Nursing Process

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation?

"Client states, 'I don't see the point in trying anymore.'" Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentations.

Which of the following entries would be an example of appropriate documentation?

"I am so down today, and I just don't have any energy." Subjective data should be recorded in the patient's own words, and quotation marks should be used. Avoid using nonspecific terms such as good, average, large, and small. Do not make judgments or inferences

The expected outcome for a client with a new diagnosis of diabetes mellitus (DM) is: client will describe appropriate actions when implementing the prescribed medication routine. Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration and storage, and conditions that require contact with the healthcare provider.

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which of the following questions is the most appropriate conclusion to the interview?

"Is there anything else we should know in order to care for you better?" A helpful strategy in the termination phase of an interview is to ask the client: "Is there anything else you would like us to know that will help us plan your care?" This gives the client an opportunity to add data the nurse did not think to include. Expectations and previous practices should be addressed during the working phase of an interview.

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual?

"Mr. Koeppe, tell me what you do to take care of yourself." Clients such as older adults with dementia, and their children, cannot be relied on to report accurately. However, they should be encouraged to respond to interview questions as best as they can. Bypassing the client communicates that the nurse does not have time or has doubts in the client's ability to communicate.

An 84-year-old male has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease (COPD) and elevated blood glucose. Which statement by the client could help identify the most likely reason for the changes in his health status?

"My wife's been gone for about seven months now."

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"Please tell me your thoughts about treating this diagnosis." In the planning stage of the nursing process the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data?

"Unable to palpate femoral pulse in left leg." Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Objective data are also called signs or overt data. The only objective data in this question would be that the nurse is unable to palpate a femoral pulse.

When the nurse is administering medication, an elderly client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?

"We ask your name to ensure that we are treating the right client." The primary reason for asking the client to state her name is to ensure that the nurse is dealing with the correct client. Asking the client to state her name is a habit that should be developed in nursing school, but that is not the reason nurses ask clients for their names. It is not just a hospital-specific policy to ask the client for her name, but it is a step that is used in all client care situations. Respecting clients' rights is important but that is not why nurses ask for their names.

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct?

"ineffective airway clearance related to thick mucus" It is important to use guidelines to formulate correctly written nursing diagnoses. The nurse would not use client needs, put defining characteristics before the diagnoses, or judge the willingness of the client to cough

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply.

38 year-old man • Weight 195 pounds • Height: 6' Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing it.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.

A pregnant client asks the nurse for information on breastfeeding her baby. What type of nursing diagnosis would the nurse formulate?

A wellness diagnosis The client is seeking information related to healthy practices. Wellness diagnoses are formulated to assist the client to meet that need. The client has no health problem or possible problem, so an actual diagnosis, a risk diagnosis, and a possible diagnosis are inappropriate.

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual "Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual diagnosis because it describes a human response to a health problem that is being manifested. A wellness diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse thinks that it is highly probable and wants to collect more information.

A nurse is assessing a client with chronic back pain and asking specific questions to obtain a focus assessment. Which of the following are features of focus assessment?

Adds depth to existing information

What nursing organization first legitimized the use of the nursing process?

American Nurses Association Although the term "nursing process" was first used by Lydia Hall in 1955 and nursing theorists delineated specific steps in a process approach to nursing, use of the nursing process was legitimized in 1973, when the American Nurses Association's Congress for Nursing Practice developed Standards of Practice to guide nursing performance

Which of the following patient situations most likely warrants a time-lapsed nursing assessment?

An elderly resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. A time-lapsed assessment is often indicated in the care of a stable patient whose current status is being compared to earlier baseline data. Shortness of breath and chest pain necessitate an emergency assessment, while a new admission to a unit or institution requires an initial assessment. Following up a known health problem most often requires a focused assessment.

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response?

Apply pressure to the surgical site to decrease bleeding. It is essential that the nurse be prepared to address life-threatening needs of the client. Excessive bleeding is a life-threatening issue. Determining the cause of the client's bleeding, assessing the vital signs, and notifying the health care provider are important, but the life-threatening issue must be addressed first.

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse's best course of action?

Ask a skilled nurse to assist with the procedure. Professional nurses should only undertake tasks that they have been properly trained to perform. Since the nurse has no experience in changing an ostomy bag, it would be most appropriate to have the assistance of an experienced nurse. It would be inappropriate to ask the client how the bag is changed. The client is relying on the nurse to have the necessary technical knowledge. Reading the policy and procedure manual alone would not ensure the successful completion of the procedure. The necessity of the ostomy bag change has already been established.

A client has just been taught about lowering cholesterol with diet and exercise. What is the best way to evaluate that the client understands the material?

Ask direct questions about the teaching plan. By permitting off-topic conversation, the nurse allows the client to avoid the issue being taught. This should be further explored by motivational interviewing. Redirection helps refocus the teaching session, but does not evaluate. Silence can mean many things. By asking direct questions about the topic, the nurse can easily find areas that need clarification and when the client has mastered the concepts.

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required. If the nurse suspects a client does not understand instructions, the first step is to assess the client's understanding. The most effective way to do that is to have the client repeat the client's understanding of the instructions. The other steps might be interventions that the nurse would institute after determining the client's needs.

During the nursing examination, the nurse notices that the patient, an elderly female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation?

Ask the patient if it is okay to interview her husband for the answers to the interview questions. The nurse is responsible for collecting data in a timely manner. If the patient is too fatigued the nurse must ask for permission to obtain answers to interview questions from the husband prior to continuing to do so. Asking the patient to wake up is disregarding the patient's needs. Waiting until the following day is too long for the collection of important data.

The surgeon is insisting that a client consent to a hysterectomy. The client says that she will not make a decision without her husband's consent. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to her husband. It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to her husband. Telling the client that she is responsible for her health care decisions does not respect the client's desire to consult her husband. The client has not indicated that there she is fearful of her husband. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request.

The nurse is caring for a client admitted to the hospital for renal calculi. What is the best action to take first?

Assess for bladder distention. Urinary retention could occur if a kidney stone has become lodged in the urethra. Forcing fluids, straining the urine after each void, and diet as tolerated are appropriate interventions, but do not address the safety issue of first assessing the bladder for distension, and could potentially cause the client discomfort and harm

One hour after receiving pain medication, a postoperative client complains of intense pain. What is the nurse's most appropriate first action?

Assess the client to determine the cause of the pain. One hour after administering pain medication, the nurse would expect the client to be relieved of pain. A new complaint of intense pain might signal a complication and requires a thorough assessment. The nurse might request an order for additional pain medication, but only after a thorough assessment. Telling the client how often medication can be received does not help relieve the client's pain. Repositioning and splinting the incision is an intervention that the nurse might perform, but only after determining the cause of the pain.

The care plan for a client who has been frequently admitted to the hospital for exacerbation of COPD (chronic obstructive pulmonary disease) has a nursing diagnosis of "Noncompliance related to lack of knowledge as evidenced by frequent admissions to the hospital." What is the most appropriate method for the nurse to use to validate the nursing diagnosis?

Assess the client's knowledge of COPD.

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation. After a nurse has performed an intervention, the next step is to evaluate the effectiveness of the intervention. The nurse should assess the client's response to the ambulation. Informing the client when ambulation is scheduled next, discussing the client's feelings, and documenting the ambulation are important, but not until after the client has been reassessed.

A client comes to the emergency department complaining of severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?

Assessing Assessing is the step in which nurses assess the client to determine the need for nursing care. When assessing, the nurse systematically collects client data.

Then nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process?

Assessment The nursing process is a systematic method used by the nurse and client. Assessment is the first step to determine the needs for client care.

