Review Questions, Exam #1, Fundamentals

You are caring for a hospitalized patient who is Muslim and has diabetes. Which of the following items do you need to remove from the meal tray when it is delivered to the patient?

Bacon and eggs

A nurse prepares to insert a Foley catheter. The procedure manual calls for the patient to lie in the dorsal recumbent position. The patient complains of having back pain when lying on her back. Despite this, the nurse positions the patient supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of:

Basic critical thinking.

Truth seeking Open-mindedness Analyticity Systematically

Be objective in asking questions of a patient Be tolerant of the patient's views and beliefs Anticipate how a patient might respond to a treatment Organize assessment on the basis of patient priorities

A nurse demonstrated caring by helping family members to:

Become active participants in care. Have uninterrupted time for family and patient to be together. Have opportunities for the family to discuss their concerns.

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation?

Beneficence

When a nurse tries to understand a patient's and family caregiver's perspective of why a patient is falling at home, the nurse applies the intellectual standard of _________________________ to understand all viewpoints.

Broad

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first?

Call the nursing supervisor to discuss the situation

A hospice nurse sits at the bedside of the male patient in the final stages of cancer. He and his parents made the decision that he would move home and they would help him in the final stages of his disease. The family participates in his care, but lately the nurse has increased the amount of time she spends with the family. Whenever she enters the room or approaches the patient to give care, she touches his shoulder and tells him that she is present. This is an example of what type of touch?

Caring touch.

The nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started noticing a glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do needlework. The nurse suspects that the woman may have

Cataract(s)

A nurse is caring for a patient experiencing a stress response. The nurse plans care with the knowledge that systems respond to stress in what manner?

Cause negative responses over time Protect an individual from harm in the short term

A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the conditions of the IV site?

Check the IV infusion rate Inspected the condition of the IV dressing at the site

Which measures does a nurse follow when being asked to perform an unfamiliar procedure?

Checks scientific literature or policy and procedure Reassesses the patient's condition Collects all necessary equipment Considers all possible consequences of the procedure

When planning patient education, it is important to remember that patients with which of the following illnesses often find relief in complementary therapies?

Chronic back pain and arthritis

The nurse is caring for a patient with a nasogastric feeding tube who is receiving a continuous tube feeding at a rate of 45 mL per hour. The nurse enters the patient assessment data and information that the head of the patient's bed is elevated to 20 degrees. An alert appears on the computer screen warning that this patient is at a high risk for aspiration because the head of the bed is not elevated enough. This warning is known as which type of system?

Clinical decision support system

Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill?

Cognitive

Which of the following family assessments are important for successful family caregiving?

Collaboration between family members Social support Conflict resolution practices

When planning for instruction on cardiac diets to a patient with heart failure, which of the following instructional methods would be the most appropriate for someone identified as a visual/spatial learner?

Colored visual diagrams that categorize foods according to fat and sodium content

A family has decided to care for a grandparent with terminal cancer in the daughter's home. Family caregiving is new to the family. When helping this family as they begin to plan for their caregiving roles, what are the two top priority assessments to best learn about family functioning?

Communication Decision making

It can be difficult to agree on a common definition of the word quality when it comes to quality of life? Why?

Community values influence definitions of quality, and they are subject to change over time.

A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's self-report of nausea has changed. This review an example of:

Comparing outcome criteria with actual response

A nurse changed a patient's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the patient discomfort. Today he gives the patient an analgesic 30 minutes before the dressing change. Then he adds some sterile saline to loosen the gauze for a few minutes before removing it. The patient reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change?

Complex critical thinking Experience

Which of the following does a nurse perform when discontinuing a plan of care for a patient?

Confirms with the patient that expected outcomes and goals have been met

A nurse on a busy medicine unit is assigned to four patients. It is 10 AM. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth patient requires instructions about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the patient group?

Consider availability of assistive personnel to obtain the specimen Combine activities to resolve more than one patient problem Analyze the diagnoses/problems and decide which are most urgent based on patients' needs

A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take?

Contact a child abuse hotline

Presence involves a person-to-person encounter that:

Conveys a closeness and a sense of caring.

Match the category of direct care on the left with the specific direct care activity on the right.

Counseling --Discussing a patient's options in choosing palliative care Lifesaving measure --Protecting a violent patient from injury Physical care technique --Using safe patient handling during positioning of a patient Activity of daily living --Assisting patient with oral care

A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation?

