Chapter 9 - Potter Text Review Questions Flashcards
A nurse working on a cardiac unit is assigned an 84 year old patient who was just admitted with symptoms of lung infection. When the nurse enters the room, the nurse notices that the patient is short of breath, coughing, and has a respiratory rate of 36 breaths/min. The patient is anxious and states that she is “scared.” The nurse does an initial preliminary assessment and follows up 30 minutes later. The nurses’s knowledge about the patient results in which of the following assessment approaches? (Select all the apply) 1. A problem-focused approach 2. A structured comprehensive approach 3. Using multiple visits to gather a complete patient database 4. Focusing on the functional health pattern of a role-relationship
1, 3
A patient has a pressure ulcer resulting from urine incontinence and sustained pressure over her coccyx. The nursing plan of care includes a goal of “Pressure ulcer in 3 weeks.” Which of the following is an evaluative measure for this goal?
- Turn patient every 90 minutes
- Measure the diameter of the ulcer
- Measure the colors of the patient’s urine
- Determine patient’s report of discomfort during turning
2
A nurse has been interviewing a newly assigned patient. The cues from the assessment suggest that the patient has a problem breathing. The nurse does not validate the findings by doing a physical examination. This is an example of which type of error?
- Error in data clustering
- Error in data collection
- Error in diagnostic statement
- Error in interpretation and analysis
2
Which of the following are examples of data validation? (Select all that apply.)
- The nurse assess the patient’s heart rate and compares the value with the last value entered in the medical record.
- The nurse asks the patient if he is having pain and then asks him to rate the severity
- The nurse observes a patient reading a teaching booklet and asks him if he has any questions about its content.
- The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurements.
- The nurse asks the patient to describe a symptom by saying “go on.”
1, 4
Identify the source of diagnostic error (1. Collecting data 2. Interpreting 3. Clustering 4. Labeling) with the following activity:
Nurse listens to lungs for the first time and is not sure if abnormal lung sounds are present.
- Collecting data
Identify the source of diagnostic error (1. Collecting data 2. Interpreting 3. Clustering 4. Labeling) with the following activity:
After reviewing objective data nurse selects diagnosis of Pain before asking patient to describe the sensation.
- Interpreting
Identify the source of diagnostic error (1. Collecting data 2. Interpreting 3. Clustering 4. Labeling) with the following activity:
Nurse identifies an incorrect diagnostic label.
- Labeling
Identify the source of diagnostic error (1. Collecting data 2. Interpreting 3. Clustering 4. Labeling) with the following activity:
Nurse does not consider the patient’s cultural background when reviewing cues.
- Interpreting
Identify the source of diagnostic error (1. Collecting data 2. Interpreting 3. Clustering 4. Labeling) with the following activity:
Nurse prepares to complete decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern.
- Clustering
A nurse completes a respiratory assessment on a patient who had abdominal surgery 1 day ago. During the assessment she auscultates crackles in both lower lobes, and the patient coughs, producing light yellow sputum. The patient’s body temperature is 37 C (98.6 F), pulse is 110, respiratory rate is 28 breaths/min, and blood pressure is 118/82. Pulse oximetry was 99% and is now 93%. The nurse identifies a nursing diagnosis of Impaired Gas Exchange. Which of the following goals are appropriate for this patient? 1. Patient’s pulse oximetry will be greater than 95% 2. Patient will deep breathe and cough every 2 hours. 3. Patient’s lungs will be clear to auscultation. 4. Patient will be able to sleep through the night.
3
A nursing student is reporting off at the end of her shift to the RN. The student tells the RN that her patient has a priority diagnosis of Pain. She tells the RN that the last time the ordered analgesic was given was 2 hours ago. The patient continues to report pain at a level 4. The student also tried repositioning and distraction to reduce the patient’s discomfort. She observed her patient grimace while turning. Which expected outcome measure did the student report to the RN? 1. Administration of the analgesic as ordered. 2. The use of a distraction as a pain-relief measure. 3. The reported pain level of 4 on a scale of 0 to 10. 4. Observation of the patient grimacing during turning.
3
The nurse prepares to administer care to a patient by first positioning him more comfortably. She inspects his surgical wound and reinforces his dressing with extra tape. She explains the procedure that she will use for insertion of a urinary catheter. Which of the following is a dependent nursing intervention?
- Insertion of the urinary catheter
- Reinforcement of dressing with tape
- Instruction about the procedure for insertion of the urinary catheter
- Positioning the patient for comfort
1
During the implementation step of the nursing process, a nurse reviews and revises the nursing care plan. Place the following steps of review and revision in the correct order.
- Review the care plan.
- Decide if the nursing interventions remain appropriate
- Reassess the patient
- Compares assessment findings to validate existing nursing diagnosis
3, 4, 1, 2
A patient tells the nurse, “I have had this dull ache in my side for 4 days; it really hurts when I bend over.” The nurse responds, “All right, go on.” The nurses response is an example of:
- Inference
- A cue
- Back-channeling
- Open-ended questions
3
