My Lab Questions
the nurse educator is teaching student. nurses about nursing judgments. which statement by a student indicates effective learning? - "intuition is an important part of nursing judgment in the new nurse" -"clinical decision making is scarcely used in nursing judgment" -" students must be skilled at using clinical judgment while in nursing school" - " Both clinical decision making and critical thinking are important parts of nursing judgements"
"Both clinical decision making and critical thinking are important parts of nursing judgments"
the nurse is presenting how to differentiate between patient goals and outcomes. which statement by the nurse is accurate. - "goals are established by the nurse and used to evaluate patient outcomes." - "Goals are patient responses, whereas outcomes are the patients response to care." - "Goals include the subjective and objective data observed by the nurse." - " Goals evaluate the patients responses to the plan of care developed by the nurse."
"Goals are patient responses, whereas outcomes are the patients responses to care."
the nurse made a medication error while caring for a patient. which statement by the nurse indicated that the nurse is interpreting the situation using guided reflection. - "I was so busy giving medication that I misread the order and gave the wrong one to the wrong patient." - "I had to tell the patient and doctor that I gave the wrong medication. it was very embarrassing." - "the medication didn't harm the patient, but i need to be more careful whenever i give medication" - "I should have remembered to check the patients wristband even though I've been taking care of this patient for several days."
"I should have remembered to check the patients wristband even though I've been taking care of this patient for several days
the nurse is describing the three column plan of care. which description by the nurse provides an accurate description. - "the three column plan only has nursing diagnosis, nursing interventions, and goals/ desired outcomes." - " the three column plan has no assessment column and combines goals/desired outcomes and evaluation into one column." - "The three-column plan combines assessment with nursing diagnosis and combines goals/desired outcomes with evaluation." - "In the three-column plan, nursing diagnosis and evaluation are stand-alone columns, whereas interventions and goals/desired outcomes are combined."
"The three-column plan has no assessment column and combines goals/desired outcomes and evaluation into one column."
the nurse is explaining how to develop an appropriate nursing diagnosis. which participant statement indicates an appropriate understanding? - "a nursing diagnosis is based on clinical judgement that is derived from assessment data." - " a nursing diagnosis is developed after the nurse evaluates the interventions provided." - "a nursing diagnosis is derived after the nurse develops the plan of care for the patient" - "a nursing diagnosis is determined by the medical diagnosis and current patient needs."
"a nursing diagnosis is based on judgment that is derived from assessment data"
the nurse is conducting an assessment on a patient who has recently been diagnosed with HIV. which question should the nurse ask during the health history to elicit subjective information concerning the patients thoughts or feelings about this recent diagnosis -"are you afraid that is okay impact your relationships" -" are you frightened this will progress to AIDS" -"you're very upset and fearful about this diagnosis, arent you" -"how did you feel when you received the HIV diagnosis"
"how did you feel when you received the hIV diagnosis"?
the nurse educator is reviewing Tanner's clinical decision- making model and asks the students about the purpose for reflecting. which response by a student is correct. - "to gain understanding about a situation" - "to learn from actions in. order to make adjustments to future practice" - " to sense. what is happening in a situation" - "to analyze a situation to choose an actions"
"to learn from actions in order to make adjustments to future practice"
an older adult states "I'm afraid i will no longer be able to live independently. i am so upset with god for all the things that have recently happened" which response by the nurse should help to address these concerns -"growing old can be difficult due to all of the changed that occur and I'm willing to listen" -"would you like me to contact our religious or spiritual department for you?" -"you know that god really isn't angry with you; sometimes things just happen together" -"I'm sorry that all of these things have happened to you, but you may still be able to live independently."
