Fundamentals Exam 2
17. The nursing process is A. The generation of nursing knowledge for use in practice. B. A systematic view of a phenomenon specific to inquiry. C. A method used to inform a system about how it functions. D. A systematic process for the delivery of nursing care.
ANS: D
Eccentric tension
helps control the speed and direction of movement
Pressure ulcer
impairment of skin as a result of prolnoged ischemia when pressure on skin is greater than pressure inside PVS
Concentric tension
increased muscle contraction causes muscle shortening resulting in movement
Body alignment
individual's center of gravity
Tendons
tissue that connects muscle to bone
Vitamin C
necessary to replace protein stores
Vitamin B complex
needed for skin integrity and wound healing
Cartilage
nonvascular, supporitng connective tissue found in joints and thorax, trachea, larynx, nose, ear
Muscle tone
normal state of balance muscle tension
Hemiplegia with "neglect"
one-sided paralysis, can distort visual field
Hemaparesis
one-sided weakness
Explain your purpose (such as collecting a brief assessment or a nursing history) and ask the patient for his or her list of concerns or problems. This is the time that allows a patient to feel comfortable speaking with you and become an active partner in decisions about care. This is what phase of an interview?
Orientation and Setting an Agenda
When one summarizes the discussion with a patient and check for accuracy of the information collected. Ex: I have just 2 more questions for you". this time also gives the patient opportunity to ask additional questions. This is what phase of the interview?
Terminating
Patient's verbal descriptions of their health problems are what type of data
Subjective
Joints
Connections b/w bones
Bed rest effect on GI
Constipation
Information that you obtain through use of the senses
Cue
Acute Care diet
High protein, high-calorie
Parenteral
IV feedings (TPN- total parenteral nutrition)
Observations or measurements of a patient's health status, measured on the basis of an accepted standard is what type of data
Objective
essential and relevant data about the symptoms and their effects on the patient's health, include Provoked questions, Quality of information, Radiation of illness or pain, severity of symptoms, Time or duration of symptoms.
Present illness or health concerns
DVT assessment- how and how often
Q8h; remove stockings or SCDs and assess red, heat, swelling, pain
Information you gather when you initially set an agenda during a patient-centered interview, considered the "chief complaint"
Reason for seeking health care or Chief Concern
Urinary stasis- risks (2)
UTI, renal calculi
Joint contracture
caused by fixation of the joint due to disuse, atrophy, and shortening of the muscle fibers; can form after only 8 hours of immobility in older adults
Body Mechanics
coordinated efforts of the musculoskeletal and nervous systems
Thrombus risk factors
damage to vessel wall, alterations in blood flow, hypercoagulability (Virchow's Triad)
Enteral
given via GI tract, feeding tubes
Ligaments
white, shiny, flexible bands of fibrous tissue binding joints together and connecting bones to cart.
Risk for pneumonia- immobilized pt (3)
(1) dec in elastic recoil, (2) Secretions accumulate in dependent areas of lungs, (3) cough reflex inefficient
Supported Fowler's Position
45-60 degrees, knees slightly elevated w/out pressure
Change in urinary output after bed rest
5th or 6th day
An older adult who was in a car accident and fractured his femur has been immobilized for 5 days. Which nursing diagnosis is related to patient safety when the nurse assists this patient out of bed for the first time? 1. Chronic Pain 2. Impaired skin integrity 3. Risk for ineffective cerebral tissue perfusion 4. Risk for activity tolerance
ANS: 4
The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teachers the patient that the stockings are used after a surgical procedure to: 1. Prevent varicose veins 2. Prevent muscular atrophy 3. Ensure joint mobility and prevent contractures 4. Promote venous return to the heart
ANS: 4
11. A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explore other options for pain relief. b. Discuss the surgical procedure and reason for the pain. c. Explain to the patient that nothing else has been ordered. d. Offer to notify the health care provider after morning rounds are completed.
ANS: A
12. A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? a. States feels better after talking with family and friends b. Consumes high-carbohydrate foods when stressed c. Dislikes the support group meetings d. Spends most of the day in bed
ANS: A
12. The nurse is visiting a patient at home after he was discharged from the hospital following a heart attack. She listens to the patient's concerns about being an invalid for the rest of his life because of his bad heart, but he is afraid of having "open heart" surgery. The nurse explains the different surgical procedures that are available to the patient, as well as other options such as cardiac rehabilitation. After several such visits, the patient states that he believes that cardiac rehabilitation therapy would be best for him, and asks the nurse how he can get in. The nurse calls the patient's physician and sets up a referral for cardiac rehabilitation. This action most closely fits which of the following theories? A. Peplau's theory B. Henderson's theory C. Nightingale's theory D. Orem's self-care deficit theory
ANS: A
A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: a) Patient's level of function. b) Patient's willingness to perform self-care. c) Patient's level of consciousness. d) Patient's health management values.