Critical thinking

A new immigrant family consisting of a grandparent, two adults, and three school-age children has decided to receive their health promotion care at the Community Wellness Center. This is their first visit, and a family assessment, a health history, and a physical of each family member are needed. Which of the following are included in a family function assessment?

Cultural practices Decision Making Rituals and celebrations

The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing:

Delirium

A patient who is hospitalized has just been diagnosed with diabetes. He is going to need to learn how to give himself injections. Which teaching method does the nurse use?

Demonstration

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing:

Depression

You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action?

Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

A nurse enters a 72-year-old patient's home and begins to observe her behaviors and examine her physical condition. The nurse learns that the patient lives alone and notices bruising on the patient's leg. When watching the patient walk, the nurse notes that she has an unsteady gait and leans to one side. The patient admits to having fallen in the past. The nurse identifies the patient as having the nursing diagnosis of Risk for Falls. This scenario is an example of:

Diagnostic Reasoning.

By using known criteria in conducting an assessment such as reviewing with a patient the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude?

Discipline

The nurse is supervising a beginning nursing student and allowing the student to complete documentation of care under direct observation. Which of the following actions are not appropriate and would require intervention? The nursing student

Documents a medication given by another nursing student. Leaves a slip of paper with her user name and password in the patient's room.

Which of the following most greatly affects a family's access to adequate health care, opportunity for education, and sound nutrition?

Economic stability

You are caring for a family that consists of a father and 3-year-old boy who has well-managed asthma but misses care infrequently. They live in state-supported housing. The father is in school studying to be an information technology professional. His income and time are limited, and he admits to going to fast-food restaurants frequently for dinner. However, he and his son spend a lot of time together. The family receives state-supported health care for his son, but he does not have health insurance or a personal physician. He has his son enrolled in a government-assisted day care program. Which of the following are risks to his family's level of health?

Economic status Underinsured Frequency of fast-food dinners

While working on a unit within a hospital, the nurse was able to access a patient's medical record and review the education that other nurses provided during an initial hospitalization and three subsequent clinic visits that occurred in different provider's offices over the past 6 months. This type of feature is most common in a(n)

Electronic health record

A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws?

Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

Swanson's caring process of _____ is demonstrated by a nurse helping a new mother through birthing experience.

Enabling.

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort?

Engage the patient in setting mutual outcomes for distance he is able to walk

A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient?

Enhancing patient knowledge about the effects of diabetes

A manager is reviewing the nursing documentation entered by a staff nurse in a patient's electronic medical record and finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following statements is most appropriate for the manager to make to the staff nurse who entered this information?

Enter only objective and factual information about a patient in the medical record.

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient?

Erythema of skin will be mild to none within 48 hours.

Of the five caring processes described by Swanson, which describes "knowing the patient"?

Establishing an understanding of a specific patient.

The ethics of care suggests that ethical dilemmas can be solved by attention to relationships. How does this differ from other ethical practices?

Ethics of care pays attention to the environment in which caring occurs. Ethics of care pays attention to the stories of the people involved in the ethical issue. Ethics of care focuses only on understanding relationships.

Which of the following statements correctly describes the evaluation process?

Evaluation in an ongoing process Evaluation involves making clinical decisions Evaluation requires the use of assessment skills

A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to preform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of:

Evaluative measures

A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had and intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to preform evaluation:

Examine results of clinical data

A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of:

Expected outcomes

A patient needs to learn how to administer a subcutaneous injection. Which of the following reflects that the patient is ready to learn?

Expressing the importance of learning the skill correctly

A patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation?

Failure to document a change in assessment data Failure to notify a health care provider about a change in the patient's condition

A hospice nurse is caring for a family that is providing end-of-life care for their grandmother, who has terminal breast cancer. When the nurse visits, the focus is on symptom management fir the grandmother and helping the family with coping skills. This approach is an example of which of the following?

Family as patient

Which of the following are possible outcomes with clear family communication?

Family goals Decision making Methods of discipline

A family is facing job loss of the father, who is the major wage earner, and relocation to a new city where there is a new job. The children will have to switch schools, and his wife will have to resign from the job she likes. Which of the following contribute to this family's hardiness?

Family meetings Established family rules Willingness to change in times of stress

When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain?

Fidelity

Which of the following might be a cause of stress for the older adult?

Financial security Housing Adjusting to decreasing health and physical strength

Older adults frequently experience a change in sexual activity. Which best explains this change?

Frequency and opportunities for sexual activity may decline.

