PrepU Questions for Exam 2 Professional Nursing

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

"Client states, 'I don't see the point in trying anymore.'"

A nurse is conducting an interview with a client. Which example best demonstrates use of open-ended questions in an interview?

"How are you feeling?"

A nurse is asking questions about a client's sexual history. Which is the best question for the nurse to ask to determine the client's use of safer sexual practices?

"How do you protect yourself when having sex?"

The expected outcome for a client with a new diagnosis of diabetes mellitus 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."

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature

When performing an assessment, the nurse should focus most on the developmental stage for which client?

Toddler

The nurse is applying the Clinical Judgment Measurement Model (CJMM) to the care of a client who has been expressing anxiety. The nurse has recognized and analyzed the various cues that the client is exhibiting, has prioritized hypotheses that may explain the client's anxiety, and is now generating possible solutions. In this particular stage of the CJMM, the nurse is demonstrating which component of Rest's framework of moral reasoning?

moral judgment/reasoning

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

Sitting at eye level with the client

A group of student nurses has been encouraged by their instructors to be intentional and deliberate about applying clinical decision-making models to their practice. A student tells a colleague, "The model that makes the most sense to me is the information-processing model, because it seems the most straightforward." How should the colleague best respond to this student?

"It is definitely a clear model, but it does not really capture all of the complexities and the human element of nursing."

A nursing student observed a staff nurse change a client's IV dressing. During post-conference, the student remarked to a classmate, "The nurse did not even follow the process we learned in lab!" What is the classmate's most appropriate response?

"You should consider some of the factors that might have influenced the nurse's action."

The nurse is applying Tanner's Clinical Judgment Model in the care of a client. Building off the context and background information, place the components of the model in the correct sequence. Use all options.

1.noticing 2.interpreting 3.responding 4.reflecting

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

A health promotion nursing diagnosis

The nurse is preparing to interview a client who demonstrates significant abdominal pain and rates the pain at 10 on a 0 to 10 pain scale. What action by the nurse can improve the outcome of the interview?

Administer prescribed pain medication prior to conducting the interview.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

Discharge planning

Which statements accurately describe NANDA-I nursing diagnoses? Select all that apply.

A risk nursing diagnosis is a clinical judgment that concludes there is a likelihood of developing a problem that others in the same or similar situation may not. A problem-focused nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics.

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

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?

All data collected need to be validated.

The nurse is caring for a 14-year-old client who has just gave birth. The client reports living with an aunt and having no other family around. The birth was uncomplicated, and the newborn is healthy. Which is the primary nursing concern the nurse will identify for this client's care planning?

Altered parenting risk

A nurse has recommended a regimen of over-the-counter medications for a client who has seasonal allergies. A colleague contends that the nurse has exceeded the scope of nursing practice by recommending medications to a client. To resolve this difference of opinion, the nurses should consult resources from what organization?

American Nurses Association

The nurse has completed a comprehensive assessment of the client and is not organizing data. Which findings would the nurse categorize as subjective data? Select all that apply.

Anxiety, Light-headedness, Nausea

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 191/110 mm Hg on a client. Which is the nurse's priority action?

Assess the client and re-evaluate the vital signs.

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data?

Both during the collection and at the end of the collection

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence

After meeting with a client and their family, the nurse has identified a nursing diagnosis of Effective Family Coping. In this diagnosis, the term "Effective" constitutes what part of the nursing diagnosis?

Discriptor

Which is the best source of information for the nurse when collecting data for an assessment?

Client

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 normotensive.

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? Select all that apply.

Client states, "I feel so sad all of the time.", Client states, "I am in pain."

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 preparing to interview several clients during clinic hours. What language difficulty might a nurse encounter while performing various interviews in a diverse population of clients?

Clients not being fluent in the same language as the nurse, Clients having a limited education, Clients fearing saying the wrong thing

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client reports cramping pain in left foot. The nurse is doing what?

Clustering significant data cues

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 Problem

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns

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 nurse is conducting a health history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?

Continue the health history with questions focusing on respiratory function.

A novice nurse has witnessed the value of critical thinking in planning and responding to clients. Which principle should inform the nurse's practice?

Critical thinking is a skill that can be learned and developed.

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?

Focused

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

An experienced nurse has received a new client and will apply the principles of inductive reasoning in the care-planning process. What action will the nurse perform first when applying this form of clinical reasoning?

Gather objective and subjective assessment data.

The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI) for the fourth time in 4 years. The nurse plans to address the potential concern for the client's risk-prone behavior. What assumption prompted the nurse to address this concern?

Having multiple STIs over multiple years means the client is sexually active.

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?

Health Promotion

The nurse has obtained a new client's nursing history. This will primarily allow the nurse to perform which of the following?

Identify actual and potential health problems

The nurse is working toward developing a nursing diagnosis for a client. What will the nurse do first?

Identify the significant data

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information?

If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

A nurse is interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because 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

A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client?

Impaired Comfort

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?

Increase hourly use of the incentive spirometer

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

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

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse will do which of the following?

Inform the client of the maintenance of confidentiality

The nurse is participating in a client conference for a client who has complex health needs. The client's psychiatrist, occupational therapist, and social worker are also participating in the conference. The nurse is most clearly demonstrating the values of what organization?

Interprofessional Education Collaborative

A skilled nurse is providing care for a client with mental health needs who is recovering from a stroke. The client is experiencing dysphagia (difficulty swallowing), so the nurse is working together with the speech-language pathologist (SLP) to ensure the client's cooperation with a swallowing assessment. This nurse's action best demonstrates:

Interprofessional Education Collaborative (IPEC) core competencies.

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

Knowledge Deficit: Medications related to new medical diagnosis

Which are accurate guidelines when formulating nursing diagnoses? Select all that apply.

