PrepU Nursing Process and Assessment

The nurses assesses a pulse rate of 42 beats per minute. Using critical thinking, what would be the best action for the nurse to take?

Check the client's previous pulse rates to validate the findings.

A client had a total hip replacement earlier in the day. The nurse sits with the client to establish some goals. One goal they agree on is to ambulate 1 to 2 miles each day. This is an example of which type of goal?

Long-term

A nurse is planning care for an older adult who lives with a number of chronic health problems. For what nursing diagnosis would education of the client be the nurse's highest priority?

Risk for ineffective health maintenance related to non-adherence to the therapeutic regimen

The nurse is preparing the client file for a client with HIV who does not exhibit any chronic signs or symptoms. The infection is currently in the second, or asymptotic, stage. The nurse knows it is the professional and clinical responsibility of the nurse to discuss issues of sexuality with the client as part of the client profile. Which of the following scenarios demonstrates that the nurse understands the best method to obtain information related to sexuality?

State near the end of the interview, "Some clients with HIV are worried about future sexual relationships" and then take a verbal sexual history.

During review of a plan of care for a client, the nurse determines that the outcomes have not been achieved. The nurse believes an error may have been made during the planning phase of the nursing process. Based on this belief, which of the following should the nurse consider during this evaluation step?

Were the time frames appropriate to achieve the expected outcomes?

A patient arrives at the clinic for an evaluation. This is the first time the patient is being seen. Which information would the nurse need to obtain first?

biographical data

The basic difference between nursing diagnoses and collaborative problems is that:

nurses manage collaborative problems using physician-prescribed interventions

A nurse is developing a nursing diagnosis for a client. Which information should she include?

* characteristics and the etiology of the client's problem * commonalities among the assessment data collected * categorization of related data

The nurse is aware that what concepts are necessary for total implementation of the nursing process? Select all that apply.

* critical thinking * clinical reasoning * problem solving x objective understanding x excellent communication skills

Which component of the nursing process deals with the identification of client problems?

* diagnosis

Which set of nursing actions demonstrates that the nurse understands the nursing process?

* obtaining vital signs, documenting the nursing diagnosis as acute pain, administering analgesic, and evaluating comfort level

The nursing process is integral to the accurate and complete delivery of nursing care. Which of the following activities represent aspects of the nursing process? Select all that apply.

* taking a client's health history * comparing client outcomes against planned goals * prioritizing activities to improve client comfort x selecting interventions to cure the client's medical diagnoses x ordering an antidiabetic agent for a client newly diagnosed with diabetes

During an assessment a client reports tightness in his chest and frequent coughing. Order from step 1 to step 5 the assessment sequence that the nurse will most likely perform. Use all the options.

1. Ask, "When do you most frequently cough?" 2. Obtain the respiratory rate 3. Inspect the anterior chest wall 4. Percuss the anterior chest wall 5. Auscultate the posterior lung field

When preparing to perform a physical assessment of a patient, the nurse performs the steps below. Place the steps in the order in which they most typically are completed.

1. Inspection 2. Palpation 3. Percussion 4. Auscultation

The nurse is caring for a client with respiratory distress caused by pneumonia who recently because homeless after losing his job. He also tells the nurse that the stress of losing both his job and his home has caused his wife to move in with one of their adult children. The nurse hears him say, "I just don't know what to do. I wish I were a better human being. I've never really done anything right." The nurse will attend to this client's needs in what order?

1. The client's respiratory distress 2. The client's homelessness 3. The client's estrangement from his wife 4. The client's feeling about himself 5. The client knowing what to do

The nurse is following the care plan that was created for a client newly admitted to the hospital unit. What spect of the care plan should the nurse consider to be a nursing implementation?

Ambulate the client twice per day with partial assistance.

While performing the physical examination, the nurse determines that a patient has an area of consolidation in the lungs suggesting pneumonia. Which technique would the nurse most likely have used to obtain this finding?

Percussion