Which of the following groups of terms best describes a nurse-initiated intervention?

Autonomous, clinical judgment, client outcomes A nursing intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. Nurse-initiated interventions are autonomous (independently performed).

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing self-care deficit related to lack of access to bathing facilities as evidenced by a strong body odor The most appropriate diagnosis would be "Bathing self-care deficit. The client is homeless and would not be able to access bathroom facilities. Homelessness has not been identified as a syndrome and there is only evidence of one problem. Inadequate hygiene has not been identified as a nursing diagnosis; furthermore, the word "stink" is an offensive term which must be avoided in nursing documentation. There is no evidence to suggest that the client has any issues with impulse control.

Which of the following activities is the clearest example of the evaluation step in the nursing process?

Checking the client's blood pressure 30 minutes after administering the captopril Measuring the client's blood pressure after performing an intervention such as drug administration determines the extent to which the client has achieved the outcome desired, which in this case is lowered blood pressure. Initially checking the client's blood pressure is an example of assessment, while recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation.

A nursing student is learning about how to perform a thorough assessment in a health assessment class. Which of the following is the best source of information for the student to learn data collection for an assessment?

Client The client is the primary, and usually the best, source of information when doing an assessment.

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normal tensive. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 mm Hg and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension.

The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal?

Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. An example of a long-term outcome is "Patient returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack." The other three examples are short-term outcomes that focus on short-term goals related to the period of time during hospitalization.

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "activity intolerance." Which expected client outcome most directly demonstrates resolution of the problem?

Client will alternate rest periods with exercise through the day. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will promote health in a client with COPD, the most direct resolution of activity intolerance is for the client to pace activities by alternating rest with exercise throughout the day.

Which is an appropriate expected outcome for a client?

Client will ambulate safely with walker in the room within three days of physical therapy. Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy is a specific and reasonably attainable goal. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable such as "know" and "understand".

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.

A client who was just fitted with a new artificial leg following a recent amputation tells the nurse, "I want to participate in a 5K race to raise money for wounded soldiers." Which client outcome is most appropriate?

Client will walk with prosthesis and assistive devise in one week. Outcomes can be categorized as clinical, functional, or quality of life. This client has set a functional goal, so the outcome should measure achievement of that goal. The option to control pain is a clinical outcome. The other two options do not measure achievement of the client's goal

A client who was just fitted with a new artificial leg following a recent amputation tells the nurse, "I want to participate in a 5K race to raise money for wounded soldiers." Which client outcome is most appropriate?

Client will walk with prosthesis and assistive devise in one week. Outcomes can be categorized as clinical, functional, or quality of life. This client has set a functional goal, so the outcome should measure achievement of that goal. The option to control pain is a clinical outcome. The other two options do not measure achievement of the client's goal.

The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective coping." What subjective assessment data would provide evidence for this nursing diagnosis?

Client's report of increased consumption of alcohol The client's increased consumption of alcohol is an unhealthy coping mechanism. The client's other statements indicate healthy ways of dealing with the illness.

In order to successfully implement the plan of care, what parties are essential for the nurse to include?

Client, family, and physician In order to assure the success of the care plan, the nurse must involve all necessary parties. It is essential that the client be involved in his own health care decisions. The family provides needed support and the physician is essential to provide medical interventions. The insurance provider is not necessary for the implementation of the plan of care. Physical therapy and a surgeon are not necessarily involved in every client's care

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this?

Cognitive Cognitive goals involve increasing client knowledge. These goals may be evaluated by asking clients to repeat information or to apply new knowledge in their everyday lives.

The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill?

Cognitive skill The student is demonstrating the use of cognitive skills, which is characterized by identifying scientific rationales for the client's plan of care, selecting nursing interventions that are most likely to yield the desired outcomes, and using critical thinking to solve problems. Technical skills focus on manipulating equipment skillfully to produce a desired outcome. Interpersonal skills are used to establish and maintain a caring relationship. Ethically and legally skilled nurses conduct themselves in a manner consistent with their personal moral code and professional role responsibilities.

The nurse is caring for a vegetarian who is suffering from iron deficiency anemia. The nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How will the nurse plan to meet this client's nutritional needs?

Collaborate with the nutritionist to modify the nutritional plan. A vegetarian does not consume animal proteins. While animal proteins are an important source of iron, plant proteins are available. To honor the preferences of the client, the nurse would collaborate with the nutritionist to include these plant sources of protein in the client's diet instead of the animal protein. It is not true that the client has to consume animal protein to cure the anemia. Meeting with the client's family would be inappropriate because this would violate the wishes of the client. Arranging for animal protein to be disguised in the client's meal would violate the client's trust and would also not be effective in the long term after the client has been discharged.

A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client's physiologic response. This action is known as a:

Collaborative problem. Collaborative problems are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems by using physician-prescribed and nursing-prescribed interventions to minimize the complications of the event.

Which statement related to the evaluation of outcome attainment for a client is correct?

Collecting data related to outcome attainment requires the nurse to know when to collect the data based upon established time criteria. In addition to knowing what type of data to collect to determine outcome achievement, it is important to know when to collect the data based upon established time criteria. It is important for the nurse to evaluate client outcome achievement as early as possible and not wait until discharge, when the plan of care cannot be modified. Evaluation of the client's attainment of outcome goals is determined by the nurse, client, and the client's family. Celebrating outcome attainment with the client usually helps encourage the client and leads to further outcome achievement.

Which of the following group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem focused, time lapsed, and emergency based describe types of assessments. Assessments are nurse focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.

The nurse is caring for a client who is recovering from a CVA (cerebrovascular accident). When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client while another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

Communicate with the physicians to coordinate their orders. As coordinator of care, the nurse is responsible for ensuring the continuity of the treatment plan. If conflicts occur in the treatment plan, the nurse first consults with the physicians who have written the conflicting orders. The nurse may assess the client to determine if the client is capable of ambulation, but this does not resolve the conflict or determine if ambulation is in the client's best interest. It is not the client's responsibility to clarify nursing orders. Collaboration with physical therapist could become part of the plan later, but the physician's orders have to be clarified first.

The client's expected outcome is "The client will maintain skin integrity by discharge." Which of the following measures is best in evaluating the outcome?

Condition of the skin over bony prominences. During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse examines client data or behaviors that validate whether the outcome is met. The condition of the skin, especially over bony prominences, provides the best measure of whether skin integrity has been maintained.

Which example of patient care is not the responsibility of the nurse?

Confirming a medical diagnosis The nursing scope of practice dictates what is allowed and not allowed when providing nursing care. Confirming a medical diagnosis is not in the scope of nursing practice. Monitoring for changes in a patient's health status, promoting safety and preventing harm, tailoring treatment and medication regimens to the patient's schedule of activities are all nursing care responsibilities.

A nurse caring for an elderly patient who has dementia observes another nurse putting restraints on the patient without a physician's order. The patient is agitated and not cooperating. What would be the best initial action of the first nurse in this situation?

Confront the nurse and explain how this could be dangerous for the patient. Confronting the nurse and explaining the danger for the patient is a form of peer evaluation. Peer evaluation involves evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is an important mechanism nurses can use to improve their professional performance and it can be done formally or informally. Reporting the nurse does not enhance a good working relationship and does not follow the chain of command. An incident report is not warranted at this point in time. The physician should not be contacted for an order unless it is decided that the restraint is going to be left on the patient.

A 50-year-old female patient is admitted to a hospital unit with the diagnosis of scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information?

Consult nursing and medical literature.

A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a one month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs?

