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
... [Show More] of 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
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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
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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]