Exam 1 Flashcards
What is an example of Nightingale’s contributions to nursing?
a. Graduated as the first trained U.S. nurse
b. Practiced nursing in the Civil War
c. Established the Red Cross
d. Emphasized respect for patients’ needs and rights
d.
_______ practiced nursing in the Civil War and established the Red Cross. ________ was the first U.S. trained nurse. _______ emphasized patients’ needs and rights.
Clara Barton
Linda Richards
Nightingale
Nurses are most likely to utilize which of the following theories or models in their leadership role?
a. Maslow and Erikson
b. Health Belief Model
c. Lewin
d. Von Bertalanffy
c.
The nurse will use _____ change theory most often in the leadership role. ______ hierarchy of needs, __________ developmental theory, and the ________ will be utilized most during patient care and education.
Lewin’s
Maslow’s
Erikson’s
Health Belief Model
A team meeting of physicians and nurses is convened to discuss a specific patient’s problems and to determine goals for the patient. During the meeting, specific accountability related to patient care for both the physicians and nurses involved is established. All members of the meeting show mutual respect by valuing each other’s clinical competence that is necessary to provide quality patient care. Of the following functions of a nurse, which one is demonstrated in the above example?
a. Delegation
b. Advocacy
c. Collaboration
d. Management
c.
__________ in which health care professionals constructively solve problems and learn from each other.
dynamic interpersonal process of collaboration
A nurse has graduated from a nursing program and is participating in a new graduate program at a local hospital as a continuing socialization to the role of the nurse. At what level is the nurse functioning at this point in the nurse’s career?
a. Expert
b. Competent
c. Novice
d. Advanced Beginner
D.
The nurse is an _______ for 2 to 3 years after graduating and doesn’t reach the level of competence until the end of that time period.
Advanced Beginner
Nursing students all belong to National Student Nurses Association when they are attending a specific nursing program. This is an important aspect of their socialization to the profession as it demonstrates which criteria of a profession?
a. Providing service to society
b. Accepting responsibility for actions and omissions
c. Participating in an organization that supports and advances the profession
d. Making independent decisions based on their scope of practice
C.
Students begin their ________ to the profession by participating in an organization, which is one criteria of a profession.
socialization
What is the nurse’s role as patient advocate? (Select all that apply.)
a. Explain to the patient the nurse’s viewpoint.
b. Provide necessary education and interpret information.
c. Accept the patient’s decision and support his or her wishes.
d. Give the patient the physician’s explanation of his or her viewpoint.
B., C.
The nurse as the _________ must first provide education and interpret information in an unbiased manner. Then the nurse must accept the patient’s decision and support his or her wishes even if it is different from the nurse’s own viewpoint or that of other health care personnel.
patient advocate
A nurse is planning a program for educating a Hispanic community regarding nutritional practices. What would be the most important aspects that the nurse takes into consideration first? (Select all that apply.)
a. Change theory and Health Belief Model
b. Previous educational programs
c. Cultural influences
d. Hospital admissions from this community
A, C
Since the nurse will be discussing nutrition to a specific cultural group, the nurse needs to understand the _________ on their nutritional practices. In addition the nurse needs to understand change theory to plan her education if she is attempting to have the group make changes in their nutritional practices. ________ would also help in understanding the community’s perceptions regarding barriers that facilitate or discourage adoption of the promoted behaviors.
Cultural influences,
The Health Belief Model
How might a nurse as a researcher approach the care of the patient? (Select all that apply.)
a. Performing technical skills as learned
b. Looking for problems and questioning practices
c. Incorporating research she has read into her practice
d. Carrying out procedures as they always have been done
B, C
By looking for problems and questioning practices, the nurse is identifying problems that can be researched. By incorporating any new research into practice, the nurse is involved in __________.
Evidence-Based Practice
In comparing the American Nurses Association (ANA) and the International Council of Nurses (ICN) definitions of nursing, what component does the ICN mention that is not included in ANA’s definition and is indicative of a more global focus?
a. Advocacy
b. Health promotion
c. Shaping health policy
d. Prevention of illness
C.
