Fundamental Week 1 PrepU review
When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?
"Demonstrated steps" Avoid ambiguous terminology, such as "inadequate," "good," or "extremely well," which can be interpreted differently by different people.
The nurse determines that a client has not met the goal of consuming at least 80% of each meal served by a designated date. Which would be appropriate responses by the nurse to the client regarding this lack of goal attainment? Select all that apply
-"What kinds of things have we been doing to increase your appetite?" -"Do you think you could meet the goal if we check on it in one week or so?" -"Do you think it is possible that you will be able to eat 80% of the food served here?"
The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome? At the client's direction On 3/3 On 3/2 At the client's direction
At the client's direction
Which are examples of subjective data? Select all that apply. Anxiety Light-headedness Nausea Edema Laceration
Correct response: Anxiety Light-headedness Nausea Explanation: Subjective data are those that only the person experiencing them can perceive and report, such as anxiety, light-headedness, and nausea. Objective data are those that someone other than the person experiencing them can observe, such as edema and laceration.
A nurse obtaining the most important information first during an assessment of a client is primarily an example of the nurse being: A) purposeful. B) factual .C) complete. D) able to prioritize.
D) able to prioritize.It is essential to get the most important information first when doing an assessment. This is prioritizing. Being purposeful is when a nurse completes a task that has meaning for the client. Complete means that the information obtained is comprehensive. Factual is concerned with what is actually the case rather than interpretations of or reactions to a situation (for example, a diagnosis as opposed to a hunch).
Identifying the kind and amount of nursing services required is a possible solution for: inadequate staffing. nurses frustrated with substandard care. nurses who are bored. clients who fail to communicate their needs. SUBMIT ANSWER
Inadequate staffing. A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who refused to cooperate with the therapeutic regimen, while educating the client to become an assertive healthcare consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period. (less)
A nurse finds that a client is not achieving the set outcomes for care and reviews the plan. Which are appropriate actions for the nurse to take while reviewing the plan of care? Select all that apply.
Modify the nursing diagnosis. Make the outcome statement more realistic. Adjust the time limits on the outcome statement. Increase the complexity of the outcome statement
A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) American Association of Critical-Care Nurses (AACN) Quality and Safety Education for Nurses (QSEN) Peer review
Peer review Peer review is a process by which one nurse evaluates the performance of another in an effort to improve their professional performance. QSEN has as its goal the preparation of nurses with the knowledge, skills, and attitudes (KSAs) necessary to improve the quality and safety of healthcare systems. AACN strives to provide safe work environments and HCAHPS measures client satisfaction with health care.
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 Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda Correct response: Risk for Falls related to altered mobility Explanation: Risk for Falls related to altered mobility is an accurately phrased risk nursing diagnosis. It is a two-part statement that contains the diagnostic statement (Risk for Falls) and risk factors (altered mobility).Two of the options (Risk for Impaired Coping and Risk for Fluid Volume Excess) incorrectly pair actual presenting manifestations, also called defining characteristics (client crying, consuming 3 L of soda), with a risk statement. Another option (Risk for Pain After Surgery) does not include a risk factor.
A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem? The client can demonstrate the correct technique for using a new glucometer. The client has maintained blood glucose levels within acceptable range in the days prior to discharge. The client is able to explain when and why the client needs to check the blood glucose level. The client expresses a desire to change the way that the client eats and exercises.
The client is able to explain when and why he needs to check his blood sugar. The ability to describe the rationale and technique for blood glucose monitoring indicates that the client has achieved a cognitive outcome.Demonstration of the technique constitutes a psychomotor outcome, while the expression of a desire for change is an affective outcome.The maintenance of healthy blood sugars is a physiologic outcome.A psychomotor outcome involves changes in the client's values, beliefs, and attitude. Psychomotor outcomes describe the client's achievement of new skills, such as correct ambulation with a walker.An affective outcome involves changes in the client's values, beliefs, and attitude, such as the client's report of cycling.