A muslim woman enters the clinic to have a woman's health examination for the first time. Which nursing behavior applies Swanson's caring process of "knowing the patient?"

Gaining an understanding of what a woman's health examination means to the patient.

Ethical dilemmas often arise over a conflict of opinion. Reliance on a predictable series of steps can help people in conflict find common ground. All of the following actions can help resolve conflict. Which is the best order of these actions in order to promote the resolution of an ethical dilemma?

Gather all relevant information regarding the clinal, social, and spiritual aspects of the dilemma. Take time to clarify values and distinguish between facts and opinions-your own and those of others involved. Agree on a statement of the problem or dilemma that you are trying to resolve. List the actions that could be taken to resolve the dilemma. Negotiate a plan. Agree on a plan to evaluate the action over time.

A preceptor observes a new graduate nurse discussing changes in a patient's condition with a physician over the phone. The new graduate nurse accepts telephone orders for a new medication and for some laboratory tests from the physician at the end of the conversation. During the conversation the new graduate writes the orders down on a piece of paper to enter them into the electronic medical record when a computer terminal is available. At this hospital new medication orders entered into the electronic medical record can be viewed immediately by hospital pharmacists, and hospital policy states that all new medications must be reviewed by a pharmacist before being administered to patients. Which of the following actions requires the preceptor to intervene? The new nurse:

Gives a newly ordered medication before entering the order in the patient's medical record.

The nurse is reviewing the Health Insurance Portability and Accountability Act (HIPAA) regulations with the patient during the admission process. The patient states, "I'm not familiar with these HIPAA regulations. How will they affect my care?" Which of the following is the best response?

HIPAA provides you with greater protection of your personal health information.

A nurse is preparing to teach an older adult who has chronic arthritis how to practice meditation. Which of the following strategies are appropriate?

Have patient identify a quiet room in the home that has minimal interruptions. Suggest use of a quiet fan running in the room. Show the patient how to sit comfortably with the limitation of his arthritis and focus on a prayer.

nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act?

Health Insurance Portability and Accountability Act (HIPAA)

In viewing the family as context, what is the primary focus?

Health needs of an individual member

During a visit to a family clinic the nurse teaches the mother about immunizations, car seat use, and home safety for an infant and toddler. Which type of nursing interventions are these?

Health promotion activities

A nurse is teaching a group of young college-age women the importance of using sunscreen when going out in the sun. Which type of content is the nurse providing?

Health promotion and illness prevention

A nurse needs to teach a young woman newly diagnosed with asthma how to manage her disease. Which of the following topics does the nurse teach first?

How to use an inhaler during an asthma attack

A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 1/2NS. Which intervention is a dependent intervention?

IV fluid administration

Place the steps of the scientific method in their correct order with number 1 being the first step of the process.

Identify the problem. Collect data. Formulate a question or hypothesis. Test the question or hypothesis. Evaluate results of the study.

A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answers clearly. What are the fall risk factors for this patient?

Impaired vision Leg weakness Exercise history

Several nurses on a busy unit are using relaxation strategies while at work. What is the desired workplace outcome from this intervention?

Improved staff satisfaction Improved staff relationships

The application of utilitarianism does not always resolve an ethical dilemma. Which of the following statements best explains why?

In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism

Which of the following is a strategy for creating work environments that enable nurses to demonstrate more caring behaviors?

Increasing the number of number of nurses who work each shift to decrease the nurse-patient ratio. Providing nursing staff an opportunity to discuss practice changes they can implement to enhance opportunities for patient caring.

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient?

Individualizing how to apply the clinical guideline for a patient

Which of the following describes a nurse's application of a specific knowledge base during critical thinking?

Initiative in reading current evidence from the literature Application of nursing theory Considering holistic view of patient needs

When a nurse helps a patient find the meaning of cancer by supporting beliefs about life, this is an example of:

Instilling hope and faith.

Which of the following statements best explains the actions of therapeutic touch (TT)?

Intentionally mobilizes energy to balance, harmonize, and repattern the recipient's biofield

Listening is not only "taking in" what a patient says; it also includes:

Interpreting and understanding what the patient means.

The nurse is organizing a disease prevention program for a specific cultural group. To effectively meet the needs of this group the nurse will:

Involve those affected by the problem in the planning process. Assess commonly held health beliefs among the cultural group. Include cultural practices that are relevant to the specific community.

The patient for whom you are caring needs a liver transplant to survive. The patient has been out of work for several months and doesn't have health insurance or enough cash. Even though several ethical principals are at work in this case, list the principles from the highest to lowest priority.