Make sure the client problem precedes the etiology. Write the diagnosis in legally advisable terms. Phrase the nursing diagnosis as a client need rather than an alteration. Be sure the problem statement indicates what is unhealthy about the client. Make sure defining characteristics follow the etiology.

A nursing student is excited to begin the first semester of the program and has learned that the competencies embedded in the program include human flourishing, nursing judgment, professional identity, and spirit of inquiry. What is the source of these competencies?

National League for Nursing

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 health care provider for additional orders.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

Which elements are common to any type of plan of care? Select all that apply.

Nursing diagnoses Client goals Nursing interventions

A nurse working on a medicine unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12-hour shift. What would be the nurse's best response to the new graduate?

Ongoing data collection is critical to the deletion or modification of old problems and finding new ones.

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

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.

Which are correctly written nursing interventions? Select all that apply.

Provide 5 to 6 small meals daily. Reposition the client from side to side every hour around the clock. Provide opportunities for the client to express concerns and verbalize feelings.

When a nurse documents an intervention involving a one-person assist of a client to the chair, which type of nursing intervention does this represent?

Psychomotor

A nurse is involved in a clinical scenario that is ethically complex and requires careful balancing between several conflicting factors. What clinical judgment model or framework will provide the most direct relevance to this nurse's circumstance?

Rest framework

After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first?

Review the client's recent food and fluid intake.

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

A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition?

Risk for Infection

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data?

Safety and Security

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

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.

A client rates their leg pain at 8/10 on a 10-point pain scale. What type of cue is the client's description of pain in the right leg?

Subjective

A nurse has entered a client's home and noticed the client's disheveled state and several fall risks in the home. The nurse has interpreted these data as indications of a need for increased home support for the client and responded by arranging for care. The nurse reflected on the client's response to this suggestion, as well as reflected on the course of this interaction after the fact. The nurse has most clearly exemplified what model?

Tanner's clinical judgment model

The nurse is caring for a client who underwent surgery 1 day ago. Which client problem can be addressed by independent nursing diagnoses?

The client has diminished breath sounds

Which factor is most likely to contribute to the nurse making a diagnostic error?

The client withholds information during the client assessment.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training?

The nurse introduces oneself to the client by pointing to the nurse's name badge.

A novice nurse is working with a more experienced nurse who has much more clinical experience. What characteristic of the more experienced nurse demonstrates that they are an "expert," according to Benner's model of nursing development?

The experienced nurse is able to notice subtle cues and navigate complex situations quickly and skillfully.

A novice nurse has received feedback from a peer that describes the nurse as lacking situational awareness. What observation by the peer likely led to this conclusion?

The nurse has difficulty identifying the less obvious changes in clients' conditions.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

A novice nurse has been growing in skill, largely as a result of experiential learning in the clinical setting. Within the model of experiential learning, what outcome would most clearly indicate that the nurse has achieved the stage of transformation?

The nurse integrates experience and reflections into new forms of practice.

A student nurse who is soon to graduate is completing a preceptorship with a nurse who has many years of clinical experience. The student has marveled at the nurse's ability to derive meaning from complex and rapidly changing situations, relying heavily on nurse intuition. What characteristic of this nurse does this ability demonstrate most clearly?

The nurse is an expert, according to Benner's novice-to-expert model of development.

A nurse is distraught that she failed to intervene promptly in a situation where a client's status declined sharply. The client was becoming agitated and aggressive. The nurse states, "There was just too much going on, all at once, and I basically froze and then panicked." What interpretation of this event is most accurate?

The speed and complexity of the situation overwhelmed the nurse's cognitive load.

A student nurse has been challenged to apply the principles of critical thinking during laboratory simulations. What characteristic of the student nurse's actions suggests that the student nurse engaged in critical thinking?

The student nurse thought systematically and reflectively before deciding what to do.

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?

Time-lapsed Assessment

A nursing student is moving through a curriculum that emphasizes the value of experiential learning. The nursing student is consciously linking previous experiences with new and transformative practices. How will the nursing student link experiences with transformative behaviors?

by engaging in frequent and thoughtful reflection

What action by the nurse in a hospital setting best exemplifies the goals of the Interprofessional Education Collaborative (IPEC) core competencies?

coordinating with the physical therapist to amend a client's activity orders in the plan of care

The nurse is describing a clinical encounter, stating, "I entered the room, gathered assessment data, and then provided the interventions specified in standard operating procedures." The nurse is applying which conceptualization of clinical decision-making?

information-processing model

The nurse has provided analgesia to a client who was reporting pain, and the nurse used the NCSBN Clinical Judgment Measurement Model (CJMM) to inform the process. What action by the nurse represents the final step in this model?

evaluating the client's pain 30 minutes after administering the analgesia

The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?

functional assessment

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

identifies factors causing undesirable response and preventing desired change.

The nurse has entered a client's home and has observed that the client's respiratory rate is elevated and that the client is exhaling audibly. Based on these cues, the nurse suspects that the client is either anxious or hypoxic. Which step of the Clinical Judgment Measurement Model (CJMM) has the nurse just applied?

prioritizing hypotheses

The community health nurse is participating in a debrief about a critical incident that involved a physical altercation with the client in the client's home. When applying Tanner's model of clinical judgment to this situation, the debriefing exercise constitutes what component of the model?

reflection on-action

A nurse is navigating a busy morning on a hospital unit and is struggling to finish the necessary tasks in the time available. In response, the nurse has assigned morning hygiene tasks for two clients to an unlicensed assistive personnel (UAP). What QSEN competency is this nurse exemplifying?

teamwork and collaboration

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:

the initial comprehensive client assessment.

The nurse is aware that nursing diagnoses are:

within the nursing scope of practice to develop and client-focused.