nursing process

the nurse is caring for a elderly client with dementia. which client need should the nurse prioritize while providing care? a. safety b. self esteem c. self actualization d. love and belonging

a. safety

the plan of care for the client was to lose 7 lbs by the end of the month. The client only lost 3 lbs. How should the nurse respond? a. assume that the client has been cheating on the diet b. increase the goal for next month to keep the client on track c. reevaluate the plan of care for appropriateness d. discontinue the plan of care because it did not work.

c. reevaluate the plan of care for appropriateness

a nurse in interviewing a client. Which of these statement is an example of an open-ended question? a. Who helps you at home b. are you having pain now c. tell me how you are feeling d. do you think the medication is helping you

c. tell me how you are feeling

Which nursing process includes tasks that can be delegated? a. Planning b. Evaluation c. Assessment d. Implementation

d. Implementation

Which feature distinguish nursing diagnoses from medical diagnoses? select all that apply. a. Nursing diagnoses involve the client when possible b. Nursing diagnoses are based on results of diagnostic tests and procedure c. Nursing diagnoses are the identification of a disease condition in the client d. Nursing diagnoses involve the sorting of health problems within the nursing domain e. Nursing diagnoses involve clinical judgment about the clients response to health problems

a. Nursing diagnoses involve the client when possible d. Nursing diagnoses involve the sorting of health problems within the nursing domain e. Nursing diagnoses involve clinical judgment about the clients response to health problems

Which actions should the nurse perform while collecting subjective date from a client during a focused urinary assessment? select all that apply. a. inquire about painful urination b. ask the client about changes in characteristics of urination c. assess the level of blood urea nitrogen and creatinine d. palpate the abdomen for bladder distention or masses e. inspect the urinary meatus for inflammation or discharge

a. inquire about painful urination b. ask the client about changes in characteristics of urination

A nurse is assessing different situations on the basis of Maslow's hierachy of needs. Which situation will the nurse address first on priority basis? a. a client feels that he/she leads a completely worthless life b. a client has multiple fainting episodes due to lack of proper nutrition c. a client show signs of lack of interest in carrying out social interactions d. a client conveys to the nurse that he/she is estranged from all family members.

b. a client has multiple fainting episodes due to lack of proper nutrition

Which client assessment finding should the nurse document as subjective date? a. BP 120/82 beats/min b. pain rating of 5 c. potassium 4.0 mEq d. pulse oximetry reading of 96%

b. pain rating of 5

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation. a. procedure used to implement client care b. sequence of steps used to meet clients needs c. activities employed to identify a clients problem d. mechanisms applied to determine nursing goals for the client.

b. sequence of steps used to meet clients needs

Which example indicates that the nurse is following evidence based practice? a, the nurse documents client care in an electronic health record b. the nurse reads current nursing journals and uses the latest scientific methods c. the nurse uses flowcharts and diagrams to record the clients progress d. the nurse encourages the hospitalized clients family to bring home cooked food

b. the nurse reads current nursing journals and uses the latest scientific methods

The nurse interviews a client about a current health problem. The nurse then obtain and documents the client's temperature, blood pressure, and heart rate. which step of the nursing process is involved in the situation? a. Planning b. Evaluation c. Assessment d. Implementation

c. Assessment

The RN is teaching a novice nurse about the rights of delegation. Which statement by the novice nurse indicates a need for further teaching? a. I will refer to the guidelines before delegating the task b. I will check for the competence of the delegate for the assigned task c. I will instruct the delegate to monitor and evaluate the client appropriately d. I will check whether the environment is conducive to completing the task safely

c. I will instruct the delegate to monitor and evaluate the client appropriately

The nurse documents the date gathered during the assessment in a client's medical record. What should the nurse do to ensure that the date is meaningful to other healthcare providers? a. record subjective information in own words. b. form judgment through written communication c. record objective information using accurate terminology d. compare date from the physical examination with client behavior.

c. record objective information using accurate terminology

the nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step in involved in this situation? a. Planning b. Evolution c. Assessment d. Implementation

d. Implementation

a nurse is reviewing a clients plan of care. what is the determining factor in the revision of the plan? a. time available for care b. validity of the problem c. method for providing care d. effectiveness of the interventions

d. effectiveness of the interventions

The RN is teaching the student nurse about writing nursing intervention. Which intervention written by the student nurse indicates effective learning? a. turn the client every 2 hours b. perform blood glucose measurements regularly c. change the client's dressing once a shift: 6am-2pm-10 pm d. irrigate the wound with 100 ml normal saline until clear"n6am-2pm-8pm

d. irrigate the wound with 100 ml normal saline until clear"n6am-2pm-8pm

the nurse is developing a plan of care for the client who has activity intolerance. In determining the desired client outcomes, What should the nurse do? a. prioritize psychosocial need over physical needs. b. use the nursing outcome classification only c. use nursing knowledge to plan outcomes and disregard client and family desires d. set priorities and outcomes using the client's and family input.

d. set priorities and outcomes using the client's and family input.