Justice: The greater question in this situation is how to determine the just distribution of resources. Respect for autonomy: This patient's autonomy will be violated if he does not receive the liver transplant. Ethics of care: The caring thing that a nurse could provide this patient is resource for a liver transplant. Accountability: You as the nurse are accountable for the well-being of this patient.

Match the following caring behaviors with their definitions.

Knowing - striving to understand an event as meaning for another person Being with - being emotionally there for another person Doing for - providing for another as he or she would do for themselves Maintaining belief - sustaining faith in one's capacity to get through a situation

What is the most common reason for calling on grandparents to raise their grandchildren?

Legal interventions

A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions?

Maintaining intravenous (IV) infusion at 100 mL/hr Consulting with dietitian on initial foods to offer patient

A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following?

Makes it quicker and easier for nurses to intervene Sets a level of clinical excellence for practice Delivers evidence-based interventions for stage II pressure ulcer

A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient?

Making a judgment of the value of improved adherence for the patient Determining all consequences associated with the patient missing specific medicines

What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey?

Measures quality of care within hospitals

While planning care for a patient, a nurse understands that providing integrative care includes treating which of the following?

Mind-body-spirit of patients and their families

A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility?

More information is needed about the wife's preference and if the husband has her medical power of attorney

A nurse is caring for a patient with a seriously advanced infection who asks to have a spiritual care provider come who can offer Blessingway, a practice that attempts to remove ill health. This patient is likely a member of which religion or culture?

Navajo

The ANA code of nursing ethics articulates that the nurse "promotes, advocates for, and strives to protest the health, safety, and rights of the patients." This includes the protection of patient privacy. On the bases of this principle, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you obscured or deleted all patient identifiers?

No because, even though the patient identifiers are removed, someone could identify the patient on the basis of other comments that you make online about his or her condition and your place of work.

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses?

Notion of urgency for nursing action Symptom pattern recognition suggesting a problem Mutually agreed on priorities set with patient

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view vulnerable?

Nurses develop a relationship with the patient that is unique among all professional health care providers.

The nurse manager of a community clinic arranges for staff in-services about various complementary therapies available in the community. What is the purpose of this training?

Nurses have a long history of providing some of these therapies and need to be knowledgeable about their positive outcomes. Nurses are often asked for recommendations and strategies that promote well-being and quality of life. Nurses play an essential role in patient education to provide information about the safe use of these healing strategies. Nurses appreciate the cultural aspects of care and recognize that many of these complementary strategies are part of a patient's life. Nurses play an essential role in the safe use of complementary therapies.

A student nurse is developing a plan of care for a 74-year-old-female patient who has spiritual distress over losing a spouse. As the nurse develops appropriate interventions, which characteristics of older adults should be considered?

Older adults achieve spiritual resilience through frequent expressions of gratitude. Have the patient determine if her husband left a legacy behind. Offer the patient her choice of rituals or participation in exercise.

Two patient deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress?

Participate in a unit meeting to discuss feelings about the patient deaths

A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician 269comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit?

Patient

For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome?

Patient describes correct schedule for taking antiarthritic medications. Patient explains situations for using heat application on inflamed joints.

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right.

Patient will ambulate independently in 3 days. --Patient walks 20 feet using a walker in 24 hrs. Patient will be injury free for 1 month. --Patient identifies barriers to remove in the home within 1 week. Patient will achieve 5-lb weight gain in 1 month. --Patient increases calorie intake to 2500 daily. Patient will achieve pain relief by discharge. --Patient expresses fewer nonverbal signs of discomfort within 24 hrs.

The nurse writes an expected outcome statement in measurable terms. An example is:

Patient will report stool soft and formed with each defecation.

A nurse is planning care for a group of patients who have requested the use of complementary health modalities. Which patient is not a good candidate for guided imagery?

Patient with post-traumatic stress disorder (PTSD)

The nurse is caring for a 50-year-old woman visiting the outpatient medicine clinic. The patient has had type 1 diabetes since age 13. She has numerous complications from her disease, including reduced vision, heart disease, and severe numbness and tingling of the extremities. Knowing that spirituality helps patients cope with their chronic illness, which of the following principles should the nurse apply in practice?

Pay attention to the patient's spiritual identity throughout the course of her illness Listen to the patient's story each visit to the clinic and offer a compassionate presence

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following?