ANS: A
19. A paradigm is useful in describing the domain of a discipline. Nursing's paradigm includes which of the following? (Select all that apply.) A. Person B. Disease C. Health D. Environment E. Nursing
ANS: A, C, D, E
The nurse enters the room of an 82 year old patient for whom she has never seen. the nurse notices that the patient wears a hearing aid. the patient looks up as the nurse approaches the bedside. which approaches are likely to be effective? a) listen attentively to the patient's story b) use gestures that reinforce your questions or comments c) Stand back away from the bedside d) maintain direct eye contact. ask questions quickly to reduce the patient's fatigue
ANS: A,B,D
2. Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? a. Sore throat b. Acute pain c. Sleep apnea d. Heart failure
ANS: B
The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? A. Call the rapid response team. B. Ask the patient to rate and describe the pain. C. Raise the head of the bed. D. Administer pain relief medications.
ANS: B
21. Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) a. Set priorities for patient care. b. Determine whether outcomes or standards are met. c. Ambulate patient 25 feet in the hallway. d. Document results of goal achievement. e. Use self-reflection and correct errors.
ANS: B, D, E
10. A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention d. Constipation
ANS: C
5. A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing? a. Assigning clinical cues b. Defining characteristics c. Diagnostic reasoning d. Diagnostic labeling
ANS: C
5. Which action demonstrates a nurse utilizing reflection to improve clinical decision making? a. Obtains data in an orderly fashion b. Uses an objective approach in patient situations c. Improves a plan of care while thinking back on interventions effectiveness d. Provides evidence-based explanations and research for care of assigned patients
ANS: C
6. A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care? a. Posttrauma syndrome b. Constipation c. Acute pain d. Anxiety
ANS: C
6. A system is made up of separate components. A closed system A. Interacts with the environment. B. Is exemplified by the human organism. C. Does not interact with the environment. D. Is exemplified by the nursing process.
ANS: C
8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write? a. Risk b. Problem focused c. Health promotion d. Collaborative problem
ANS: C
The nurse anticipates administering an opioid fentanyl patch to which patient? A. A 15-year-old adolescent with a broken femur B. A 30-year-old adult with cellulitis C. A 50-year-old patient with prostate cancer D. An 80-year-old patient with a broken hip
ANS: C
1. A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting? a. Assessment b. Planning c. Implementation d. Evaluation
ANS: D
Always stand on the patient's ___________ side
Affected
Factual demographic data that includes a patient's age, address, occupation, and working status; marital status; source of health care; and types of insurance are considered
Biographical information
The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding? A. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." B. "When patients say they don't need pain medication, they aren't in pain." C. "Pain assessment scales determine the quality of a patient's pain." D. "A patient's behavior is more reliable than the patient's report of pain."
CANS:
Sim's position
Client places weight on anterior ileum, humerus, and clavicle
Limiting answers to one or two words such as yes and no are considered
Close-ended questions
Comparison of data with another source to determine data accuracy
Validation
Earliest sign of CHF
3rd heart sound heard at apex
An older adult has limited mobility as a result of a surgical repair of a fracture hip. During assessment you note that the patient cannot tolerate lying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply). 1. BP 128/84 2. RR 26 on room air 3. HR 114 4. Crackles heard on auscultation 5. Pain reported as 3 on a scale of 0-10 after medication
ANS 2, 3, 4
The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. The nurse would recommend which of the following menus? 1. Cream of broccoli soup with whole wheat crackers and tapioca for dessert 2. Hamburger on soft roll with a side salad and an apple for dessert 3. Low fat turkey chili with sour cream and fresh pears for dessert 4. Chicken salad on toast with tomato and lettuce and honey bun for dessert.
ANS: 1
Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? 1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment 5. 24 hour calorie intake
ANS: 1, 2, 3, 4
A patient of any age can develop a contracture of a joint when: 1. The adductors muscles are weakened as a result of immobility 2. The muscle fibers become shortened because of disuse 3. The calcium to phosphorus ration becomes disrupted 4. There is a deficiency in Vitamin D
ANS: 2
The patient at greatest risk for developing multiple adverse effects of immobility is a: 1. 1 year old child with a hernia repair 2. 80 year old woman who has suffered a hemorrhagic cerebrovascular accident (CVA) 3. 51 year old woman following a thyroidectomy 4. 38 year old woman undergoing a hysterectomy
ANS: 2
Which is an outcome for a patient diagnosed with osteoporosis? 1. Maintain serum level of calcium 2. Maintain independence with activities of daily living 3. Reduce supplemental sources of vitamin D 4. Reverse bone loss through dietary manipulation
ANS: 2
A home care nurse is preparing the home for a patient who is discharged to home following a left sided stroke. The patient is cooperative and can ambulate with a quad cane. Which of the following must be corrected or removed for the patient's safety? (Select all that apply.) 1. The rubber mat in the walk in shower 2. The three-legged stool on wheels in the kitchen 3. The braided throw rugs in the entry hallway and between the bedroom and bathroom 4. The night lights in the hallways, bedroom, and bathroom 5. The cordless phone next to the patient's bed
ANS: 2, 3
Immobilized patients are at risk for impaired skin integrity. Which of the following interventions would reduce this risk? (Select all that apply.) 1. Repositioning patient every 1 to 2 hours while awake 2. Using an objective, valid scale to asses patient's risk for pressure ulcer development 3. Using a device to relieve pressure when patient is seated in chair 4. Teaching patient how to shift weight at regular intervals while sitting in a chair 5. A good rule is: the higher the risk for skin breakdown, the shorter the interval between position changes.