Consult reference materials to determine the normal vital signs for one month old infants. It is part of nursing practice to interpret the significance of assessment data by comparing it to standards. The nurse should consult reference materials to determine the normal range of vital signs for this client. Deferring to the emergency room is unprofessional and may result in harm to the client. Asking the mother if the infant's vital signs are higher than normal is unprofessional practice. A complete physical assessment is not necessary a this time.

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

Consult with a more experienced nurse. A newly graduated nurse does not have the experience to interpret all data. The nurse must recognize when a consult with a more experienced nurse is needed. There is no evidence that the nurse needs to collect more data. The data must be documented, but if the data is significant, it may harm the client if no action is taken. There is no need to contact the health care provider at this time.

Which action is appropriate when evaluating a patient's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes. The patient's goals/outcomes sometimes are not met or partially met only because more time is needed for the plan of care to be effective. It is not necessary to reinforce the plan of care when each expected outcome is achieved because as goals are met, the plan can simply continue to the next goal. Termination of the plan is not warranted due to difficulties in achieving goals/outcomes; modifications to the plan of care may only be required. The plan of care may continue past discharge if necessary

The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action?

Coordinate with the case manager to make a safe discharge plan. The nurse's top priority is the safety of the client. The person most qualified to consider the options available to protect the mother and client is the case manager. It is not sufficient to simply give the mother telephone numbers of women's shelters. This does not take into account the possible needs of the child after discharge. Advising the mother that she should report concerns to the police does not address the discharge needs of the client. Arranging a counseling session does not meet the immediate discharge needs of the client.

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client. The nurse's most appropriate course of action is to coordinate with the other disciplines to plan the scheduling of the tests with opportunities for the client to rest. Since the tests have been ordered by the physician, the other disciplines and the nurse cannot change the orders without the physician's orders. If the nurse feels that any of the tests are unnecessary, the appropriate course of action would be to consult with the ordering physician. While the client has the right to refuse any treatment, it would be more beneficial to the client if steps were taken earlier to prevent the necessity of the client's refusal.

What is a systematic way to form and shape one's thinking?

Critical thinking

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?

Delay the instruction until the visitors leave. The nurse must take into consideration the client's developmental level and willingness to participate in care in order to successfully implement the plan of care. The client is a teenager and socialization with a peer group is essential, so the nurse would most appropriately wait until the visitors left. Telling the visitors to leave in 10 minutes might upset the client and hinder the education. Simply asking if the client has questions does not appropriately educate the client. Leaving written information does not ensure that the client will read or understand the information.

A nurse has developed a plan of care for the nursing diagnosis Risk for Loneliness for a recently widowed man. When evaluating the plan, the man tells the nurse new information about his active social life. What would the nurse do next?

Delete the nursing diagnosis. When modifying a plan of care, many courses of action are available to the nurse. If a nursing diagnosis is not a problem or concern for the patient, the nurse may delete the nursing diagnosis.

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

Developing the plan without client input Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care.

The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process?

Diagnosis The diagnosis phase involves the analysis of information and deriving the meaning from the analysis. The planning phase involves preparing a care plan and directing the nursing staff in providing care. The implementation phase involves initiation, evaluation of response to the plan, record of nursing actions, and client response to actions. Outcome identification involves formulating and documenting measurable, realistic, client-focused goals.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the teaching and attempt the teaching at another time. The nurse should always perform client teaching when the client is receptive of the education. The client verbalizes not being ready to learn, so education should be discontinued and continued at another time. Asking for permission to teach a family member does not encourage the client to learn self-care and acquire independence. The client does not need medication for anxiety at this time. This is a normal reaction. It would not be productive to continue the teaching because the client is not ready to learn.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?

Discuss possible alternatives to a blood transfusion with the physician. As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery. The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete.

A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern?

Disturbed body image The diagnosis of disturbed body image is appropriate for the client because he is worried about the appearance of his legs due to swelling and the external fixation device. There is no mention about impaired physical mobility or risk for social isolation in the client's concern. There may be a risk of infection, but the client does not mention it.

Which of the following is an important element of implementation?

Documentation An important element of implementation is documentation. The client database includes all the information that is obtained from the medical and nursing history. Physical examination and diagnostic studies are not an important element of implementation. Critical thinking is intentional, contemplative, and outcome-directed thinking. Developing good critical thinking skills will make nurses more efficient and effective at resolving situations requiring multiple interventions. Nursing orders are specific nursing directions so that all healthcare team members understand what to do for the client and, therefore, are not an important element of implementation.

Place the nursing activities in the order that they would most likely occur when a health care professional uses the nursing process:

Establishing the database Interpreting and analyzing patient data Establishing priorities Carrying out the plan of care Measuring how well the patient has achieved desired outcomes Modifying the plan of care (if indicated) A complete database must first be established in order to allow for interpretation and analysis of the patient data. Once problems or potential patient problems have been identified prioritization can occur in the form of establishment of goals/outcomes and planned nursing interventions. The plan can then be carried out, which leads to measuring if the patient achieved the desired outcomes. If outcomes were not met or partially met the plan of care can be modified.

A nurse administers medications to a patient as part of the implementation step of the nursing care plan. What step of the nursing process would the nurse perform next?

Evaluating

The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect?

Evaluation

What common problem is related to outcome identification and planning?

Failing to involve the client in the planning process One of the most important considerations in outcome achievement is to encourage the client and family to be as involved in goal development as their abilities and interest permit. The more involved they are, the greater the probability that the outcomes will be achieved.

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do?

Focused assessment A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.

Which type of assessment would the nurse be expected to perform on the client who is one day post-op following a cholecystectomy?

Focused assessment The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems.

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment

Focused assessment The nurse is performing a focused assessment to determine whether the problem still exists, and whether the status of the problem has changed. An initial or admission assessment is the initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. Time-lapsed reassessment is performed after the initial assessment when substantial periods of time have elapsed between assessments. An emergency assessment is performed any time a physiologic, psychological, or emotional crisis occurs.

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment?

Focused assessment The nurse is performing a focused assessment to determine whether the problem still exists, and whether the status of the problem has changed. An initial or admission assessment is the initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. Time-lapsed reassessment is performed after the initial assessment when substantial periods of time have elapsed between assessments. An emergency assessment is performed any time a physiologic, psychological, or emotional crisis occurs.

An older adult male with a history of benign prostatic hyperplasia presents to the emergency room with complaints of urinary retention. The nurse collects data related to the patient's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?

Focused assessment The nurse is performing a focused assessment that involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the patient's health. An emergency assessment is performed to identify life-threatening problems. A time-lapsed assessment compares a patient's current status to baseline data obtained earlier.

A nurse has gathered data through interview, observation, and physical assessment of a client and has formulated diagnostic statements. Which of the following would the nurse do during the outcome identification phase?

Formulate client-focused goals During the outcome identification stage, the nurse should formulate client-focused goals that are measurable and realistic. Analyzing assessment information and performing diagnostic validation are completed during the diagnosis phase. Establishing nursing interventions is completed during the planning phase.

Nurses perform many independent nursing actions when caring for patients. Which action is considered an independent (nurse-initiated) action?

Helping to allay a patient's fears about surgery An independent (nurse-initiated) action is one that is not dependent on the physician. Helping the patient with decreasing their fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Executing physician's orders, such as catheterization and medication administration, are examples of dependent nursing interventions. Meeting with other health care professionals describes collaborative care.

A nurse is interviewing an elderly client who has experienced a drastic weight loss following a CVA (cerebrovascular accident). The client states, "I have trouble getting groceries since I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis?