Physical care technique

What is the appropriate way for a nurse to dispose of information printed out from a patient's electronic health record?

Place papers with patient information in a secure canister marked for shredding

A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care?

Policies and procedures of the employing hospital State Nurse Practice Act Regulations identified in The Joint Commission manual The American Nurses Association standards of nursing practice

A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities?

Policy for conducting hourly rounds Staffing level Interruption by staff nurse colleague

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the 314patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)?

Posting medical information about the patient on a message board in the patient's room

Which complementary therapies are most easily learned and applied by a nurse?

Progressive relaxation Breathwork and guided imagery

A patient newly diagnosed with cervical cancer is going home. The patient is avoiding discussion of her illness and postoperative orders. What is the nurse's best plan in teaching this patient?

Provide only the information that the patient needs to go home

A family has decided to care for their father who is in the last stages of a debilitating neurological illness. Although, he is alert, he cannot speak clearly or carry out self-care activities; he indicated that he wants to remain involved in family life as long as possible and loves spending time with his wife and two teenage children. Which best defines family caregiving?

Providing physical and emotional care for a family member Establishing a safe physical environment for a family Monitoring for side effects of illness and treatments

A patient needs to learn to use a walker. Which domain is required for learning this skill?

Psychomotor domain

A patient newly diagnosed with diabetes needs to learn how to use a glucometer. What type of learning is the best way to evaluate the patient's understanding of how to do this?

Psychomotor learning

The nurse at a community health center has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self-management of asthma medications. Identify appropriate evaluative indicators for self-management for this patient.

Quality of life Use of clinic services Adherence to use of inhaler

The nurse is working with an older adult after an acute hospitalization. The goal is to help this person be more in touch with time, place, and person. Which intervention will likely be most effective?

Reality orientation

During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. Place the following steps of review and revision in the correct order.

Reassess the patient. Compare assessment findings to validate existing nursing diagnoses. Decide if the nursing interventions remain appropriate. Modify care plan as needed.

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first?

Reconnect the drainage tubing

After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with diabetes. The nurse's behavior is an example of which of the following?

Reflection-on-action

A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breastfeeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called:

Reflection.

The Collins family includes a mother; stepfather, two teenage biological daughters of the mother; and a 25-year-old biological daughter of the father. The father's daughter just moved home following the loft of her job in another city. The family is converting a study into Stacey's bedroom and is in the process if distributing household chores. When you talk to a members of the family, they all think that their family can adjust to lifestyle changes. This is an example of family:

Resiliency

A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude:

Responsible

A family is undergoing a major change. Just as twins graduate from college and leave home to being their careers, the husband loses his executive well-paying job. Because the family had two children in college at the same time, they did not save for retirement. They planned to save aggressively after the children left college. In this situation, which of the following demonstrate family resiliency?

Resuming full-time work when spouse loses job Developing hobbies when children leave home Consulting a financial planner

A student nurse is telling a faculty member that her patient talked about gaining spiritual comfort from being focused on her inner self, including her values and principles. The instructor explains that this is an example of:

Self-transcendence.

A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the 268patient's plan of care. In which ways can the nurse develop trust with members of the conference team?

Shows competence in how to monitor patients' clinical status and inform the physician of critical changes Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly

A nurse begins a night shift, assuming care for a critically ill patient who was resuscitated earlier in the day from cardiac arrest. He survived and is physically stable, alert, oriented, and responding appropriately to the nurse's questions. Knowing that the patient experienced a period when his heart stopped beating, what would be the best approach for the nurse to use with him?

Sit and encourage the patient to share what he experienced during resuscitation

A patient has just learned she has been diagnosed with a malignant brain tumor. She is alone; her family will not be arriving from out of town for an hour. You have cared for her for only 2 hours but have a good relationship with her. What might be the most appropriate intervention for support of her spiritual well-being at this time?

Sit down and talk with the patient; have her discuss her feelings and listen attentively

A nurse is caring for a patient preparing for discharge form the hospital the next day. The patient does not read. His family caregiver will be visiting before discharge. What can the nurse do to facilitate the patient's understanding of his discharge instructions?

Sit facing the patio so he is able to watch your lip movements and facial expressions Present one concept or idea at a time Include the family caregiver in the teaching session

An aspect of clinical decision making is knowing the patient. Which of the following is the most critical aspect of developing the ability to know the patient?

Spending time establishing relationships with patients

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits?

Surgeon

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings places him at risk for an adverse drug event?

Taking a total of eight different medications during the day. Patient's health history

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse?

