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Fundamentals Exam 1 Practice Questions with complete solutions graded A+
1. A patient's outcome was to have a pain level of 4 out of 10, 30 minutes after receiving medication. 30 minutes later the patient reported a pain level o... [Show More] f 3 out of 10. Has the outcome been: a. Met b. Not met c. Partially met d. Not enough information A 2. A patient's outcome at the end of the shift is to ambulate down the hall and back twice. By the end of the shift the patient was able to ambulate once. Since the outcome was not met, what would be the best recommendation to change the care plan? a. Go to the doctor and ask for advice b. Change the care plan to ambulating once per shift c. Change the care plan to ambulating three times per shift d. Continue the care plan to ambulate twice per shift D 00:54 01:42 3. Which of the following is an example of an appropriately written assessment intervention for a post appendectomy patient experiencing pain at 7/10? a. Help patient ambulate every 2 hours b. Assess patient for pain at the beginning of every shift, after giving mediation, and when patient complains of pain c. Take patient's health history and vital signs d. Administer pain medications B 4. Which of the following is an example of an appropriately written assessment intervention? a. Patient will ambulate down the hall 2x daily b. The patient was able to ambulate down the hall 2x daily c. Administer pain medications regularly and assess patient's pain d. The patient's pain is 7/10 C Expected outcome should be written following which five step guideline? a. Specific, medications, availability, response, time b. Selective, measureable, availability, reasonable, treatment c. Measurable, achievable, reasonable, time, selective d. Selective, medications, achievable, response, treatment C 6. Which of the following is a correct expected outcome of a nursing diagnosis? a. Patient will have no crackles in lower lobes b. Patient will feel better c. Patient will ambulate the hall 3 times and back by the end of my shift d. Patient will experience a decrease in pain level C 7. What are the 3 parts of the nursing diagnosis? a. Temperature, Pulse, respirations b. Problem, etiology, symptoms c. Medical diagnosis, defining characteristics, health perception d. Medical diagnosis, MAR, potential risks B 8. Which of the following is the correctly written first part of the nursing diagnosis? a. Arthritis pain b. Status post historectomy c. Dermatitis inflammation d. Impaired skin integrity D 9. When taking a patient's health history, the nurse nods to certain information trying to show acceptance or agreement. What non-verbal cue is the nurse demonstrating? a. Physical appearance b. Gestures c. Touch d. Posture B 10. Which nonverbal skill would suggest the patient could be physically or emotionally ill? a. Open posture b. Nodding while listening c. Maintaining eye contact d. Lack of grooming D 11. You are going into surgery and your nurse says, "I'm sure you're going to be fine!" What type of interviewing trap is this? a. Giving unwanted advice b. Leading or biased question c. Providing false assurance d. Talking too much C 12. What is an example of a leading question? a. How much do you smoke per day? b. How long have you smoked for? c. Have you ever smoked? d. You don't smoke do you? D 00:14 01:42 13. What would you say when assisting the narrative through clarification? a. "Uh-huh" b. "Tell me what you mean by that?" c. "It seems like every time you feel stomach pain you have some type of stress in your life" d. Remain silent B 14. During the interview process, what type of response encourages the patient to continue with their story? * technically all answers would encourage the patient to keep talking a. Reflection b. Facilitation c. Silence d. Clarification B 15. Which of the following questions are considered open-ended? a. Is there anything else you need to tell me? b. Do you have difficulty breathing while performing daily activities? c. Do you eat a balanced diet? d. Are you currently living with anyone? A 16. Which statement reflects the goal of a close-direct question? a. A further explanation b. A long, detailed response c. One that may or may not be relevant to the topic d. A concise yes or no answer D 17. A physician came into the room and interrupted the interview while a nurse was taking a patient's health history. What type of factors would this situation be that influenced the communication? a. External factor b. Internal factor c. Physical environment d. Ability to listen A 18. Which of the following nursing actions is considered an external factor? a. Being tolerable to a patients weakness b. Equal status eating c. Ability to listen d. Body language B 19. What is the purpose of providing cross cultural care? a. It helps recognize expected findings for that culture b. It provides data that supports cultural sensitive and appropriate care for the patients c. It helps distinguish the difference between objective and subjective data d. It allows you to make accurate nursing diagnosis and know what care to give B 20. Who should provide culturally sensitive care when assessing? a. Pharmacist b. Nurse c. House keeper d. Casey Pachall B 21. Which is include in a focused database? *good question a. Limited or short term problem for a mini database b. Labs, health history and full physical c. Analysis of previous issues after treatment d. Rapid data collection for lifesaving measures A 22. Which type of data would you collect for a patient who came into the hospital with a collapsed lung? a. Focus database b. Follow up database c. Total health database d. Emergency database D 23. Which statement about the four types of data collection is true? a. A complete database is more focused than problem centered b. Follow up data involves rapid collection c. Complete database is only objective data d. Complete database is used to formulate nursing diagnosis and nursing process D What is the correct sequence? A Percussion, auscultation, inspection, palpation B Auscultation, palpation, percussion, inspection C Inspection, palpation, percussion, auscultation D Palpation, auscultation, inspection, percussion C You as the nurse observe that a patient is incoherent and confused. What type of data is this? • Subjective • Personal History • Objective data • Present data C While assessing your patient he informs you that his arm is itchy and he had developed a rash. This is: • Objective data • Subjective data • Formulating diagnostic hypothesis • Onset B At what step in Diagnostic reasoning would you use symptom analysis to obtain missing information? • Formulating diagnostic hypothesis • Gathering data relative to tentative hypothesis • Evaluating each hypothesis with new data collected • Attending initially available cues B In response to the patient's complaint of poor sleep, the nurse asks: how many hours of sleep a patient gets, what time he sleeps, what time he wakes. This is which step of diagnostic reasoning: • Attending to initially available cues • Formulating diagnostic hypothesis • Gather data relative to tentative hypothesis • Evaluating each hypothesis with new data collected C The nurse hears the patient say "I've had a bloody nose for 3 days." • Attending to initially available symptoms • Formulating diagnostic hypothesis • Gather data relative to tentative hypothesis • Attending to initially available signs. A The nurse determines the patient's lack of respirations and inability to sleep are related. What step in diagnostic reasoning? • Attending to available cues • Formulating diagnostic hypothesis • Gathering data relative to hypothesis • Evaluating each hypothesis with new data collected. B Identify a first priority problem: • The patient complains of acute pain • The patient appears confused and disoriented. • The patient has not peed in 8 hours. • The patients potassium levels are abnormal. D An organized method of giving individualized nursing care that focuses on identifying and treating unique responses of individuals or groups to actual or potential health problems? • Written Care Plan • Nursing Process • Functional Health Patterns • Assessment B What does the D in the nursing process stand for? • Documentation • Duration • Database • Diagnosis D A patient comes into the hospital with a sudden, life-threatening onset of pulmonary distress. What kind of data collection would you use to get a health history? • Follow up Database • Complete • Focused/problem-centered • Emergency D This type of data collection is used for gathering information about a limited or short-term problem such as sudden change in blood pressure. • Emergency database • Focused or problem-centered database • Complete total health database • Follow up database B Which type of data collection is used to formulate nursing diagnosis and the nursing process? • Emergency database • Complete (total health) database • Follow up DB • Focused/problem-centered B How would you apply the nursing process to cultural sensitivity? • Assessment: assume info about patient based on their religion. • Planning; plan nursing care based on your previous experience with the same culture. • Implantation: care for patient the way you would want to be cared for. • Evaluation: consider how culture has altered your outcome. D You walk into your patient's room and realize that they only speak Spanish. What action do you take? • Have the patient's family answer health history. • Find the patient a translator • Try and communicate using your Spanish • Speak loudly and slowly B What is the best reason for why a nurse would want to provide culturally sensitive care? • Provide best possible care for the patient. • Make the patient feel more comfortable • To not offend the patient • To provide the best possible care that is both appropriate and comfortable to the patient. D [Show Less]
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Fundamentals of Nursing: Nursing Diagnosis 100% correct answers latest 2023
The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n) a) Risk nursing diagnosis b) Problem focused nursi... [Show More] ng diagnosis c) Health Promotion nursing diagnosis d) wellness nursing diagnosis B This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: a) Collaborative data set b) Diagnostic label c) Related Factors d) Data cluster D A data cluster is a set of cues 01:34 01:42 A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? a) Identifying the clinical sign instead of an etiology b) Identifying a diagnosis on the basis of prejudicial judgment c) Identifying the diagnostic study rather than a problem caused by the diagnostic study d) Identifying the medical diagnosis instead of the patient's response to the diagnosis D Intestinal colitis is a medical diagnosis. the related factor in a nursing diagnostic statement is always within the domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not change a medical diagnosis A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step? 1. considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. clusters clinical cues that form a pattern 4. chooses diagnostic label 2,3,4,1 A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? a) insufficient cluster of cues b) Disorganization c) insufficient number of cues d) Evidence that another diagnosis is more likely C It is likely the charge nurse suspects that the student has not collected enough cues to support the diagnosis. A change in blood pressure and mental status changes are significant findings that can be attributed to fluid volume excess and other diagnoses. The recommendation of the symptom cluster by the registered nurse would allow the student to have sufficient data to confirm a deficient fluid volume. A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? a) infant crying at breast b) Infant unable to latch on to breast correctly c) Mother's deficient knowledge d) Lack of infant weight gain C In this scenario, the related factor is the mother's deficient knowledge. a related factor is a condition, historical factor or etiology that gives a context for the defining characteristics. in this care, the infant crying, inability to latch on to breast, and absent weight gain. A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? a) incorrect clustering b) wrong diagnostic label c) condition is a collaborative problem d) premature closure of clusters B The more appropriate nursing diagnosis for this patient would be Risk for impaired skin integrity because the patient's skin is clean and intact. a risk nursing diagnosis is appropriate because the patient has two risk factors, radiation and secretions on the skin Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) a) impaired skin integrity related to physical immobility b) fatigue related to heart disease c) nausea related to gastric distention d) Need for improved oral mucosa integrity related to inflamed mucosa e)risk for infection related to surgery A,C The related factors in diagnoses "Fatigue related to heart disease" and "Need for improved oral mucosa integrity related to inflamed mucosa" are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart disease) cannot be corrected through nursing intervention. In "Need for improved oral mucosa integrity related to inflamed mucosa" there is no diagnosis, but instead a goal of care. "Risk for infection related to surgery" is incorrect; risk nursing diagnoses do not have defining characteristics or related factors because they have not occurred yet The identification of a disease condition based on a specific evaluation of physical signs and symptoms, a patient's medical history, and the results of diagnostic tests and procedures. Medical diagnosis A clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat. Nursing diagnosis An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status and with personnel from other health care disciplines Collaborative problem A clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. Problem-focused nursing diagnosis Observable assessment cues such as patient behavior, physical signs that support each problem-focused diagnostic judgment. Defining characteristics An etiological or causative factor for the diagnosis; i.e. the data that appear to show some type of patterned relationship with a nursing diagnosis. Allows one to individualize a problem-focused nursing diagnosis for a specific patient need Related Factor A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life process. Risk nursing diagnosis A clinical judgement concerning a patient's motivation and desire to increase well-being and actualize human health potential. Health promotion nursing diagnosis Analysis and interpretation of assessment data begin by organizing all of a patient's data into meaningful and usable... when analyzed with other cues, begins to lead to diagnostic conclusions Data clusters The name of the nursing diagnosis as approved by NANDA-I Diagnostic label Three part nursing diagnostic label P- Problem E- Etiology S- Symptoms [Show Less]
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Fundamentals of Nursing, Communication 100% accurate answers with rated content
