Prep u chapter 2
A 45-year-old client has presented to the emergency department with a report of nausea and vomiting and severe pain just under the right rib cage. Which response(s) should the nurse prioritize? Select all that apply.
"Can you tell me more about the nausea and vomiting?" "I am going to apply some pressure to your abdomen to see just exactly where the pain "How long have your eyes had the yellow tinge?"
A client is caring for the client's mother-in-law, who is an older adult who requires assistance with performing activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain?
"I just don't have time to take a shower."
A client being treated with chemotherapy for breast cancer tells the nurse that she no longer wants to receive the medication because of the overwhelming nausea and vomiting. What is the best response by the nurse?
"I will consult with the health care provider to see how the nausea and vomiting can be prevented."
A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly " What is the nurse's most therapeutic statement to the client?
"It seems like you are having difficulty with your care regimen."
The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns?
"Leaning forward may help you to breathe better."
The charge nurse overhears two nurses talking about nursing interventions. Which statement by one of the nurses indicates that further education is required?
"Nursing interventions must be approved by other members of the health care team."
As part of an assignment, a nursing student is asked to create a concept map for a client. The student asks the instructor, "Why is this necessary? Isn't the plan of care enough?" Which response by the instructor would be most appropriate?
"The map helps you to think more critically about the relationship between concepts."
A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which nursing diagnosis would be correct?
"ineffective airway clearance related to thick mucus"
The nurse has been assigned to a group of clients. Which client should be the nurse's priority?
A 32-year-old client with a urinary tract infection who is receiving an intravenous antibiotic and reporting swelling in the tongue.
Which scenario is an example of a time-lapse reassessment?
A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.
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
A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?
Add the nursing diagnosis: Risk for Self-Harm.
While caring for a client admitted to the hospital for a fractured tibia, the nurse notes the client's blood pressure readings are consistently higher the expected range for the client's age. How would the nurse most appropriately plan to care for this client?
Address the collaborative problem PC: Hypertension.
The nurse is selecting interventions after gathering and analyzing client data. Interventions that the nurse includes will meet what criterion?
Aligned with a goal
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?
Altered Gas Exchange
What nursing organization first legitimized the use of the nursing process?
American Nurses Association
A client, who has limited finances, requires home health care for a chronic illness. For the nurse to meet the client's unique needs, the nurse must first perform what action?
Apply critical thinking skills
The nurse performs discharge teaching for a client. How would the nurse best evaluate the effectiveness of the discharge teaching?
Ask the client to repeat back to the nurse how care will be conducted at home.
While bathing the client, the nurse observes the client grimacing. The nurse asks whether the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which action clearly demonstrates assessing?
Asking whether the client is having pain
One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?
Assess the client to determine the cause of the pain.
The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take?
Assess the client's blood pressure to determine if the medication is indicated.
The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?
At the completion of each meal
The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?
Auscultate the chest for breath sounds.
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
Which is an appropriate expected outcome for a client?
Client will ambulate safely with walker in the room within 3 days of physical therapy.
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.
The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome?
Client will maintain nutritional intake without pain or diarrhea.
Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?
Collaborate with other disciplines to revise the discharge plans.
The nurse is caring for a client whose health problem requires both health care provider- and nurse-prescribed actions to address. What type of problem is being addressed for this client?
Collaborative health problems
Which group of terms best defines assessing in the nursing process?
Collection, validation, communication of client data
The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the health care providers wrote orders to ambulate the client, whereas another health care provider ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?
Communicate with the health care providers to coordinate their orders.
The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome?
Condition of the skin over bony prominences.
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.
The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this infant, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?
Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement
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.
A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do
Determine whether the prescribed treatment was effective.
Which describes the best approach for the development of nursing diagnoses?
Develop nursing diagnoses from clusters of significant data.
A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?
Disturbed Body Image related to loss of hair
Which is the priority question for the nurse to consider before implementing a new intervention?
Does this treatment make sense for this client?
The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management?
Effectiveness of intervention including current pain scale, time frame, and client self-report.
What should the nurse do to make outcomes more achievable?
Encourage the client and family to be involved in the development of outcomes.