"would you like me to contact our religious or spiritual department for you"
The nurse has been using a standardized care plan to guide care for a patient hospitalized following open heart surgery. The patient is not married and lives with his 85-year-old mother who has unstable diabetes and congestive heart failure. Which nursing diagnosis would require the nurse to create an individual plan to supplement the standardized plan? - Self-care Deficit: Toileting - Cardiac Output, Decreased, Risk for - Tissue Integrity, Impaired - Caregiver
Caregiver
the nurse is performing a complete physical examination on a patient who was admitted for abdominal pain. which is the most appropriate way for the nurse to proceed with this examination _listening to the patients breath sounds -osculating the patients bowel sounds -palpitating the patients lymph nodes - inspecting the patients abdomen
Inspecting the patients abdomen
the nurse is completing an assessment for a patient with undiagnosed sever right flank pain. which technique should the nurse use when completing an examination of the right flank areas using palpation. -Using two hands and applying pressure with the top hand while keeping the lower hand relaxed -Completing deep palpation first followed by light palpation as tolerated by the patient -Extending the dominant hand's fingers parallel to the skin surface and pressing gently while moving the hand in a circle -Palpating all other areas of the abdomen and left flank but not palpating the right flank area
Extending the dominant hand's fingers parallel to the skin surface and pressing gently while moving the hand in a circle
the nurse manager is looking at models of clinical judgment to use as an employee assessment tool. the nurse manager wishes to use a model that can evaluate clinical competence in the workplace. which is best suited for the job? - Benner's skill acquisition model - tanners clinical judgment model - guided reflection - Lasater's clinical judgment rubric
Benner's skill acquisition model
the nurse works on a cardiopulmonary step down unit that is less standardized care plan for patients. in which patient scenario would a standardized plan of care be most appropriate - a patient 1 week post stroke tearful and depressed is not participating actively in rehabilitation efforts and is refusing to eat. - The family of a patient with chronic obstructive pulmonary disease (COPD) exacerbation indicates they are tired of dealing with the patient's issues because the patient refuses to quit smoking. - A patient with recently diagnosed inoperable lung cancer has been homeless for the past 7 years. - A patient 2 days post-stroke, with vital signs within normal limits, has begun the rehabilitation program.
A patient 2 days post-stroke, with vital signs within normal limits, has begun the rehabilitation program.
A healthcare team on an orthopedic unit is discussing ways to reduce cost, increase efficiency, and improve patient outcomes while collaboratively providing care. Which approach to care would be most useful in guiding daily, multidisciplinary care for the patient population on this unit? - Column care plan - Concept map - Clinical pathway - Standardized care plan
Clinical pathway
During a discussion of clinical pathways with a recent nursing graduate, the nurse preceptor mentions the use of diagnosis-related groups (DRGs) as the basis for clinical pathways. The new nurse asks what the DRGs are used for. Which information should the nurse preceptor provide to the new nurse? - DRGs determine the number of preset days allowed for care for patients with that specific medical diagnosis. - DRGs are used to determine the detailed nursing interventions to include in the clinical pathway. - DRGs are used to group conditions that are often comorbid together into one diagnosis-related group to account for the contribution of each diagnosis to days needed for care. - DRGs are used by hospitals to provide effective patient care while remaining profitable.
DRGs determine the number of preset days allowed for care for patients with that specific medical diagnosis.
In which column in a plan of care should the nurse place this information: "Patient will walk 100 feet two times each shift"? - Goals/desired outcomes - Evaluation - Assessment - Nursing
Goals/desired outcomes
the nurse determines the following nursing diagnosis for a patient: impaired Urinary elimination related to retention secondary to enlarged prostate. which portion represents axis 3 in the nursing diagnosis? - Urinary - Enlarged prostate - retention - impaired
Impaired
A facility has decided to use clinical pathways to guide multidisciplinary care for patients on the cardiac unit. This decision was made due to the multidisciplinary nature of clinical pathways Which information included in the pathway best supports multidisciplinary use? - Inclusion of clinical interventions and time frames for completion - Inclusion of projected length of stay and daily sequence of care by providers - Inclusion of medical treatments to be performed by different providers - Inclusion of usual expectations of response and expected outcomes
Inclusion of medical treatments to be performed by different providers
`the family of a nursing home resident tells the nurse that they think their family member is experiencing cognitive changes. during the assessment, which additional resource should the nurse use to help interpret findings. - mini mental status exam -nursing home staff observations -geriatric depression scale -stanford-binet IQ test
Mini- mental status exam
the nurse is caring for a patient who has difficulty breathing. which nursing action would be considered independent? - administering medication to relax breathing - sitting the patient up in the bed - prescribing oxygen therapy - ordering chest physiotherapy
sitting the patient up in bed
The nursing team is reviewing the possible use of clinical pathways to guide care for patients on the pulmonary care unit. One of the team members asks how the number of columns is determined for the clinical pathway. Which response by the team facilitator provides the best explanation? - Preset diagnosis-related groups (DRGs) determine the number of days allowed for this diagnosis and thus the number of columns. - Each insurer determines the number of days it will cover for a patient related to the specific diagnosis, which determines the number of columns. - The number of columns is preset regardless of diagnosis and includes assessment, pretreatment, and treatment of the specified diagnosis. - Column numbers vary by each patient's diagnosis, patient age, and existence of comorbidities; thus, the number of columns can vary widely between patients.
