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Fundamentals > Chapters 3-7 > Flashcards

Chapters 3-7 Flashcards

1
Q

Rosalind, a nurse, considers the most recent evidence-based policy on care of the client with pneumonia while identifying patient needs.
What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

D

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2
Q

Mrs. Clancy is a nursing home patient at risk for falls. The head nurse asks one of the unlicensed assistive personnel to assist Mrs. Clancy to the dining hall and help prepare her for dinner. What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

E

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3
Q

Mr. Thompson had surgery yesterday for a hernia repair. His pain is significant. The nurse delivers an injection of pain medicine 30 minutes before Mr. Thompson needs to ambulate in the hall. What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

E

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4
Q

The nurse is caring for Ms. Lee, a client who does not speak English. The nurse learns from the patient’s family that Ms. Lee has specific religious needs that she cannot address because of the hospital routine. Adjustments are made in the plan of care based on this information. What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

F

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5
Q

Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asks what Mr. Patel has eaten in the last 24 hours. What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

A

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6
Q

Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was “no further falls will occur while in the care center.” What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

C

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7
Q

Upon discharge, the nurse realizes that all care plan goals were met. The documentation is updated to reflect this. What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

F

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8
Q

Mary is a 17-year-old, diagnosed with a brain tumor, who has recently begun chemotherapy. The nurse asks her how being hospitalized is impacting her senior year of high school. What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

A

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9
Q

Adrian, a nurse, reflects on her client’s admission information, including physical assessment and related family concerns. She considers all information to reach conclusions. What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

B

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10
Q

The nurse, Linda, identifies some concerns about her patient’s financial situation and ability to pay the hospital bill. She approaches the healthcare provider to request that a social worker meet with the client prior to discharge. What step of the nursing process is this?
A - Assessment
B - Diagnosis
C - Planning outcomes
D - Planning interventions
E - Implementation
F - Evaluation

A

C

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11
Q

Which of the following about the nursing process is correct?
A - Includes only the care that the nurse will deliver
B - Works alongside an individualized plan of care
C - Results in outcomes designed by the client
D - Composed of a linear process with unique, distinct steps

A

B

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12
Q

The diagnosis step of the nursing process includes which activity?
A - Performing and documenting nursing actions
B - Evaluating goal achievement
C - Analyzing data
D - Assessing and diagnosing

A

C

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13
Q

Which statement or command made by the nurse is an example of the evaluation phase of the nursing process?
A - “Mr. Sullivan may be able to ambulate with the use of a walker and stand-by assistance.”
B - “Mr. Sullivan will be able to walk the length of the hallway before discharge.”
C - “Ambulate Mr. Sullivan in the hallway three times today, please.”
D - “I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal.”

A

D

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14
Q

The nurse is performing an assessment on a client. What should be included in this process?
A - Religious and spiritual needs
B - Ability to pay for hospital stay
C - Who brought patient to the hospital
D - Level of education

A

A

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15
Q

Which statement is correct about critical thinking and the nursing process?
A - Everything a nurse does requires critical thinking.
B - The nursing process is a critical-thinking, problem-solving model.
C - Nursing process is the only form of critical thinking used in nursing.
D - When using the nursing process, critical thinking is not needed.

A

B

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16
Q

Which type of assessment is performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected?
A - Initial assessment
B - Focused assessment
C - Global assessment
D - Special needs assessment

A

B

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17
Q

During an assessment, the nurse notes that the client has an elevated temperature. Which type of data is this?
A - Subjective
B - Objective
C - Secondary
D - Reported

A

B

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18
Q

Which type of evaluation is performed while implementing care, immediately after an intervention, and at each client contact?
A - Ongoing evaluation
B - Intermittent evaluation
C - Terminal evaluation
D - Subjective evaluation

A

A

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19
Q

Which describes components of implementation in the nursing process? Select all that apply.
A - Doing
B - Deciding
C - Delegating
D - Documenting
E - Caring

A

A
C
D

20
Q

Which are examples of a direct-care nursing intervention? Select all that apply.
A - Giving a medication
B - Notifying the physician of a change in assessment
C - Obtaining vital signs
D - Giving a bedside bath
E - Consulting case management for home oxygen