Imbalanced nutrition: less than body requirements related to difficulty in procuring food The client's relates the drastic weight loss to the inability to bring food into the house. The client's statement is the most appropriate etiology for the nursing diagnosis. Drastic weight loss is the evidence of imbalanced nutrition. Cerebrovascular accident is the medical diagnosis. The client could have had a CVA and still have the ability to grocery shop. There is no evidence that the client has lost appetite

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which of the following as a nursing diagnosis in the client's records?

Impaired physical mobility related to pain "Impaired physical mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired movement due to pain" is an inaccurate entry because the descriptor is inaccurate and the related factor is not written using approved words. "Ineffective physical mobility due to pain" has an erroneous diagnostic label and the related factors are written incorrectly.

As you are completing your nursing rounds, you notice the patient has slumped down in bed. You assist him up in bed and settle him more comfortably, but he grimaces and tenses his body. You do a complete pain assessment, check the time of his last analgesic, and prepare the medication. As you give him the medication, you are accomplishing which step of the nursing process?

Implementation Implementation is the step of the nursing process that carries out the nursing care, administering medication to relieve the patient's pain.

A nurse who has been employed by the facility is scheduled for an evaluation by a group of nurses with similar education and experience. The nurse most likely is undergoing which of the following?

Individual peer review Individual peer review involves evaluation of the nurse's performance by other nurses in which the individual nurse is evaluated and judged by other nurses with similar education and experience. Nursing monitor is a type of peer review that involves a review of a client's care or records to evaluate whether established standards were met. A process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent. Quality improvement is a mechanism for healthcare organizations to assess and improve care and to ensure that quality client care is provided and standards are upheld.

A client is being admitted from the emergency room with complaints of shortness of breath, wheezing, and coughing. Which of the following would the nurse as an appropriate nursing diagnosis?

Ineffective airway clearance Since wheezing, shortness of breath, and coughing are signs of a constricted airway, the nursing diagnosis of ineffective airway clearance is the appropriate diagnosis. Bronchial pneumonia and asthma attack are both medical diagnoses. Acute dyspnea is a symptom.

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis?

Ineffective airway clearance as evidenced by inability to clear secretions The appropriately written nursing diagnosis is "ineffective airway clearance related to inability to clear secretions." "Ineffective health maintenance related to unhealthy habits" is incorrect because it shows value judgments by the nurse. "Ineffective breathing pattern related to dyspnea" is incorrectly written because the "related to" statement essentially restates the nursing diagnosis. "Ineffective therapeutic regimen management due to smoking" is incorrect because the clause "due to" implies a direct cause-and-effect relationship.

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

Ineffective health maintenance related to client's denial of illness The most appropriate diagnosis is ineffective health maintenance related to client's denial of illness. The data presented in the question stem point to the fact that the client is not managing the diabetes because the client is denying that it is a problem at all. The client is at risk for unstable blood glucose, but the client's denial is the underlying problem. Risk for injury relates to safety issues. It is also inappropriate documentation to say the client is "mismanaging" the illness. Ineffective coping could be an appropriate diagnosis, but the client is not "unable" to manage the illness, just unwilling.

The nurse is caring for a client with AIDS (acquired immune deficiency syndrome) who frequently misses clinic appointments. The client states that transportation to the clinic is very difficult. What would be the nurse's most appropriate diagnosis?

Ineffective health maintenance related to transportation difficulties

When charting the assessment of a client, the nurse writes,"Client is depressed." This documentation is an example of which of the following?

Interpretation of data It is always best to describe behavior rather than to interpret behavior. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client. Stating that "client is depressed" is an interpretation of the client's behavior and not a factual statement.

A nurse is assessing a client admitted to the health care facility with angina. Which of the following would be most appropriate for the nurse to use to collect subjective data?

Interview The nurse should interview the client to collect subjective data, which include the client's feelings and statements about his health problems. Objective data are collected through measuring devices and equipment such as a stethoscope and scale as well as laboratory studies. Objective data are known as signs and are observable, perceptible, and measurable.

Two nurses have disagreed about the role of intuition in nursing practice, with one nurse characterizing it as "hocus-pocus" and the other nurse advocating it as a superior problem-solving strategy. Which of the following statements best conveys the role of intuition in nurses' problem solving?

Intuition can be a clinically useful adjunct to logical problem solving.

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem?

Investigate the circumstances that contributed to client falls The most effective method to address the increased frequency of client falls and to promote a positive working environment would be to determine the circumstances that contributed to the clients' falls. Attempting to identify and reprimand individual nurses does not lead to an atmosphere of openness and honesty in determining the causes. Instituting a new policy to prevent falls is premature before identifying why the falls are occurring. It may be relevant later to determine if other nursing units are having the same problem, but it is not necessary at this time.

The nurse recognizes that identifying outcomes/goals must include which of the following?

Involvement of the client and family One of the most important considerations in writing outcomes is to encourage clients and families to be as involved in goal development as their abilities and interests permit. The more involved they are, the greater the probability that the goals will be achieved.

As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

It enables the nurse to revise the care plan appropriately. Continuous data collection ensures that the nurse has the most current patient data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed upon admission, but the patient's condition is always changing. The purpose of continued data collection is to provide good patient care; it does not related directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

A nursing instructor is describing the nursing model of 'person-centred care' to a class. Which of the following would the instructor include as a characteristic of 'person-centred care'?

It is a framework for providing care. The model of 'person-centred care' is a framework for providing care. The approach is not independent of other disciplines, but is interdependent with other disciplines such as medicine, physiotherapy, surgery, etc. The model can be used in all settings and is not limited to hospital settings. 'Person-centred care' aims to provide specific care to people based on individual needs.

Which of the following is a true statement regarding critical thinking in nursing?

It is a systemic way of thinking Critical thinking is a systemic way of thinking that involves purposeful, outcome-directed thinking. Critical thinking makes judgment based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement and showing trends and patterns in client status are functions served by documentation.

Your patient is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8, P. 88, Resp. 28. The nursing care priority is which of the following?

Maintain an open airway A patent airway is always the priority of nursing care, particularly for patients with a head injury and hypoventilation.

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Make recommendations for revising the plan of care. Client outcomes are meaningless unless the nurse evaluates the client's progress toward their achievement. If the plan is not achieved (not met), recommendations for revising the plan of care are included in the evaluative statement.

The nurse caring for a client formulates client outcomes based on the understanding that the outcomes should be which of the following?

Measurable

The physician has ordered that the client should ambulate three times a day. The nurse enters the room to ambulate the client and the client complains of pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later. It is most appropriate to manage the client's pain first. The client will be able to ambulate more easily and it is not necessary to cause the client further pain. Ambulating first considers the needs of the nurse, not the client. The client has not indicated misunderstanding of benefits or the importance of ambulation.

A nurse is developing a care plan for a client with a stroke and is including surveillance interventions. Which of the following would the nurse most likely include?

Monitoring blood pressure Monitoring blood pressure is an appropriate example of a surveillance intervention, as it can detect changes in blood pressure. Giving a bed bath is an example of maintenance intervention. Demonstrating range of motion exercises is an example of an educational intervention. Applying a dressing is an example of a psychomotor intervention. (

The nurse has identified a collaborative problem of risk for complications of electrolyte imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action?

Notify the physician for additional orders. The client's decreased level of consciousness could indicate that the client is developing an electrolyte imbalance. The change in the client's status requires notification of the physician. Medication orders are required to treat the electrolyte imbalance. Documenting the level of consciousness is appropriate, but not as the priority action. Another nurse is not necessary to check the nurse's assessment. Decreasing stimulation and allowing the client to rest with no further action may result in harm to the client.