Preset diagnosis-related groups (DRGs) determine the number of days allowed for this diagnosis and thus the number of columns.
the nurse identifies the diagnosis Imbalance nutrition less then body requirements related to poor nutrition, as evidenced by low serum albumin level for a 65 year old patient with osteoporosis. which format should the nurse use to write goals for this patients? - SBAR - PIIE - SMART - CBE
SMART
the nurse is assessing a 15 year old adolescent. after introducing themselves which should the nurse discuss first with the patient to help build rapport. -the patients diet and physical activity -the patients current concerns or physical complaints -how the patient is doing in school activities that the patient is involved in
activities that the patient is involved in
the family of an older adult patient reports recent changed they have noticed in the older adult, including some short term memory loss and intermittent confusion. which should the nurse recommend to understand this older adult patients health needs? -a comprehensive geriatric assessment -referral to a neurologist -social services assessment for possible alternative living options -CT scan to rule out a brain disorder
a comprehensive geriatric assesment
the nurse is caring for a 3 year old and an 8 year old patient who are sharing the same room. which intervention is appropriate for the 8 year old but not the toddler? - providing age appropriate explanations - giving options when appropriate - using play therapy and dolls and toys to explain treatments - allowing the child to help the care provider whenever possible
allowing the child to help the care provider whenever possible
when preparing to complete a healthy history, which strategy should the nurse use to help the patient feel that they are on equal terms with the nurse. -arranging chairs at right angles just a few feet apart conducting the interview in a well lit well ventilated room -conducting the interview when the patient is free from pain or other distraction -arranging the interview in an area with some privacy
arranging chairs at right angles just a fe feet apart
the nurse is providing care to a patient who recently had back surgery. which nursing action is a collaborative nursing activity? - assisting the patient with bathing - adjusting the head of the patients bed for comfort - assessing the patients surgical would site - arranging for physical therapy to ambulate the patient
arranging for physical therapy to ambulate the patient
which action by the nurse indicates support for a preschoolers decision making ability? - inviting the child to the interdisciplinary meeting - showing the child the materials that will be used to stitch. up the wound in the child knee. - soothing the child by rocking the child until calm - asking if the child would like to have the scheduled snack before or after going for an x ray
asking if the child would like to have the scheduled snack before or after gong for an x ray
the nurse is completing an assessment n a 2 year old patient at the pediatric office. which assessment should the nurse take to help enhance compliance of the toddler with the assessment. - encouraging the accompanying parent to hold the toddlers had and speaking calmly to the child -quickly initiating an accompanying assessment activities - asking the accompanying parents to hold the child on their lap - asking the child if it is okay for you to do the physical exam prior to starting
asking the accompanying parent to hold the child on their lap
which activity should the nurse complete during the body of a patient interview? -telling the patient how obtained information will be used -offering to answer questions -asking the patient questions that follow a logical sequences -informing the patient that they have the right not to provide information
asking the patient questions that follow a logical sequences
the nurse is formulating a plan of care for a pregnant patient. one goal set by the nurse is that the patient should attend all prenatal classes. which step should the nurse take to motivate the patient to attend the goal? - tell the patient that it is in her best interst to attend classes - inform the pateint that insurance will not pay for the hospital stay for nonattendance at prenatal classes - attend the classes with teh patient to ensure compliance - associate the goal with a personal meaning for the patient
associate the goal with a personal meaning for the patient
the nurse is caring for a patient with an electrolyte disturbance. the healthcare provider asks the nurse to draw an arterial blood gas (ABG), but the nurse has never performed the procedure and asks a more senior nurse to assist. which critical thinking attitude is exemplified by the nurses action? - differentiating fact from fiction - approaching situations objectiviely - awareness of self limits - perservance
awareness of self limites
the nurse decides suction and preform tracheostomy care on a patient before sending the patient to a schedules procedure. which process does the nurses action define. - intuition - trial and error - choosing among alternatives - clinical decision making
clinical decision making
During an interview with a patient, the nurse states "lets go over what we have discussed today." which phase of the interview process should this statement reflect? -body -development -opening -closing
closing
during an interview with a patient, the nurse states "well i don't have any more questions" During which phase of the interview -opening -body -development -closing
closing
the nurse is preparing to discharge a patient after a hospital stay. which task should the nurse perform to determine if goals have been met? - collect date develop new nursing diagnoses for the home health nurse to follow - collect date related to the goal and make decisions about nursing care effectiveness. - collect data to provide discharge instructions to follow when at home. - collect data related to patient specific outcomes for accrediting bodies.