The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which should the nurse recognize as an example of outcome evaluation? A 4% increase in the number of baccalaureate-prepared nurses employed in the facility Bed occupancy rates of 97% in the critical care areas and 92% in the non-critical care areas A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery A rate of 98% of clients admitted to the hospital who had a nursing history completed within 24 hours after admission
You Selected: A rate of 98% of clients admitted to the hospital who had a nursing history completed within 24 hours after admission Correct response: A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery Explanation: Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Structure evaluation focuses on the environment in which care is provided, such as the number of baccalaureate-prepared nurses employed in the facility and bed occupancy rates. Process evaluation focuses on the nature and sequence of activities carried out by nursing implementing the nursing process, such as a rate of 98% of clients admitted to the hospital who had a nursing history completed within 24 hours after admission.
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.
You Selected: An 82-year-old client with emphysema who is receiving 2 liters of oxygen and is concerned about a pulse oximetry reading of 91%. Correct response: A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue. Explanation: The client receiving the intravenous antibiotic may be experiencing a possible airway obstruction secondary to an allergic reaction and should be the nurses first priority. Caring for a postoperative client reporting pain is important, but the client is not at risk of further deterioration if not cared for immediately. A client with an oxygen saturation of 91% is within normal limits and not the nurse's priority. A client with a low hemoglobin and symptoms of anemia is not in eminent danger and not the nurse's first priority.
45 A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? Client will have formed stools within 24 hours. Client will eat small meals of bland foods for 3 days. Client will identify the food that caused the condition within 3 hours. Client will maintain adequate hydration within 2 days.
You Selected: Client will eat small meals of bland foods for 3 days. Correct response: Client will have formed stools within 24 hours. Explanation: Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.
When developing a nursing diagnosis for a client, which should the nurse do first? Identify the significant data Cluster the cues Synthesize cue clusters Validate the diagnosis
You Selected: Cluster the cues Correct response: Identify the significant data Explanation: The first step in developing a nursing diagnosis is to look at the data for significant cues. After identifying significant data or cues, the nurse then groups the cues together to form meaningful clusters that describe specific client problems. Cluster interpretation involves synthesizing the cue clusters, to see the whole picture and attach meaning to the cluster. After developing the nursing diagnosis, the nurse should validate it with the client.
40 After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? Document the interventions and the result. Reassess the client for improvement in 30 minutes. Communicate with the physician for additional orders. Determine the client's code status in case of an emergency.
You Selected: Determine the client's code status in case of an emergency. Correct response: Communicate with the physician for additional orders. Explanation: If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care.
The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next? Recheck the client's pulse in 2 hours. Recheck the client's pulse at the next scheduled assessment time and document the findings on the chart. Document the findings on the chart and recheck in 1 hour. Notify the physician of the change and document the finding. Notify the physician after the next scheduled assessment time if the pulse is unchanged.
You Selected: Document the findings on the chart and recheck in 1 hour. Correct response: Notify the physician of the change and document the finding. Explanation: When a pulse deficit is present, the radial pulse rate is always lower than the apical pulse rate. The nurse should document and report to the physician any new finding of a pulse deficit immediately so that evaluation and follow-up can occur. The nurse should not wait until after rechecking the pulse to document the finding or report it to the physician.
A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern? Risk for Powerlessness Disturbed Body Image Impaired Comfort Risk for Suicide
You Selected: Impaired Comfort Correct response: Risk for Powerlessness Explanation: The most appropriate nursing diagnosis for the client is the Risk for Powerlessness. The client feels that the disease is not under the client's control and any personal efforts will not affect outcome. Disturbed Body Image is not an appropriate answer because the client does not seem to be concerned about the appearance of the body. Impaired Comfort is also not an appropriate nursing diagnosis because the client does not demonstrate any sign of discomfort. There is not enough indication that the client is at risk for suicide.
Which is the best example of a nursing diagnosis? Gastroesophageal Reflux related to low stomach pH as evidenced by foul breath and burning sensation in throat. Ineffective Airway Clearance as evidenced by client not speaking. Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. Cellulitis related to infection as evidenced by warm, reddened skin.
You Selected: Ineffective Airway Clearance as evidenced by client not speaking. Correct response: Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. Explanation: Ineffective breastfeeding contains all the correct and necessary components of a nursing diagnosis. Both Gastroesophageal Reflux and Cellulitis are medical diagnoses. Ineffective Airway Clearance is an appropriate diagnostic label. However, a client not speaking does not match the diagnosis.