A

A
C
D

21
Q

A nurse who is obtaining a health history through an interview asks, “What can you tell me about your previous knee replacement surgery?” Which type of question is this?
A - Closed
B - Open-ended
C - Chief complaint
D - Contributing history

A

B

22
Q

Which of the following best demonstrate nurse’s critical thinking skills?
A - Individualized patient care plans
B - Physician’s orders
C - Critical pathways
D - Electronic medical records

A

A

23
Q

The nurse in a community clinic is assessing a 23-year-old client who reports upper respiratory congestion and a cough that has lingered for 3 weeks. In the initial interview, the nurse learns the client’s family lives out of state and that the client goes to school part-time while waiting tables part-time. What might the nurse infer from this information?
A - The client has most likely not had a recent physical examination.
B - The client’s parents have provided health care up to this point.
C - Waiting tables places the client at a higher risk for developing illnesses.
D - The client’s age indicates he or she may not be compliant.

A

A

24
Q

While helping a postsurgical client ambulate, the nurse notices the client becomes short of breath with little exertion. Which is the next step in the nursing process for this client?
A - Reevaluating and creating a new nursing diagnosis and outcome
B - Continuing with the current nursing plan but with modifications
C - Starting over in the assessment process to recreate the nursing plan so it is effective
D - Creating a new intervention based on the current status of client

A

A

25
Q

What does the nurse know is true about conducting the nursing assessment?
A - Assessments must be completed within 24 hours of inpatient admission.
B - Assessment cannot be delegated to others.
C - All clients are assessed for pain, nutritional status, and risk for falls.
D - Vital signs can always be conducted by nursing assistive personnel.
E - Assessments are not required for clients who are not being admitted.

A

A
B
C

26
Q

During a client’s appointment at the women’s clinic, she states her menstrual flow is very heavy, occurs about every 3 weeks, and is accompanied by severe abdominal cramping. The breast exam is normal, and the results of the Pap smear are normal. However, the client’s hemoglobin level is low, and the nurse suspects the heavy menstrual bleeding may be causing anemia. Which information is considered primary data?
A - Heavy menstrual flow every 3 weeks with severe abdominal cramping
B - Normal breast exam
C - Normal Pap smear
D - Evidence of link between anemia and heavy menstruation
E - Low hemoglobin

A

A
D

27
Q

When creating a nursing diagnosis for a client with renal failure, what questions should the nurse ask during the assessment process?
A - Is the client still producing urine?
B - What is the client’s oral intake?
C - Does the client exhibit signs of edema?
D - Can the client ambulate without assistance?
E - Can the client engage in activities of daily living?

A

A
B
C
E

28
Q

Why is the diagnosis step critical to the nursing process?
A - It connects the assessment with planning, interventions, and follow-up evaluation.
B - Without a complete nursing diagnosis, insurance will not compensate the hospital.
C - It provides the physician with necessary information to make a medical diagnosis.
D - Nursing diagnoses are needed to support any therapeutic treatments and diagnostic testing.

A

A

29
Q

Which is the best explanation of the difference between a medical diagnosis and a nursing diagnosis?
A - A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client’s health status and how a nurse can help independently.
B - A medical diagnosis is made by a physician, and a nursing diagnosis is created by a nurse.
C - A medical diagnosis involves interventions and medical treatment, and a nursing diagnosis involves client comfort and activities of daily living.
D - A medical diagnosis determines the nursing diagnosis, while the nursing diagnosis has no bearing on the medical diagnosis.

A

A

30
Q

Which are examples of nursing diagnoses?
A - Risk for impaired skin/tissue integrity
B - Ineffective impulse control
C - Insufficient breast milk
D - Renal failure
E - Emphysema with chronic obstructive pulmonary disease (COPD)

A

A
B
C

31
Q

Which scenarios are considered collaborative problems?
A - Hyperglycemia with type 2 diabetes
B - Infection in a postsurgical client
C - Hemorrhage in a postpartum client
D - Oliguria with renal failure
E - Shortness of breath with emphysema