The main purpose of the working phase of a therapeutic nurse-patient relationship is to: 1. Establish a formal or informal contract that addresses the pat... [Show More] ients problems 2. Implement nursing interventions designed to achieve expected patient outcomes. 3. Develop rapport and trust so the patient feels protected and an initial care plan can be identified 4. Clearly identify the role of the nurse and establish parameters of the professional relationship. 2. During the working phase of the therapeutic relationship, nursing interventions have a two fold purpose: assisting patients to explore and understand their thoughts and feelings and supporting patient decisions and actions. The nurse uses reflective technique when communicating with an anxious patient. The nurse uses reflective technique in this situation because it focuses on: 1. Feelings 2. Content themes 3. Clarification of information 4. Summarization of the topics discussed 1. The reflective technique requires active listening to identify the underlying emotional concerns or feelings contained in a patient's messages. These feelings are then referred back to the patients to promote a clearer understanding of what they have said. A patient says, "I don't know if I'll make it through this surgery." Which response by the nurse may block further communication by the patient? 1."You sound scared" 2."You think you will die" 3."Surgery can be frightening" 4."Everything will be alright" 4. This response is false reassurance. It denies the patient's concerns about survival and does not invite the patient to elaborate. The patient states "My wife is going to be very upset that my prostate surgery probably is going to leave me impotent." What is the best response by the nurse? 1.I'm sure your wife will be willing to make the sacrifice in exchange for your well-being 2.The doctors are getting great results with nerve-sparing surgery today. 3.Your wife may not put as much emphasis on sex as you think. 4.Let's talk about how you feel about this surgery. 4. The patient may be using projection to cope with the potential for impotence. This response indicates that it is acceptable to talk about sexuality and invites the patient to verbalize concerns. The patient states " I think that I am dying" The nurse responds, "You feel as though you are dying?". What interview approach did the nurse use? 1.Focusing 2. Reflecting 3.Validating 4. Paraphrasing 4. The nurses response is an example of paraphrasing because it uses similar words to restate the patients message. The nurse plans to foster a therapeutic relationship with a patient. It is most important that the nurse: 1. Works on establishing a friendship with the patient. 2. Use humor to defuse emotionally charged topics of discussion. 3. Sympathize with the patient when the patient shares sad feelings. 4. Demonstrate respect when discussing emotionally charged topics. 4. Emotionally charged topics should be approached with respectful, sincere, interactions that are accepting and non-judgmental, which will promote further verbalization. A patient who is to receive nothing by mouth (NPO) in preparation for a bronchoscopy says,"I am worried about the test and I can't even have a drink of water." What is the best response by the nurse? 1. "Lets talk about your concerns regarding this test." 2. "I'll see if the doctor will let you have some ice chips" 3. "The doctor will review the results of the test as soon as possible." 4. As soon as the test is over I'll get you whatever you would like to drink." 1. This response encourages the patient to explore concerns. Verbalization of concerns, validating of feelings, and patient teaching may help reduce anxiety. A patient verbally communicates with the nurse while exhibiting nonverbal behavior. To confirm the meaning of the nonverbal behavior, the nurse should: 1. Look for similarity in meaning between the patient's verbal and nonverbal behavior. 2. Ask family members to help interpret the patient's behavior. 3. Validate inferences by asking patient questions. 4. Recognize that what the patient says is most important. 1. The patient is the primary source of information. When nonverbal communication reinforces the verbal message, the message reflects the true feelings of the patient because non verbal behavior is under less conscious control than verbal statements. The patient appears tearful and is quiet and withdrawn. The nurse says, "You seem very sad today." What interviewing approach did the nurse use? 1.Examining 2.Reflecting 3.Clarifying 4.Orienting 2. Reflective technique refers to feelings implied in the content of verbal communication or in exhibited nonverbal behaviors. Patients who are crying, quiet and withdrawn are often sad. The nursing action that best reflects the concept of therapeutic communication is: 1. Using interviewing skills to discuss the patients concerns 2. Letting the patient control the focus of the conversation 3. Setting time aside to talk with the patient 4. Agreeing with the patient's statements. 1. Therapeutic communication is patient-centered and goal-directed. It facilitates the exploration of the patient's thoughts and feelings and helps to establish a constructive relationship between the nurse and patient. The nurse is attempting to develop a helping relationship with a patient who was recently diagnosed with cancer. The nurse understands that a factor that is unique to this helping relationship is that it is: 1. Characterized by allowing the patient to take the dominant role. 2. Distinguished by an equal sharing of information. 3. Specific to a person while guided by a purpose 4. Based on the needs of both participants. 3. The helping relationship (interpersonal relationship, therapeutic relationship) is a personal, client-focused, goal oriented process whereby the nurse assists a person to problem solve and meet needs. The nurse is collecting data for an admission nursing history. Which question by the nurse is best to open the discussion? 1. What brought you to the hospital? 2. Would it help to discuss your feelings? 3. Do you want to talk about your concerns? 4. Would you like to talk about why you are here? 1. This is a focused open-ended statement that invites the patient to communicate while centering on the reason for seeking health care. The nurse must conduct a focused interview to complete an admission history. Which interviewing technique should the nurse use? 1. Probing 2. Clarification 3. Direct questions 4. Paraphrasing 3. A focused interview explores a particular topic or obtains specific information. Direct questions meet these objectives and avoid extraneous information. The nurse understands that the statement that is most accurate about communication is: 1. Communication is inevitable 2. Behavior clearly reflects feelings. 3. Hands are the most expressive part of the body. 4. Verbal communication is essential for human relationships. 1. Theory indicates that all behavior has meaning, people are always behaving, and we cannot stop behaving or communicating, therefore communication is inevitable. The patient is upset and crying and mentions something about her job and the nurse cannot understand. The nurse's best response is: 1. It's natural to be worried about your job. 2. Your job must be very important to you. 3. Calm down so that I can understand what you are saying. 4. I am not quite sure I heard what you were saying about your work. 4. This response requests additional information in an attempt to clarify an unclear message. When providing nursing care, humor should be used to: 1. Diminish feelings of anger 2. Refocus the patients attention 3. Maintain a balanced perspective 4. Delay dealing with the inevitable 3. Humor is an interpersonal tool and it is a healing strategy. It releases physical and psychic energy, enhances well-being, reduces anxiety, increases pain tolerance, and places experiences within the context of life. The nurse evaluates that therapeutic communication is effective when: 1.Verbal and nonverbal communication is congruent. 2. Interaction is conducted in a professional manner. 3. Common understanding is achieved. 4. Thoughts can be put into words. 3. Understanding is the foundation of therapeutic communication. When the nurse comprehends, appreciates and empathizes with the patient, therapeutic communication is achieved. The patient states "I can't believe I couldn't even eat half my breakfast." Which statement by the nurses uses the interviewing skill of reflection? 1. Let's talk about your inability to eat. 2. What part of your breakfast were you able to eat? 3. How long have you been unable to eat most of your breakfast? 4. You seem surprised that you weren't able to eat all of our breakfast. 4. This question is an example of reflective technique because it focuses on the feeling of surprise. A mother whose daughter has died of leukemia is crying, and is unable to talk about her feelings. What is the best response by the nurse? 1. "Everyone will remember he because she was so cute, she was one of our favorites." 2. "As hard as this is, it is probably for the best because she was in a lot of pain." 3. She put up a good fight but now she is out of pain and in heaven." 4. I feel so sad. It can be hard to deal with such a precious loss. 4. The first sentence communicates empathy. The second sentence focuses on the feeling surrounding loss and provides and opportunity for the patient to verbalize.Both of these are therapeutic responses to the situation. The goals of therapeutic communication mainly should depend on: 1. Environment in which communication takes place. 2. Role of the nurse in that particular setting 3. Skill level of the nurse in the situation. 4. Concerns of the patient. 4. The patient and significant others and their needs are always the focus of nursing interventions, including the goals of communication. A young man who had a leg amputated because of trauma says " No one will ever choose to love a person with one leg." What is the best response by the nurse? 1. You are a good looking young man, and you will have no trouble meeting someone who cares. 2. You may feel that way now, but you will feel differently as time passes. 3. Do you feel that no one will marry you because you have one leg? 4. How do you see our situation at this point? 3. This is an example of paraphrasing, which restates the patients message in similar words. It promotes communication. The nurse is changing a patient's dressing over an abdominal wound. What level of space around the patient is entered during the dressing change? 1. Personal 2. Intimate 3. Social 4. Public 2. Physically caring for a patient involves inspection and touch that invades the instinctual, protective distance immediately surrounding an individual. Intimate space (less than 1.5 feet) is characterized by body contact and visual exposure. The stage of the interview that establishes the relationship between the nurse and the patient is the: 1. Orientation stage 2. Working stage 3. Surrogate state 4. Examining state 1. The purposes of the orientation stage of an interview are to establish rapport and orient the interviewee. A relationship is established through a process of creating goodwill and trust. The orientation focuses on explaining the purpose and nature of the interview and what is expected of the patient. The patient is exhibiting anxious behavior and states, "I just found out that I have cancer everywhere and I don't have long to live. My life is over." What is the best response by the nurse? 1. It might be good if your wife were here right now. Shall I call her? 2. What might be the best way to approach this terrible news? 3. That is so sad, you must feel like crying. 4. It sounds like you feel hopeless. 4. This is an example of reflective technique. When no solutions to a problem are evident, a person becomes hopeless. Which interviewing skill is being used when the nurse says, "You mentioned before that you are having a problem with your colostomy?": 1. Focusing 2. Clarifying 3. Paraphrasing 4. Acknowledging 1. This example of focusing helps the patient explore a topic of importance. The nurse selects one topic for further discussion from among several topics presented by the patient. The patient says, "I'm really nervous about having a spinal tap tomorrow." The best response by the nurse is: 1. "I'll ask the doctor for a little medication to help you relax." 2."Patients who have had a spinal tap say it's not that uncomfortable." 3. " The doctor is excellent and is very careful when spinal taps are done." 4. " It's alright to be nervous, and I don't remember anyone who wasn't." 4. This statement is therapeutic. It recognizes the patient's feelings, gives the patient permission to feel nervous and reassures the patient that one's behavior is not unusual. This statement sets the groundwork for the next statement, such as "Let's talk a little about the spinal tap and the concerns you may have." When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of the patient?: 1. Reassess the patient 2. Examine the "related to" factors 3. Analyze the "secondary to" factors 4. Review the defining characteristics 4. The first thing the nurse should do to differentiate between two closely related nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the diagnoses being considered. The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to: 1. Diagnose if the patient is at risk for falls 2. Ensure that the patient's skin is intact 3. Establish a therapeutic relationship 4. Identify important data 4. This is the primary purpose of a nursing admission assessment. Data must be collected and then analyzed to determine significance, and grouped in meaningful clusters before a nursing diagnosis can be made. The nurse identifies that the patient statement that provides subjective data is: 1. I am not sure that I am going to be able to manage at home by myself 2. I can call a home-care agency if I feel I need help at home. 3. What should I do if I have uncontrollable pain at home? 4. Will a home health aide help me with my care at home? 1.This is subjective information because it is the patient's perception and can only be verified by the patient The nurse understands that evaluation most directly relates to which aspect of the nursing process? 1. Goal 2. Problem 3. Etiology 4. Implementation 1. The evaluate the effectiveness of a nursing action, the nurse needs to compare the actual patient outcome with the expected patient outcome. The expected outcomes are measurable data that reflect goal achievement, while the actual outcomes are what really happened. The nurse comes to the conclusion that a patient's elevated temperature, pulse, and respiration are significant. What step of the Nursing Process is being used when the nurse comes to this conclusion? 1. Implementation 2. Assessment 3. Evaluation 4. Diagnosis 4. During the diagnosis step of the Nursing Process data are critically analyzed and interpreted, significance of the data is determined, inferences are made and validated, sues and clusters of cues are compared with the defining characteristics of nursing diagnoses, contributing factors are identified, and nursing diagnoses are identified and prioritized. When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to: 1. Plan 2. Evaluate 3. Diagnose 4. Implement 4. This is the correct analogy. The words identify and recognize have the same definition. The words do and implement also have the same definition. The nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect this information? 1. Observing 2. Inspection 3. Auscultation 4. Interviewing 4 Interviewing a patient is the most effective data collection method when collecting subjective data associated with a patient's anxiety. The patient is the primary source for information about perceptions, feelings, fears, concerns, beliefs and values. Which nursing action reflects an activity associated with diagnosis step of the Nursing Process? 