The ____ definition of nursing expands on the _____ definition by providing for the concept of shaping health policy as a responsibility of nursing.
ICN’s
ANA’s
A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized processes? (Select all that apply.)
a. Code of ethics
b. Licensing
c. Body of knowledge
d. Educational preparation
e. Altruism
a, b, c, e
______ as a profession has a code of ethics, licensing, a body of knowledge, and altruism. Because there are multiple paths of education for nursing and not a standard entry into practice, this is one criterion of a profession that is not standard and consistent.
Nursing
What specific aspect of a profession does the development of theories provide?
a. Altruism
b. Body of knowledge
c. Autonomy
d. Accountability
B
_____ establish a specific nursing body of knowledge that is unique to the discipline, which is one criterion of a profession.
Theories
Health care workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs and practices of these patients. What important aspect of nursing professional practice are they exhibiting?
a. Autonomy
b. Accountability
c. Cultural competence
d. Autocratic leadership
C
The nurse and other health care workers are exhibiting ________ by being responsive to patients’ health beliefs and practices that are influenced by the individual’s culture.
cultural competence
A nurse makes a medication error, immediately assesses the patient, and reports the error to the nurse manager and the primary care provider. Which characteristic of a professional is the nurse demonstrating?
a. Autonomy
b. Collaboration
c. Accountability
d. Altruism
C.
The nurse is demonstrating ______ by taking responsibility for the error and reporting it after an initial assessment of the patient. Criteria of a profession include _______ (public service over personal gain), ________ (independence), accountability, and diversity; however, in this case, the nurse is demonstrating accountability. Although _________ is important for the health care team, it is not a criterion for a profession.
accountability
altruism
collaboration
Of the following, which are included in the ANA standards? (Select all that apply.)
a. Standards for professional performance
b. Code of ethics
c. Standards of care
d. Legal scope of practice
e. Licensure requirements
A, C
____ standards have two parts: one is standards for professional performance, and the other is standards of care. _____ has a separate document that is a code of ethics. Nurse practice acts are a legal scope of practice.
ANA
Which core competency of advanced practice nursing is the Master of Science in Nursing (MSN) nurse educator exhibiting when counseling a student in therapeutic communication techniques?
a. Leadership
b. Ethical decision making
c. Direct clinical practice
d. Expert coaching
D.
A _______ who is teaching and counseling students is practicing expert coaching and guidance. A _______ with a master’s degree practices the other competencies of leadership and ethical decision making in other situations. Although a _______ may also work as a nurse involved in direct patient care, this is not part of the _______ role.
nurse educator
Which of the following statements describes a component discussed in nursing theories? (Select all that apply.)
a. Optimal functioning of the patient
b. Interaction with components of the environment
c. The conceptual makeup of the administration of the hospital
d. The illness and health concept
e. Safety aspect of medication administration
A, B, D
There are four components that a nursing theory discusses:
(1) the patient
(2) health
(3) environment
(4) nursing—not the hospital administration.
Which factors affect the nursing shortage? (Select all that apply.)
a. Aging faculty
b. Increasing elderly population
c. Job satisfaction due to adequate number of nurses
d. Aging nursing workforce
e. Greater autonomy for nurses
A, B, D
A nurse has performed a physical examination of the patient and reviewed the laboratory results and diagnostics on the patient’s chart. The nurse is performing which specific nursing function?
a. Diagnosis
b. Assessment
c. Education
d. Advocacy
B.
Nurses need to understand how beliefs and values are different. A nurse begins to offer information to a patient and the patient says, “I’ve already heard all of that before and I don’t agree with any of it.” How should the nurse proceed?
a. Ask the patient to explain his values.
b. Ask the patient to explain what he believes.
c. Ask the patient about his prejudicial attitude.
d. Confront the patient about the values conflict he’s experiencing.