A

A
B
C

32
Q

Which are examples of cue clusters for a nursing diagnosis?
A - Hard, painful bowel movement approximately every 3 to 4 days; sedentary lifestyle; low dietary fiber intake; dry skin
B - Pain and limited range of motion in knees, use of walker, medical diagnosis of osteoarthritis
C - Sore throat, fever, inability to ambulate, medical diagnosis of depression
D - Dry skin, painful urination, epistaxis
E - Urinary incontinence, lower abdominal pain, bladder spasm

A

A
B
D

33
Q

A statement such as “readiness for enhanced self-care” is an example of which type of nursing diagnosis?
A - Wellness diagnosis
B - Syndrome diagnosis
C - Very specific NANDA-l label
D - Risk diagnosis

A

A

34
Q

The abbreviations “AEB” and “AMB” are considered connecting phrases for which portion of the nursing plan?
A - Basic three-part statement
B - Two-part NANDA-I label
C - Collaborative problem
D - Complex etiology

A

A

35
Q

A client admitted 2 days ago has not slept well due to pain from injuries. The nurse recognizes this and adjusts the client’s nursing diagnosis to reflect the change in status. The nurse then creates a new plan to address the change. What type of planning is this considered?
A - Initial planning
B - Ongoing planning
C - Discharge planning
D - Preexisting planning

A

B

36
Q

Which type of data should be included in the discharge planning?
A - Functional and self-care limitations
B - Emotional stability and ability to learn
C - Family or other caregivers available
D - Use of community services before admission
E - Medical diagnosis

A

A
B
C
D

37
Q

Which is an appropriate goal statement for a postpartum female client with a nursing diagnosis of “lower abdominal pain r/t uterine contractions and hyperextension of cervix”?
A - Client will verbalize reduced pain with pain management interventions to a satisfactory level within a 12-hour period
B - Uterus will cease contracting after treatment within 2 hours
C - Lower abdominal pain will be relieved by analgesics as prescribed by physician
D - Client will ambulate to the bathroom at least twice within 8 hours to relieve pressure from abdomen

A

A

38
Q

A postsurgical client has a new nursing diagnosis of “Constipation related to immobility and decreased gastrointestinal (GI) motility secondary to narcotic analgesics.” Which are appropriate nursing interventions for this client?
A - Administer laxative or stool softener as prescribed.
B - Encourage increased fluid intake, including warm liquids.
C - Educate the client about and encourage a high-fiber diet.
D - Discontinue analgesic.
E - Encourage an increased exercise program.

A

A
B
C

39
Q

Which nursing interventions are considered direct-care interventions?
A - Physical care
B - Emotional support
C - Client education
D - Making a referral
E - Managing the environment

A

A
B
C

40
Q

Which is an appropriate nursing order for a client with a nursing diagnosis of “ineffective airway clearance”?
A - Turn, cough, and deep breathe every 2 hours.
B - Client will maintain open, clear airways as evidenced by normal breath sounds.
C - Client will recognize differences in sputum color, odor, amount, and character.
D - Refer to pulmonary specialist as indicated.

A

A

41
Q

When working with a postoperative bariatric client, how can the nurse promote client participation and adherence to the nursing plan? Select all that apply.
A - Ensure the client feels comfortable asking questions.
B - Keep the instructions simple, clear, and as specific as possible.
C - Determine if the client’s goals for weight loss are the same as those in the nursing plan.
D - Help the client set realistic goals.
E - Carry out goal implementation and interventions even when the client doesn’t “feel like it.”

A

A
B
C
D

42
Q

Which information is needed to record an evaluative statement?
A - Conclusion and supportive data
B - Original goal with outcome
C - Outcome and changes made to the plan
D - Initial assessment date and final evaluation date

A

A

43
Q

Which type of assessment is performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected?
A - Initial assessment
B - Focused assessment
C - Global assessment
D - Special needs assessment

A

B

44
Q

Which are tools for recording assessment data? Select all that apply.
A - Graphic flow sheet
B - Intake and output sheet
C - Client handbook
D - Shift report form
E - Primary survey

A

A
B

45
Q

When a client is hospitalized, at which point in the treatment regime should discharge planning begin?
A - Initial assessment
B - Focused assessment
C - After the discharge order is written
D - After the special needs assessment

A

A

Fundamentals (7 decks)

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