Chapter 3 & 5 test review

Question 1

A nurse is caring for a client who is two days postop and has not achieved satisfactory pain relief. According to the nursing process, which of the following actions should the nurse take first?
A. Check the client to determine the reason for inadequate pain relief
B. Determine whether the change in plan reduces the client’s pain
C. change the plan of care to provide a different method of pain relief.
D. Educate the client about the plan of care for managing the pain.

Answer 1

A

Question 2

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?
A. Orient the client to their room
B. Conduct a client care conference
C. Review medical prescriptions
D. Develop a plan of care

Answer 2

A. Orient the client to their room.

Question 3

As part of the admission process, a nurse at a long term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client’s family?
A. Body mass index
B. Usual time for meals and snacks
C. Favorite foods
D. Difficulty swallowing

Answer 3

D. Difficulty swallowing

Question 4

What does documentation of type of care, time of care, and signature of person prove?
A. The person who signed the document did all the work noted
B. No litigation can be brought against the person who signed
C. Interventions were implemented to meet the patients needs
D. The patients response to the intervention was positive

Answer 4

C. Interventions were implemented to meet the patients needs.

Question 5

Why is documentation especially significant in managed care?
A. The hospital needs to show that employees care for patients
B. Institutions are reimbursed only for patient care that is documented
C. Patients might bring lawsuits if care was not given
D. Documents may become part of a lawsuit

Answer 5

B. Institutions are only reimbursed for care that is documented

Question 6

The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation?
A. SOAP
B. Block
C. CBE
D. Focus

Answer 6

C. CBE

Question 7

What form explains the lapse when events that are not consistent with facility or national standards of expected care?
A. Subjective data
B. Focus chart
C. Incident report
D. Nursing assessment

Answer 7

C. Incident report

Question 8

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as:
A. nursing order
B. Kardex
C. nursing care plan
D. critical pathway

Answer 8

D. critical pathway

Question 9

What makes home health care documentation unique?
A. Some charting is retained at the hospital
B. The health care provider’s office needs separate charting
C. Different health care providers need access
D. The health care provider is the pivotal person in the charting

Answer 9

C. Different health care providers need access

Question 10

What regulates standards for long term care documentation?
A. OBRA
B. Title XXII
C. patient problems
D. the care plan

Answer 10

A. OBRA

Question 11

What is the nurse required to do to adhere to the concept of confidentiality for the patient’s medical record?
A. provide information only to another nurse
B. provide information only to an attorney
C. share information only with the family
D. have a clinical reason for reading the record

Answer 11

D. have a clinical reason for reading the record

Question 12

Documentation is necessary for the evaluation of patient care. Which of the following phases of the nursing process is necessary for the evaluation of care?
A. Assessment
B. Planning
C. Implementation
D. Evaluation

Answer 12

C. implementation

Question 13

What does the nurse use as a basis for documentation in focus charting?
A. problem list
B. nursing orders
C. patient problems
D. evaluation

Answer 13

C. patient problems

Question 14

What is the purpose of quality assurance?
A. to screen employment applications
B. to evaluate care results against accepted standards
C. to conduct in-services for “quality documentation”
D. to report deviation from standards to the state health department

Answer 14

B. to evaluate care results against accepted standards

Question 15

What is the process used to appraise the practice of an individual nurse known as?
A. Quality assurance
B. incident reporting
C. OBRA
D. peer review

Answer 15

D. Peer review

Question 16

What is the documentation format that uses the acronym SOAPE?
A. problem oriented
B. focused
C. traditional
D. crisis

Answer 16

A. problem oriented

Question 17

Who is the legal owner of the patient’s medical record?
A. patient
B. health care provider
C. institution
D. state

Answer 17

C. institution

Question 18

When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
A. charting in code
B. logging off
C. charting in privacy
D. signing on with a password

Answer 18

B. logging off

Question 19

What is the system that classifies patients by age, diagnosis, and surgical procedure, and produces 300 different categories used for predicting the use of hospital resources?
A. quality assurance
B. resource assessment
C. quality improvement
D. Diagnosis related groups

Answer 19

D. diagnosis related groups

Question 20

A nurse is using the data, action, response, education(DARE) system of charting, and is completing the data portion. What data are the nurse’s focus?
A. Planning
B. Assessment
C. Implementation
D. patient teaching