The nursing staff on a hospital unit are using peer review to improve professional performance. Who performs the review?

Nurses Peer review is the evaluation of one staff member by another staff member on the same level of the hierarchy of the organization. Peer review is not done by the unit manager, clients, or visitors.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order. A physician-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions.

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective Objective data is data that is observable and measurable data that can be seen, heard, felt, or measured by someone other than the client. Subjective data are information perceived only by the affected person. The others are not types of data.

The nurse is conducting a nursing assessment with a client who is unwilling to participate in the interview process. If the nurse makes a diagnostic error it would most likely be because of:

Omission of pertinent data. The diagnostic process is dependent on complete and accurate data. A nursing assessment with a client who is unwilling to participate in the interview process would most likely result in incomplete data. Omission of pertinent data would lead to diagnostic errors.

A nurse assesses the vital signs of a patient who is one day postsurgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of care. What are these actions considered?

Ongoing planning Ongoing planning is carried out by any nurse who interacts with the patient. Its chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function. The nurse caring for the patient uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore, more effective.

The quality assurance model of the ANA identifies three essential components of quality care. Which one of these components does the nurse use when determining whether a patient has met the goals stated on the care plan?

Outcome The ANA's three essential components of quality care are nursing-sensitive indicators that reflect the structure, process, and outcomes of nursing care. Outcomes are also referred to as goals in the nursing process. Retrospect is not a component of quality care.

A nurse is writing goals for a patient who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this patient?

Over the next 24-hour period, the patient will walk the length of the hallway assisted by the nurse Goals must be patient-centered, specific, measurable, attainable, realistic, and timebound. "Over the next 24-hour period, the patient will walk the length of the hallway assisted by the nurse" has all of these characteristics. "The nurse will help the patient ambulate the length of the hallway once a day" is not specific in whether assistance is required and it is not timebound. "Offer to help the patient walk the length of the hallway each day" is a nursing intervention. "Patient will become mobile within a 24-hour period" is not specific or measurable.

While examining a client, the nurse assesses the temperature of the client's skin. The nurse most likely would be using which technique?

Palpation Palpation is used to assess the temperature of the skin. Inspection would reveal color, shape, movement, pulsations, and texture of an involved body part. Percussion determines a structure's denseness or hollowness and aids in discovering the location and level of organs, consistency of body structures, the presence of tenderness, and identification of masses or tumors. Auscultation identifies normal and abnormal sounds such as in the bowel, lungs, heart, as well as the sound of blood moving through a narrowed or twisted vessel.

What activity is carried out during the implementing step of the nursing process?

Planned nursing actions (interventions) are carried out. During the implementing step of the nursing process, nursing actions (interventions) planned during the planning step are carried out.

A home health nurse reviews the nursing care with the client and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?

Planning During the planning step, the nurse identifies expected outcomes of the plan of care. The plan of care should be holistic and individualized, specify desired client goals and related outcomes, and identify the nursing interventions most likely to meet those expected outcomes.

The nurse has measured from the tip of the client's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which of the following components of the nursing process has the nurse demonstrated?

Planning; implementing

The nurse participates in a quality assurance program and reviews evaluation data for the previous month. The data indicates a nursing plan was developed within 8 hours of admission for 97% of all admissions. The nurse recognizes this is which type of evaluation?

Process evaluation Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Process evaluation focuses on the nature and sequence of activities carried out by nurses implementing the nursing process, such as the timing of nursing care plan creation. Outcome evaluation focuses on measurable changes in the health status of clients, whereas structure evaluation focuses on the environment in which care is provided. There is no design evaluation.

Which of the following interpersonal skills is essential to the practice of nursing?

Promoting the dignity and respect of patients as people Characteristics of interpersonal caring that are essential to the practice of nursing include promoting the dignity and respect of clients as people, the centrality of the caring relationship, and a mutual enrichment of both participants in the nurse-client relationship.

A nurse has identified on the plan of care for a client a nursing diagnosis of "anxiety related to concerns about cancer treatment as evidenced by client's statement." One of the interventions that the nurse writes on the plan of care is to encourage the client to verbalize his feelings about the diagnosis and its effect on his quality of life. The nurse has identified which type of nursing intervention?

Psychosocial The nurse has identified a psychosocial intervention, which focuses on supporting, exploring, and encouraging. Psychomotor interventions involve actions such as positioning, inserting, or applying. Sociocultural interventions involve spending time and incorporating cultural differences into the care regimen. Educational interventions involve demonstrating, teaching, and observing return demonstrations.

Many of the homeless clients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the clients state that the clinic is difficult to find and in an intimidating environment. This demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed?

Psychosocial background of clients Requiring clients to attend a clinic that is difficult to access, and located in a daunting environment, shows a lack of consideration for clients' psychosocial backgrounds. Resources, development, and ethics are not central to this lapse in care.

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?

Quality assurance Accreditation by the Joint Commission evaluates quality assurance. Quality assurance is an externally driven process, demonstrating nursing excellence by meeting professional standards of care. Quality improvement is an internally driven continuous process, focusing on the processes of client care. Peer review is a process whereby individual nurses improve their professional performance through the evaluation of one staff member by another staff member on the same level of the hierarchy. Magnet status is awarded by the American Nurses Credentialing Center, recognizing health care organizations for their excellence in nursing.

Which of the following nursing diagnoses is an example of a wellness diagnosis?

Readiness for Enhanced Parenting Wellness diagnoses are clinical judgments about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness. The diagnostic statement for a wellness diagnosis contains the label Readiness for Enhanced Parenting, followed by the desired higher-level wellness. Related factors are not included.

A client recovering after an appendectomy is complaining of pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?

Reassess the client to determine the effectiveness of the interventions. After implementing any interventions, such as pain medication or any non-pharmacological pain control method, such as splinting the incision, the nurse must always reassess the client to determine the effectiveness of the interventions. If the interventions are ineffective, the plan is revised and additional interventions are planned.

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation?

Record an evaluative statement in the client's plan of care. The client has successfully met this outcome, and the nurse should note the time and date that it was achieved in the client's plan of care. The outcome should not be removed from the plan of care and it is unnecessary to have the original author of the plan update it. Further observation may or may not be necessary at dinner time, but an evaluative statement should nonetheless be recorded at the present time.

Self-evaluation is a method that nurses use to promote their own development, and to grow in confidence in their nursing roles. This process is referred to as what?

Reflective practice. Reflective practice is the use of self-evaluation by nurses committed to quality nursing practice. The others may be additional gains but are not descriptive of self-evaluation.

While interviewing a client diagnosed with cirrhosis of the liver, the nurse asks about alcohol consumption. The client is hesitant to give information. Which of the following would be most appropriate for the nurse to do to elicit this information from the client?

Rephrase the question in a more acceptable form The nurse should rephrase the question in a more acceptable form if the client is hesitant to answer. Avoiding further discussion of the topic is inappropriate because alcoholism is an important factor in liver disease. Requesting that the client answer the question and explaining the importance of the question may not help because it may make the client anxious and block communication.

A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care?

Research findings Nurses concerned about improving the quality of nursing care use research findings to enhance their nursing practice. Reading professional journals and attending continuing education workshops and conferences are excellent ways to learn about new nursing strategies that have proved effective.

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which of the following is the best example of establishing a therapeutic nurse-client relationship?

Respect for the client, and engaging in open communication in getting to know the client. Answer A is the best response: Respect for the client's dignity, and establishing a caring relationship is furthered by mutual interchange of communication. Approaching care/client as a job, doing things without client input, and doing things your way and efficiently are not necessarily therapeutic nor do they initiate communication.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action?