ANS: 2, 3, 4, 5
A patient has her call bell on and looks frightened when you enter the room. She has been on bed rest for 3 days following a fractured femur. She says, "It hurts when I try to breathe, and I can't catch my breath." Your first action is to: 1. Call the health care provider to report this change in condition. 2. Give the patient a paper bag to breathe into to decrease her anxiety. 3. Assess her vital signs, perform respiratory assessment, and be prepared to start oxygen. 4. Explain that this is normal after such trauma and administer the ordered pain medications.
ANS: 3
Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? 1. The patient is 5'6" and weighs 120 lbs 2. The patient speaks and understands English 3. The patient received an injection of morphine 30 minutes ago for pain 4. You feel comfortable handling a patient of his size and with his level of cooperation
ANS: 3
A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements made by a woman in the audience reflects a need for further education. 1. "I usually go swimming with my family at the YMCA 3 times a week." 2. "I need to ask my doctor if I should have a bone mineral density check this year." 3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet." 4. "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill."
ANS: 4
A patient had a left sided cerebrovascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The patient is receiving enteral feedings through a small bore nasogastric tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately? 1. Pale yellow urine 2. Unilateral neglect 3. Slight movement noted on right side 4. Coffee ground like aspirate from the feeding tube
ANS: 4
A patient with left sided weakness asks his nurse, "Why are you walking on my left side? I can hold on to you better with my right hand." What would your best therapeutic response? 1. "Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you." 2. "Would you like me to walk on your right side so you feel more secure?" 3. "Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will hold you on the right side." 4. "By walking on your left side I can support you and help you from injury if you start to fall. By holding your waist I would protect your shoulder if you start to fall or faint."
ANS: 4
13. The nurse is caring for a patient who is actively bleeding. The physician orders blood transfusions. The nurse notes in the chart that the patient is a Jehovah's Witness and informs the patient of the physician's order. The patient states that she is a Jehovah's Witness and does not want blood products. The nurse contacts the physician to tell him that blood cannot be given to this patient and requests alternative treatment. In doing so, the nurse is operating within which of the following theories? A. Leininger's cultural care diversity and universality theory B. Roy's adaptation theory C. Watson's philosophy of transpersonal caring D. Orem's self-care deficit theory
ANS: A
15. A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document? a. Decreased cardiac output related to altered myocardial contractility. b. Patient needs a low-fat diet related to inadequate heart perfusion. c. Offer a low-fat diet because of heart problems. d. Acute heart pain related to discomfort.
ANS: A
16. A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient? a. Identify factors interfering with goal achievement. b. Counsel the nursing assistive personnel on duty when the patient fell. c. Remove the fall risk sign from the patient's door because the patient has suffered a fall. d. Request that the more experienced charge nurse complete the documentation about the fall.
ANS: A
16. The prospective nursing student is trying to decide on which nursing program to attend. She is examining the nursing philosophies of each program. She believes that the essence of nursing is "Caring." Which of the following theories would most likely meet her needs? A. Benner and Wrubel's theory of nursing B. Roy's adaptation theory C. Orem's self-care deficit theory D. Rogers' theory
ANS: A
18. A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? a. Heart rate 78 beats/min on 12/3 b. Heart rate 78 beats/min on 12/4 c. Heart rate 80 beats/min on 12/3 d. Heart rate 80 beats/min on 12/4
ANS: A
19. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a. "Do you feel like you need to go to the bathroom?" b. "Are you able to walk to the bathroom by yourself?" c. "When was the last time you took your medicine?" d. "Do you have a safety rail in your bathroom at home?"
ANS: A
2. The nurse is caring for a patient who is known as a "frequent flyer," and who has been labeled as "noncompliant" by most of the staff because she does not follow her prescribed regimen for diabetes management. As a prescriber to Orem's theory, the nurse interviews the patient in an attempt to identify the cause of the patient's "noncompliance." This is because Orem's theory? A. Is useful in designing interventions to promote self-care. B. Does not allow for environmental influences on care. C. Allows for development of a plan of care that the patient must follow. D. Is not useful in promoting self-care regimens.
ANS: A
20. A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2. Writes a diagnostic label of impaired gas exchange 3. Organizes data into meaningful clusters 4. Interprets information from patient 5. Writes an etiology a. 1, 3, 4, 2, 5 b. 1, 3, 4, 5, 2 c. 1, 4, 3, 5, 2 d. 1, 4, 3, 2, 5
ANS: A
20. In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals 2. Assessing patient needs 3. Planning priorities of care 4. Determining nursing diagnoses 5. Implementing nursing interventions a. 2, 4, 3, 5, 1 b. 4, 3, 2, 1, 5 c. 1, 2, 4, 5, 3 d. 5, 1, 2, 3, 4
ANS: A
4. The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? a. Etiology b. Nursing diagnosis c. Collaborative problem d. Defining characteristic
ANS: A
4. The nurse researcher is evaluating whether holding pressure at an injection site after injecting the anticoagulant enoxaparin (Lovenox) will reduce bruising at the injection site. This study involves a prescriptive theory because it A. Tests a specific nursing intervention. B. Explains why bruising occurs. C. Is broad in scope and complex. D. Reflects a wide variety of nursing care situations.