Answer 20

B. assessment

Question 21

A new patient is being admitted to a long term care facility. Who has primary responsibility for each new patient’s initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified?
A. health care provider
B. RN
C. unlicensed assistive personnel
D. LPN

Answer 21

B. RN

Question 22

Which of the following will the nurse implement when an error is made when documenting in a patient’s chart?
A. scratch out the error
B. apply correction fluid
C. erase the error completely
D. draw a single line through the error

Answer 22

D. draw a single line through the error

Question 23

What should the nurse be sure to do when documenting in a patient’s chart?
A. include speculation
B. chart consecutively
C. leave blank spaces
D. include retaliatory comments

Answer 23

B. chart consecutively

Question 24

A nurse is receiving a telephone order from a health care provider. The nurse uses a safety measure of preventing errors that is recognized by The Joint Commission as one method of meeting National Patient Safety Goals. What is the second step of this method?
A. read back
B. background
C. situation
D. assessment

Answer 24

B. background

Question 25

What are categories of inadequate documentation that may lead to a malpractice claim? Select all that apply
A. incorrectly recording the time of an event
B. failing to record the verbal orders
C. charting events in advance
D. documenting an incorrect date
E. marking out and initialing a charting error

Answer 25

A, B, C, D

Question 26

What are some problems associated with electronic charting? Select all that apply
A. security
B. expense of training staff
C. legibility
D. easy retrieval
E. new terminology

Answer 26

A, B, E

Question 27

What is the basic purpose of written patient records? Select all that apply
A. teaching
B. legal record of care
C. written communication
D. research and data collection
E. permanent record for accountability
F. temporary record of hospitalization

Answer 27

A, B, C, D, E

Question 28

What should a medical record provide for all health care providers? Select all that apply
A. care given to the patient
B. care planned for the patient
C. a patient’s nursing problem
D. a patient’s medical problems
E. details about any incident reports
F. the patient’s response to treatment

Answer 28

A B, C, D, F

Question 29

The best defense against malpractice claims associated with nursing care is accurate ______?

Answer 29

Documentation

Question 30

Twenty four hour charting is designed to establish _______ levels to help determine staffing needs.

Answer 30

Acuity

Question 31

Documentation using the DARE format includes elements of the ______ charting system.

Answer 31

focused

Question 32

A health care audit that evaluates services provided and results achieved compared with accepted standards is known as _______________.

Answer 32

Quality assurance

Question 33

What best defines the nursing process?
A. A method to ensure that the health care provider’s orders are implemented correctly
B. a series of assessments that isolate a patient’s health problem
C. a framework for the organization of the individualized nursing plan
D. a preset formula for the design of nursing care

Answer 33

a framework for the organization of the individualized nursing care.

Question 34

All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?
A. a 53 year old admitted with a perforated ulcer
B. 5 year old for the implant of grommets in the middle ear
C. 76 year old admitted for knee replacement
D. 40 year old admitted for possible bowel obstruction

Answer 34

A. 53 year old with perforated ulcer

Question 35

What subjective data does the nurse record following a head to toe examination?
A. rash on back
B. prolonged nausea
C. blood pressure of 190/100
D. white blood cell count of 19,000

Answer 35

B. prolonged nausea

Question 36

What objective data should the nurse include after a patient assessment?
A. headache of 3 days duration
B. Flatulence
C. Anxiety

Answer 36

B. Flatulence

Question 37

When the nurse is prioritizing care during the planning phase of the nursing process, what is the guiding framework?
A. primary
B. secondary
C. unreliable
D. biased

Answer 37

B. secondary

Question 38

What are two primary methods used to collect data?
A. written report by the patient and family
B. review of the chart and nurse’s notes
C. interview and physical examination
D. review of the health care provider’s order and the Kardex

Answer 38

Interview and physical exam

Question 39

The nurse writes two patient problems 1) inadequate nutritional intake related to vomiting as manifested by a 3lb weight loss and 2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses?
A. the second diagnosis needs no defined nursing intervention
B. the second diagnosis needs medical intervention
C. the second diagnosis will not need to be evaluated
D. the second diagnosis reflects a problem that doesn’t exist yet

Answer 39

D. the second diagnosis reflects a problem that doesn’t exist yet

Question 40

What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
A. erikson’s developmental tasks
B. Piaget’s cognitive table
C. Maslow’s hierarchy of needs
D. Freud’s classifications