A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? Knowledge Deficit: Medications related to new medical diagnosis Ineffective Airway Clearance related to bronchial constriction Noncompliance related to deficient knowledge of a new medical diagnosis Anticipatory Grieving related to chronic illness management
You Selected: Ineffective Airway Clearance related to bronchial constriction Correct response: Knowledge Deficit: Medications related to new medical diagnosis Explanation: To most appropriately address the client's health problem, the nurse should educate the client about the new medications the physician has prescribed to treat the asthma. Ineffective Airway Clearance refers to the physiologic processes of asthma. There is no evidence of noncompliance. There is no indication that the client is having difficulty dealing with the diagnosis
A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem? Risk for Unstable Blood Glucose related to client's reluctance to manage the diabetic regimen Ineffective Health Maintenance related to client's denial of illness Risk for Injury related to client's mismanagement of disease Ineffective Coping related to client's inability to manage the diabetic regimen
You Selected: Ineffective Coping related to client's inability to manage the diabetic regimen Correct response: Ineffective Health Maintenance related to client's denial of illness Explanation: The most appropriate diagnosis is Ineffective Health Maintenance related to client's denial of illness. The data point to the fact that the client is not managing the diabetes, since the client denies that a problem exists. The client is at risk for unstable blood glucose, but the client's denial is the underlying problem. Risk for Injury relates to safety issues. It is also inappropriate documentation to say the client is "mismanaging" the illness. Ineffective Coping could be an appropriate diagnosis, but the client is not "unable" to manage the illness, just unwilling.
A client is brought to the emergency room in respiratory arrest and is immediately intubated and placed on mechanical ventilation. What is the most appropriate nursing diagnosis for this client? Ineffective spontaneous ventilation Ineffective breathing pattern Ineffective airway clearance Impaired gas exchange
You Selected: Ineffective airway clearance Correct response: Ineffective spontaneous ventilation Explanation: Ineffective spontaneous ventilation is the most appropriate nursing diagnosis for the client because the client unable to breathe as the result of respiratory failure. Ineffective breathing pattern is appropriate when the client can breathe on one's own but has difficulty breathing due to a high respiratory rate. Ineffective airway clearance is an inaccurate diagnosis here because the airways are clear and not blocked by secretions. Additionally, the diagnosis of impaired gas exchange is inappropriate because there is no known lung pathology or anemia.
A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis? Impaired Respiration Ineffective Airway Clearance Altered Airway Infection (Pulmonary)
You Selected: Infection (Pulmonary) Correct response: Ineffective Airway Clearance Explanation: Ineffective Airway Clearance is a plausible nursing diagnosis for a client with pneumonia. The other listed options are not recognized NANDA nursing diagnoses.
A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing? Focused Initial Emergency Time-lapse
You Selected: Initial Correct response: Focused Explanation: The nurse is performing a focused assessment, which involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the client's health. An emergency assessment is performed to identify life-threatening problems. A time-lapse assessment compares a client's current status to baseline data obtained earlier.
44 A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? On the client's admission to the hospital Once the client has received a discharge order As soon as possible after the client's surgery Once the client is admitted to the nursing unit from postanesthetic recovery
You Selected: Once the client is admitted to the nursing unit from postanesthetic recovery Correct response: On the client's admission to the hospital Explanation: Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.
The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? Algorithm Standing orders Protocol Order set
You Selected: Order set Correct response: Standing orders Explanation: Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.
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.
You Selected: Perform a focused assessment related to the reason for admission. Correct response: Collect client subjective and objective data. Explanation: Nursing diagnoses are developed as the second step of the nursing process. The first step is to collect all assessment data so that appropriate actual or potential nursing problems can be selected and addressed in the client's plan of care. Nursing diagnoses are not related to the medical diagnosis or the specific written orders from the primary care provider. Goals can only be established after the problem is identified. Although assessment--collecting subjective and objective client data--is necessary before developing nursing diagnoses, this assessment does not necessarily have to be a focused assessment.
The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? Encourage the client to provide as much self-care as possible. Perform all care activities for the client to facilitate rest. Teach the family to anticipate the client's needs to care for the client. Arrange with the nurse case manager for an early discharge.
You Selected: Perform all care activities for the client to facilitate rest. Correct response: Encourage the client to provide as much self-care as possible. Explanation: The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.
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
You Selected: Performing an abdominal assessment Correct response: Obtaining data regarding the amount and frequency of drinking Explanation: A focused assessment is information that provides more details about specific problems and expands the original database. Obtaining data regarding the amount and frequency of drinking qualifies as a focused assessment. The other actions do not relate to the client's drinking habits or potential for alcohol overuse and thus would not be included in a focused assessment of these issues.