ANS: A
6. A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? a. Concept mapping b. Reflective journaling c. Lecture and discussion d. Reading assignment with a written summary
ANS: A
7. The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation
ANS: A
8. A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next? a. Reassess the patient and situation. b. Revise the turning schedule to increase the frequency. c. Delegate turning to the nursing assistive personnel. d. Apply medication to the area of skin that is broken down.
ANS: A
9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a. Assessment b. Diagnosis c. Implementation d. Evaluation
ANS: A
A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? A. Relaxation and guided imagery B. Transcutaneous electrical nerve stimulation (TENS) C. Herbal supplements with analgesic effects D. Pudendal block
ANS: A
A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? A. Patient drinks 1 to 2 glasses of wine every night. B. Patient smokes 2 packs of cigarettes a day. C. Patient occasionally smokes marijuana. D. Patient takes antianxiety medications.
ANS: A
The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? A. Increasingly higher doses of opioid are needed to control pain. B. The patient needed a substantial dose of naloxone (Narcan). C. The patient asks for pain medication close to the time it is due around the clock. D. The patient no longer experiences sedation from the usual dose of opioid.
ANS: A
The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient's pain during dressing changes? A. The patient's need for analgesic medication decreases during the dressing changes. B. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. C. The patient's facial expressions are stoic during the procedure. D. The patient can tolerate more pain, so dressing changes can be performed more frequently.
ANS: A
Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain? A. "Meditation controls pain by blocking pain impulses from coming through the gate." B. "Meditation will help me sleep through the pain because it opens the gate." C. "Meditation stops the occurrence of pain stimuli." D. "Meditation alters the chemical composition of pain neuroregulators, which closes the gate."
ANS: A
Which of the following examples are steps of nursing assessment? (Select all that apply.) a) Collection of information from patient's family members b) Recognition that further observations are needed to clarify information c) Comparison of data with another source to determine data accuracy d) Complete documentation of observational information e) Determining which medications to administer based on a patient's assessment data
ANS: A, B, C
1. Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.) a. Tense muscles b. Reactive responses c. Trouble concentrating d. Very tired feelings e. Managed emotions
ANS: A, B, C, D
20. Psychosocial theories are needed in nursing because nursing is a diverse discipline that strives to meet which criteria? (Select all that apply.) A. Physiological needs of the patient B. Psychological needs of the patient C. Sociocultural needs of the patient D. Spiritual needs of the patient E. The nurse-patient relationship
ANS: A, B, C, D
20. A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.) a. Observations of wound healing b. Daily blood pressure measurements c. Findings of respiratory rate and depth d. Completion of nursing interventions e. Patient's subjective report of feelings about a new diagnosis of cancer
ANS: A, B, C, E
When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.) a) An observation of how a patient turns and moves in bed b) The unit policy and procedure manual c) The care recommendations of a physical therapist d) The results of a diagnostic x-ray film e) Your experiences in caring for other patients with similar problems
ANS: A, C, D
A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she rounds on the patient? (Select all that apply.) a) The nurse asks the patient to rate his pain on a scale of 0 to 10. b) The nurse asks the patient what caused his fall. c) The nurse asks the patient if he has had pain in his back in the past. d) The nurse assesses the patient's lower-limb strength. e) The nurse asks the patient what pain medication is most effective in managing his pain.
ANS: A, D
A nurse gathers the following assessment data. Which of the following cues together form a pattern suggesting a problem? a) The skin around wound is tender b) Fluid intake for 8 hours is 800 ml c) patient has a HR of 78 BPM d) Patient has drainage from wound e) Body temp is 101 f) patient states "im worried that I won't be able to return to work when i planned
ANS: A, D, E
1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? a. To form a language that can be encoded only by nurses b. To distinguish the nurse's role from the physician's role c. To develop clinical judgment based on other's intuition d. To help nurses focus on the scope of medical practice
ANS: B
11. As the initial model for nursing, Nightingale's "descriptive theory" encouraged nurses to A. Know all about the disease processes affecting their patient. B. Think about their patients and patients' environment. C. Combine nursing knowledge with medicine. D. Focus on medication administration and treatments
ANS: B
11. The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action? a. Wait and change the dressing at 1800 as ordered. b. Revise the plan of care and change the dressing now. c. Reassess the dressing and the wound in 2 hours. d. Discontinue the plan of care for wound care.
ANS: B
11. The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance? a. Decreased oral intake and decreased oxygen saturation when ambulating b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed c. Reports of shortness of breath when getting out of bed and a productive cough d. Productive cough and decreased oral intake
ANS: B
13. A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene? a. Wandering b. Hemorrhage c. Urinary retention d. Impaired swallowing
ANS: B
13. A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate? a. Health status b. Health behavior c. Psychological self-control d. Health service utilization
ANS: B
13. While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take? a. Postpone catheter insertion until the next shift. b. Adapt the positioning technique to the situation. c. Notify the health care provider for a urologist consult. d. Follow textbook procedure with contraindicated position.