Answer 40

C. Maslow’s hierarchy of needs

Question 41

What is an appropriate outcome statement for a patient with a patient problem of ineffective airway clearance related to thick secretions?
A. the patient will increase intake to 1000mL daily to liquify secretions
B. the patient will cough more frequently within 3 days
C. the patient will breathe better within 3 days
D. the patient will perform deep breathing exercises 4 times daily

Answer 41

A. the patient will increase intake to 1000mL daily to liquify secretions

Question 42

What is the primary purpose of nursing interventions?
A. to support the health care providers orders
B. to provide direction for all caregivers
C. to provide broad, general statements
D. to clarify nursing principals

Answer 42

B. to provide direction for all caregivers

Question 43

What documentation reflects implementation?
A. “patient selected low sugar snacks independently”
B. “patient was medicated with Tylenol 500mg PO for pain”
C. “ patient was ambulated for 15 minutes after lunch”
D. “patient participated in group therapy without reminder”

Answer 43

C. “patient was ambulated for 15 minutes after lunch”

Question 44

Which nursing intervention is complete and correct?
A. “ May 10: Unlicensed assistive personnel will ambulate patient A. Nurse”
B. “Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse”
C. “Unlicensed assistive personnel will serve 8oz glass of juice at each meal, 5/10.”
D. “ PM nurse will ensure that heel protectors are in place before bedtime.”

Answer 44

B. “Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse”

Question 45

A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred?
A. omission
B. variance
C. failure
D. error

Answer 45

B. variance

Question 46

During a physical exam, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this represent?
A. symptoms
B. data clustering
C. signs of fluid overload
D. urinary retention

Answer 46

B. data clustering

Question 47

What type of assessment is performed continuously throughout nurse-patient contact?
A. complete
B. body systems
C. focused
D. narrative

Answer 47

C. focused

Question 48

What assists the nurse in the identification of patient problems?
A. objective data
B. subjective data
C. data clustering
D. validated data

Answer 48

C. data clustering

Question 49

What organized approach might the nurse use when performing a complete physical exam?
A. Maslow’s
B. Head to toe assessment
C. subjective data collection
D. objective data collection

Answer 49

B. head to toe assessment

Question 50

Who is the person responsible for analyzing and interpreting data to arrive at a patient problem?
A. health care provider
B. LPN
C. RN
D. technician

Answer 50

C. RN

Question 51

What is the basis for designing and selecting nursing interventions to meet patient needs?
A. patient problem
B. care plan
C. health care providers orders

Answer 51

A. patient problem

Question 52

The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation?
A. contributing to a patient’s recovery
B. a risk factor
C. difficult to maintain
D. a nursing responsiblity

Answer 52

B. a risk factor

Question 53

What is a patient problem considered when a problem is suspected but data to support it are lacking?
A. a syndrome patient problem
B. an actual patient problem
C. a “risk for” diagnosis
D. a possible patient problem

Answer 53

D. a possible patient problem

Question 54

In which phase of the nursing process does the nurse select interventions to assist the patient to meet the needs demonstrated?
A. assessment
B. planning
C. implementation
D. evaluation

Answer 54

B. planning

Question 55

What is an important consideration when developing the care plan?
A. ensure the patient is involved in the process
B. ensure the interventions are easy to implement
C. ensure evaluation of the patient problems is possible

Answer 55

A. ensure the patient is involved in the process

Question 56

From where are the “risk for” problems identified?
A. the care plan
B. the interventions
C. the assessment
D. the evaluation

Answer 56

C. the assessment

Question 57

What expected outcome exemplifies accepted criteria?
A. nurse will assess vital signs every day
B. resident will observe safety guidelines while smoking
C. resident will take part in one activity daily for the next 90 days
D. nurse will monitor O2 saturation to maintain at greater than 90%.

Answer 57

C. resident will take part in one activity daily for the next 90 days.

Question 58

During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
A. the patient complains of nausea
B. the patient is vomiting
C. the patient experiences tachycardia
D. the patient is pacing the halls

Answer 58

A. the patient complains of nausea

Question 59

During an admission assessment, the nurse collects objective and subjective data. Which is an example of subjective data?
A. the patient is asleep
B. the patient is tearful
C. the patient has facial grimamcing
D. the patient states, “ I hurt all over”

Answer 59

D. the patient states, “I hurt all over”

Question 60

During an admission assessment, the nurse collects objective and subjective data. Which is an example of subjective data?
A. the patient is coughing
B. the patient has cyanosis of the lips
C. the patient experiences tachypnea
D. the patient complains of generalized discomfort