Taking or selling controlled substances Applying physical restraints without a written physician's order

A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first?

Talking with the patient about her concerns and acknowledging her sense of unfairness

A nurse enters a patient's room, arranges the supplies for a Foley catheter insertion, and explains the procedure to the patient. She tells the patient what to expect; just before inserting the catheter, she tells the patient to relax and that, once the catheter is in place, she will not feel the bladder pressure. The nurse then proceeds to skillfully in the Foley catheter. This is an example of what type of touch?

Task-oriented touch.

The ______________ is a closed-loop communication technique used to evaluate patient understanding and retention of material.

Teach Back method

F—Faith ___ I—Importance of spirituality ___ C—Community ___ A—Interventions to address spiritual needs ___

Tell me if you have a higher power or authority that helps you act on your beliefs Your illness has kept you from attending church. Is that a problem for you? To whom do you go for support in times of difficulty? Describe which activities give you comfort spiritually?

A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1 C (98.8 F). The student reports her recent assessment to the RN: the patient's temperature is 37.2 C (99 F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first?

Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture

A patient with chest pain is having an emergency cardiac catheterization. Which teaching approach does the nurse use in this situation?

Telling approach

While reviewing the pulmonary assessment entered by a nurse in a patient's electronic medical record (EMR), a physician notices that the only information documented in that section is "WDL" (within defined limits). The physician also is not able to find a narrative description of the patient's respiratory status in the nurse's progress notes. What is the most likely reason for this?

The EMR uses a charting-by-exception format.

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation?

The Good Samaritan law, which grants immunity from suit if there is no gross negligence

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions?

The call to the ostomy and wound care specialist is an indirect care measure. The cleansing of the skin is a direct care measure.

Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep?

The intervention should be directed at reducing noise. The intervention should be one shown to be effective in promoting sleep on the basis of research. The intervention should be one acceptable to the patient.

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient?

The loss of his work role How the wife expects household tasks to be divided in the home in the retirement

A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which statement is appropriate for evaluating a patient's expectations of care?

The nurse asks, "Did you believe that you received the information you needed to follow your diet?"

Select the three factors that are evident when a healing relationship develops between nurse and patient.

The nurse being able to realistically mobilize hope for the patient Finding an interpretation or understanding of the patient's illness that is acceptable to the patient Helping the patient use spiritual resources that he or she chooses

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech?

The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure.

A nurse is caring for an older adult who needs to enter in assisted-living facility following discharge from the hospital. Which of the following is an example listening that displays caring?

The nurse listens to the patient's story while sitting on the side of the bed and then summarizes the story.

In which of the following examples is a nurse applying critical thinking skills in practice?

The nurse thinks back about a personal experience before administering a medication subcutaneously. The nurse uses a pain-rating scale to measure a patient's pain. The nurse gathers data on a patient with a mobility limitation to identify a nursing diagnosis.

In addition to an adequate patient assessment, when a nurse uses one of the nursing-accessible complementary therapies, he or she must ensure that which of the following has occurred?

The patient has provided permission and consent.

A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit?

The patient must prove injury, damage, or loss occurred. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. The patient must prove that a breach in the prevailing standard of care caused an injury.

The nurse is transferring a patient to a long-term, skilled care facility and has just given a telephone report to a registered nurse (RN) who works at that facility and who will be receiving the patient. In documenting this call, the nurse begins by writing the date and time the report was given and the name of the RN taking the report. Which of the following pieces of information does the nurse include in the documentation of this telephone call?

The patient's name, age, and admitting diagnoses The discussion of any allergies to food and medications that the patient has That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol Description of any unresolved problems and current interventions in place

Which statement best describes the evidence associated with complementary therapies as a whole?

The science supporting the effectiveness of complementary therapies is early in its development.

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following describes the role of the nurse in the resolution of ethical dilemmas?

To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations.

Purposes of the Nursing outcomes Classification (NOC) include which of the following?

To identify and label nurse-sensitive patient outcomes To test the classification in clinical settings To define measurement procedures for outcomes

A patient who has been using relaxation wants a better response. The nurse recommends the addition of biofeedback. What is the expected outcome related to using this additional modality?

To learn how to control some autonomic nervous system responses

A nurse is participating in a health and weakness event at the local community center. A woman approaches and relates that she is worried her widowed father is becoming more functional impaired and may need to move in with her. The nurse inquires about his ability to complete ADLs. ADLs include independence with:

Toileting Bathing Eating

A nurse hears a colleague tell a nursing student that she never touches a patient unless she is preforming a procedure or doing an assessment. The nurse tells the student that from a caring perspective:

Touch forms a connection between nurse and patient.