1. Formulating a plan of care. 2. Identifying the patient's potential risks 3. Designing ways to minimize a patients stressors 4. Making decisions about the effectiveness of patient care. 2. Potential risk factors are identified during the diagnosis step of the nursing process. The nurse collects objective data when a hospitalized patient states: 1. "I am hungry" 2. "I feel very warm" 3. "I ate half my lunch" 4. I have the urge to urinate" 3. The amount of food eaten by a patient can be objectively verified. The nurse measures and documents the percentage of a meal ingested by a patient to quantify the amount of food consumed. The nurse understands that subjective data has been obtained when the patient states: 1. "I just went in the urinal and it needs to be emptied" 2. "My pain feels like a 5 on a scale of 1 to 5." 3. "The doctor said I can go home today." 4. " I only ate half my breakfast." 2. A patient's perception about pain level is subjective information. It is a feeling only the patient can confirm. During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved? 1. Implementation 2. Evaluation 3. Diagnosis 4. Planning 2. Evaluation occurs when actual outcomes are compared with expected out comes that reflect goal achievement. If a goal is achieved, the patient's needs are met. When considering the Nursing process, the nurse understands that the word "observe" is to "assess" as the word "determine" is to: 1. Plan 2. Analyze 3. Diagnose 4. Implement 3. The definitions of the words "observe" and "assess" are similar as are the definitions of "determine" and "diagnose". An essential concept related to understanding the Nursing Process is that it: 1. Is dynamic rather than static 2. Focuses on the role of the nurse 3. Moves from simple to the complex 4. Is based on the patient's medical problem 1. The nursing process is dynamic process that is designed to diagnose and treat human responses to health problems. The nurse moves among the steps as necessary to meet the needs of the patient. The nurse is caring for a male patient with a urinary elimination problem. Which is the most accurately stated goal? "The patient will...": 1. Be taught how to use the urinal when on bed rest 2. Experience fewer incontinence episodes at night 3. Be assisted to the toilet every two hours and whenever necessary 4. Transfer independently and safely to a commode before discharge. 4. This is a correctly worded goal. Goals must be patient centered, measurable, realistic and include a time frame. Which word best describes the role of the nurse when using the Nursing Process to meet the needs of the patient holistically? 1. Teacher 2. Advocate 3. Surrogate 4. Counselor 2. When the nurse supports, protects, and defends a patient from a holistic view point, the nurse functions as an advocate. The nurse understands that the word most closely associated with scientific principles is: 1. Data 2. Problem 3. Rationale 4. Evaluation 3. The word rationale is closely related to the term "scientific principles". Scientific principles are based on rationales. A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is most directly related to this concept? 1. Defining characteristics 2. Outcome criteria 3. Etiology 4. Goal 3. The etiology (also known as contributing factors) are the conditions, situations, or circumstances that add to the development of the human response identified in the problem statement of the nursing diagnoses. The nurse teaches a patient to use visualization to cope with chronic pain. This action reflects which step of the nursing process? 1. Planning 2. Diagnosis 3. Evaluation 4. Implementation 4. This is an example of implementation during the NP. During the implementation step, planned nursing care is delivered. A patient has multiple diagnostic tests performed. Where in the patient's chart can the nurse find documentation about the current medical diagnosis after the diagnostic test results are reported? 1. Physician's History and Physical 2. Social Service Record 3. Admission Sheet 4. Progress Notes 4. Generally the Progress Notes contain the documentation by all members of the health team. After a patient is admitted and diagnostic tests are completed, the patient's medical diagnosis may change. The ingoing changes are documented in the progress notes. During which of the 5 steps in the nursing process does the nurse analyze the data critically? 1. Diagnosis 2. Clustering 3. Collection 4. Assessment 1. During the diagnosis step of the Nursing Process data are critically analyzed and interpreted, significance of the data is determined, inferences are made and validated, sues and clusters of cues are compared with the defining characteristics of nursing diagnoses, contributing factors are identified, and nursing diagnoses are identified and prioritized. The nurse is caring for a patient with a fever. Which is a well designed goal for this patient? "The patient will..." 1. Have a lower temperature 2. Be given aspirin every eight hours p.r.n 3. Be taught how to take an accurate temperature 4. Maintain fluid intake sufficient to prevent dehydration. 4. This is a well written goal. Goals must be patient centered, measurable, realistic and include a time frame. During the evaluation step of the Nursing Process, the nurse must: 1. Establish outcomes 2. Determine priorities 3. Take corrective action 4. Set the time frames for goals 3. Corrective action takes place in the evaluation step of the NP. If during an evaluation is it determined that a goal was not met, the reasons for failure must be identified and the plan modified. Determine what nursing actions will be employed occurs during which step of the nursing process? 1.Implementation 2. Assessment 3. Diagnosis 4. Planning 4. The identification of nursing actions designed to help a patient achieve a goal occurs during the planning step of the NP. The nurse understands that the appropriateness of a Nursing diagnosis is supported by: 1. Defining characteristics 2. Planned interventions 3. Diagnostic statement 4. Related risk factors 1. The defining characteristics are the major and minor cues that form a cluster that support or validate a nursing diagnosis. At least one major defining characteristic must be present for a nursing diagnosis to be considered appropriate for that patient. The nurse understands that the primary goal of the assessment phase of the Nursing Process is to: 1. Build trust and rapport 2. Collect and cluster data 3. Establish goals and outcomes 4. Identify and validate the medical diagnosis. 2. The primary purpose of assessment in the NP is to collect data from various sources using a variety of approaches. After data is collected, it should be clustered into meaningful categories. The planning step of the nursing process is influenced most directly by the: 1. Related factors 2. Diagnostic label 3. Secondary factors 4. Medical diagnosis 1. Related factors (etiology, contributing factors) contribute to the problem statement of the nursing diagnosis and directly impact on the planning step of the NP. The nurse collects data about the patient. Next the nurse should? 1. Write a patient centered goal 2. Formulate a nursing diagnosis 3. Design a plan of nursing interventions 4. Determine the significance of the information. 4. After data are collected, they are clustered to determine significance. The nurse understands that human responses can be classified as objective or subjective. Identify those that are subjective: SELECT ALL THAT APPLY 1. Nausea 2. Jaundice 3. Dizziness 4. Diaphoresis 5. Hypotension 1, 3 [Show Less]
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Fundamentals of Nursing - Chapter 44, Nutrition 100% correct answers graded A+
Which statement made by an adult patient demonstrates understanding of healthy nutrition teaching? A. I need to stop eating red meat. B. I will increase ... [Show More] the servings of fruit juice to four a day. C. I will make sure that I eat a balanced diet and exercise regularly. D. I will not eat so many dark green vegetables and eat more yellow vegetables. C The nurse teaches a patient who has had surgery to increase which nutrient to help with tissue repair? A. Fat B. Protein C. Vitamin D. Carbohydrate B The nurse is caring for a patient experiencing dysphagia. Which interventions help decrease the risk of aspiration during feeding? (Select all that apply.) A. Sit the patient upright in a chair. B. Give liquids at the end of the meal. C. Place food in the strong side of the mouth. D. Provide thin foods to make it easier to swallow. E. Feed the patient slowly, allowing time to chew and swallow. F. Encourage patient to lie down to rest for 30 minutes after eating. A, C, E The nurse suspects that the patient receiving parenteral nutrition (PN) through a central venous catheter (CVC) has an air embolus. What action does the nurse need to take first? A. Raise head of bed to 90 degrees B. Turn patient to left lateral decubitus position C. Notify health care provider immediately D. Have patient perform the Valsalva maneuver B Which action is initially taken by the nurse to verify correct position of a newly placed small-bore feeding tube? A. Placing an order for x-ray film examination to check position B. Confirming the distal mark on the feeding tube after taping C. Testing the pH of the gastric contents and observing the color D. Auscultating over the gastric area as air is injected into the tube A The catheter of the patient receiving parenteral nutrition (PN) becomes occluded. Place the steps for caring for the occluded catheter in the order in which the nurse would perform them. A. Attempt to aspirate a clot. B. Temporarily stop the infusion. C. Flush the line with saline or heparin. D. Use a thrombolytic agent if ordered or per protocol. B, C, A, D Based on knowledge of peptic ulcer disease (PUD), the nurse anticipates the presence of which bacteria when reviewing the laboratory data for a patient suspected of having PUD? A.Micrococcus B.Staphylococcus C.Corynebacterium D.Helicobacter pylori D The nurse is assessing a patient receiving enteral feedings via a small-bore nasogastric tube. Which assessment findings need further intervention? A. Gastric pH of 4.0 during placement check B. Weight gain of 1 pound over the course of a week C. Active bowel sounds in the four abdominal quadrants D. Gastric residual aspirate of 350 mL for the second consecutive time D The home care nurse is seeing the following patients. Which patient is at greatest risk for experiencing inadequate nutrition? A. A 55-year-old obese man recently diagnosed with diabetes mellitus B. A recently widowed 76-year-old woman recovering from a mild stroke C. A 22-year-old mother with a 3-year-old toddler who had tonsillectomy surgery D. A 46-year-old man recovering at home following coronary artery bypass surgery B Which statement made by a patient of a 2-month-old infant requires further education? A. I'll continue to use formula for the baby until he is a least a year old. B. I'll make sure that I purchase iron-fortified formula. C. I'll start feeding the baby cereal at 4 months. D. I'm going to alternate formula with whole milk starting next month. D The nurse is checking feeding tube placement. Place the steps in the proper sequence. A. Draw 5-10 mL gastric aspirate into syringe. B. Flush tube with 30 mL air. C. Mix aspirate in syringe and place in medicine cup. D. Observe color of gastric aspirate. E. Perform hand hygiene and put on clean gloves F. Dip pH strip into gastric aspirate. G. Compare strip with color chart from manufacturer. E, B, A, D, C, F, G The nurse is teaching a program on healthy nutrition at the senior community center. Which points should be included in the program for older adults? (Select all that apply.) A. Avoid grapefruit and grapefruit juice, which impair drug absorption. B. Increase the amount of carbohydrates for energy. C. Take a multivitamin that includes vitamin D for bone health. D. Cheese and eggs are good sources of protein. E. Limit fluids to decrease the risk of edema. A, C, D The nurse sees the nursing assistive personnel (NAP) perform the following for a patient receiving continuous enteral feedings. What intervention does the nurse need to address immediately with the NAP? The NAP: A. Fastens the tube to the gown with tape. B. Places the patient supine while giving a bath. C. Performs oral care for the patient. D. Elevates the head of the bed 45 degrees. B The patient receiving total parenteral nutrition (TPN) asks the nurse why his blood glucose is being checked since he does not have diabetes. What is the best response by the nurse? A. TPN can cause hyperglycemia, and it is important to keep your blood glucose level in an acceptable range. B. The high concentration of dextrose in the TPN can give you diabetes; thus you need to be monitored closely. C. Monitoring your blood glucose level helps to determine the dose of insulin that you need to absorb the TPN. D. Checking your blood glucose level regularly helps to determine if the TPN is effective as a nutrition intervention. A The nurse is performing blood glucose monitoring for a patient receiving parenteral nutrition. Place the steps of the procedure in the correct sequence. A. Clean puncture site with antiseptic solution. B. Identify patient using two identifiers. C. Check code on test strip vial. D. Wick blood drop into test strip. E. Gently squeeze fingertip until drop of blood appears. F. Assess area of skin to be used as puncture site. G. Read results and document in medical record. F, B, C, A, E, D, G Vitamin C & B complex. A. Water-soluble vitamins B. Trace elements C. Basal metabolic rate D. Amino acid A Inorganic elements that act as catalysts in biochemical reactions. A. Water-soluble vitamins B. Trace elements C. Basal metabolic rate D. Amino acid B Energy needed to maintain life-sustaining activities for a specific period of time at rest. A. Water-soluble vitamins B. Trace elements C. Basal metabolic rate D. Amino acid C Simplest form of a protein. A. Water-soluble vitamins B. Trace elements C. Basal metabolic rate D. Amino acid D Made up of three fatty acids attached to a glycerol. A. Triglycerides B. Nitrogen balance C. Polyunsaturated fatty acids D. Resting energy expenditure (REE) A The intake and output of nitrogen are equal. A. Triglycerides B. Nitrogen balance C. Polyunsaturated fatty acids D. Resting energy expenditure (REE) B Fatty acids that have two or more double carbon bonds. A. Triglycerides B. Nitrogen balance C. Polyunsaturated fatty acids D. Resting energy expenditure (REE) C Resting megabolic rate over a 24-hour period. A. Triglycerides B. Nitrogen balance C. Polyunsaturated fatty acids D. Resting energy expenditure (REE) D Kolocalorie. A. kcal B. Simple carbohydrates C. Fiber D. Water A Are found primarily in sugars. A. kcal B. Simple carbohydrates C. Fiber D. Water B Polysaccharide that does not contribute calories to the diet. A. kcal B. Simple carbohydrates C. Fiber D. Water C Makes up 60% - 70% of total body weight. A. kcal B. Simple carbohydrates C. Fiber D. Water D Most calorie-dense nurtrient; provides 9 kcal/g. A. Lipids B. Nutrient density C. Saccharides D. Dispensable amino acids A The proportion of essential nutrients to the number of kilocalories. A. Lipids B. Nutrient density C. Saccharides D. Dispensable amino acids B Carbohydrate units. A. Lipids B. Nutrient density C. Saccharides D. Dispensable amino acids C Alanine, asparagine, and glutamic acid. A. Lipids B. Nutrient density C. Saccharides D. Dispensable amino acids D Unequal number of hydrogen atoms are attached and the carbon atoms attach to each other with a double bond. A. Unsaturated fatty acids B. Saturated fatty acids C. Indispensable amino acids D. Hypervitaminosis A Each carbon has two attached hydrogen atoms. A. Unsaturated fatty acids B. Saturated fatty acids C. Indispensable amino acids D. Hypervitaminosis B Histidine, lysine, and phenylalanine. A. Unsaturated fatty acids B. Saturated fatty acids C. Indispensable amino acids D. Hypervitaminosis C Results from megadoses of supplemental vitamins, fortified food, and large intake of fish oils. A. Unsaturated fatty acids B. Saturated fatty acids C. Indispensable amino acids D. Hypervitaminosis D Vitamins A, D, E, and K. A. Fat-soluble vitamins B. Proteins C. Monounsaturated fatty acids D. Polyunsaturated fatty acids A A source of energy (4 kcal/g). A. Fat-soluble vitamins B. Proteins C. Monounsaturated fatty acids D. Polyunsaturated fatty acids B Fatty acids with one double bond. A. Fat-soluble vitamins B. Proteins C. Monounsaturated fatty acids D. Polyunsaturated fatty acids C Anabolism of glucose into glycogen for storage: A. Glycogenesis B. Chyme C. Glycogenolysis D. Anabolism E. Catabolism A Acidic, liquefied mass: A. Glycogenesis B. Chyme C. Glycogenolysis D. Anabolism E. Catabolism B Catabolism of glycogen into glucose, carbon dioxide, and water. A. Glycogenesis B. Chyme C. Glycogenolysis D. Anabolism E. Catabolism C Building of more complex biochemical substances by synthesis of nutrients: A. Glycogenesis B. Chyme C. Glycogenolysis D. Anabolism E. Catabolism D Breakdown of biochemical substances into simpler substances, occurring during a negative nitrogen balance: A. Glycogenesis B. Chyme C. Glycogenolysis D. Anabolism E. Catabolism E Proteinlike substances that act as catalysts to speed up chemical reactions: A. Enzymes B. Active transport C. Peristalsis D. Gluconeogenesis A Particles move from an area of greater concentration to an area of lesser concentration: A. Enzymes B. Active transport C. Peristalsis D. Gluconeogenesis B Wavelike muscular contractions: A. Enzymes B. Active transport C. Peristalsis D. Gluconeogenesis C Catabolism of amino acids and glycerol into glucose for energy: A. Enzymes B. Active transport C. Peristalsis D. Gluconeogenesis D [Show Less]