Answer 60

D. the patient complains of generalized discomfort

Question 61

During an admission assessment, the nurse collects objective and subjective data. Which is an example of objective data?
A. the patient complains of chest pain
B. the patient states, “ I feel nauseous”
C. the patient complains of feeling faint
D. the patient is short of breath on exertion

Answer 61

D. the patient is short of breath on exertion

Question 62

During an admission assessment, the nurse collects objective and subjective data. Which is an example of objective data?
A. the patient is jaundiced
B. the patient states, “I am nervous”
C. the patient complains of palpitations
D. the patient denies dizziness when ambulating

Answer 62

A. the patient is jaundiced

Question 63

During an admission assessment, the nurse collects objective and subjective data. Which is an example of objective data?
A. the patient complains of feeling depressed
B. the patient states, “I hear voices in my head”
C. the patient complains of auditory hallucinations
D. the patient is pacing back and forth while chanting

Answer 63

D. the patient is pacing back and forth while chanting

Question 64

What is an example of an appropriate patient problem?
A. impaired skin integrity
B. skin breakdown noted
C. turn patient every 2 hours
D. the patient has scabies on his back

Answer 64

A. impaired skin integrity

Question 65

What is an example of an appropriate patient problem?
A. constipation
B. patient complains of constipation
C. need for laxatives
D. patient has a duodenal ulcer

Answer 65

A. constipation

Question 66

A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?
A. risk for impaired skin integrity due to immobilization
B. physical immobilization secondary to risk for impaired skin integrity
C. risk for impaired skin integrity related to diagnosis of decubitus ulcers
D. physical immobilization secondary to decreased cognitive ability

Answer 66

A. risk for impaired skin integrity due to immobilization

Question 67

Which is an example of a patient problem?
A. Pneumonia
B. Diabetes
C. impaired skin integrity
D. congestive heart failure

Answer 67

C. impaired skin integrity

Question 68

Which is an example of a medical diagnosis?
A. constipation
B. Diabetes
C. impaired skin integrity
D. Altered nutrition; less than body requirements

Answer 68

B. Diabetes

Question 69

Which is an example of a medical diagnosis?
A. pneumonia
B. anxiety
C. pain
D. impaired skin integrity

Answer 69

A. pneumonia

Question 70

Which are acceptable sources of secondary data? select all that apply
A. patient
B. family members
C. other health professionals
D. diagnostic reports
E. textbooks

Answer 70

B, C, D, E

Question 71

Which are official categories of patient problems? select all that apply
A. actual
B. risk
C. wellness
D. syndrome
E. potential

Answer 71

A,B,C,D

Question 72

What are considered the phases of the nursing process? select all that apply
A. Diagnosis
B. prediction
C. assessment
D. evaluation
E. implementation
F. outcome identification

Answer 72

A, C, D, E, F

Question 73

NANDA International meets to reorganize diagnosis labels and language every 2 ____.

Answer 73

Years

Question 74

The standards that name and measure patient __________ are referred to as NOC (nursing outcome classification)

Answer 74

outcomes

Question 75

The document that outlines a ___________ plan for care interventions over a specified time frame is called a clinical pathway.

Answer 75

multidisciplinary

Question 76

A systematic method by which nurses plan and provide care for patients is known as the nursing _________.

Answer 76

process

Question 77

A systemic dynamic way to collect and analyze data about a patient that includes physiologic data as well as psychological, sociocultural, spiritual, economic, and lifestyle factors is known as ____________.

Answer 77

Assessment

Question 78

Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a _________.

Answer 78

problem

Question 79

A clinical judgement concerning a human response to health conditions/ life processes, or a vulnerability for that response, by an individual, family, group, or community is known as a nursing _______.

Answer 79

diagnosis

Question 80

The human responses to health conditions/ life processes that exist in an individual, family, or community are known as an _________ patient problem.

Answer 80

Actual

Question 81

Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a _________ patient problem.

Answer 81

risk

Question 82

Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a _____________ patient problem.

Answer 82

wellness

Question 83

The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, lab tests, and procedures is known as a _________ diagnosis.

Answer 83

medical

Question 84

A health care system that provides control over health care services for a specific group of individuals in an attempt to control cost is known as _________ care.

Answer 84

managed

Question 85

A multidisciplinary plan that schedules clinical ____________ over an anticipated time frame for high risk, high volume, and high cost types of cases is known as a clinical pathway.

Answer 85

interventions