in the house B) Safety of the immediate environment C) Frequency of home visits to be made D) Friendliness of the client and family
B) Safety of the immediate environment
What is the focus of a diagnostic statement for a collaborative problem? A) The client problem B) The potential complication C) The nursing diagnosis D) The medical diagnosis
B) The potential complication
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A) "Do you have a family history of chest problems?" B) "Why don't you use a laxative every night?" C) "Do you take anything to help your constipation?" D) "Everyone who ages has bowel problems."
C) "Do you take anything to help your constipation?"
A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this 13. problem? A) "I often have diarrhea after I eat spicy foods." B) "My skin is so dry I just can't keep from scratching." C) "I get out of breath when I walk a few steps." D) "I just feel so bad about myself these days."
C) "I get out of breath when I walk a few steps."
A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual? A) "Can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."
C) "Mr. Koeppe, tell me what you do to take care of yourself."
Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview? A) "Why didn't you go to the doctor when you began to have this pain?" B) "Are you feeling better now than you did during the night?" C) "Tell me more about what caused your pain." D) "If I were you, I would not wait to get medical help next time."
C) "Tell me more about what caused your pain."
A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct? A) "needs nasal oxygen to improve breathing" B) "cough related to ineffective airway clearance" C) "ineffective airway clearance related to thick mucus" D) "refuses to cough and expectorate thick mucus"
C) "ineffective airway clearance related to thick mucus"
The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse recognizes this information is an example of what? A) Subjective data B) A data cue C) An inference D) Primary data
C) An inference
A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart:"appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis? A) Neither appendicitis nor acute pain B) Both appendicitis and acute pain C) Appendicitis D) Acute pain
C) Appendicitis
A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan? A) Risk for impaired physical mobility due to surgery B) Ineffective denial related to poor coping mechanisms C) Disturbed body image related to the incision scar D) Risk of injury related to surgical outcomes
C) Disturbed body image related to the incision scar
Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses? A) Defining the domain of nursing practice B) Informing patients of their care C) Improving communication among nurses D) Structuring curricular content
C) Improving communication among nurses
While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and 34. documents the event in the client's chart. Which of the following actions clearly demonstrates assessing? A) The nurse bathing the client B) The nurse documenting the incident C) The nurse asking if the client is having pain D) The nurse removing the wash basin
C) The nurse asking if the client is having pain
Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client? A) The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client. The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the B) client. C) The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it. D) The health care facility directs the nursing diagnosis in order to receive payment for services performed.
C) The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it.
When a life-threatening physiologic or psychological crisis occurs, the nurse performs an emergency assessment to identify life-threatening problems. Emergency assessments are not used to establish a database for medical care, practice assessment skills, or help a physiologic process (such as breathing). A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment? A) Comprehensive B) Focused C) Time-lapsed D) Emergency
C) Time-lapsed
In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process? A) To collect information about subjective and objective data B) To correlate nursing and medical diagnostic criteria C) To identify etiologies of health problems D) To evaluate mutually developed expected outcomes
C) To identify etiologies of health problems
A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply. A) Carrying out a physician's order to intubate a client B) Educating a novice nurse on the principles of triage C) Using the nursing process to diagnose a blocked airway D) Interviewing privately a client suspected of being a victim of abuse E) Checking with the family about the data supplied by a client suffering from dementia
C) Using the nursing process to diagnose a blocked airway D) Interviewing privately a client suspected of being a victim of abuse E) Checking with the family about the data supplied by a client suffering from dementia
A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client's physiologic response. This action is known as a: A) medical diagnosis. B) nursing diagnosis. C) collaborative problem. D) goal for care.
C) collaborative problem.
10. Of the following information collected during a nursing assessment, which are subjective data? A) vomiting, pulse 96 B) respirations 22, blood pressure 130/80 C) nausea, abdominal pain D) pale skin, thick toenails
C) nausea, abdominal pain
A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem? A) "I have assessed you and find you are fatigued." B) "I analyzed and interpreted your information as fatigue." C) "Why are you so tired all the time?" D) "I think fatigue is a problem for you. Do you agree?"
D) "I think fatigue is a problem for you. Do you agree?"
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A) "My leg hurts so bad. I can't stand it." B) "Appears anxious and frightened." C) "I am so sick; I am about to throw up." D) "Unable to palpate femoral pulse in left leg."
D) "Unable to palpate femoral pulse in left leg."
A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ... A) Categorizing B) Diagnosing C) Grouping D) Clustering
D) Clustering
Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process? A) Trust clinical judgment and experience over asking for help. B) Respect clinical intuition, but never allow it to determine a diagnosis. C) Recognize personal biases as a strength in formulating diagnoses. D) Keep an open mind and trust your intuition when formulating diagnoses.
D) Keep an open mind and trust your intuition when formulating diagnoses.
A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse 16. about the baby's strengths? A) Nothing; this observation is not important. B) The mother is just behaving as all mothers do. C) A baby is not capable of having strengths. D) Nurturing is a strength for developing infants.
D) Nurturing is a strength for developing infants.
According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? A) Ineffective airway clearance B) Ineffective coping C) Impaired urinary elimination D) Risk for body image disturbance
D) Risk for body image disturbance
A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase "Disturbed Self-Esteem" identify? A) The expected outcome of the plan of care B) A cue to determining a health problem C) The major defining characteristic of a health problem D) The health state or problem of the client
D) The health state or problem of the client
The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? A) To gather data about a specific and current health problem B) To identify life-threatening problems that require immediate attention C) To compare and contrast current health status to baseline data D) To establish a database to identify problems and strengths
D) To establish a database to identify problems and strengths
What is the primary purpose of validation as a part of assessment? A) To identify data to be validated B) To establish an effective nurse-client communication C) To maintain effective relationships with coworkers D) To plan appropriate nursing care
D) To plan appropriate nursing care
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself? A) Standing at the end of the bed B) Standing at the side of the bed C) Sitting at least six feet from the beside D) sitting at a 45-degree angle to the bed
D) sitting at a 45-degree angle to the bed