Which part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
Etiology of the problem
The nurse assesses a client's blood pressure, which is 160/90 mm Hg. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure, finding it to be 140/78 mm Hg. What has the nurse implemented with the second action?
Evaluating
The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client is breathing easier. The nurse is engaging in which phase of the nursing process?
Evaluating
A client is receiving care on a rehabilitative medicine unit during recovery from a stroke. The client voices frustration that the physical therapist, occupational therapist, neurologist, primary care health care provider, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration?
Facilitate communication between the different professionals and attempt to coordinate care.
What common problem is related to outcome identification and planning?
Failing to involve the client in the planning process
Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?
Finances of the client
A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?
Gastrointestinal upset from food poisoning
A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?
Health promotion nursing diagnosis
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 client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?
Health promotion nursing diagnosis
The nurse is proceeding through the nursing process in the care of a new client. During the implementation phase, the nurse will most likely accomplish what task?
Help the client achieve optimal levels of health
A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?
Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?
Impaired Physical Mobility related to pain
A nurse working in a critical care unit has formulated the following nursing diagnoses for a client. Which nursing diagnosis likely would be the priority?
Impaired gas exchange
A nurse cares for a client with congestive heart failure. The nurse administers a prescribed dose of furosemide intravenously after noting an increase in dyspnea and audible wheezing. The nurse's action demonstrates which step in the nursing process?
Implementation
The nurse is preparing a client to be discharged from the surgical unit following abdominal surgery. Which intervention will the nurse use to ensure the client's adherence to proper wound care techniques?
Include family members or other caregivers in the education.
A client is being admitted from the emergency room reporting shortness of breath, Whee coughing. What would the nurse formulate as an appropriate nursing diagnosis?
Ineffective Airway Clearance
The client is being seen for chest congestion, coughing up thick secretions, and shortness of breath for several days and is diagnosed with pneumonia. The client has a two-pack-per-day smoking habit. When developing the plan of care, what would be a priority nursing diagnosis for this client?
Ineffective Airway Clearance related to tracheobronchial secretions as evidenced by expectorating thick, yellow secretions
Which is the best example of a nursing diagnosis?
Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.
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 clients denial of illness
Which is a characteristic of person-centered care?
It is a framework for providing care.
The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?
Listen to the new nurse's suggestion and evaluate its usefulness.
The client is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8/37.1, P. 88, Resp. 28. Which is the client care priority?
Maintain open airway
What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?
NANDA-International (NANDA-I)
A 33-year-old client is brought to the urgent care center, doubled over in pain and crying. Upon assessment, the client admits to nausea and vomiting ×3 during the morning. Which action should the nurse prioritize after noting right lower quadrant (RLQ) rebound tenderness, blood pressure of 130/92 mm Hg, and pulse 100 beats/min and weak?
Notify the health care provider immediately.
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.
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are derived from the nursing diagnosis.
À nursing student is discussing assessment findings of an assigned client with the instructor. The instructor determines that the student needs additional assistance and review when the student identifies which as objective data?
Nursing staff
A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered?
Ongoing planning
When planning a client's care, the nurse has drafted specific, measurable and realistic statements of goal attainment. What component of the care planning process has the nurse included?
Outcomes
A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?
PC: Decreased Cardiac Output related to cardiac tissue damage
A client with diabetes mellitus has been admitted to the intensive care unit with a serum glucose reading of 400 mg/dL (22.20 mol/L). Because the care for this client will involve multiple disciplines, which diagnostic statement would be most appropriate for the nurse to select?
PC: Hyperglycemia related to uncontrolled serum glucose
A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse?
Perform hourly neurovascular assessment.
The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment?
Perform vital signs and blood glucose level.
What activity is carried out during the implementing step of the nursing process?
Planned nursing actions (interventions) are carried out.
A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select?
Readiness for Enhanced Knowledge: Childhood Immunizations
The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?
Reassess the appropriateness of the method of instruction.
Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?
Reporting signs and symptoms related to the client's kidney failure
The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?
Repositioning the client
A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement?
Return the client to bed and provide pain relief measures.
According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitled to the intensive care unit with a diagnosis of Congestive Heart Failure?
Risk for Body Image Disturbance
An older adult client's venous ulcer has become foul-smelling after the client began using strips of a sheet to dress the wound due to running out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances?