ANS: B
15. A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation? a. Humility b. Creativity c. Risk taking d. Confidence
ANS: B
15. The patient is newly diagnosed with diabetes and will be discharged in the next day or so. The nurse is teaching the patient how to draw up and self-administer his insulin. Which nursing theory is the nurse utilizing? A. Watson's philosophy of transpersonal caring B. Orem's self-care deficit theory C. Rogers' theory D. Henderson's theory
ANS: B
16. A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? a. Refusing the assignment b. Asking for an orientation to the unit c. Admitting lack of knowledge and going home d. Assuming that patient care will be the same as on the other units
ANS: B
18. Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. "What types of foods do you think caused your upset stomach?" b. "How many bowel movements a day have you had?" c. "Are you able to get to the bathroom in time?" d. "What medications are you currently taking?"
ANS: B
19. A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. 4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90. a. 1, 5, 2, 4, 3 b. 2, 1, 5, 4, 3 c. 4, 3, 1, 5, 2 d. 5, 4, 5, 1, 2
ANS: B
19. A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise? a. Patient's outcomes for learning b. Nurse's assumptions about hospital discharge c. Identification of several actual health problems d. Documentation of patient's ability to meet the goal
ANS: B
3. The type of theory that is used to develop and test specific nursing interventions is known as _____ theory. A. Grand B. Prescriptive C. Descriptive D. Middle-range
ANS: B
3. Which action indicates a registered nurse is being responsible for making clinical decisions? a. Applies clear textbook solutions to patients' problems b. Takes immediate action when a patient's condition worsens c. Uses only traditional methods of providing care to patients d. Formulates standardized care plans solely for groups of patients
ANS: B
5. A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care? a. Determine whether the patient has transportation to get home. b. Evaluate whether patient goals and outcomes have been met. c. Establish whether the patient has a follow-up appointment scheduled. d. Ensure that the patient's prescriptions have been filled to take home.
ANS: B
6. The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome? a. The nurse provides assistance while the patient is walking in the hallways. b. The patient is able to ambulate in the hallway with crutches. c. The patient will deny pain while walking in the hallway. d. The patient's level of mobility will improve.
ANS: B
7. The nurse is caring for a patient diagnosed with essential hypertension. The physician orders blood pressure medication that the nurse administers. The nurse then monitors the patient's blood pressure for several days to help determine the effectiveness of the administration. In doing so, the nurse evaluates which of the following system components? A. Input B. Output C. Feedback D. Content
ANS: B
9. A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? a. "Evaluative measures are multiple-page documents used to evaluate nurse performance." b. "Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals." c. "Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse." d. "Evaluative measures are objective views for completion of nursing interventions."
ANS: B
9. Many aspects of nursing theory are based on developmental theories because human growth and development is believed to be A. Erratic and difficult to predict. B. An orderly predictive process. C. An orderly process until adulthood. D. Unpredictable during childhood.
ANS: B
A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What type of pain does the nurse document that the patient has? A. Visceral pain B. Somatic pain C. Peripherally generated pain D. Centrally generated pain
ANS: B
A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior and response to surgery? A. The surgery successfully cured the patient's pain. B. The patient's culture is possibly influencing the patient's experience of pain. C. The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain. D. The nurse is allowing personal beliefs about pain to influence pain management at this time.
ANS: B
A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's best next action? A. Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain. B. Ask the health care provider to verify the dosage and frequency of the medication. C. Ask the health care provider for an order for a nonsteroidal antiinflammatory drug (NSAID). D. Ask the health care provider for an order to play music for the patient, in addition to providing the pain medication.
ANS: B
A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student's knowledge? A. "Older patients often have difficulty determining what is causing their pain." B. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication." C. "As adults age, their ability to perceive pain decreases." D. "Patients who have dementia probably experience pain, and their pain is not always well controlled."
ANS: B
A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA? A. The patient is sleeping and is difficult to arouse. B. The patient rates pain at an acceptable level of 3 on a 0 to 10 scale. C. Sufficient medication is left in the PCA syringe. D. The patient presses the control button to deliver pain medication.
ANS: B
The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? A. "Have you considered working with a physical therapist?" B. "What activities, if any, has your pain prevented you from doing?" C. "Would you please rate your pain on a scale from 1 to 10 for me?" D. "What effect does your pain medication typically have on your pain?"
ANS: B
The nurse knows that which technique is best for assessing pain in a child who is 4 years of age? A. Ask the parents if they think their child is in pain. B. Use the FACES scale. C. Ask the child to rate the level of pain on a 0 to 10 pain scale. D. Check to see what previous nurses have charted.
ANS: B
The nurse recognizes that which of the following is a modifiable contributor to a patient's perception of pain? A. Age and gender B. Anxiety and fear C. Culture D. Previous pain experience
ANS: B
Which statement made by a nursing educator best explains why it is important for nurses to determine a patient's medical history and recent drug use? A. "Health care providers have a responsibility to prevent drug seekers from gaining access to drugs." B. "This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief." C. "Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain." D. "Getting this information gives the nurse an opportunity to provide patient teaching about drug abstinence."