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Fundamentals of Nursing: Ch. 28 - Infection Prevention and Control
If an infectious disease can be transmitted directly from one person to another, it is a: A) Susceptible host. B) Communicable disease. C) Port of entry... [Show More] to a host. D) Port of exit from the reservoir. Communicable disease. Which is the most likely means of transmitting infection between patients? A) Exposure to another patient's cough B) Sharing equipment among patients C) Disposing of soiled linen in a shared linen bag D) Contact with a health care worker's hands Contact with a health care worker's hands Identify the interval when a patient progresses from nonspecific signs to manifesting signs and symptoms specific to a type of infection. A) Illness stage B) Convalescence C) Prodromal stage D) Incubation period Prodromal stage Which of the following is the most effective way to break the chain of infection? A) Hand hygiene B) Wearing gloves C) Placing patients in isolation D) Providing private rooms for patients Hand hygiene A family member is providing care to a loved one who has an infected leg wound. What would you instruct the family member to do after providing care and handling contaminated equipment or organic material? A) Wear gloves before eating or handling food. B) Place any soiled materials into a bag and double bag it. C) Have the family member check with the doctor about need for immunization. D) Perform hand hygiene after care and/or handling contaminated equipment or material. Perform hand hygiene after care and/or handling contaminated equipment or material. A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? A) Provide a dark, quiet room to calm the patient. B) Reduce the level of precautions to keep the patient from becoming angry. C) Explain the reasons for isolation procedures and provide meaningful stimulation. D) Limit family and other caregiver visits to reduce the risk of spreading the infection. Explain the reasons for isolation procedures and provide meaningful stimulation. The nurse wears a gown when: A) The patient's hygiene is poor. B) The nurse is assisting with medication administration. C) The patient has acquired immunodeficiency syndrome (AIDS) or hepatitis. D) Blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform. Blood or body fluids may get on the nurse's clothing from a task that he or she plans to perform. The nurse has redressed a patient's wound and now plans to administer a medication to the patient. Which is the correct infection control procedure? A) Leave the gloves on to administer the medication. B) Remove gloves and administer the medication. C) Remove gloves and perform hand hygiene before administering the medication. D) Leave the medication on the bedside table to avoid having to remove gloves before leaving the patient's room. Remove gloves and perform hand hygiene before administering the medication. When a nurse is performing surgical hand asepsis, the nurse must keep hands: A) Below elbows. B) Above elbows. C) At a 45-degree angle. D) In a comfortable position. Above elbows. What is the best method to sterilize a straight urinary catheter and suction tube in the home setting? A) Use an autoclave. B) Use boiling water. C) Use ethylene oxide gas. D) Use chemicals for disinfection. Use boiling water. A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? A) It keeps an incontinent patient's skin dry. B) It can get caught in the linens or equipment. C) It obstructs the normal flushing action of urine flow. D) It allows the patient to remain hydrated without having to urinate. It obstructs the normal flushing action of urine flow. Put the following steps for removal of protective barriers after leaving an isolation room in order: A) Untie top, then bottom mask strings and remove from face. B) Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side. C) Remove gloves. D) Remove eyewear or goggles. E) Perform hand hygiene. Remove gloves. Remove eyewear or goggles. Untie waist and neck strings of gown. Allow gown to fall from shoulders and discard. Remove gown, rolling it onto itself without touching the contaminated side. Untie top, then bottom mask strings and remove from face. Perform hand hygiene. Your ungloved hands come in contact with the drainage from your patient's wound. What is the correct method to clean your hands? A) Wash them with soap and water. B) Use an alcohol-based hand cleaner. C) Rinse them and use the alcohol-based hand cleaner. D) Wipe them with a paper towel. Wash them with soap and water. A patient's surgical wound has become swollen, red, and tender. You note that the patient has a new fever and leukocytosis. What is the best immediate intervention? A) Notify the health care provider and use surgical technique to change the dressing. B) Reassure the patient and recheck the wound later. C) Notify the health care provider and support the patient's fluid and nutritional needs. D) Alert the patient and caregivers to the presence of an infection to ensure care after discharge. Notify the health care provider and support the patient's fluid and nutritional needs. While preparing to do a sterile dressing change, a nurse accidentally sneezes over the sterile field that is on the over-the-bed table. Which of the following principles of surgical asepsis, if any, has the nurse violated? A) When a sterile field comes in contact with a wet surface, the sterile field is contaminated by capillary action. B) Fluid flows in the direction of gravity. C) A sterile field becomes contaminated by prolonged exposure to air. D) None of the principles were violated. A sterile field becomes contaminated by prolonged exposure to air. Infection the invasion of a susceptible host by pathogens or microorganisms, resulting in disease. Colonization the presence and growth of microorganisms within a host but without tissue invasion or damage Carrier shows no symptoms of illness but has pathogens on or in their body that can be transferred to others Communicable disease an infectious disease that is transmitted directly from one person to another Symptomatic infections the pathogens multiply and cause clinical signs and symptoms Asymptomatic infections clinical signs and symptoms are not present Chain of infection An infectious agent or pathogen A reservoir or source for pathogen growth A port of exit from the reservoir A mode of transmission A port of entry to a host A susceptible host Virulence ability to produce disease Reservoir place where microorganisms survive, multiply, and await transfer to a susceptible host Bacteriostasis prevent growth and reproduction of bacteria Bactercidal A temperature or chemical that destroys bacteria What are some examples of port of entry/exit? blood, skin, respiratory tract, GI tract, feces, draining wounds, transplacental, and reproductive tract Modes of transmission Contact, air, vehicles, vectors Contact mode of transmission Direct (person to person) & indirect (person to inanimate objects) Air mode of transmission Airborne (Droplet nuclei or residue or evaporated droplets suspended in air during coughing or sneezing or carried on dust particles ) Droplet (Large particles that travel up to 3 feet during coughing, sneezing, or talking and come in contact with susceptible host) Vehicle mode of transmission Contaminated items, water, drugs, blood, food Vector mode of transmission Flies, mosquitoes, louse, fleas, ticks Course of infection stages incubation period, prodromal stage, illness state, convalescence stage Incubation period Interval between entrance of pathogen into body and appearance of first symptoms (e.g., chickenpox, 10 to 21 days after exposure; common cold, 1 to 2 days; influenza, 1 to 5 days; mumps, 12 to 26 days). Prodromal stage Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow and multiply, and patient may be capable of spreading disease to others.) For example, herpes simplex begins with itching and tingling at the site before the lesion appears. Illness stage Interval when patient manifests signs and symptoms specific to type of infection. For example, strep throat is manifested by sore throat, pain, and swelling; mumps is manifested by high fever, parotid and salivary gland swelling. Convalescence stage Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and patient's host resistance; recovery may take several days to months.) Suprainfection Secondary infection usually caused by an opportunistic pathogen. Develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection. When normal bacterial floras are eliminated, body defenses are reduced, which allows for disease-producing microorganisms to multiply, causing illness. Serous exudate clear, like plasma Sanguineous exudate containing red blood cells Purulent exudate containing white blood cells and bacteria Healthcare Associated Infections Infection that was not present or incubating at the time of admission to a health care setting. Iatrogenic infection type of HAI from a diagnostic or therapeutic procedure. Exogenous Infection comes from microorganisms found outside the individual such as Salmonella, Clostridium tetani, and Aspergillus. They do not exist as normal floras Endogenous Infection occurs when part of the patient's flora becomes altered and an overgrowth results (e.g., staphylococci, enterococci, yeasts, and streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter the normal floras. Susceptible Host most likely to acquire an infection Immune Senescence An age-related decline in immune system function Normal WBC count 5000-10,000/mm3 (Increased in acute infection, decreased in certain viral or overwhelming infections) Erythrocyte sedimentation rate Up to 15 mm/hr for men and 20 mm/hr for women Elevated in presence of inflammatory process Iron Level 60-90 g/100 mL Decreased in chronic infection Cultures of urine and blood Normally sterile, without microorganism growth Culture of gram stain of wound, sputum, and throat No WBCs on Gram stain, possible normal flora A 51 year old patient is admitted to a medical-surgical unit with a systemic infection. The nurse would expect to see which of the following signs and symptoms in this patient? A) redness, fever, edema B) drainage, nausea, fever C) edema, malaise, and fever D) fever, fatigue, nausea fever, fatigue, nausea Which U.S. city has the highest rate of patient's with HIV? NYC Can blood spill be cleaned with a paper towel and water? No, must use bleach solution of 1 part bleach and 9 parts water. How much more expensive are biohazzard bags compared to regular trash bags? 20 times Asepsis is the absence of pathogenic (disease-producing) microorganisms. Medical asepsis clean technique, includes procedures for reducing the number of organisms present and preventing the transfer of organisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples Standard Precautions Guidelines recommended by the Centers for Disease Control and Prevention (CDC) to reduce risk of transmission of bloodborne and other pathogens in hospitals. Surgical asepsis sterile technique prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery. Includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area Cleaning the removal of all soil (e.g., organic and inorganic material) from objects and surfaces Disinfection describes a process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects Sterilization the complete elimination or destruction of all microorganisms, including spores. Who do you use Tier One Standard Precautions with? All patients! Isolation the separation and restriction of movement of ill persons with contagious diseases Contact precautions Used for direct and indirect contact with patients and their environment. Direct contact refers to the care and handling of contaminated body fluids. An example includes blood or other body fluids from an infected patient that enter the health care worker's body through direct contact with compromised skin or mucous membranes. Indirect contact involves the transfer of an infectious agent through a contaminated intermediate object such as contaminated instruments or hands of health care workers. The health care worker may transmit microorganisms from one patient site to another if hand hygiene is not performed between patients Droplet precautions Focus on diseases that are transmitted by large droplets expelled into the air and travel 3 to 6 feet from the patient. Droplet precautions require the wearing of a surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated-care equipment. An example is a patient with influenza. Airborne precautions Focus on diseases that are transmitted by smaller droplets, which remain in the air for longer periods of time. This requires a specially equipped room with a negative air flow referred to as an airborne infection isolation room. Air is not returned to the inside ventilation system but is filtered through a high-efficiency particulate air (HEPA) filter and exhausted directly to the outside. All health care personnel wear an N95 respirator every time they enter the room. Protective Environment Focuses on a very limited patient population. This form of isolation requires a specialized room with positive airflow. The airflow rate is set at greater than 12 air exchanges per hour, and all air is filtered through a HEPA filter. Patients are not allowed to have dried or fresh flowers or potted plants in these rooms. 7 Principles of Surgical Aspesis A sterile object remains sterile only when touched by another sterile object. Only sterile objects may be placed on a sterile field. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. A sterile object or field becomes contaminated by prolonged exposure to air. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action.Fluid flows in the direction of gravity. The edges of a sterile field or container are considered to be contaminated. [Show Less]