Which group of terms best defines assessing in the nursing process? Problem-focused, time-lapsed, emergency-based Designing a plan of care, implementing nursing interventions Collection, validation, communication of client data Nurse-focused, establishing nursing goals
You Selected: Problem-focused, time-lapsed, emergency-based Correct response: Collection, validation, communication of client data Explanation: Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem-focused, time-lapsed, and emergency-based describe types of assessments. Assessments are nurse-focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.
A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain? Assess nonpharmacologic modalities used to reduce pain. Implement the ABC guide of pain management. Ambulate the client after administration of pain medication. Review client goals for comfort.
You Selected: Review client goals for comfort. Correct response: Implement the ABC guide of pain management. Explanation: Because administering a pain medication is implementing the plan of care, the next step would be to monitor and evaluate the client's pain level. By using the ABC guide to pain management in reassessing the client's pain, the nurse knows whether the current plan of care is safe and effective for the client, or if changes need to be made to meet the client's needs. Stating the use of pharmacologic and nonpharmacologic pain management modalities and ambulation and reviewing goals for comfort are all interventions to reduce pain, not methods for monitoring pain or evaluating the current plan.
The nurse is caring for a client who is postoperative day 2 after a total knee replacement. The client refuses to ambulate when the physiotherapist arrives at the unit. The client states, "It is too soon to get up and walk. I am worried my incision will tear open." The nurse correctly documents the problem-focused nursing diagnosis using which statement? Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. Risk for anxiety related to fear of ambulating postoperatively. Anxiety related to knowledge deficit regarding normal postoperative activities. Risk for postoperative complications due to disturbed body image.
You Selected: Risk for anxiety related to fear of ambulating postoperatively. Correct response: Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications. Explanation: A problem-focused nursing diagnostic statement contains three parts, sometimes referred to as "PES." P: Name of the health-related issue or problem as identified in the NANDA-I list. E: Etiology (the problem's cause). S: Signs and symptoms, also called defining characteristics. The name of the nursing diagnosis is linked to the etiology with the phrase "related to," and the signs and symptoms are identified with the phrase "as evidenced by." The client's ability to ambulate when expected postoperatively is impaired by anxiety related to fear of postoperative complications. A statement regarding an actual client problem must include what the problem is related to and what evidence the nurse has to indicate that there is a problem. The client is having actually anxiety and is not at risk for it. Beginning the statement with "at risk for" would make the statement inaccurate. The client has not demonstrated a knowledge deficit about normal postoperative activities. The barrier to ambulating is fear and anxiety. There is no evidence to indicate that the client has a disturbed body image. The nurse would have to assess further to confirm this is accurate and include this as evidence in the problem-focused statement.
42 A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? Opioid analgesic to treat pain Septic workup due to blood pressure and heart rate elevation Isolation for suspected respiratory illness Acetaminophen to treat pain and fever
You Selected: Septic workup due to blood pressure and heart rate elevation Correct response: Opioid analgesic to treat pain Explanation: A sickle cell crisis is an extremely painful event. Most clients with sickle cell disease have an individualized opioid plan that will help them to receive opioids in an expedited manner when they present in crisis. The slight elevations in the client's blood pressure and heart rate are likely secondary to pain, not sepsis. There is no evidence of respiratory illness based on the information given. Acetaminophen is not strong enough to treat this client's pain; furthermore, the client does not have a fever.
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
You Selected: Sleepiness Correct response: Pain Explanation: Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.
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
You Selected: Time-lapse Correct response: Focused Explanation: The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish a baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems. A time-lapse assessment is one in which the nurse reassesses a client to evaluate the client's progress since a previous assessment for the same condition
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
You Selected: Time-lapse Correct response: Focused Explanation: The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish a baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems. A time-lapse assessment is one in which the nurse reassesses a client to evaluate the client's progress since a previous assessment for the same condition.
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: diagnosis. evaluation. intervention. goal.
You Selected: evaluation. Correct response: intervention. Explanation: A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance client goals and outcomes. Nursing diagnoses are statements of the client's actual or potential health problems that the nurse is seeking to address through interventions and are the overarching driver of goal-setting, care planning, and interventions. Evaluation, the final phase of the nursing process, involves assessing the client's response to interventions on an ongoing basis and making any necessary adjustments and changes to the nursing care plan.