ANS: B
Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? a) Probing b) Open-ended c) Problem-oriented d) Confirmation
ANS: B
1. Which action should the nurse take when using critical thinking to make clinical decisions? a. Make decisions based on intuition. b. Accept one established way to provide care. c. Consider what is important in a given situation. d. Read and follow the heath care provider's orders.
ANS: C
10. The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take? a. Ask the nursing assistive personnel if the wound looks better. b. Document the progress of wound healing as "better" in the chart. c. Measure the wound and observe for redness, swelling, or drainage. d. Leave the dressing off the wound for easier access and more frequent assessments.
ANS: C
10. The nurse is making rounds and finds her older adult patient sobbing and obviously upset. She states that her doctor told her that she has cancer, and she does not want to die. "What's the matter?" she says. "I might as well die. I'm going to anyway. I guess that shows how useless I really am. Nobody wants an old lady around." The nurse notices that the patient's respirations have increased, and the tip of her nose and ear lobes are becoming cyanotic. The nurse assesses the patient and finds that the patient's pulse rate is over 150 beats per minute. According to Maslow's hierarchy of needs, the nurse should first A. Call the physician to request a psychiatric consult. B. Reassure the patient that she has value as a human being. C. Place the patient on oxygen and try to calm her. D. Call the patient's family to help her realize that she is wanted
ANS: C
10. The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill? a. Evaluation b. Explanation c. Interpretation d. Self-regulation
ANS: C
12. A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain? a. Discomfort while changing position b. Reports pain as a 7 on a 0 to 10 scale c. Disruption of tissue integrity d. Dull headache
ANS: C
12. Which action should the nurse take to best develop critical thinking skills? a. Study 3 hours more each night. b. Attend all inservice opportunities. c. Actively participate in clinical experiences. d. Interview staff nurses about their nursing experiences.
ANS: C
14. A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal? a. "I'm worried about what those other girls will think of me." b. "I can't wear that color. It makes my hips stick out." c. "I'll wear the blue dress. It matches my eyes." d. "I will go to the pool next summer."
ANS: C
14. A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan? a. Infection b. Risk for infection c. Impaired skin integrity d. Staphylococcal leg infection
ANS: C
14. The patient is terminally ill and is under hospice care. The nurse cares for the patient by bathing, shaving, and repositioning him. The family believes that the end is very near and would like a Catholic priest called to provide the patient with the Sacrament of the Sick. The nurse places a call to the Catholic Church the patient attended and arranges for the priest's visit. Under which of the following theories does the nurse's care fall? A. Roy's adaptation theory B. Watson's philosophy of transpersonal caring C. Henderson's theory D. Orem's self-care deficit theory
ANS: C
16. A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up? a. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics b. Completing an interview and physical examination before adding a nursing diagnosis c. Developing nursing diagnoses before completing the database d. Including cultural and religious preferences in the database
ANS: C
17. A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient? a. Adult failure to thrive b. Hypothermia c. Deficient fluid volume d. Nausea
ANS: C
18. Nursing has its own body of knowledge that is both theoretical and practical. Which of the following is an example of theoretical knowledge? A. Reflection on care experiences B. Synthesis and integration of the art and science of nursing C. Reflection on basic values and principles D. Creating a narrow understanding of nursing practice
ANS: C
2. Which patient scenario of a surgical patient in pain is most indicative of critical thinking? a. Administering pain-relief medication according to what was given last shift b. Offering pain-relief medication based on the health care provider's orders c. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past d. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed
ANS: C
3. A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate? a. "An evaluation helps you determine whether all nursing interventions were completed." b. "During evaluation, you determine when to downsize staffing on nursing units." c. "Nurses use evaluation to determine the effectiveness of nursing care." d. "Evaluation eliminates unnecessary paperwork and care planning."
ANS: C
4. After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient? a. Eliminate headache from the nursing care plan. b. Direct the nursing assistive personnel to ask if the headache is relieved. c. Reassess the patient's pain level in 30 minutes. d. Revise the plan of care.
ANS: C
8. The patient is admitted to the ICU to rule out a myocardial infarction (MI). During the admission process, the patient is noted to have a history of methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and the patient declared noninfectious. During the isolation process, the nurse encourages family visits, realizing that which level of Maslow's hierarchy of needs is at risk? A. First level B. Second level C. Third level D. Fourth level E. Fifth level
ANS: C
A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? A. "This medication will still be providing you relief at the time of your dressing change." B. "OK, swallow this pain pill, and I will return in a minute to fill your wound." C. "Would you like medication to be given for dressing changes on top of your regularly scheduled medication?" D. "Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now."
ANS: C
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? a) "I can tell that your eating habits have led to your diabetes. Is that right?" b) "It's been difficult for people to find jobs. Is that why you work part time?" c) "You have four children; do you have any concerns about going home and caring for them?" d) "I wish patients understood how overeating affects their health
ANS: C
A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management? A. "To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain." B. "You should take your medication after you walk to make sure you do not fall while you are walking." C. "We should work together to create a regular schedule of medications that does not allow for breakthrough pain." D. "You need to take oral pain medications when you experience severe pain."