collect data related to the goal and make decisions about nursing care effectiveness
the nurse is planning care for a patient bases on the patients established goals. which character should the nurse consider for nursing interventions? - can be performed with limited resources - identified with specific laws and regulations - can be interchangeable among patients for optimal applicability - consistent with the patients values, beliefs, and culture
consistent with the patients values, beliefs, and culture
the nurse is sitting with the healthcare provider and a pregnant patient. the provider is explaining to the pregnant women the various options for genetic testing that are currently available. the provider asks the patient which testing she would like to have done. the nurse understands that the provider is displaying which decision making model? - maternalism - paternalism - mutualism - consumerism
consumerism
the nurse is caring for a toddler who appears frightened by the nurse. to make the child more at ease, the nurse gives the toddler a disposable tape measure to play with. which critical thinking concept is the nurse displaying. - concreteness - confidence - independence - creativity
creativity
during an assessment at the community based clinic for a patient who recently immigrated to the united state, the nurse notes that the patient does not look at the nurse when questions are being asked. when interpreting this finding which factor should the nurse take into consideration? -fear of being deported may be impacting the patients behavior -differences in sex may be a factor leading to this behavior. -cultural norms may play a role in this behavior -psychological factors such as anxiety may be causing this behavior
cultural norms may play a role in this behavior
the nurse is beginning a new shift and is reviewing the report given by the previous nurse. which decision by the nurse is an example of a scheduling decision? - deciding what information to share with other healthcare providers - deciding when to change a dressing - deciding what can be completing by a nursing assistant - deciding to bathe the patient before therapy
deciding to bathe the patient before therapy
the nurse is creating a concept map for a patient with multiple health problems. after creating clusters of assessment data, which should the nurse complete next to prioritize patient needs? - determine the priority nursing diagnosis for each cluster; use lines to connect them to the cluster - develop appropriate goals and outcomes for care; use lines to connect these to the relevant cluster - develop priority nursing interventions, use lines to connect them to the relevant nursing diagnoses - determine goals and outcomes that can be achieved through nursing care; use lines to connect these to relevant nursing diagnoses
determine the priority nursing diagnosis for each cluster; use lines to connect them to the clusters
the nurse is creating a patient concept map for a simulation scenario. which should the nurse do first when creating the concept map? - gather and sort significant cluster of assessment data - develop a legend for the concept map - look at the assessment data, including both subjective and objective data - put a shape with patient information and priority medical diagnosis in the middle of the paper
develop a legend for the concept map
the nurse is working on a concept cap for a patient with multiple health problems. which non-computerized method should the nurse consider that would most easily allow the nurse to move data around until the concept map is finished? - pencil and paper - different colored ink pins and paper = formatted concept map template - different colored sticky notes
different colored sticky notes
the nurse is planning to transfer a 76 year old patient to a long term care facility. the patient wants to live close to family; however, the facility that would best meet the patients needs is a few miles farther away. which action should the nurse implement? - discuss the advantages of the facility that is a bit farther away. - tell the patient that being near family is not alway a good idea - list other facilities so that the patient can make a better decision - tell the patient that the facility that is closer is not accepting admissions
discuss the advantages of the facility that is a bitt farther away
a respiratory therapist is working with pediatric patients with cystic fibrosis. when the therapist asks the nurse about treatment Guidelines for the patient, the nurse refers the therapist to a clinical pathway algorithm. which described the goal of this algorithm? -improve a visual depiction fo the nursing care plan - ensure standardization of care provided across clinical disciplines - improve time efficiency when providing care for patients. - define interventions for which each discipline will be held accountable
ensure standardization of care provided across clinical disciplines
which action should the nurse take to prepare the environment for an adult patients physical examination? -inviting the patients family to be present -ensuring that the room is well lit, war, and private -informing the patient that the examination will take place as a specific time -informing the patient that hospital policy states that a nurse of the opposite sex will preform the examination
ensuring that the room is well lit, warm, and private
the nurse is preforming a head to toe physical assessment on a patient who is 10 years old. which approach is the most appropriate when assessing this patient - expecting reluctance to cooperate -beginning the session with the physical examination -promising toys for cooperation during the exam -establishing a rapport before the physical assessment.