The purpose of obtaining a nursing history is to: assist the physician to establish a medical diagnosis. minimize the time required to establish a nursing diagnosis. focus on objective physical data specific to the client. identify actual and potential health problems.
You Selected: minimize the time required to establish a nursing diagnosis. Correct response: identify actual and potential health problems. Explanation: The purpose of the nursing health history is to identify the patient's strengths and weaknesses; health risks, such as hereditary and environmental factors; and potential and existing health problems. This interview does not typically include physical assessment of a client. As part of the nursing assessment and overall nursing process, its purpose is not to influence time within the process. The physician's medical work-up provides the data to develop the medical diagnoses.
41. One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's: support system. medical orders. past medical history. condition.
You Selected: support system. Correct response: condition. Explanation: Because a person's condition changes, priorities change. Priorities are based on information collected during reassessment after recovery and assignment to the acute care setting. As the client heals these priorities can shift rapidly. The client's support system would have more of an impact on priorities of care once the client is being discharged to home, not while the client is in the acute care setting immediately after surgery. Both the client's medical orders and the client's nursing priorities change in response to the client's condition, rather than in response to one another. The client's past medical history, which doesn't change, is less likely to affect the nursing priorities of the client after surgery than the client's condition, which does change.
The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is: the focus assessment done when admitted to the ER. the initial comprehensive client assessment. the health record from a previous admission. the client record from the physician's office.
You Selected: the client record from the physician's office. Correct response: the initial comprehensive client assessment. Explanation: The initial comprehensive client assessment results in the baseline data that enables the nurse to make judgments, plan care, and refer clients to other health care workers if necessar
Which action should the nurse take during the evaluation phase of the nursing process? a. Document reassessment of pain after medication administration. b. Provide the client with a follow-up appointment after discharge. c. Have the client give input into plan of care upon admission. d. Discontinue the indwelling urinary catheter per the provider's order.
a. Document reassessment of pain after medication administration. The evaluation phase includes documenting a reassessment of pain following an intervention such as the administration of pain medication. Providing a client with an appointment and discontinuing an indwelling urinary catheter are interventions. Having a client give input into a plan of care is part of the planning process.
A new mother is having difficulty breastfeeding a newborn. A goal was established stating that the infant would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding 4 days ago. The nurse evaluates the original goal as:
completely unmet. After collecting data and evaluating the client's behavioral responses, the nurse makes a judgment about goal attainment by comparing the client's actual behavioral responses with the predicted responses or predetermined outcome criteria developed in the planning phase. In this case the mother abandoned breastfeeding, which represents a complete failure to meet the collaborative goal established. If the mother reported breastfeeding the baby every 4 to 5 hours, the nurse could consider the goal partially met. There is no evidence that the goal was inappropriately chosen for the client.
The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing? focused assessmentfunctional assessmentdatabase assessmentcomprehensive assessment
functional assessment The nurse is performing a functional assessment that focuses on areas that relate to the physical performance of activities, such as how the client is able to meet activities of daily living, demonstration of cognitive abilities, and social functioning. A comprehensive assessment encompasses all of the assessment data for the client. The focused assessment relies on one area of functioning such as the respiratory system if a client is having an asthma attack. The database assessment is performed during the initial history and physical portion of the client's illness and represents a comprehensive and all inclusive initial collection of data.
During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should: review literature pertinent to the client's attributes. assess personal feelings regarding similar clinical situations. inform the client of the maintenance of confidentiality. implement supportive nursing interventions.
ou Selected: assess personal feelings regarding similar clinical situations. Correct response: inform the client of the maintenance of confidentiality. Explanation: During the introductory phase, the nurse should inform the client how the information will be used and that confidentiality will be maintained. The alternate responses are not associated with the interview process and experience for the client.
The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to: examine certain body systems. complete an exam of all body systems. perform a review of the problem areas. focus on only the systems that the client is comfortable with.
ou Selected: examine certain body systems. Correct response: complete an exam of all body systems. Explanation: The nursing physical assessment that involves the examination of all body systems is called the review of systems. An assessment only on a specific problem area is a focused assessment. Nurses do not assess clients by focusing on the system that the client is most comfortable with. Examining a certain body system is not relevant in nursing.