Revise the care plan to allow the client to ambulate to the bathroom independently. The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist.

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." In order to assure the safety of the client, what nursing diagnosis would the nurse address?

Risk for allergy response related to latex allergy To assure the safety of the client, the nurse must address the risk for an allergic response due to the client's latex allergy. Anxiety refers to a vague feeling of dread; however, the client is responding with fear to a very real threat. There is no evidence that the client does not understand the surgical procedure. Risk for injury is not an appropriate diagnosis, because it does not adequately address the specific health problem.

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for community contamination related to possible environmental pollution The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for community contamination would address the broad concerns of the nurse. Knowledge deficit is not appropriate because it has too narrow a focus. Deficient community health is not a NANDA diagnosis and the etiology must deal with how the plant may possibly affect the community. Risk for infection has a very narrow focus. The etiology of community contamination has not been proven.

A nurse is caring for a client in the ER who was injured in a snowmobile accident. The nurse documents the following client data: uncontrollable shivering, weakness, pale and cold skin. Th nurse suspects the client is experiencing hypothermia. Upon further assessment, the nurse notes a heart rate of 53 BPM and core internal temperature of 90°F, which confirms the initial diagnosis. The nurse then devises a plan of care and continues to monitor the client to evaluate the outcomes. This nurse is using which of the following types of problem solving in her care of this client?

Scientific Scientific problem solving is a systematic, seven-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the study. This method is used most correctly in a controlled laboratory setting but is closely related to the more general problem-solving processes commonly used by health care professionals as they work with clients, such as the nursing process.

Which of the following statements is true of the nursing process?

Scientific problem solving can occur within the nursing process. Problem solving and the nursing process are not competing or mutually exclusive processes. Rather, both scientific problem solving and trial-and-error may take place within the nursing process. One of the strengths of the nursing process is that it is applicable to all nursing contexts.

The nursing instructor is teaching the students how to do an interview on a client. Which of the following statements made by a student indicates a need for further instruction?

Show your name badge to the client so they can read who you are When conducting an interview the nurse should sit at eye level and introduce themselves and tell their position. This sends the message that the nurse accepts responsibility and are willing to be accountable.Verify the client's name and ask what they would like to be called. Some clients cannot read and they should not be expected to know your name and your position by reading a name badge.

Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

Standardized Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.

The terms "criteria" and "standard" are often used interchangeably but actually have distinct separate definitions. "The levels of performance accepted by and expected of nursing staff or other health team members" is known as which of the following?

Standards Standards are the "levels of performance accepted by and expected of nursing staff or other health team members." Criteria are "measurable qualities, attribute, or characteristics that identify skill, knowledge, or health status." Evidence-based practice incorporates delivering nursing care that evidence supports as likely to result in meeting the expected patient outcomes. Evaluation involves measuring how well the patient has achieved the outcomes that were set forth in the plan of care.

A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill?

Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing Performing tasks that require manual dexterity is a manifestation of technical skills. Explaining the transfusion process is largely dependent on interpersonal skills, while understanding the theory behind blood types is indicative of cognitive skills. Informed consent lies within the domain of legal/ethical skills.

A group of student nurses are working on developing various nursing skills and are at various stages of skill acquisition. The instructor determines that which student is at the novice stage?

Student uses rules to guide practice During the novice stage of skill acquisition, the learner uses rules to guide practice. The learner considers more facts and rules during the advanced beginner stage. At the competence stage, the learner feels responsible for outcomes. The learner knows the goal and how to achieve it at the expert stage.

The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which of the following types of data?

Subjective Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by anyone else. Examples are feeling nervous, nauseated, or chilly, to name a few.

The nurse is assessing a male client with a diagnosis of vascular dementia. As a result of his cognitive deficit, the client is unable to provide many of the data that are required on the hospital's nursing admission history document. How should the nurse best proceed with this assessment?

Supplement the client's information by speaking with family or friends. Family and friends can be an invaluable source of assessment data, especially in the care of clients who have cognitive deficits. It would be inappropriate to limit an assessment to solely objective data. Utilizing previous medical records and breaking up the assessment are appropriate measures, but they do not supersede the importance of using family and friends as data sources.

The student nurse is preparing to ambulate an obese client. The RN is concerned about the student's ability to safely ambulate the client. What would be the nurse's most appropriate action?

Tell the student that the RN will assist the student with the client's ambulation. The client's safety is always the nurse's primary concern. If the nurse feels there is a possibility for injury to the client, one strategy to prevent it is to offer assistance. By the nurse assisting the student, client safety is assured while still allowing the student to learn. Having the nursing assistant ambulate the client or instructing the student not to ambulate the client does not assist the student's learning. Asking the client if the client feels comfortable is inappropriate.

A client presents to the clinic for a routine postoperative visit. The nurse assesses the site of the incision and determines that the edges of the incision are approximated, sutures have been removed, and there is no redness or edema at the site. The incision appears to be well healed. The nurse reviews the plan of care and notes that one nursing diagnosis is related to potential infection related to impaired skin integrity. The nurse determines that this is no longer an issue for the client. Which of the following changes should the nurse make to the plan of care?

Terminate the plan of care as it relates to infection The nurse should terminate the section of the plan of care that relates to infection. Other parts of the plan of care may still need to be monitored. There is no need to modify the plan of care as it relates to infection because at this time it is no longer an issue. The current plan of care should not be continued as the client is progressing toward outcome achievement.

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

The North American Nursing Diagnosis Association (NANDA) North American Nursing Diagnosis Association (NANDA) conferences are held every 2 years, and much progress continues to be made in defining, classifying, and describing nursing diagnoses.

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for three years. If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the teaching. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.

Which client outcome is an example of a cognitive outcome?

The client identifies three strategies for minimizing leakage of an ileostomy bag. Cognitive outcomes demonstrate increases in client knowledge, such as strategies for minimizing leakage of an ileostomy bag. An affective outcome involves changes in the client's values, beliefs, and attitude. Physiologic outcomes are physical changes in the client, such as blood sugar values and pulse rate. Psychomotor outcomes describe the client's achievement of new skills, such as taking a radial pulse.

A male client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that he has achieved a cognitive outcome in the management of his new health problem?

The client is able to explain when and why he needs to check his blood sugar. The ability to describe the rationale and technique for blood glucose monitoring indicates that the client has achieved a cognitive outcome. Demonstration of the technique constitutes a psychomotor outcome, while the expression of a desire for change is an affective outcome. The maintenance of healthy blood sugars is a physiologic outcome.

At the beginning of prenatal care, the goal for the client was to gain 25 pounds by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 pound. Which of the following would help the nurse most appropriately interpret this data?

The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight. The client is not achieving the goal. The nurse should determine what the causes are in order to revise the plan of care. It is important to determine as early as possible if the plan of care is being successful. This will allow sufficient time to revise the plan of care. It is unrealistic to think the client will achieve the goal in the next 10 weeks. The client may not achieve the goal, but the priority at this time is to determine the reasons and revise the plan of care.

A client diagnosed with advanced lung cancer has a nursing diagnosis of ineffective coping. What assessment data would provide evidence to the nurse for this diagnosis?

The client states, "I am sure the doctors have misdiagnosed me." Denying the illness by stating a belief that the cancer diagnosis is incorrect is evidence that the client is not dealing with the illness. Inquiring about hospice and making funeral plans shows acceptance of the advanced stage of the illness. Stating a hope to attend the daughter's wedding is expressing hope for the future and is evidence of effective coping.

An older adult female client has been admitted to hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which of the following statements constitutes a long-term outcome?