establishing a rapport before the physical assessment
the nurse has developed a plan for a patient for a patient with a specific goal. the patient was unable to meet the goal by the stated time frame. before revising the goal, which step must the nurse perform? - compare patient progress with that of other patients. - document noncompliance with the plan - evaluate factors impeding goal attainment - ask the healthcare provider for a more reasonable goal
evaluate factors impeding goal attainment
the nurse evaluates the plan of care for a patient admitted with pneumonia who still has difficulty breathing related to an ineffective breathing pattern. which step should the nurse include to select new interventions for the plan of care? - setting more realistic patient goals and easier interventions - evaluating the current interventions and patient needs. - delegating the selection of the new interventions to another nurse. - deleting the current nursing diagnosis because it was not meeting the patients needs
evaluating the current interventions and patient needs
which statement describes the evaluation phase of the nursing process/ - evaluation is performed only after nursing interventions are performed - evaluation is preformed throughout all phases of the nursing process - evaluation is determined based on gathering subjective and objective date - evaluation focuses on determining changed and preventing complications
evaluation is preformed throughout all phases of the nursing process.
the nurse is caring for a patient with schizophrenia. the patient is at risk for disturbed thought process. which nrusing intervention could the nurse implement without an order form the healthcare provider? - referring the patient to an ourpatient program on discharge. - explaining that the nurse does not hear the voices - complying with taking all medications as prescribed - placing the client in a seclusion room for a time-out
explaing that the nurse does not hear the voices
the nurse manager is preparing an annual performance appraisal for a staff nurse who has worked on a medical surgical care area for 2 years. the manager determines that the staff nurses level of proficiency is competent. which action by the staff nurse prompts the manager to make this decisions? - determined how a new medication would impact a patients other health problems - focused on a specific problem when planning care - referred to the procedure manual to change the dressing at an intravenous (IV) site - waited for direction from charge nurse before providing care
focused on a specific problem when planning care
which assessment should the nurse complete during the assessment of an infant that is NOT generally included during the assessment of a toddler. - height -weight -head circumference -child and care-giver interactions
head circumference
a patient is recovering from a motor vehicle crash has been ordered complete bedrest for 3 months. the patient presents with skin breakdown. which nursing diagnosis statement is correct? - impaired skin integrity related to skin breakdown - impaired skin integrity related to motor vehicle crash - impaired skin integrity related to time in bed - impaired skin integrity related to immobility
impaired skin integrity related to immobility
The nurse is working on the oncology floor of the hospital and notes that many of the patients request internet access so that they can communicate with loved ones more easily. Using this information, the nurse obtains a grant to purchase several laptops for the patients to share. which type of reasoning did the nurse use to develop this protocol? - clinical reasoning - careful reasoning - deductive reasoning - inductive reasoning
inductive reasoning
the nurse is caring for a neonate who requires nasogastric (NG) tube feedings due to prematurity. the NG tube frequently slips out of position, and the nurse tries different approaches to prevent this from happening. which critical thinking skill is the nurse demonstrating? - reasoning - reflection - intellect - inquiry
inquiry
the nurse if caring for a newly admitted patients. which skills should the nurse use to build rapport and trust with the patients. - interpersonal - technical - cognitive - multidisciplinary
interpersonal
after completing an assessment the nurse make determinations about the data collected. which term described this process during assessment. -differentiation -validation -interpretation -organization
interpretation
the nurse is caring for a patient who was admitted with abdominal pain. the patients complete blood count (CBC) is normal, but the nurse is still concerned about the patient having a gastrointestinal bleed and monitors the patient closely. which cognitive skill is the nurse displaying? - reasoning - inquiry - refelction - intuition
intuition
the nurse with 15 years of obstetric experience if caring for a patient in labor who is reporting extreme pain. the nurse knows that the patient is likely getting very close to delivery but asks the provider to come and evaluate the patient. which decision making process is reflected in this situation? - trail and error - the scientific method - intuition - the nursing process
intuition
the nurse is supervising na unlicensed assistive personnel (UAP). which task should the nurse delegate to the UAP? - evaluating color of urine - determining a patients hydrations status - measuring intake and output - analyzing urine test results.