ANS: C
A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide? A. "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." B. "Narcotics can be addictive, so do not take them unless you are in severe pain." C. "You need to drink plenty of fluids and eat a diet high in fiber." D. "As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections."
ANS: C
A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works? A. "Ibuprofen helps to remove factors that cause or stimulate pain." B. "Ibuprofen reduces anxiety, which will help you better cope with your pain." C. "Ibuprofen helps to decrease the production of prostaglandins." D. "Ibuprofen binds with opiate receptors to reduce your pain."
ANS: C
A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management? A. "This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication." B. "The patient is sleeping, so I pushed her PCA button for her." C. "I need to reassess the patient's pain 1 hour after administering oral pain medication." D. "It wasn't time for the patient's medication, so when she requested it, I gave her a placebo."
ANS: C
A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? A. Frequently reassesses the patient's pain scores B. Reassures the patient that the provider will come to the emergency department soon C. Softly plays music that the patient finds relaxing D. Teaches the patient how to do yoga
ANS: C
During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? a) So you've had headaches periodically in the last week and sometimes they cause you nausea, correct? b) Have you taken anything for your headaches c) tell me what makes your headaches begin d) Uh huh, tell me more
ANS: C
The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? a) Orientation b) Working phase c) Data validation d) Termination
ANS: C
The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? A. Neurological factors B. Competency of the surgeon C. Meaning of pain D. Postoperative support personnel
ANS: C
The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: a) Cue. b) Reflection. c) Clinical inference. d) Probing.
ANS: C
What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery? A. Assess the patient's body language. B. Observe cardiac monitor for increased heart rate. C. Ask the patient to rate the level of pain. D. Ask the patient to describe the effect of pain on the ability to cope.
ANS: C
What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia? A. Keeping the reversal agent in a syringe in the patient's bedside table B. Applying a gauze dressing to the epidural catheter insertion site C. Labeling the tubing that leads to the epidural catheter D. Asking the nursing assistive personnel to check on the patient at least once every 2 hours
ANS: C
Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis? A. Administer pain medication before any activity. B. Provide intravascular bolus as needed for breakthrough pain. C. Give medications around-the-clock. D. Administer pain medication only when nonpharmacological measures have failed.
ANS: C
Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective? A. "This is the only pain medication I will need to be on." B. "I can administer the pain medication as frequently as I need to" C. "I feel less anxiety about the possibility of overdosing." D. "I will need the nurse to notify me when it is time for another dose."
ANS: C
1. A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.) a. Anxiety related to barium enema b. Impaired gas exchange related to asthma c. Impaired physical mobility related to incisional pain d. Nausea related to adverse effect of cancer medication e. Risk for falls related to nursing assistive personnel leaving bedrail down
ANS: C, D
5. The student nurse is learning nursing theories but fails to see how they relate to the nursing process. The professional nurse realizes that nursing theory A. Has a minor role in professional nursing. B. Requires the nursing process to develop knowledge. C. Can direct how a nurse uses the nursing process. D. Is specific to certain patients only.
ANS: C.
9. A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? a. Examine the meaning of data. b. Support findings and conclusions. c. Review the effectiveness of nursing actions. d. Search for links between the data and the nurse's assumptions.
ANS: C.
1. The nursing instructor is teaching a class on nursing theory. One of the students asks, "Why do we need to know this stuff? It doesn't really affect patients." The instructor's best response would be? A. "You are correct, but we have to learn it anyway." B. "Exposure to theories will help you later in graduate school." C. "Theories help keep the focus of nursing narrow." D."Theories help explain why nurses do what they do.
ANS: D
14. The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? a. Provide privacy and check on the patient 30 minutes later. b. Set a box of tissues at the patient's bedside before leaving the room. c. Limit visitors while the patient is upset. d. Ask the patient about the crying.
ANS: D
15. A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? a. Patient wanders halls at night. b. Patient's side rails are up with bed alarm activated. c. Patient denies pain while ambulating with assistance. d. Patient correctly states names of family members in the room.