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Fundamentals of Nursing- Lab Values 100% answers well elaborated
Red Blood Cell Count (RBC) Normal Lab Value Male and Female Male: 4.6 - 6.2 million/mm3 Female: 4.2 - 5.4 million/mm3 Polycythemia Increased R... [Show More] ed Blood Cells Decreased RBC Anemia Increased Red Blood Cells Polycythemia Anemia Decreased RBC Hemoglobin (Hgb) Normal Lab Values Male: 13-18g Female: 12-16g Hematocrit (Hct) Normal Lab Values Males: 42-50% Females: 40-48% White Blood Cells (WBC) Normal Lab Values Normal Values: 5,000 to 10,000/mm3 Increased WBC Leukocytosis What is Leukocytosis a sign of? Infection Leukocytosis Increased WBC Decreased WBC Leukopenia Leukopenia decreased WBC Neutropenia Low WBC (neutrophils) Platelets (Plts) Normal Value Normal Values: 100,000 to 400,000/mm3 thrombocytopenia Decreased platelets BMP basic metabolic panel CMP complete metabolic panel what is CMP or complete metabolic Panel? blood test that measures your sugar (glucose) level, electrolyte and fluid balance, kidney function, and liver function(WebMD) What is a BMP or basic metabolic panel measures your sugar (glucose) level, electrolyte and fluid balance, and kidney function. (WebMD) Components of BMP Glucose BUN Creatinine Sodium Potassium Carbon Dioxide Chloride Calcium Components of CMP BMP Plus the following Total Protein Albumin ALP ALT AST Bilirubin Normal Blood Urea Nitrogen (BUN) Lab values Normal Values: 8-25 mg/ 100mL Increased BUN levels lead to typically increase with renal malfunction Creatinine and BUN increased are signs of Renal Failure Creatinine is normal but BUN is increased it is most likely caused by Dehydration Decreased BUN is associated with liver malfunction Normal Creatinine and low BUN overhydration Creatinine Normal values Normal Values: 0.6-1.5 mg/100 mL Decreased Creatinine and debilitation will most like result in decreased muscle mass Sodium (Na) normal values 135-145 mEq/L Hypernatremia Increased Sodium What does Hypernatremia indicate? increased sodium, dehydration [Show Less]
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Fundamentals of Nursing: Chapter 5 questions and answers with complete top solutions
What is subjective data? Data obtained from the patient verbally. They are SYMPTOMS. Examples = headache, tingling in the feet, pain, nauseated Wh... [Show More] at is objective data? Info obtained through the senses and hands-on physical examination. They are SIGNS. Examples = vital signs, physical examination findings (bruises), results of diagnostic tests, patient inability to support themselves, number of visitors 01:05 01:42 What is the initial goal of the patient interview? Find out the patient's major complaints, performs a physical examination, and determine the patient's overall health status. When/how often do you assess patients during your shift? After the admission assessment, each patient should be visited and assessed during the first hour of each shift. Perform a head-to-toe examination, which should take about 10 minutes. What is NANDA-I? North American Nursing Diagnosis Association-International. Formulates diagnostic labels. The list of diagnostic labels is used to form the first part (stem) of the nursing diagnoses used in nursing care plans and is revised every 2 years. What does a nursing diagnosis consist of? It is a statement that indicates the patient's actual health status or the risk of a problem developing, the causative or related factors, and specific defining characteristics (signs and symptoms). What is the construction of a nursing diagnosis? Problem + Etiology (cause) + signs and symptoms What is an etiology factor? Cause of the problem. What is a sign? Abnormalities that can be verified by repeat examination and are objective data. Example = bruise What is a symptom? Factors the patient has said are occurring that cannot be verified by examination; they are subjective data. Example = headache How are nursing diagnosis prioritized? Priorities of care are set so that the most important interventions for the high-priority problems for each patient are attended first. Then, as time permits, the lower-priority problems are considered. Once the nursing diagnosis have been formulated, they are ranked according to their importance. This order can be guided by the hierarchy of needs adopted from Maslow, by the patient's beliefs regarding the importance of each problem, and by what is most life threatening or problematic for the patient. True or false?: Physiological needs (basic survival needs) take precedence over everything. One of the first rules concerning priorities of care is that the airway ALWAYS comes first. True A __________ is a broad idea of what is to be achieved through nursing intervention. goal What are short-term goals? Goals that are achievable within 7 to 10 days or before discharge. What are long-term goals? Goals that take weeks or months to achieve. What are expected outcomes? Derived from goals. It is a specific statement regarding the goal the patient is expected to achieve as a result of nursing intervention. It should be realistic and attainable, have a defined time line and be a collaboration with the patient and health care professionals involved with the patient's care. What is an assessment? Gathering info about patients and their needs using a variety of methods. During this phase of the nursing process, data are systematically obtained, organized into a logical database and documented. Who performs an assessment? A RN is designated as the staff member who must perform the initial admission assessment of each patient. However, the LVN is often asked to assist with this task and participates in carrying out the plan by continuing to collect data. What are the 3 basic stages of an interview? 1. The opening, when rapport is established with the patient 2. The body of the interview, when the necessary questions are presented 3. The closing segment What info is documented in the face sheet? Age, sex, martial status/significant other, religion, occupation, residence, next of kin and address, allergies, insurance status. What info is documented in physician's orders? Admitting diagnosis, date of admission; current orders regarding diet, activity, frequency of vital signs measurement, daily weight, treatments, medications, diagnostic tests ordered, IV fluids, therapies ordered. What info is documented in nurse's notes? Patient status during the last 24 hours. What info is documented in physician's progress notes? Findings from the last 2 days; status of problems. What info is documented in medication administration record (MAR)? Medications received, frequency of PRN medications, allergies. What info is documented in physician's patient history and physical? Current complaint, chronic problems, physical finding abnormalities, allergies, impressions. What info is documented in surgery operative report? Procedure done, organs removed, type of incision, drains or equipment in place, blood loss, problems during surgery. What info is documented in pathology report? Presence of malignancy or infection What info is documented in current diagnostic tests? Abnormal findings, CBC, UA, blood chemistries, x-ray films, culture and sensitivity, other tests. What info is documented in nursing admission history and assessment? Reason for hospitalization, average number of cigarettes smoked per day, average amount of alcohol consumer per day, last bowel movement, special diet requirements, use of aids or prostheses (hearing aid, eyeglasses), medications taken regularly, identification of significant other, previous hospitalizations or surgeries, baseline vital signs, physical abnormalities. Inspection = ? looking Auscultation = ? listening Palpation = ? touching Percussion = ? thumping True or false?: Usually the LVN collects data for the RN, who finalizes the assessment. True ________ are pieces of data or info that influence decisions. cues How does a nursing diagnosis differ from a medical diagnosis? A nursing diagnosis defines the patient's response to illness, while a medical diagnosis labels the illness. [Show Less]
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Fundamentals of Nursing, Nursing Process questions and answers graded A+
A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which ph... [Show More] ase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation A. Assessment Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data. The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone." B. The client's urine output was 450 mL. Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4. 00:30 01:42 When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones A. Compare this reading against defined Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement. Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help B. Using clever and persuasive remarks to support an opinion or position C. Accepting without question the values acquired in nursing school D. Finding a quick and logical answer, even to complex questions E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. A. Admitting not knowing how to do a procedure and requesting help E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking. The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time D. Target time Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The performance criterion is "from bed to chair." The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation B. Planning Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4). When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician inability to give the client this medication B. Suggesting the medication can be diluted in a beverage Rationale: Diluting the medication in a beverage may make the medication more palatable. Using critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking for the assistance of the nurse manager. Suggesting an alternative method of taking the medication (provided that there are no contraindications to diluting the medication) should improve the likelihood of the client taking the medication. Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co-workers C. Ask for the rationale behind the new policy Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior. Option 1 also places a client's safety at risk. The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure B. Ask the client if he or she is ready to ambulate C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client during this shift A. Assess the client to be sure ambulation with assistance is an appropriate care measure Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status. The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis B. Reexamine the nursing orders Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome. In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens C. Include the client and family when setting goals and formulating the plan of care Rationale: In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care for clients; instead they plan care with clients and families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take, but they will have less overall effectiveness if the client and family are not part of the plan. Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals C. The nurse who ask the client how much lunch he or she ate Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implemention phase. Option 4 represents the planning phase. 00:14 01:42 The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness C. Risk for impaired skin integrity related to malnutrition Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions. The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of 91% C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain B. Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91% Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague. Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal. The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? A. Administer the medication as ordered by the prescriber B. Call the prescriber to discuss the order and the nurse's concern C. Administer the medication, but chart the nurse's concern about the dosage D. Give the client half the dosage and document accordingly B. Call the prescriber to discuss the order and the nurse's concern Rationale: Client safety is of the utmost importance when implementing any nursing intervention. If the nurse feels that an order is unsafe or inappropriate for a client, the nurse must act as a client advocate and collaborate with the appropriate healthcare team member to determine the rationale for the order and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate and unsafe. Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit B. Assisting the physician with an invasive procedure C. Adjusting the rate on an infusion pump D. Evaluating achievement of client outcome goals A. Taking vital signs of clients on the nursing unit Rationale: Part of the professional nurse's role is to delegate responsibility for activities while maintaining accountability. The nurse must match the needs of the client with the skills and knowledge of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope of practice for a UAP. In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? A. Vital signs are stable B. Client is pleasant, alert, and oriented to time, place, and person C. The chest x-ray results were negative D. Client voided 250 mL of urine 2 hours after the urinary catheter removal D. Client voided 250 mL of urine 2 hours after the urinary catheter removal Rationale: A change-of-shift report should include significant changes (good or bad) in a client's condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift report. Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation D. Evaluation Rationale: Evaluating is the process of comparing client responses to the outcome goals to determine whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating the nursing interventions. During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction B. Body C. Closing D. Orientation A. Introduction Rationale: Asking about the weather initiates the social or introductory phase of the interview and allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport with the client at the beginning of the interview. In the body the client responds to the nurse's questions. During the closing the nurse or the client terminates the interview. The nurse is most likely to collect timely, specific information by asking which of the following questions? A. "Would you describe what you are feeling?" B. "How are you today?" C. "What would you like to talk about?" D. "Where does it hurt?" A. "Would you describe what you are feeling?" Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client's current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client's pain. A better approach to collect specific information might be, "Describe any pain you are having." The nurse should avoid asking the client which of the following leading questions during a client interview? A. "What medication do you take at home?" B. "You are really excited about the plastic surgery, aren't you?" C. "Were you aware I've has this same type of surgery?" D. "What would you like to talk about?" B. "You are really excited about the plastic surgery, aren't you?" Rationale: A leading question directs the client's answer. The phrasing of the question indicates an expected answer. The client may be influenced by the nurse's expectations and may give inaccurate responses. This process can result in an error in diagnostic reasoning. The nurse needs to validate which of the following statements pertaining to an assigned client? A. The client has a hard, raised, red lesion on his right hand. B. A weight of 185 lbs. is recorded in the chart C. The client reported an infected toe D. The client's blood pressure is 124/70. It was 118/68 yesterday. C. The client reported an infected tow Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client's toe to validate the statement. Which of the following items of subjective client data would be documented in the medical record by the nurse? A. Client's face is pale B. Cervical lymph nodes are palpable C. Nursing assistant reports client refused lunch D. Client feel nauseated D. Client feel nauseated Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm. A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition D. Nurse rapidly reset priorities for client care based on a change in the client's condition Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process. The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an abnormal assessment C. Administer an anti-nausea medication D. Notify the physician B. Complete an Abdominal assessment Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment. The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following? A. Incomplete data B. Generalize from experience C. Identifying with the client D. Lack of clinical experience A. Incomplete data Rationale: To collect data accurately, the client must actively participate. Incomplete data can lead to inappropriate nursing diagnosis and planning. The other options are not relevant to the question as presented. The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply. A. Hopelessness B. Powerlessness C. Interrupted sleep pattern D. Disturbed self esteem E. Self care deficit A. Hopelessness B. Powerlessness Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5). Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B. Anxiety C. Oxygenation saturation 93% D. Output 500 mL in 8 hours B. Anxiety Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement. Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes B. The client will lose 4 lbs. within next 2 weeks Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed. The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals D. Long-term goals Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings. Which of these is a correctly stated outcome goal written by the nurse? A. The client will walk 2 miles daily by March 19 B. The client will understand how to give insulin by discharge C. The client will regain their former state of health by April 1 D. The client achieve desired mobility by May 7 A. The client will walk 2 miles daily by March 19 Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19). The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours B. Skin will remain intact and without redness during hospital stay Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly B. Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs D. Observe client's skin color and take another set of vital signs Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions. After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods? A. Return demonstration B. Explanation C. Achievement of 90 on written test D. Have client explain produce to the family A. Return demonstration Rationale: Interpersonal skills are the sum of the activities the nurse uses when communicating with others. Technical/psychomotor skills are "hands-on" skills, which are often procedures and are evaluated by return demonstration. Cognitive skills are the intellectual skills of analysis and problem-solving and are evaluated by tests. The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief B. Record in the medical record the distance a client ambulate in the hall Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note? A. Client appears to be depressed, possibly suicidal B. Client reports being tired of being ill and wants to die C. Client does not want to live any longer and is tired of being ill D. Client states, "I'm tired of being sick. I wish I could end it all." D. Client states, "I'm tired of being sick. I wish I could end it all." Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal. The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team? A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan B. Recopy the care plan without the resolve diagnosis C. Write a nursing process not indicating that the outcome goals have been achieved D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a "Date Resolved" column. Using Liquid PaperTM is not a legal way to amend client records. Outcome goals that have been met and nursing diagnoses that have been resolved should be documented on the care plan. A progress note should also be written, but a single note may not be read by all health team members. The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should: A. Formulate post-discharge nursing diagnoses B. Draw conclusion about resolution of current client problems C. Assess the client for baseline data to be used at the LTC facility D. Plan the care that is needed in the LTC facility B. Draw conclusion about resolution of current client problems Rationale: Terminal evaluation is done to determine the client's condition at the time of discharge. This evaluation is best reflected in option 2 because it focuses on which goals were achieved and which were not. Ongoing evaluation is done while or immediately after implementing a nursing intervention. Intermittent evaluation is performed at specified intervals, such as twice a week. Items related to care post-discharge (options 2, 3, and 4) should be done on admission to the LTC facility. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview? A. Help the client to get settled and do the interview the next morning when the client is rested B. Do the interview immediately, directing the majority of the questions to the client's spouse C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns Rationale: To collect data accurately, the client must participate. Attending to the client's immediate personal needs before expecting the client to focus on the interview will maximize the accuracy of the data collected. Data should be collected shortly after admission. The best source of data is the client. The management of the client's anxiety is the responsibility of the nurse conducting the interview and initiating the relationship. The nurse overhears an unlicensed assistive person (UAP) who has just been accepted to nursing school say to a client, "You must be so pleased with your progress." The nurse later explains to the UAP that this is an example of what type of question? A. Close-ended question B. Open-ended question C. Leading question D. Neutral question C. Leading question Rationale: A leading question is asked in a way that suggests the type of answer that is expected. This can result in inaccurate data collection. A closed-ended question generally requires only a "yes" or "no" or short factual answer. Open-ended questions encourage clients to elaborate on their thoughts and feelings. Neutral questions do not influence the client's answer. The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. A. Collect and organize client information B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses E. Develop client goals B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase. The functional health pattern assessment data states: "Eats three meals a day and is of normal weight for height." The nurse should draw which of the following conclusions about this data? Select all that apply. A. Client has an actual health problem B. Client has a wellness diagnosis C. Collaborative health problem needs to be written D. Possible nursing diagnosis exists E. Specific questions about the diet should be asked next B. Client has a wellness diagnosis E. Specific questions about the diet should be asked next Rationale: The description indicates a healthy pattern of nutrition for the client. A wellness diagnosis might be stated as: "Potential for enhanced nutrition." An actual health problem is a client problem that is currently present. The nurse should also do a diet assessment to determine the quality of the food eaten during meals. These actions by the nurse are within the scope of independent nursing practice and are not collaborative in nature. For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse? A. Discomfort B. Deficit C. Feeding D. Fractured wrists D. Fractured Wrists Rationale: The etiology or related factors of a nursing diagnostic statement define one or more probable causes of the problem and allow the nurse to individualize the client's care. In this case, the fracture is the cause of the client's feeding problem. The nurse would make which of the following inferences after performing the appropriate client assessment? A. Client is hypotensive B. Respiratory rate of 20 breaths per minute C. Oxygen saturation of 95% D. Client relays anxiety about blood work A. Client is hypotensive Rationale: An inference is the nurse's judgment or interpretation of cues such as judging a blood pressure to be lower than normal. A cue is any piece of data information that influences a decision. Options 2, 3, and 4 are cues that could lead to inferences. The nurse would write which of the following outcome statements for a client starting an exercise program? A. Client will walk quickly three times a day B. Client will be able to walk a mile C. Client will have no alteration in breathing during the walk D. Client will progress to walking a 20-minute mile in one month D. Client will progress to walking a 20-minute mile in one month Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable. The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply. A. Client and Family B. Other nursing staff on the unit C. Security department D. Hospital administration E. This is not a collaborative intervention so no collaboration will be needed prior to implementation A. Client and Family B. Other nursing staff on the unit Rationale: Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it. The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? A. Assessment B. Planning C. Implementation D. Evaluation C. Implementation Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation. A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write? A. Client understands the signs of impaired circulation B. Goal met: Client cited numbness and tingling as sign of impaired circulation C. Goal not met: Client able to name only two signs of impaired circulation D. Goal not met: Client unable to describe signs of impaired circulation C. Goal not met: Client able to name only two signs of impaired circulation Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal. [Show Less]
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Fundamentals of Nursing - Chapter 27 - Review Questions latest 2023.verified
The nurse's first action after discovering an electrical fire in a patient's room is to: a. Activate the fire alarm. b. Confine the fire by closing all... [Show More] doors and windows. c. Remove all patients in immediate danger. d. Extinguish the fire by using the nearest fire extinguisher. c. Remove all patients in immediate danger. Follow the acronym RACE. The first step, R, is to rescue and remove all patients in immediate danger. A parent calls the pediatrician's office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? a. Give the child milk. b. Give the child syrup of ipecac. c. Call the poison control center. d. Take the child to the emergency department. c. Call the poison control center. A poison control center is the best resource for patients and parents needing information about the treatment of an accidental poisoning. The nursing assessment on a 78-year-old woman reveals shuffling gait, decreased balance, and instability. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? a. Activity intolerance b. Impaired bed mobility c. Acute pain d. Risk for falls d. Risk for falls For adults age 65 and older, impaired balance and difficulty with gait are risks for the nursing diagnosis of risk for falls. A couple is with their adolescent daughter for a school physical and state they are worried about all the safety risks affecting this age. What is the greatest risk for injury for an adolescent? a. Home accidents b. Physiological changes of aging c. Poisoning and child abduction d. Automobile accidents, suicide, and substance abuse d. Automobile accidents, suicide, and substance abuse Risks to the safety of adolescents involve many factors outside the home because much of their time is spent away from home and with their peer group. According to the Centers for Disease Control and Prevention, the risk of motor vehicle accidents is higher among 16- to 19-year-old drivers than any other age-group. In an attempt to relieve the tensions associated with physical and psychosocial changes and peer pressures, some adolescents engage in risk-taking behaviors such as smoking, drinking alcohol, and using drugs. The nurse found a 68-year-old female patient wandering in the hall. The patient says she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply.) a. Insert a urinary catheter. b. Leave a night light on in the bathroom. c. Ask the physician to order a restraint. d. Keep the bed in low position with upper and lower side rails up. e. Assign a staff member to stay with the patient. f. Provide scheduled toileting during the night shift. g. Keep the pathway from the bed to the bathroom clear. b. Leave a night light on in the bathroom. f. Provide scheduled toileting during the night shift. g. Keep the pathway from the bed to the bathroom clear. Older adults in an unfamiliar environment may become confused. A night light may be beneficial for safety and orientation. Toileting is a common reason for a patient attempting to get out of bed. Placing the patient on a routine toileting schedule should help decrease this risk factor. Hospital environments can quickly become cluttered with equipment, personal items, and other things that create a hazard for falling. Keep pathways clear. All alternatives should be tried and considered before using a restraint. Restraint should not be an initial response. The bed should be kept in a low position. Upper side rails may be used; however, the addition of lower side rails can increase the risk of injury. The use of side rails alone for a disoriented patient may cause more confusion and further injury. A confused patient who is determined to get out of bed attempts to climb over the side rail or climbs out at the foot of the bed. Either attempt usually results in a fall or injury. The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) a. Contact the nursing supervisor. b. Restrict the family's visiting privileges. c. Ask the family to stay with the patient if possible. d. Inform the family of the risks associated with side-rail use. e. Thank the family for being conscientious and put the four rails up. f. Discuss alternatives with the family that are appropriate for this patient. c. Ask the family to stay with the patient if possible. d. Inform the family of the risks associated with side-rail use. f. Discuss alternatives with the family that are appropriate for this patient. The family is concerned about ensuring a safe environment for their loved one. The nurse should discuss their concerns, the risk of using restraints related to using four side rails, and safer alternatives such as the presences of a family member. If the family still insists on use of four side rails, you could contact the nursing supervisor to further discuss the situation with them. This is not a reason to restrict visitation; but, although you should appreciate their concern, the use of four side rails should be avoided. A physician writes an order to apply a wrist restraint to a patient who has been pulling out a surgical wound drain. Place the following steps for applying the restraint in the correct order. a. Explain what you plan to do. b. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure. c. Determine that restraint alternatives fail to ensure patient's safety. d. Identify the patient using proper identifier. e. Pad the patient's wrist. c. Determine that restraint alternatives fail to ensure patient's safety. d. Identify the patient using proper identifier. a. Explain what you plan to do. e. Pad the patient's wrist. b. Wrap a limb restraint around wrist or ankle with soft part toward skin and secure. A child in the hospital starts to have a grand mal seizure while playing in the playroom. What is your most important nursing intervention during this situation? a. Begin cardiopulmonary respiration. b. Restrain the child to prevent injury. c. Place a tongue blade over the tongue to prevent aspiration. d. Clear the area around the child to protect the child from injury. d. Clear the area around the child to protect the child from injury. Once a seizure begins, you need to monitor the patient and provide a safe environment. A seizure is not an indication for cardiopulmonary resuscitation. A person having a seizure should not be restrained, but the environment should be made safe. Objects should not be forced into the mouth. See the Skills in the chapter for more information. A 62-year-old woman is being discharged home with her husband after surgery for a hip fracture from a fall at home. When providing discharge teaching about home safety to this patient and her husband, the nurse knows that: a. A safe environment promotes patient activity. b. Assessment focuses on environmental factors only. c. Teaching home safety is difficult to do in the hospital setting. d. Most accidents in the older adult are caused by lifestyle factors. a. A safe environment promotes patient activity. Older adults are frequently fearful of falling and thus often limit activity. A safe environment, which decreases the risk of a fall, promotes patient activity. A fragile, 87-year-old nursing home resident is admitted to the hospital with dehydration and increased confusion. The patient has upper limb restraints to prevent her from pulling out her nasogastric tube. What instructions does the nurse give to nursing assistive personnel (NAP)? The use of restraints is associated with serious complications resulting from immobilization such as pressure ulcers, pneumonia, constipation, and incontinence. In some cases death has resulted because of restricted breathing and circulation. The restraint itself could injure the underlying skin. Routine checks are required to prevent or decrease these complications. The NAP needs to notify the nurse if there is a change in skin integrity, circulation, or patient's breathing and provide range of motion, nutrition and hydration, skin care, toileting, and opportunities for socialization at least every 2 hours. The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: a. Place a bed alarm device on the bed. b. Place the patient in a belt restraint. c. Provide one-on-one observation of the patient. d. Apply wrist restraints. a. Place a bed alarm device on the bed. Consider and implement alternatives as appropriate before the use of a restraint. A bed alarm is an alternative that the nurse implements independently. To ensure the safe use of oxygen in the home by a patient, which of the following teaching points does the nurse include? (Select all that apply.) a. Smoking is prohibited around oxygen. b. Demonstrate how to adjust the oxygen flow rate based on patient symptoms. c. Do not use electrical equipment around oxygen. d. Special precautions may be required when traveling with oxygen a. Smoking is prohibited around oxygen. c. Do not use electrical equipment around oxygen. d. Special precautions may be required when traveling with oxygen When oxygen is in use, precautions need to be taken to prevent fire and protect the patient. Patients need to be taught precautions, which include posting "Oxygen in Use" signage, not using oxygen around electrical equipment or flammable products, properly handling oxygen cylinders/containers, ensuring that tubing is unobstructed, not adjusting liter flow without a physician's order, and taking precautions when traveling with oxygen. How does the nurse support a culture of safety? (Select all that apply.) a. Completing incident reports when appropriate b. Completing incident reports for a near miss c. Communicating product concerns to an immediate supervisor d. Identifying the person responsible for an incident a. Completing incident reports when appropriate b. Completing incident reports for a near miss c. Communicating product concerns to an immediate supervisor Completing incident reports for actual and near-miss events helps the facility track information and identify trends and patterns that need to be addressed. Communicating product concerns to a responsible supervisor allows the facility to further investigate and determine if additional action is required. You are admitting Mr. Jones, a 64-year-old patient who had a right hemisphere stroke and a recent fall. The wife stated that he has a history of high blood pressure, which is controlled by an antihypertensive and a diuretic. Currently he exhibits left-sided neglect and problems with spatial and perceptual abilities and is impulsive. He has moderate left-sided weakness that requires the assistance of two and the use of a gait belt to transfer to a chair. He currently has an intravenous (IV) line and a urinary catheter in place. What factors increase his fall risk at this time? (Select all that apply.) a. Smokes a pack a day b. Used a cane to walk at home c. Takes antihypertensive and diuretics d. History of recent fall e. Neglect, spatial and perceptual abilities, impulsive f. Requires assistance with activity, unsteady gait g. IV line, urinary catheter c. Takes antihypertensive and diuretics d. History of recent fall e. Neglect, spatial and perceptual abilities, impulsive f. Requires assistance with activity, unsteady gait g. IV line, urinary catheter Smoking is not a risk factor for falls. Because the patient used the cane at home, it is not a current risk factor for falls. Risk is determined by his current status. At 3 AM the emergency department nurse hears that a tornado hit the east side of town. What action does the nurse take first? a. Prepare for an influx of patients b. Contract the American Red Cross c. Determine how to restore essential services d. Evacuate patients per the disaster plan a. Prepare for an influx of patients The emergency department nurse needs to prepare for the potential influx of patients first. Staff need to be aware of the disaster plan. Patients may need to be evaluated but not initially. The American Red Cross is not contacted initially. Determination of how to restore essential services is part of the disaster plan and is determined before an actual event. [Show Less]
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Taylor: Fundamentals of Nursing, Ninth Edition - Chapter one quiz latest 2023 verified
Which nursing group provides a definition and scope of practice for nursing? A.) International Council of Nurses (ICN) B.) American Academy of Neurology ... [Show More] (AAN) C.) American Nurses Association (ANA) D.) The Joint Commission C.) American Nurses Association (ANA) pg. 11 The registered nurse (RN) working with a licensed practical nurse (LPN) understands which about LPNs? A.) They must take a licensure exam. B.) They may work independently. C.) They have a higher degree than most RNs. D.) The program is 4 years in length. A.) They must take a licensure exam. p. 13-14 The nurse going back to school for nurse midwifery can trace education for nurse midwifery to which nursing leader? A.) Mary Breckinridge B.) Sojourner Truth C.) Lavinia Dock D.) Margaret Sanger A.) Mary Breckinridge p. 9 Which scenario is the best example of a nurse in the role of counselor? A.) A nurse allowing a crying client to verbalize fears of death B.) A nurse telling a client the side effects of a medication C.) A nurse providing the physician a client's test results D.) A nurse ensuring that a client has follow-up care at a free clinic A.) A nurse allowing a crying client to verbalize fears of death pg. 11 A nurse identifies a client's health care needs and devises a plan of care to meet those needs. Which guideline is being followed in this case? A.) Nursing standards B.) Nursing orders C.) Nurse practice acts D.) Nursing process D.) Nursing process pg. 19 A client is distraught because a recent computed tomography (CT) scan shows that the client's colon cancer has metastasized to the lungs. Which nursing aim should the nurse prioritize in the immediate care of this client? A.) Facilitating coping B.) Preventing illness C.) Restoring health D.) Promoting health A.) Facilitating Coping pg. 13 Why are nursing organizations important for the continued development and improvement of nursing as a whole? A.) To provide socialization and networking for members B.) To regulate work activities for members C.) To set standards for nursing education and practice D.) To provide information to nurses about legal requirements C.) To set standards for nursing education and practice pg. 13 Which is an appropriately stated nursing intervention? A.) Ambulate in the hall. B.) Stand at bedside with assistance. C.) Ambulate 30 ft (9 m) twice a day with the assistance of a walker. D.) Ambulate with the assistance of a walker. C.) Ambulate 30 ft (9 m) twice a day with the assistance of a walker. pg. 18 During the course of any given day of work in the acute care setting, the nurse may need to perform which roles? Select all that apply. A.) Communicator B.) Counselor C.) Teacher D.) Financier E.) Statistician A.) Communicator B.) Teacher C.) Counselor pg. 11 The nursing process includes step(s)? Select all that apply. A.) Assess B.) Plan C.) Prescribe D.) Implement E.) Evaluate A.) Assess B.) Plan D.) Implement E.) Evaluate pg. 11-18 Which nursing action best exemplifies the nurse's role in promoting health? A.) encouraging a group of junior high school students to engage in regular physical activity B.) facilitating a support group for the friends and families of clients affected by stroke C.) performing deep suctioning on a client who has a tracheotomy and copious secretions D.) administering a beta-adrenergic blocker and diuretic to a client who has a history of hypertension A.) Encouraging a group of junior high school students to engage in regular physical activity. pg. 11-12 When administering immunizations, the nurse is engaged in: A.) health promotion. B.) illness prevention. C.) health restoration. D.) coping facilitation. B.) Illness Prevention pg. 13 The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step? A.) Caregiver B.) Client advocate C.) Decision-maker D.) Educator D.) Educator pg. 11-16 The primary aim of the Healthy People 2020 initiative is: A.) health promotion. B.) illness prevention. C.) health restoration. D.) coping with disability. A.) health promotion p. 12 The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state: A.) "Everything in nature is alive with invisible forces." B.) "The physician is viewed as a god-like figure." C.) "The nurse is the handmaiden of the physician." D.) "Pets can help heal clients." A.) "Everything in nature is alive with invisible forces." pg. 7 The nurse asks a client about his spiritual health. Which statement best explains the standard of care utilized by the nurse? A.) The RN provides spiritual counseling. B.) The RN collects comprehensive data. C.) The RN prays with clients. D.) The RN collaborates with spiritual healers. B.) The RN collects comprehensive data. p. 18 A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing? A.) Clinical nurse specialist B.) Nurse manager C.) Nurse-midwife D.) Physician assistant A.) Clinical nurse specialist p. 16 What is the best nursing intervention to promote health in a client at risk for heart disease? A.) Emphasizing a client's strengths to encourage weight loss B.) Informing the client that the client must lose weight C.) Instructing the client to adhere to a high-sodium diet D.) Taking the client's pulse rate daily A.) Emphasizing the client's strength to encourage weight loss p. 11-12 Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding? A.) Refer the mother for a home care visit. B.) Ask the mother to come to the emergency room. C.) Email the mother a link for breastfeeding. D.) Suggest that the mother bottle feed her infant. A.) Refer the mother for a home care visit. p. 11-12 The nurse is attempting to provide anticipatory guidance for the parents of an 18-month-old child. Which statement would be best for the nurse to make? A.) "Keep all medications in a locked cabinet." B.) "Does the child have nightmares often?" C.) "The child is in the 95th percentile for weight." D.) "Do not give the child a bottle now." A.) "Keep all medications in a locked cabinet." p. 12 The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing? A.) art of nursing B.) science of nursing C.) evidence-based practice D.) application of research A.) art of nursing p. 23 Which action should the nurse implement when working with a medically homeless client? A.) Encourage client to utilize the free health care clinic. B.) Assist the client in finding housing. C.) Encourage the client to utilize the emergency room when ill. D.) Assist the client in finding a job. A.) Encourage client to utilize the free health care clinic p. 19 The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize? A.) Work effectively in interdisciplinary teams B.) Correctly utilize and troubleshoot high-tech equipment C.) Navigate the electronic medical records system D.) Do things the way they have always been done A.) Work effectively in interdisciplinary teams p. 6 A nurse wishes to pursue a degree as a nurse practitioner. What is the minimal degree needed by the nurse? A.) Diploma B.) Associate's C.) Master's D.) Baccalaureate C.) Master's p. 15 A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care? A.) The nurse's actions B.) The client receiving the care C.) The nurse as the caregiver D.) Nursing as a profession B.) The client receiving the care p. 11 A nurse manager is teaching staff how to use a new piece of hospital equipment. Which educational setting would be most appropriate for this process? A.) Continuing education B.) Graduate education C.) In-service education D.) Undergraduate studies C.) In-service education p. 16 The role of the nurse developed from the pre-civilization era through the eras representing the beginning of civilization, the beginning of the 16th century, the 18th and 19th centuries, World