The client will return home able to conduct her activities of daily living without experiencing shortness of breath. Resumption of ADLs in the home setting is characteristic of a long-term outcome. Explaining energy-conservation techniques, mobilizing in the hospital, and demonstrating correct medication administration are short-term outcomes that may be accomplished prior to discharge.

A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority?

The need to feel good about oneself When setting priorities, it is best to first meet the needs that the client believes are most important. In this situation, the woman is not refusing food altogether; rather, she wants to feel good about herself (self-esteem) when she does eat.

Which of the following best summarizes the evaluating step of the nursing process?

The nurse and client measure achievement of planned outcomes of care. In evaluating, which is the fifth step of the nursing process, the nurse and client together measure how well the client has achieved the outcomes specified in the plan of care.

Which nursing action reflects evaluation?

The nurse assesses the client's response to pain medication. Examples of evaluation include assessing the client's response to pain medication. The focus of diagnosing is recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as a wound infection. Setting an anxiety rating with the client is an example of is an example of planning. Performing colostomy irrigation is an example of implementation.

The nurse caring for a client who is recovering after a motor vehicle accident is planning for the client to begin increasing responsibility for self-care. What would be the nurse's most appropriate strategy?

The nurse encourages the client to take a shower instead of receiving a bed bath. It is important for the nurse to encourage the client to achieve independence in self-care. The nurse would best accomplish this by encouraging the client to gradually do more for himself. There is no evidence that the client's recovery is progressing too slowly. There is no indication that an early discharge would be beneficial for the client. There is also no indication that the family is doing too much for the client. The client is not fully capable of self-care and will still need the assistance of family.

A nurse evaluates patients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?

The nurse evaluates the patient's goal/outcome achievement. The priority is to evaluate the patient's goal/outcome achievement. This determines if the nursing diagnosis has been resolved. If the patient's goal/outcome had not been met the nurse should then begin evaluating all aspects of the plan of care. It is not the responsibility of the nurse to evaluate the competence of nurse practitioners. The nurse can evaluate services available to the patient but his is not the purpose of the evaluation phase of the nursing process.

Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes?

The nurse expresses the client outcome as a nursing intervention. A common error made when writing client outcomes includes the nurse expressing the client outcome as a nursing intervention. The other mentioned criteria for writing client outcomes are correct.

A nurse who believes strongly that women should make their own decisions is caring for a female client from a culture where women defer decisions to their husbands. Based on the client's insistence that her husband make all decisions for her, the nurse formulates a nursing diagnosis of "Dysfunctional family processes." What type of nursing diagnosis error has the nurse made?

The nurse has inserted her own beliefs into the interpretation of the data. The nurse has made an error by using her own beliefs that women should make autonomous decisions. She is taking a paternalistic attitude toward the client's cultural beliefs. This is the most appropriate answer. There is no health care problem, so no nursing diagnosis is necessary. The nurse is not addressing the reason the client is seeking health care, but that is not an issue at this time. The nurse would need further evidence to make this nursing diagnosis, however, there is no evidence to make the diagnosis at all.

When caring for a client in the emergency room who has presented with symptoms of a (MI) myocardial infarction, the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. In order for the nurse to be operating within the nurse's scope of practice, what conditions must be present?

The nurse is operating under standing orders for clients with MIs. In order for the nurse to administer medications or order laboratory tests, the nurse must have a physician's order. In special circumstances, such as in the emergency room, there are standing orders in place to authorize the nurse's actions in certain situations. The other three items may also be true, but they do not give the nurse the authority to institute these actions independent of a physician's order.

When reviewing the client's history, the nurse notes that it has been recorded that the client's last bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?

The nurse should determine the client's normal bowel elimination pattern. In order to validate the diagnosis, the nurse must determine what is the normal for the client. Dietary habits may contribute to the constipation, but do not evidence the nursing diagnosis. Assessing bowel sounds would be important data, but would not evidence the diagnosis of constipation. There is no standard elimination pattern; it is highly individualized.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the client's reason for the client's refusal. Before addressing the issue, the nurse must determine why the client refused the lab draw. It is essential to know the cause before planning how to address the issue. It is immaterial how long the client has been in the hospital, what laboratory tests are critical, or what the client's last results were.

A nurse who is experienced caring only for well babies is assigned to the newborn intensive care nursery (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. The nurse should recognize that she lacks the competence to safely care for a client with these complex needs and inform the charge nurse of the fact. This assignment would be an inappropriate delegation on the part of the charge nurse and could cause injury to the client. The other options do not take the safety of the client into consideration.

The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment?

The nurse's physical assessment will focus on the client's functional abilities. Unlike the physical assessment performed by the physician to identify pathologic conditions and their causes, the nursing physical assessment focuses primarily on the client's functional abilities.

During a home health care visit, the nurse identifies a nursing diagnosis of "Caregiver role strain" for a parent who is caring for a ventilator dependent child. What subjective assessment data would support the nurse's diagnosis?

The parent states, "I cannot allow anyone else to help because they won't do it right." The parent's statement of not allowing anyone to help because "they won't do it right" is the correct answer. The parent's statement indicates an inability to allow help, which will cause mental and physical strain. The other statements are statements of a healthy ability to use coping mechanisms to deal with this difficult situation.

What must occur before physician-initiated interventions can be carried out?

The physician gives a verbal or written order. Physician-initiated interventions, or dependent nursing actions, involve carrying out physician-prescribed (verbal or written) orders. Nurses are accountable for dependent orders.

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care. Quality-assurance (QA) programs enable nursing to be accountable to society for the quality of nursing care. They are a response to the public mandate for professional accountability. QA programs do not facilitate increased enrollment, specify how resources are to be used, or increase retention of nurses.

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated?

Throughout the client's hospital admission It is important to evaluate client outcomes early and frequently. Reserving evaluation for the time of discharge or after discharge is inappropriate, even if the designated time criteria for the outcome specifies "by time of discharge."

What is the primary purpose of the outcome identification and planning step of the nursing process?

To design a plan of care for and with the client The primary purpose of outcome identification and planning is to design a plan of care for (and with) the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.

In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?

To identify etiologies of health problems The purpose of diagnosing, the second step in the nursing process, is to identify how an individual, a group, or a community responds to actual or potential health and life processes; to identify etiologies (factors that contribute to or cause health problems); and to identify resources or strengths that the individual, group, or community can draw on to prevent or resolve problems.

Nursing is a profession in a rapidly changing health care environment. What is the most important reason for the nurse to develop critical thinking and clinical reasoning?

To provide quality care with nursing ability and knowledge. The goal of all nursing is to meet the standard of quality care. Clinical reasoning and critical thinking may be applied in all of the answers but the most important goal in health care is to provide quality nursing care to clients.

When performing an assessment, the nurse should focus on the developmental stage for which of the following clients?

Toddler Nursing assessments vary according to the client's developmental needs. When assessing an infant, toddler, or child, special attention is given to physiological and psychosocial aspects of growth and development to identify client problems. It is not as important to focus assessment on the developmental stages in the other age groups.

Select the best description of how the nurse applies the nursing process in caring for patients. The nurse:

Uses critical thinking to direct care for the individual patient.

The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is "no." What is the best thing for the nurse to do next?

Validate the data Data needs to be validated when there are discrepancies such as the client saying there is no pain but the nonverbal behavior indicates that they are experiencing pain.

While doing an assessment, the nurse identifies questionable data. Which of the following should the nurse do first?

Validate the questionable data Questionable data are verified (validated) as part of the assessment step of the nursing process. It is not necessary to inform the doctor or the client that the data are questionable but that it needs to be verified.