B
Which nursing theory of care describes how the nurse’s presence in the nurse-patient relationship transcends the physical and material world, facilitating the development of a higher sense of self by the patient?
a. Swanson’s Theory of Caring Processes
b. Madeline Leininger’s Cultural Care Theory
c. Watson’s Theory of Human Science and Human Care
d. Travelbee’s Human-to-Human Relationship Model
C
Which statement best describes for new parents how and when children develop first-order beliefs?
a. During infancy, and once developed, such beliefs seldom change
b. From life experiences during the toddler and preschool years
c. Throughout life from first-hand experiences and information provided by authority figures
d. From teen and young-adult peer interaction and mentorship of professional role models
C
As the nurse explained the preoperative instructions to the patient, the patient’s older brother suddenly stepped into the doorway and yelled, “People who go under the knife always die. Don’t do it! They’re going to kill you.” What type of higher-order belief is the patient’s older brother displaying?
a. Distress
b. Stereotype
c. Prejudice
d. Denial
B
After admitting a homeless patient to the floor, the nurse tells a colleague that “homeless people are too dumb to understand instructions.” What action should the colleague take first?
a. Ignore the nurse’s prejudicial comment without responding
b. Offer to trade assignments and care for the homeless patient
c. Ask the nurse about the patient’s personal history assessment data
d. Challenge the nurse’s thinking, pointing out the ability of all people
C
The nurse in the emergency department is caring for an 8-year-old who has had a serious asthma attack. When the nurse attempts to explain the problem to the child’s mother, she smells cigarette smoke on the mother’s breath. The nurse asks the mother if she has been smoking and the mother responds, “Yes, and I know they’ve told me before I can’t smoke around him.” What should the nurse do next?
a. Ask the patient’s mother what she values more, her child or her habit.
b. Ask the patient’s mother to explain what she believes about smoking and asthma.
c. Ask the patient’s mother about her prejudicial attitude toward smoking.
d. Confront the patient’s mother about the values conflict she’s experiencing.
B.
A nurse is working with a 35-year-old patient who needs to decide whether to donate a kidney to his brother who has been in renal failure for 5 years. The patient shares with the nurse that the decision is especially difficult because he would not be able to continue to work in his current profession and would be unable to support his three small children if he ever needed dialysis. Which intervention(s) would be most appropriate for the nurse to implement in this situation? (Select all that apply.)
a. Explain that it is unlikely that he will ever need dialysis even if he has only one kidney.
b. Guide the patient through a values clarification process to help him make a decision based on his values.
c. Provide information the patient needs to help him make an informed decision.
d. Ask for his permission to contact the kidney donation team to answer any questions he may have.
B, C, D
A 57-year-old male patient who was hospitalized with an admitting blood pressure of 240/120 asked the nurse if his family could bring in some meat and vegetable dishes from home. He explained that he cannot eat the foods on the hospital menu because it is summer and the hospital is only offering chicken and fish, which in his culture are “hot” foods that will interfere with his healing. Which response by the nurse would best demonstrate an application of Leininger’s theory?
a. Discourage the family from bringing in food, explaining that the idea of “hot” and “cold” foods is a superstition without scientific basis.
b. Negotiate home-prepared food options with the patient and his family to ensure that treatment for the patient’s blood pressure is supported.
c. Explain that the patient will need to have home-prepared foods evaluated by the dietary staff to ensure that they are acceptable options.
d. Tell the family to bring in any foods they want, to help preserve the patient’s cultural practices and dietary preferences.
B.
In Swanson’s Caring Theory, the nurse demonstrates caring using several techniques. Which of the following is (are) included in the five caring processes? (Select all that apply.)
a. Call patients by their first name to demonstrate a caring attitude.
b. Sit at the bedside for at least 5 minutes each hour.
c. Use touch based on the nurse’s judgment of what is appropriate.
d. Ask the patient to identify the most important thing to accomplish during the nurse’s shift.
D.