Traditional Chinese medicine (TCM) is used by many patients. Which statement most accurately describes intervention(s) offered by TCM providers?

Uses many modalities based on the individual's needs

It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off?

Using a standardized checklist for essential information Doing prework such as checking laboratory results before giving a report Including the wife in the hand-off discussion

A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 1/2NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off?

Walked to end of hall No shortness of breath

Evaluation of spiritual care is necessary to determine if a patient's level of spiritual health has changed following intervention. If the use of rituals was part of a nurse's care plan, which of the following questions is most appropriate to evaluate its efficacy?

Were prayer or meditation helpful to you?

A nurse is caring for a 78-year-old patient with chronic multiple sclerosis. The patient has severe fatigue, muscle weakness, severe muscle spasms, and difficulties with coordination and balance. Her disease will likely worsen. The nurse has gained the patient's trust and wants to assess her life satisfaction. Which of the following questions should the nurse ask?

What about your family makes you proudest? Looking back, what is your greatest accomplishment?

The nurse is planning to teach a patient about the importance of exercise. When is the best time for teaching to occur?

When the patient states that he or she is pain free Just before lunch, when the patient is most awake and alert

From the following list of indicators, determine which indicators are goals (G) and which indicators are outcomes (O).

Will achieve pain relief - G Ambulates 10 feet down hallway - O Will remain free of infection - G Will be afebrile - G Reports pain severity reduced from 6 to a 4 on a scale of 0 to 10 - O Will gain improved mobility - G

Match the examples with the professional nursing code of ethics: 1 You see an open medical record on the computer and close it so no one else can read the record without proper access. 2 You administer a once a day cardiac medication at the wrong time, but nobody sees it. However, you contact the primary care provider and your head nurse and follow agency procedure. 3 A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patients request. 4 You tell your patient that you will return in 30 minutes to give him his next pain medication.

You see an open medical record on the computer and close it so no one else can read the record without proper access. - Confidentiality You administer a once a day cardiac medication at the wrong time, but nobody sees it. However, you contact the primary care provider and your head nurse and follow agency procedure. - Accountability A patient at the end of life wants to go home to die, but the family wants every care possible. The nurse contacts the primary care provider about the patients request. - Advocacy You tell your patient that you will return in 30 minutes to give him his next pain medication. - Responsibility

The point of ethical practice is an agreement to reassure the public that in all ways the health care team not only works to heal patients but agrees to do this in the least painful and harmful way possible. The principle is commonly called the principle of

nonmaleficence

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE?

"CPOE reduces transcription errors."

Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally?

"I am thinking about joining the health committee at my church." "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing."

A 44-year-old male patient has just been told that his wife and child were killed in an auto accident while coming to visit him in the hospital. Which of the following statements are defining characteristics that support a nursing diagnosis of Spiritual Distress related to loss of family members?

"I have nothing to live for now." "Why would my God do this to me?"

A patient who is recovering from a bilateral amputation of the legs below the knee shows transcendence when she states:

"I see God's grace and become relaxed when I watch the sun set at night."

Which of the following documentation entries is most accurate?

"Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, HR 94 and regular following exercise."

A patient is fearful of upcoming surgery and a possible cancer diagnosis. He discussed his love for the Bible with his nurse, who recommends a favorite Bible verse. Another nurse tells the patient's nurse that there is no place in nursing for spiritual care. The patient's nurse replies:

"Spiritual, mind, and body connections can affect health."

As the nurse enters a patient's room, the nurse notices that the patient is anxious. The patient quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate way for the nurse to document this observation of the patient?

"The patient stated feelings of frustration from the lack of information received regarding test results."

A nursing professor is teaching a nursing student about caring patients who use herbal preparations in addition to prescribed medications. Which of the following statements made by the student indicates that the student understands herbal preparations?

"We need to treat herbal preparations as though they are "drugs" because many have active ingredients that can interact with other medications and change physiological responses."

A patient states, "I would like to see what is written in my medical record." What is the nurse's best response?

"You have the right to read your record."

Label each line of documentation with the appropriate SOAP category (Subjective [S], Objective [O], Assessment [A], Plan [P]).