measuring intake and output
the nurse is sitting with a laboring patient who is requesting intermittent fetal monitoring. the nurse is explaining the risks, benefits, and evidence to support the different types of monitory. which type of decision making is the nurse demonstrating? - mutualism - consumerism - paternalism - maternalism
mutualism
the nurse auscultates a patients breath sounds after the patient receives an albuterol nebulizer treatment secondary to wheezing. the nurse finds that the patient is still wheezing despite the therapy. which aspect of tanners clinical judgment model is the nurse displaying - noticing - interpreting - responding - reflecting
noticing
the nurse is working for a facility that requires the use of a column framework for planning care. information in which column of the plan of care is best derived from and supported by research evidence - nursing diagnosis - nursing interventions - goals/desired outcomes - evaluation
nursing nterventions
during a patient interview, the nurse asks the patient why they came to the triage center at the mental health facility. this question should be considered as which type of interview question. -open ended -close -neutral -leading
open ended
a pregnant patient presents with rising blood pressure and protein in her urine. after testing, the provider diagnoses the patent with preeclampsia and informs her that they are taking her to the operating room to deliver the baby through Caesarean delivery immediately. which decision making model is displayed? - consumerism -mutualism - paternalism - maternalism
paternalism
the nurse is examining the following nursing diagnosis statement. risk for impaired skin integrity related to decrease peripheral circulation secondary to diabetes. the use of "secondary to" in this diagnosis reflects which component? - pathophysiological disease process - axis 2 of the nursing diagnosis - primary identifiable nursing problem - subjective data obtained
pathophysiological disease process
the nurse is providing care for a patient who has emphysema. which techniques are most appropriate for the nurse to use when assessing the patients lungs. -palpation and percussion -inspection and palpation -percussion and auscultation -auscultation and palpation
percussion and auscultation
The nurse receives report from the nursing assistant concerning vital signs on one of the assigned patients. The nursing assistant reports that the patient's blood pressure is extremely high at 212/106 mmHg. Prior to this reading, the nurse is aware that this patient's blood pressure readings have been averaging a more expected reading of 136/84 mmHg. Which action should the nurse complete first? - check prescriptions for a prn antihypertensive order -ask the nursing assistant to repeat the blood pressure measurement -personally confirm the finding by retaking the blood pressure -contact the heath-care provider for orders based on this reading
personally confirm the finding by retaking the blood pressure
the nurse is looking at ways to help infants in the healthcare process. which intervention is appropriate for this age group? - encourage the use of play therapy and toys in the treatment rooms - place cots for parents to stay over in all patient rooms. - provide simple options when appropriate - allow for hands on exploration for all equipment
place cots for parents to stay over in all patient rooms.
the nurse is developing a plan of care for a patient admitted to the hospital for pneumonia. which phases of the nursing process will the nurse use to develop interventions? - Assessment - implementation - nursing diagnosis - planning
planning
the nurse is completing an initial assessment ton a patient who indicates they recently notes a mass in their breast. which palpation technique should the nurse use to determine the details of this mass? -using even and consistent pressure to clearly delineate the edges of the mass -using both hands, applying pressure with the top hand -supporting the mass with the non-dominant hand while palpating the mass deeply with the other hand -pressing lightly several times around the mass
pressing lightly several times around the mass
the nurse is creating a plan of care for a patient with complex health problems, including sepsis. which action should the nurse take to focus nursing care and support the best patient outcomes? - Create two to three general categories of nursing diagnosis. - Focus nursing diagnoses only on those issues caused by the sepsis. - prioritize three to five nursing diagnosis - List all applicable nursing diagnoses, highlighting those that have highest priority.