War II era, and up to the present day. Place the following roles of the nurse listed below in the correct chronologic order to follow this timeline. Nurses were portrayed as a mother, caring for family and delivering physical care and health remedies. Nurses were viewed as slaves, carrying out menial tasks based on the orders of the priest. There was a shortage of nurses; criminals were recruited as nurses; nursing was viewed as disreputable. Florence Nightingale elevated nursing to a respected occupation and founded modern methods in nursing education. Efforts were made to upgrade nursing education, and women were more assertive and independent. Nursing was broadened in all areas and was practiced in a wide variety of settings; nursing was viewed as a profession. Nurses were portrayed as a mother, caring for family and delivering physical care and health remedies. Nurses were viewed as slaves, carrying out menial tasks based on the orders of the priest. There was a shortage of nurses; criminals were recruited as nurses; nursing was viewed as disreputable. Florence Nightingale elevated nursing to a respected occupation and founded modern methods in nursing education. Efforts were made to upgrade nursing education, and women were more assertive and independent. Nursing was broadened in all areas and was practiced in a wide variety of settings; nursing was viewed as a profession. p.7-23 Which explanation accurately differentiates the role of the registered nurse (RN) from that of the licensed practical/vocational nurse (LPN/LVN)? A.) The RN is permitted to prescribed medications. B.) The LPN/LVN can only work in a long-term care facility. C.) The RN directs the workload of an LPN/LVN. D.) The LPN/LVN should work under the supervision of an RN. C.) The RN directs the workload of an LPN. p.13-14 A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)? A.) administering bedside blood glucose testing B.) administering blood products C.) administering intravenous push medication D.) administering chemotherapy A.) administering bedside glucose testing p. 14 The nurse is performing care for a client in the end stage of cancer. How can the nurse best facilitate the client and family's ability to cope? Select all that apply. A.) Assist the client with activities of daily living (ADLs). B.) Encourage the family to leave and let the nurse take over care. C.) Inform the family that there is nothing they can do for their loved one. D.) Assist the client and family with the preparation for end-of-life. E.) Refer the client and family to hospice services. A.) Assist the client with activities of daily living (ADLs). D.) Assist the client and family with the preparation for end-of-life. E.) Refer the client and family to hospice services. What was one barrier to the development of the nursing profession in the United States after the Civil War? A.) lack of educational standards B.) hospital-based schools of nursing C.) lack of influence from nursing leaders D.) independence of nursing orders A.) lack of educational standards p. 7 After hearing a presentation about the American Nurses Association (ANA), a nurse decides to join the organization based on the understanding that: A.) ANA invites students showing excellence in scholarship to become members. B.) ANA aims at fostering high standards of nursing in the United States. C.) members include nurses, other health care providers, and lay people. D.) membership is open to all nurses in the United States. B.) ANA aims at fostering high standards of nursing in the United States. p. 10 A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers? A.) They are responsible for the continued development and advancement of nursing. B.) They usually have a baccalaureate degree in nursing. C.) They serve as liaisons between staff members and directors of nursing. D.) They tend to work in community health centers and long-term care units. A.) They are responsible for the continued and advancement of nursing. p. 16 The client's plan of care is created by the nurse using which guideline for nursing practice? A.) Nursing process B.) Nursing's Social Policy Statement C.) Nurse practice act D.) ANA Standards of Nursing Practice A.) Nursing process p. 11 Which are approved as nursing diagnoses? Select all that apply. A.) Impaired Skin Integrity B.) Congestive Heart Failure C.) Caregiver Role Strain Abdominal Hernia D.) Compromised Family Coping A.) Impaired Skin Integrity C.) Caregiver Role Strain D.)Compromised Family Coping p. 11 Due to the rising cost of health care services, many procedures and treatments are being delivered in what type of setting? A.) hospitals B.) medical centers C.) outpatient facilities D.) community health care centers C.) outpatient facilities p. 15 A prospective nursing student desires a career that will allow the opportunity to provide client care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student? A.) associate of science registered nursing program B.) baccalaureate of science registered nursing program C.) licensed or vocational nursing program D.) diploma nursing program C.) licensed or vocational nursing program p. 14 The Quality and Safety Education for Nurses (QSEN) initiative has identified which key competencies for nurses? Select all that apply. A.) Client-centered care B.) Teamwork and collaboration C.) Evidence-based practice D.) Quality improvement E.) Correct documentation A.) Client-centered care B.) Teamwork and collaboration C.) Evidence-based practice D.) Quality improvement p. 6-11 A nurse is discussing the history of the profession with a client and describes that a shift in societal focus from religion to warfare had a negative impact on nursing due to: A.) female criminals recruited as nurses. B.) nurses caring for war victims and soldiers. C.) nurses no longer praying for their clients. D.) unmarried females recruited as nurses. A.) female criminals recruited as nurses. p. 7 The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented? A.) The RN promotes a safe environment. B.) The RN identifies client outcomes. C.) The RN educates about preventing falls. D.) The RN develops a plan of care. A.) The RN promotes a safe environment. p. 8 A nurse is considering relocating to another state to practice nursing. Which is the most appropriate action by the nurse to ensure ability to practice in the new state? A.) asking the current state to transfer the license B.) applying for a reciprocal license in the new state C.) taking the new state's licensing exam D.) No action is needed by the nurse. B.) applying for a reciprocal license in the new state p. 14 The registered nurse is performing a nutritional assessment to ensure that the client's diet is optimal for wound healing. The nurse's intervention can be traced back to which key contributor to nursing? A.) Florence Nightingale B.) Clara Barton C.) Dorothea Dix D.) Linda Richards A.) Florence Nightingale p. 7-9 The nurse is documenting the client's response to a medication. This action reflects a practice that was started by which key figure in nursing's history? A.) Linda Richards B.) Clara Barton C.) Florence Nightingale D.) Lillian Wald C.) Florence Nightingale p. 7-8 Attracting minorities to the profession of nursing is an important consideration for the future of nursing. Which key historical nursing figure set a precedent in this area? A.) Mary Eliza Mahoney B.) Nora Gertrude Livingston C.) Mary Agnes Snively D.) Mary Ann Bickerdyke A.) Mary Eliza Mahoney p. 9 Which scenario is the best example of the nurse in the role of teacher/educator? A.) Assessing whether the client is able to perform a dressing change B.) Teaching a first-grader to read C.) Communicating discharge status to a home care agency D.) Conducting research on dressing changes A.) Assessing whether the client is able to perform a dressing change. p.11 What are the best examples of the role of the nurse as a communicator? Select all that apply. A.) Telling a client their blood pressure B.) Calling a physician about a client's blood pressure C.) Informing the physical therapist that the client's therapy was discontinued D.) Telling a friend about something that happened to a client that day E.) Discussing laboratory values with a client A.) Telling a client their blood pressure B.) Calling a physician about a client's blood pressure C.) Informing the physical therapist that the client's therapy was discontinued E.) Discussing laboratory values with a client p. 11 Which is the best example of a nurse demonstrating the role of caregiver? A.) starting an intravenous line in the client's arm B.) referring the client to a mental health clinic C.) assigning a room for a new hospital client D.) reporting lab values to a client's physician A.) starting an intravenous line in the client's arm p. 11 During World War II, nurses were actively recruited and enlisted in the military. What effect did this have on the nursing profession? A.) caused a civilian nursing shortage B.) encouraged more men to become nurses C.) increased demand for ambulatory services D.) inspired the formation of home health nursing A.) caused a civilian nursing shortage p. 19-23 The nurse is caring for a client who cannot meet health needs independently. Which action made by the nurse depicts concern and attachment? A.) telling the client, "I will be back in 15 minutes to change your dressing." B.) asking the client, "How are you today? I am really worried about you." C.) talking about diabetes and teaching the client how to do foot care D.) organizing the work for the day and evaluating how the day went B.) asking the client, "How are you today? I am really worried about you." p. 11 The nurse graduated several years ago from a 2-year nursing program at a community college near the home city. Recently, the nurse has considered moving from providing direct client care into an administrative role, but recognizes the need for further education to be considered for such a position. The nurse most likely possesses which nursing qualification? A.) graduate degree B.) diploma C.) baccalaureate D.) associate degree D.) associate degree p. 13 Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice? A.) American Nurses Association B.) National League for Nursing C.) National Council of State Boards of Nursing D.) International Council of Nurses A.) American Nurses Association p. 10 The nurse is caring for a postoperative client. The health care provider has written a prescription for a pain medication, and the prescription gives a dosage range for the amount the nurse may give depending on the severity of the client's pain. This type of functioning within the health care team is called: A.) collaborative functioning. B.) assistive functioning. C.) authoritative functioning. D.) independent functioning. A.) collaborative functioning p. 8 A client asks an RN to prescribe a medication for pain. What is the best answer by the nurse? A.) "Only advanced practice registered nurses have prescriptive authority." B.) "Take one acetaminophen every 4 hours." C.) "Take two ibuprofen every 4 to 6 hours." D.) "No nurse can prescribe a medication." A.) "Only advanaced practice registered nurses have prescriptive authority." p. 15 A nurse is thinking about pursuing a master's degree in nursing (MSN) and is reviewing information about various programs. What would the nurse expect to find about such programs? A.) Such degrees can be attained only in a certain specific area of interest. B.) Students need to take the licensure examination after the course. C.) Nurses pursuing such programs require solid scholastic abilities. D.) Master's degree nursing education began in the late 18th century. C.) Nurses pursuing such programs require solid scholastic abilities. p. 13 Of the following orders, which is considered to be the first to provide visiting nurses in Canada? A.) The Daughters of Charity B.) The Grey Nuns of Montreal C.) The Deaconesses of Kaiserwirth D.) The Sisters of Mercy B.) The Grey Nuns of Montreal What might a nurse need to do to ensure the continuation of his or her nursing license? A.) Obtain a baccalaureate degree. B.) Obtain a master's degree. C.) Obtain continuing education credits. D.) Attend hospital in-services. C.) Obtain continuing education credits. The nurse is utilizing knowledge about a blood pressure medication's actions and side effects to determine whether or not to give a client, whose blood pressure is low, the prescribed blood pressure medication. What best describes the aspect of nursing demonstrated? A.) conduction of research B.) science of nursing C.) quality improvement D.) art of nursing B.) Science of nursing p. 9 The nurse is demonstrating traits of leadership. What actions by the nurse would be recognized as leadership behaviors? Select all that apply. A.) Participates on an evidence-based practice council B.) Develops and implements a quality improvement project C.) Serves as president of local chapter of Sigma Theta Tau International D.) Communicates an issue to a fellow colleague in the cafeteria E.) Attends a mandatory hospital in-service A.) Participates on an evidence-based practice council C.) Serves as president of local chapter of Sigma Theta Tau International B.) Develops and implements a quality improvement project p. 34 A nurse mentoring second-year nursing students from a community college plans clinical experiences for them. These students will most likely graduate in which time frame? A.) in 3 more years B.) at the end of the year C.) in 2 more years D.) in 1 more year B.) at the end of the year p. 14 Which is the best example of a client-centered approach to care? A.) The nurse draws a blood sample from a client. B.) The nurse asks the client what the client would like to order from the menu. C.) The nurse asks the client about health goals. D.) The nurse helps a client ambulate. C.) The nurse asks the client about health goals p. 11 The American Nurses Association (ANA) Standards of Professional Nursing Practice provides standard of care for all nurses. Which statement on the assessment of the nursing process is accurate? A.) The nurse monitors the ethical conduct of authorities and clients. B.) The nurse collects comprehensive data pertinent to the client's health or situation. C.) The nurse evaluates progress toward implemented actions. D.) The nurse dictates the plan that prescribes strategies of care. B.) The nurse collects comprehensive data pertinent to the client's health or situation. p. 17-18 The new nursing graduate is concerned about some of the critical changes that will be occurring in nursing. What changes does the nurse anticipate will impact nursing care? A.) Rapid growth of nurses and shortage of job opportunities B.) Limitations that nurses have in the workforce C.) Difficulty for nurses to remain current in a rapidly changing medical and technology environment D.) Decrease in health care costs C.) Difficulty for nurses to remain current in a rapidly changing medical and technology environment p. 19-24 The nursing process is: A.) the promotion of health, prevention of illness, and care of ill, disabled, and dying individuals. B.) a mechanism for increasing the knowledge and skill of the nurse through programs of education. C.) an approach for identifying and analyzing the best available scientific evidence for nursing care. D.) a critical thinking method used by nurses to provide nursing care that is individualized and holistic. D.) a critical thinking method used by nurses to provide nursing care that is individualized and holistic. p. 19 [Show Less]
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