Risk for Infection related to knowledge deficit
According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of Congestive Heart Failure?
Risk for body image disturbance
The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?
Start from client's knowledge, teach about diet modifications, and check for learning.
At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25 kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 lb (0.45 kg). Which statement helps the nurse interpret these data appropriately?
The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight.
A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply.
The client no longer indulges in usual activities. The client attempted suicide 1 month ago. The client states, "I have no interest in doing anything."
A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client?
The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day.
Which is a correctly written client outcome?
The client will ambulate 10 ft (3 m) with a walker by October 12.
Which is an example of a long-term outcome for a client with asthma?
The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.
Which of the following best summarizes the evaluation step of the nursing process?
The nurse and client measure achievement of planned outcomes of care.
The nurse has selected a nursing diagnosis of "Impaired Home Maintenance" for an older adult client. What assessment data would evidence this diagnosis?
The nurse observes unsafe conditions in the client's home.
When reviewing the client's history, the nurse notes that the client's last documented 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.
Which statement best describes the relationship between nursing diagnosis and medical diagnosis?
The nursing diagnosis is based on client response to the medical diagnosis.
A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?
To be sure the intervention is safe
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
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
A nurse in the emergency department is completing an emergency assessment for an adolescent admitted from a car crash. Which statement represents objective data the nurse is likely to gather and document during this assessment?
Unable to palpate femoral pulse in left leg.
A new mother is having difficulty breastfeeding a newborn. A goal was established stating that the infant would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding 4 days ago. How will the nurse characterize the original goal?
Unmet
A client is required to have nothing by mouth (NO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?
Updating the diet orders in the client's plan of care
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
A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." Which nursing action is the priority?
address the client's anxiety.
The 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
Who or what is the primary source of information for a nursing history?
client
One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:
condition
The nurse prepares a concept map for a client who is newly diagnosed with atrial fibrillation. According to the concept map pictured above, what is the highest prioritized nursing diagnosis?
decreased cardiac output
A client comes to the health care provider's office reporting abdominal pain, for which the client has previously sought care. Which type of assessment would the nurse perform?
focused
Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?
focused
The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?
inspection
A nurse is assessing a client admitted to the health care facility with angina. Which method would be most appropriate for the nurse to use to collect subjective data?
interview
What is the nurse accountable for, according to state nurse practice acts?
making nursing diagnoses
The sclerae of a 3-day-old infant have a yellowish tint, and the nurse has just received an order to initiate phototherapy. Which nursing diagnosis should the nurse use to plan care for this client?
neonatal jaundice
What phrase best describes nurse-initiated interventions?
nurse-prescribed interventions
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs?
physiological
On admission, a health care provider diagnoses a client with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nurse diagnosing?
the response of the client to the illness
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
When documenting subjective data, the nurse should:
use the client's own words placed in quotation marks.
Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:
uses critical thinking to direct care for the individual client.
Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent?
verb (action)
A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try ar 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
A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling make his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern?
Disturbed body image
A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse?
Encourage hourly use of the incentive spirometer.
The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?
Ensuring that the endotracheal tube is secure
The client is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8/37.1, P. 88, Resp. 28. Which is the client care priority?
Maintain an open airway
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.
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.
A nursing diagnosis of "Ineffective Coping" has been chosen for a client after receiving a diagnosi of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? Select all that apply.
The client reports an inability to get adequate restful sleep. The client has difficulty concentrating on the details of treatment options. The client states, "I can't handle all of this.
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 uses the nursing process to provide care to clients. What are the nursing benefits when the nurse does this? Select all that apply.
The plan is clear and efficient to other health care professionals who read it. Best results can be achieved for the client. The nurse obtains satisfaction by impacting the client's life in a positive manner.
A nurse develops the nursing diagnoses "Appendicitis" and "Acute Pain" for a client. Which of the diagnoses is a medical diagnosis?
appendicitis
A nurse has encouraged a bedridden hospital client to perform deep breathing and coughing exercises each hour to prevent respiratory complications. After performing this intervention, the nurse should:
assess the client's lungs to determine the effectiveness of the intervention.
A home health nurse reviews the nursing care plan with the client and family. Then they mutually discuss the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?
planning