prioritize three to give nursing diagnosis
the nurse is caring for a patient with a history of diabetes mellitus. the nurse notices an upward trend to the patients daily fasting serum blood glucose and notifies the patients healthcare provider. which level best describes this nurse according to Benner's skill acquisition model? - competent - advance beginner - novice - profiecient
proficient
the nurse is implementing care for patients in an acute care facility and asks a patient about dietary restrictions related to religion or ethnicity. which nursing goal is the nurse meeting with this question? - follow prescribed dietary needs - provide culturally competent care - determine need for special services - promote contentment in the patient
provide culturally competent care
the nurse is developing a plan of care for a patient with the nursing diagnosis Impaired physical mobility related to inactivity secondary to arthritis. the nurse and patient develop a goal of ambulating the hall three times a day with a wheeled walker. which purpose should this goal help achieve? - measure the end result of nursing action - identify a time frame for an action to occur - provide direction for nursing interventions - evaluate the patients response to the plan of care
provide direction for nursing interventions
An 82-year-old patient is brought to the healthcare provider's office due to recent inability to complete activities of daily living (ADLs). Until recently, the daughter reports that the patient had been able to live independently. The patient lives alone since their spouse died one month prior. The patient is alert and oriented but appears a bit disheveled and does not look at the nurse during the assessment process.Which factors in the patient's history might be most important to interpreting this patient's recent inability to complete ADLs? -Psychological and emotional factprs -developmental factors -cognitive facotrs -environmental factors
psychological and emotional factors
the nurse determines that the patient has not met the plan of care for the nursing diagnosis Skin Integrity, impaired because the wound has not healed within the time frame specified. the nurse chooses to revise the plan of care. which steps should the nurse preform first? - reassess the wound - talk to the healthcare provider - set a new reachable goal - change the interventions
reassess the wound
a new nurse is speaking with a mentor about a mistake made the day before/ the mentor encourages the nurse to review the situation and make a mental note to respond differently the nest time the situation occurs. which process is the mental encouraging? - reflecting - responding - interpreting - noticing
reflecting
the nurse is caring for a young women who is receiving antibiotics for a urinary tract infection. the patient returns to the cliic complaining of continues burning urination 4 days after starting the medication. the nurse looks at the patients chart and notices that a urine culture was never performed.
reflecting
the nurse is evaluating the current plan of care for a patient who is receiving care in a long term healthcare facility. the evaluation indicates that the patient is not meeting goals related to mobility. which is an appropriate nursing action at this time? - revising the plan of care - concluding that the problem is resolved - determining that the patient does not have any risk factors - asking the patient to try harder
revising the plan of care
which factor should the nurse assess when working with older adult patients to promote greater independence and safety. - risk for falls - rick for social isolation -medication history -current medical diagnoses
risk for falls
the nurse is obtaining a history from the parents of a 10 month old infant. the parents re concerned that compared with other infants their child seems very small. which resource should ht ensures use to provide assistance when interpreting findings related to the infants heights and weights -size of both parents -amount of weight gain since last visit -standardized growth charts -comparison of current weight and length to birth weight and length.
standardized growth charts
a patient presents to the emergency department with high fever and coughing. which information should the nurse collect for analysis? - subjective data - judgments - inferences - opinions
subjective date
while auscultating the ling sounds of a patient with chronic obstructive pulmonary disease (COPD), the nurse notes scattered high pitches wheezes. which aspect of lung sounds is described by this assessments? -the intensity of the sounds -the duration of the sounds - the frequency of vibrations -the quality of the sounds
the frequency of vibrations
The nurse has just admitted a 72-year-old patient for total hip replacement to a unit that utilizes clinical pathways. The patient is otherwise healthy, and recovery is expected to progress normally. How will the clinical pathway for this patient be initiated? -The healthcare provider will write an order for the appropriate clinical pathway for this patient. - The physical therapist will initiate the clinical pathway for this patient if appropriate. - The nurse will initiate the clinical pathway after verification of appropriateness by the nursing supervisor. - The nurse will complete a patient assessment to determine if the patient meets the parameters for the clinical pathway, then initiate it.