A new nurse is about to insert a nasogastric tube for the first time but is not sure what equipment to gather or how to begin the procedure. The patient is an 80-year-old woman who is frightened and slightly confused. Which actions by the nurse would best demonstrate caring? (Select all that apply.)
a. Offer the patient pain medication to help her calm down.
b. Hold the patient’s hand while inserting the nasogastric tube.
c. Speak calmly while explaining the procedure to the patient beforehand.
d. Ask another, more experienced nurse for assistance before initiating care.
C, D
According to _____, negotiation and adaptation are part of what nurses do to accommodate the patient’s cultural ways of life. As long as the foods from home have low concentrations of sodium or other ingredients that are known to affect blood pressure, the nurse can accommodate the patient’s beliefs and cultural dietary practices as well as the medical plan of care. Rejecting the patient’s cultural traditions and/or accepting them without regard for the well-being of the patient are unacceptable actions. Food given to patients from family members does not need to be evaluated by the dietary staff before consumption.
Leininger’s theory
One of the major concepts of ________ is described in the stem of the question. Watson’s theory is based on a holistic paradigm in which both the nurse and the patient transcend time and the physical and material world.
Watson’s Theory of Human Caring
________ focuses on practical ways the nurse can help the patient through the use of the five caring processes.
Swanson’s theory
________ focuses on maintaining and preserving the patient’s cultural practices and ways of living but never mentions transcending beyond the physical world.
Leininger’s theory
________ focuses on the nurse and the patient creating a relationship bond, but the only mention of transcendence is that the nurse and the patient must transcend the roles that each has assumed.
Travelbee’s theory
The best approach for a nurse who is performing an assessment on a patient from an ethnic group the nurse knows nothing about is to
a. use the information the nurse already knows about the other ethnic groups that may be similar to the patient’s group to come up with assessment questions.
b. ask the same questions the nurse typically asks of all patients and not deviate from the questions on the assessment form.
c. ask the patient to explain what he or she believes his or her health problem is and what he or she thinks caused it.
d. ask the patient to help the nurse understand anything about the patient’s ethnic group that may have a bearing on the patient’s health care needs.
D
A co-worker is an excellent nurse but often assumes responsibility for other people’s irresponsible behaviors. Her nurse manager notices that in the past several months she has become overly sensitive with her patients and that she complains of feeling stressed and worn out because she has taken on too much. She admits to having a family background that makes her suspect she has some co-dependent traits. How should her nurse manager proceed if the nurse’s work continues to suffer?
a. The manager should offer her emotional support for as long as she needs it.
b. Help her recognize that she may be co-dependent and needs to get professional help.
c. Take her to the next scheduled group therapy session in the mental health ward.
d. Confront her about her inappropriate behavior and threaten to fire her if her work doesn’t improve.
B
A nurse recognizes the importance of active listening as a way to show the nurse cares. Which of the following actions by the nurse describes active listening? (Select all that apply.)
a. Sitting at the patient’s bedside and listening to the patient talk while inserting an IV
b. Sitting in a chair facing a patient and making a mental note of the major points of the conversation
c. Listening to what the patient says and what he means while she conducts her early morning assessment
d. Engaging both the patient and the family members while taking careful notes of the conversation
B
Which of the following actions by the nurse demonstrates “doing for” as described in Swanson’s theory?
a. Going the extra mile
b. Thoroughly assessing in order to know what the patient thinks
c. Seeking cues and expertise from colleagues about the patient’s condition
d. Preserving the patient’s dignity and performing competently
D
A nursing student walks into the patient’s room and is unsure about when it is appropriate to use caring touch in a nurse-patient care situation. What should the student do?
a. Leave the room and ask her clinical instructor when and where she should touch her patient.
b. Ask the patient for permission to touch her before proceeding.
c. Disregard the use of touch since she is unsure of how to maintain professional boundary when it comes to touching a patient.
d. Assume all patients want to be touched and that they see it as an act of caring.