ANS: D
17. A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions? a. Establishes minimal passing standards for testing b. Utilizes evidence-based practice based on nurses' needs c. Bypasses the patient's feelings to promote ethical standards d. Uses critical thinking for the highest level of quality nursing care
ANS: D
17. A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal? a. No sputum or cough present in 4 days b. Congestion throughout all lung fields in 2 days c. Shallow, fast respirations 30 breaths per minute in 1 day d. Lungs clear to auscultation following use of inhaler
ANS: D
18. A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following? a. Fairness b. Intellectual standards c. Independent reasoning d. Institutional practice guidelines
ANS: D
2. A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next? a. Assessment b. Planning c. Implementation d. Evaluation
ANS: D
3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? a. Ineffective breathing pattern related to pneumonia b. Risk for infection related to chest x-ray procedure c. Risk for deficient fluid volume related to dehydration d. Impaired gas exchange related to alveolar-capillary membrane changes
ANS: D
4. A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene? a. Making an ethical clinical decision b. Making an informed clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments
ANS: D
7. A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions? a. Attitude b. Experience c. Nursing process d. Specific knowledge base
ANS: D
7. The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule? a. Staff documentation of turning the patient every 2 hours b. Presence of redness only on the heels of the patient c. Patient's eating 100% of all meals d. Absence of skin breakdown
ANS: D
8. Which action by a nurse indicates application of the critical thinking model to make the bestclinical decisions? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process
ANS: D
A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? a) Review of systems approach b) Use of a structured database format c) Back channeling d) A problem-oriented approach
ANS: D
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? a) Value-belief pattern b) Cognitive-perceptual pattern c)Coping-stress-tolerance pattern d) Health perception-health management pattern
ANS: D
A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." What type of pain does the nurse document that the patient is having at this time? A. Superficial pain B. Idiopathic pain C. Chronic pain D. Visceral pain
ANS: D
A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient's blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? A. "Your vitals do not show that you are having pain; can you describe your pain?" B. "You do not look like you are in pain." C. "OK, I will go get you some narcotic pain relievers immediately." D. "What would you like to try to alleviate your pain?"
ANS: D
A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?" 4, 2, 1, 3, 5 2, 4, 3, 1, 5 4, 2, 5, 1, 3 2, 4, 1, 5, 3
ANS: D
A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction? A. "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." B. "Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy." C. "Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet." D. "You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot."
ANS: D
A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? a) Health perception-health management pattern b) Value-belief pattern c) Cognitive-perceptual pattern d) Self-perception-self-concept pattern
ANS: D
The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? A. The patient who needs to take a scheduled dose of maintenance pain medication B. The patient who needs to be premedicated before walking C. The patient with a PCA running who needs to have the syringe replaced D. The patient who is experiencing 8/10 pain and has a STAT order for pain medication
ANS: D
The nurse is caring for a patient who recently had surgery to repair a hernia. The patient's pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication. Which is the nurse's best response? A. "This medication can be given only every 4 hours. It is not time for you to have any other pain medication right now." B. "I will notify the health care provider to come perform an assessment if your pain doesn't improve in 30 minutes." C. "If the pain becomes severe, we may need to transfer you to an intensive care unit." D. "It can take 2 hours for oral pain medication to work, and your pain is going down. Let's try boosting you up in bed and putting an ice pack on the incision to see if that helps."
ANS: D
The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient? A. Infants cannot tolerate analgesics owing to an underdeveloped metabolism. B. Infants have an increased sensitivity to pain when compared with older children. C. Pain cannot be accurately assessed in infants. D. Infants respond behaviorally and physiologically to painful stimuli.
ANS: D
foot drop
Ankle fixed in plantar flexion (permanent)
The nursing process 5 steps include...
Assessment Diagnose Planning Implementation Evaluate
The patient-centered interview, a physical exam, and periodic assessments are examples of
Assessments
Bed rest effect on Respiratory (2)
Atelectasis, hypostatic pneumonia
Using phrases like "all right" "go on" or "Uh-huh" are examples of
Back channeling
Clients- shift weight ________
Every 15 mins
Prone Position
Face/chest down
Negative nitrogen balance
Inc excretion of nitrogen more than ingestion in proteins
Bed rest effect on Calcium
Inc resorption--> hypercalcemia
Lying down effect on Cardio
Inc workload and in HR
Judgement or interpretation of cues
Inference
Open-ended question/Leading question/Back channeling/Probing/Direct Closed-Ended questions These are all examples of...
Interview Techniques
Bed rest on muscle strength
Loss of 3% per day
Range of Motion
Max amt of mvmt available at a jointin one of the three planes
A process of interview that addresses a patient's ambivalence to medically indicated behavior change and supports patients in making health care decisions in cases in which there is more than one reasonable option.
Motivational interview
Instrumental Activities of Daily Living
Necessary to be independent (eating, grooming, toileting, shopping, meal prep, taking meds)
2 step process that allow one to identify the problem correctly, involves critical thinking: 1: collection of information from a primary source and secondary sources 2: The interpretation and validation of data to ensure a complete database
Nursing Assessment
The five-step process nurses use to apply the best available evidence to care giving and promoting human functions and responses to health and illness. It is the fundamental blueprint for how to care for patients.
Nursing Process
Bed rest effect on Cardio
Orthostatic Hypotension
Patients typically want to receive information about their treatment and prognosis and plan of care for returning home. in addition, they expect relief of pain and other symptoms and caring expressed by health care providers. These are considered...
Patient expectations
asking the patient to emphasize on a complaint or explanation to encourage a full description is considered
Probing
Side-lying position
Rests of side with major portion of body weight on dependent hip and shoulder
systematic approach for collecting subjective information from patients about the presence or absence of health related issues in each body system
Review of Systems
Isotonic contraction
Static, inc in muscle tension w/ no shortening of muscle
This involves open ended questions that allow patients to describe more clearly their concerns and problems. Use attentive listening and other therapeutic communication techniques that encourage a patient to tell his or her story. This is what phase of the interview?
Working Phase