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this patient is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Wellness Diagnosis Readiness for Enhanced Coping is an example of a Wellness Diagnosis. Two cues must be present for a valid wellness diagnosis: a desire for a higher level of wellness and an effective present status or function. An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. A risk nursing diagnosis is a clinical judgment that an individual, family, or community is more vulnerable to develop the problem than are others in the same or a similar situation. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.

The parent of a hospitalized toddler tells the nurse, "If my child uses the word 'toytoy' a bathroom trip is needed." What action by the nurse best communicates this information about basic care needs for the client?

Writing the information in the plan of care The plan of care communicates three different types of nursing care related to: meeting basic human needs, nursing diagnoses, and to coordination with medical and interdisciplinary care. Elimination is a basic human need. The words the toddler uses to indicate elimination needs should be documented in the record. The other options are not the best, most direct methods for conveying this information to all who may need it.

The nurse makes a diagnostic error when the:

client withholds information during the nursing assessment.

Your patient has had major abdominal surgery and just returned to the unit from the operating room. Your nursing priority is to:

complete post-operative assessment. Assessment is the first priority, which would include breathing, level of consciousness (LOC), vital signs, dressing check, IVs, and pain level. After assessing, pain medication may be needed. You may expect him to be drowsy but ongoing assessment is required.

A father runs into the emergency room with his 18-month-old son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?

high priority To develop a prioritized list of nursing diagnoses, the nurse needs guidelines for ranking diagnoses as high, medium, or low priority. High-priority diagnoses pose the greatest threat to the patient's well-being (in this case, decreased oxygenation is the greatest threat to well-being and life)

According to the American Nurses Association, who determines the scope of nursing practice?

nurses According to the American Nurses Association, it is the nursing profession that determines the scope of nursing practice.

Use of the nursing process in healthcare allows the nurse to address the needs of the client. The nursing process:

provides a universally applicable framework for nursing activities. The nursing process can be used with all clients, sick or well, of all ages and in all settings. The nursing process was not developed in 1955 nor designed for use by students in their assignments. Critical pathways target desired outcomes for particular illnesses, procedures, or conditions

The nurse is developing outcomes for the care plan of a patient admitted with Parkinson's disease. The nurse will derive the outcomes for this patient's care plan from:

the problem statement of the nursing diagnosis. Outcomes are derived from the problem statement of the nursing diagnosis. Remember that the nursing process is based upon independent nursing actions.

A nurse working in an outpatient surgery center is responsible for taking a health history and performing a physical assessment on each patient scheduled for surgery. Why is establishing this database so important for nursing care?

to identify strengths and problems Without a complete and accurate database, it is impossible for the nurse to identify patient strengths and problems. Assessing and establishing a database is the first step in the ordered sequence of events in the nursing process.

A nursing student is performing an assessment on a client. Which of the following would the student record as subjective data? Select all that apply.

• "I am always anxious." • "I am so afraid of what my diagnosis is." • "My leg hurts when I move." Subjective data are information perceived only the the affected person.

Nurses collect objective and subjective data during the patient interview. Which patient data is subjective data? (Select all that apply.)

• A patient describes his pain as an 8 on the pain assessment scale. • A patient feels nauseated after eating his breakfast. • A patient complains of being cold and requests an extra blanket. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. A patient's pain, nausea, and feeling cold can only be felt by that person. Data collected about a patient, such as the patient wringing their hands, redness and swelling at an IV site, and a blood pressure measurement are considered objective data. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same patient.

A nurse is evaluating the plan of care for a client and determines that the achievement of goals is difficult to evaluate. Which of the following might the nurse do in evaluating the plan to see that the outcomes are correctly written? Select all that apply.

• Be sure that the criteria for appropriate response are clearly specified • Be certain that the subject is the client or some part of the client • See if the clients expected behavior is written in observable measurable terms • Specify time limits in the plan The nurse would not rewrite the plan of care just so the client meets the outcomes. It should be ascertained that the plan of care leads to a better state of health not just modify it so the client achieves the outcomes. The other choices are appropriate to evaluate the plan of care.

The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply.

• Client will increase nutrition, eating 75% of meals. • Client will report pain is controlled at or below 3 of 10. • Client will perform dressing change independently. The focus of planning for a client who is expected to make a full recovery is promotion and restoration of health, alleviation of suffering, and prevention of illness, injury, and disease. A client recovering from surgery needs adequate pain control, sufficient nutritional intake for healing, and education in self-care if there are special needs, such as treating a wound, caring for a port, or administering medications. The oxygen saturation level is too low. The influenza vaccine should not be administered to someone with a moderate to severe acute illness.

A client with end-stage respiratory failure is admitted to hospice for nursing care. What nursing goals will the nurse use to direct care? Select all that apply.

• Control pain level at or below 3 of 10. • Support end-of-life discussions. • Reduce anxiety level to mild or none. The focus of planning for clients at end of life moves from promotion and restoration of health to supportive care. This includes emotional and spiritual support, pain control, and comfort measures such as ice chips, positioning, and skin care. A client may not be restored to physical health, but may experience emotional and spiritual health.

A client has been admitted with symptoms of shortness of breath on exertion, edematous lower extremities, and high blood pressure. Which of the following would the nurse select as appropriate nursing diagnoses? (Select all that apply.)

• Excess fluid volume • Activity intolerance The client's excess fluid volume and activity intolerance can be addressed independently by the nurse so those diagnoses are appropriate. Risk for cardiac dysfunction requires the collaboration of other disciplines. Hypertension and congestive heart failure are medical diagnoses.

A nurse is planning a class for hospital nurses on the use of nursing diagnoses in client care. When discussing possible arguments that have been made against the use of nursing diagnoses, what information will the nurse include? (Select all that apply.)

• Nursing diagnoses promote a paternalistic attitude from health care providers. • Nursing diagnoses apply limits to nursing practice. • Nursing diagnoses discourage innovative thinking. • Nursing diagnoses focus on negative client factors. Arguments against using nursing diagnoses include some nurses' beliefs that nursing diagnoses promote a standardized method of care with little thought to client's individual needs. Nursing diagnoses do focus on the client's deficits and not their strengths. Nursing diagnoses encourage health care providers to put a label on client's behavior & promotes an "I know best" mentality. Members of the health care community do not confuse medical and nursing diagnoses.

A busy nurse is working with a UAP (unlicensed assistive personnel). What tasks can the nurse appropriately delegate to the UAP? Mark all that apply.

• Record the client's intake and output. • Assist the client to the bedside commode. It is crucial for the nurse to be aware of the legalities of delegation to unlicensed assistive personnel. Appropriate delegation to a UAP would include recording intake and output and assisting the client to the bedside commode. Assessment of the client's educational needs and the risk for pressure ulcers fall only under the nurse's scope of practice. Administering oral medications is not appropriate for unlicensed personnel.

Which of the following qualities does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply.

• Respect for client • Competence • Professionalism • Caring The nurse's interpersonal competence is critical beginning with the very first assessment. The client's initial impression is crucial. The nurse's competence, professionalism, and interpersonal qualities of caring and respect invite confidence and assure the client that help is available. How long the nurse has practiced does not influence this

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the teaching plan? Mark all that apply.

• The client is blind. • The client denies the need for teaching. The client's blindness will require the nurse to alter the teaching plan to fit the client's needs. The teaching might also require teaching another person to perform the wound care. If the client denies the need for teaching, attempting to teach the client at this time will be ineffective. The nurse will need to determine why the client denies the need for teaching and address that issue first. The facts that the client is male, married, and an architect do not have any bearing on the instruction.