the healthcare provider will write an order for the appropriate clinical pathway for this patient
which clinical situation best exemplifies the nurse who is choosing between alternatives when making a clinical decision? - the nurse administers an intravenous (IV) narcotic instead of an oral narcotic - the nurse changes the patients position numerous times until the patient appears in less pain. - the. nurse has a "gut reaction" to the patients pain and calls the patients physician - the nurse determines that the patients nursing diagnosis in Pain, acute
the nurse administers an intravenous (IV) narcotic instead of an oral narcotic
the nurse is caring for a teenager who requires surgery to repair a broken femur after a motor vehicle crash - the parents must provide consent - the teenager must sign the consent form - the parents must provide consent, the teen must sign an assent form. - the teenager must sign the consent form, and the parents must also provide assent
the parents must provide consent
a patient is admitted to the hospital with pneumonia. the nurse develops a plan of car with a nursing diagnosis of impaired gas exchange related to inadequate ventilation secondary to atelectasis. which goal indicates all elements of a goal statement? - the patient will be given supplemental oxygen to use via nasal cannula - the patient will demonstrate correct use of the incentive spirometer after the teaching session. - the patient will be given bronchodilators as prescribed - the patient will be instructed in use of the incentive spirometer every hour.
the patient will demonstrate correct use of the incentive spirometer after the teaching session
which short term goal should the nurse view as appropriate for a patient with the nursing diagnosis deficient knowledge relate to disease process secondary to diabetes - the patient will flow a diabetic with 90% compliance within 3 months - the patient will verbalize understanding of how insulin effects blood sugar by the end of the day - the patient will maintain blood sugars between 80 and 120 mg/dl within 1 month - the patient will identify ways to prevent complications from diabetes within 2 moths
the patient will verbalize understanding of how insulin effects blood sugar by the end of the day
The nurse is caring for a patient with malnutrition and identifies a nursing diagnosis of imbalanced nutrition less then body requirements related to poor oral intake secondary to cancer treatment. which goal set by the nurse is an example of a specific and measurable goal? - the patient will take in 80 grams of protein per day - the patient will verbalize foods that are needed to gain weight - the patient will experience no further nausea and vomiting - the patient will gain weight over the next few months
the patients will take in 80 grams of protein per day
The school nurse is looking at the effects that increasing recess and recreation time has in the classroom. The nurse plans to assign some classes within the school an additional hour of recess each day, and the remaining classes will stay on the current schedule. Which concept of problem solving and critical thinking should be most useful in this situation? - intuition - the nursing process - the scientific method - trial and error
the scientific method
when documenting a recently completed patient assessment, which information indicates the pitch pf an auscultated sound? - tinkling sounds heard upon abdominal assessment -normal breath sounds noted on lung auscultation -medium dullness noted with percussion of the abdomen -expiratory phase being longer than inspiratory phase
tinkling sounds heard upon abdominal assessment
the nurse is caring for a patient who is having back discomfort. this nurse helps the patient change position several times until comfortable. which process is defined by this action - trial and error - the nursing process -intuition - clinical decision making
trial and error
a patient reports hematuria along with the pain. after reviewing the patients chart and assessing the patient, the nurse documented the following nursing diagnosis: acute pain related to urinary obstruction secondary to prostate cancer. which part of the nursing diagnosis statement reflects the etiology. - hematuria - acute pain - urinary obstruction - prostate cancer
urinary obstruction
The nurse is creating a concept map to guide a plan of care for a patient with multiple health problems. The nurse is using paper and pencil to create the map because the nurse is not comfortable with using the computer for this activity. How could the nurse easily improve the readability of the map? - use a concept map template - make sure to match colors and shapes and coordinate patterns - find a software program that the nurse is comfortable with - use colored pencils or markers - use colored pencils or markers
use colored pencils or markers
the nurse is planning interventions for a patient with a nursing diagnosis of activity intolerance related to weakness as evidenced by inability to walk two steps. which part of the nursing diagnosis statement is used as the framework for planning nursing interventions. - weakness - previous health history - activity intolerance - inability to walk two steps
weakness
when is it appropriate to conduct a problem focused r system specific assessment -when assessing a patient in psychologic or physical crisis -when comparing findings several months after initial patient assessment -when is it part of an ongoing process integrated with nursing care -at the patients first appointment to establish criteria for later comparison
when it is part of on ongoing process integrated with nursing care
as the nurse completes an assessment on a patient, the nurse notes that the patient defers all questions to the spouse, rarely looking at the nurse when the questions are asked. which questions might the nurse ask to best clarify how healthy decisions are made in the family. -"have you ever independently made any health decisions of your own?" -"you are aware that it is necessary for you to make your own health decisions, aren't you?" -"who usually make decisions concerning health in your family?" -"would you prefer that your spouse wait outside of the room until we are done with this assessment?"
who usually makes decisions concerning health in your family?