1 P Repositioned patient on right side. Encouraged patient to use patient-controlled analgesia (PCA) device. 2. S "The pain increases every time I try to turn on my left side." 3. A Acute pain related to tissue injury from surgical incision. 4. O Left lower abdominal surgical incision, 3 inches in length, closed, sutures intact, no drainage.

The nurse is working the evening shift at a hospital that uses military time for documentation. The nurse administered morphine 2 mg intravenously (IV) for pain at 3:45 PM, changed the dressing over the patient's abdominal incision at 5:34 PM, and administered Ancef 1 g IV at 8:00 PM. Using correct military time, label the documentation for each task with the time that it was completed.

1. ______ Morphine 2 mg IV given for pain rating of 8/10. 1545 2. ______ Dressing changed over midline abdominal incision using aseptic technique. 1734 3. ______ Ancef 1 g given IVPB over 30 minutes. 2000

A nurse is planning a teaching session about healthy nutrition with a group of children who are in first grade. The nurse determines that after the teaching session the children will be able to name three examples of foods that are fruits. This is an example of:

A learning objective

A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow?

A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

Which of the following properly applies and ethical principle to justify access to health care?

Access to health care reflects the commitment of society to principles of beneficence and justice. If low income compromises access to care, respect for autonomy is compromised. Poor access to affordable health care causes harm that is ethically troubling because nonmaleficence is a basic principle of health care ethics.

What role do patients have in complementary and alternative therapies?

Actively involved in the treatment

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following crirteria does the nurse recommend in choosing a nursing center?

Adequate staffing is available on all shifts Social activities are available for all residents Staff encourage family involvement in care planning and assisting with physical care

A nurse who has recently graduated has been assigned to be a primary nurse on a geriatric unit. After completing a review of development and aging, the nurse recalls that changes for the older adult include:

Adjusting to decreasing health and physical strength

A nurse administered an antibiotic 30 minutes ago and returns to the patient's room to determine if the patient is having any unexpected symptoms. This is an example of assessing for a

Adverse reaction

A patient states that he does not believe in a higher power but instead believes that people bring meaning to what they do. This patient most likely is an:

Agnostic

The nurse is completing an admission assessment with an 80-year-old man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife's death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse expect?

Alcohol abuse

Sexuality is maintained throughout our lives. Which answer below best explains sexuality in an older adult?

All older adults, whether healthy or frail, need to express sexual feelings.

An older adult is being started on a new antihypertensive medication. In teaching the patient about the medication, the nurse:

Allows the patient time to express himself or herself and ask questions.

Two single mothers are active professionals and have teenage daughters. They also have busy social lives and date occasionally. Three years ago they decided to share a house and housing costs, living expenses, and child care responsibilities. The children consider one another as their family. What type of family form does this represent?

Alternative family relationship

When a nurse is teaching a patient about how to administer an epinephrine injection in case of a severe allergic reaction, the nurse tells the patient to hold the injection like a dart. Which of the following instructional methods did the nurse use?

Analogy

Meditation may compound the effects of which of these medications?

Antihypertensive and thyroid-regulating medications

A nurse is teaching a 27-year-old gentleman how to adjust his insulin dosages on the basis of his blood sugar results. This type of activity addresses learning in the cognitive domain at the level of

Application

A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of:

Applying ethical criteria.

A faculty member is reviewing a nursing students' plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional website to identify interventions successful in reducing wandering in patients with dementia. The faculty member should evaluate which of the following?

Appropriateness of the intervention for the patient Correct application of the intervention for the patient care setting

What are the correct steps to resolve an ethical dilemma on a clinical unit? Place the steps in the correct order.

Ask the question, Is this an ethical dilemma? Gather information. Clarify values. Verbalize the problem. Identify course of action. Negotiate a plan. Evaluate the plan.

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new brushes from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to

Ask the son to step out of the room so she can complete her assessment

A nurse is caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will preform which of the following evaluation measures to determine success of her instruction.

Asking a patient to identify three low-sodium foods to eat for lunch

An example of a nurse caring behavior that families of acutely ill patients perceive as important to patients' well-being is:

Asking permission before performing a procedure on a patient.

A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do?

Assess condition of skin before making the call Explain the patient's response emotionally to the repeated leaking of stool Describe the type of bag being used and how long it lasts before leaking

A patient is admitted to a medical unit. The patient is fearful of hospitals. The nurse is carefully assesses the patient to determine the exact fears and then establishes interventions designed to reduce these fears. In this setting how is the nurse practicing patient advocacy?

Assessing the patient's point of view and preparing to articulate it