B
While doing her morning assessment, the nurse shares with her patients the tests and procedures they have scheduled for that day as well as when she expects to return to deliver their medications or do their treatments. Even though the hospital is a hectic and difficult environment to predict, the nurse regards this information session with her patients as an important way to demonstrate she cares. The rationale behind her action is
a. to increase the patients’ sense of security by making the environment more predictable for the patients.
b. to ease her patients’ fears since they may worry that she’ll forget to give them their medications.
c. to point out to her patients that the care they are receiving is consistent and delivered on time so they will rate her care higher when they leave the hospital.
d. to allow the patients some flexibility in when they want to take their medications or have their tests and procedures done.
A.
The nurse recognizes the importance of a patient’s beliefs in influencing the patient’s behaviors and responses to health care problems. Which of the following are examples of a patient’s beliefs? (Select all that apply.)
a. A patient explains that the medication he is taking is helping him overcome his anxiety.
b. A patient reflects on her values and uses them to help her make a decision about whether or not to have breast reconstruction surgery.
c. A patient expresses a feeling of dread about the future to his nurse.
d. A 78-year-old man signs a “Do Not Resuscitate Order” when he learns he’s had a massive heart attack because, he explains, “he can hardly wait to go and be with his wife in heaven.”
A, D
A nurse is gathering an admission assessment on a patient who recently emigrated from Japan and is a Buddhist. The man told the nurse that he normally meditates daily and lives almost exactly the way he did in Japan. However, he has not been able to walk for the past weeks. Based on the assessment findings, which questions would be important for the nurse to ask before implementing his nursing care? (Select all that apply.)
a. What have you done to cope with your health problem?
b. What do you call your health problem? What do you think is wrong?
c. What concerns you most about the recommended treatment plan?
d. What do you think caused your health problem?
A, B, C, D
________ means doing nothing else but listening to the patient. It’s about being attentive and engaged.
Active listening
A hospitalized patient experiences a sharp, stabbing pain while visiting with his spouse. Both the patient and his wife become very concerned, and the patient’s call light is activated. What referent initiated communication between the patient and the nurse?
a. Interaction between the patient and his wife
b. Concern on the part of the patient’s spouse
c. Pain experienced by the patient
d. Activation of the call light
c.
Which factor influences whether a message is effectively communicated? (Select all that apply.)
a. Timing of the conversation
b. Educational level of participants
c. Mode of communication utilized
d. Physical environment of discussion
A, B, C, D
If a patient is grimacing, what assessment statement or question would be most beneficial to identifying the underlying cause of the nonverbal communication?
a. “Did you lose something?”
b. “You appear to be having pain.”
c. “I will turn off the lights and let you rest.”
d. “May I get you something to relieve your tension?”
B.
What action by the nurse would most ensure accurate interpretation of patient communication?
a. Providing feedback regarding the conveyed message
b. Writing down the patient’s conversational highlights
c. Assuming significant cultural differences exist
d. Verifying the patient’s emotional state
A.
If a patient’s verbal and nonverbal communications are inconsistent, which form of communication is most likely to convey the true feelings of the patient?
a. Written notes
b. Facial expressions
c. Implied inferences
d. Spoken words
B
What strategy would be most effective in communicating with a highly anxious adult immediately before surgery?
a. Providing specific, concise instructions
b. Detailing likely causes of their anxiety
c. Focusing on postoperative details
d. Using instructional multimedia DVDs
A
What action should the nurse take if an alert and oriented patient asks the nurse for personal contact information?
a. Ask the patient why the personal information is needed.
b. Report the interaction to the nursing supervisor immediately.
c. State that it would not be appropriate to share that information.
d. Change the subject, and hope that the patient does not ask again.
C
What would be the best therapeutic response to a patient who expresses indecision about recommended chemotherapy treatments?
a. “Can you tell me why you are undecided?”
b. “It’s always a good idea to have chemotherapy.”
c. “You should follow whatever your health care provider recommends.”
d. “What are you thinking about the treatments at this point?”
D
Which statement is most accurate regarding symbolic expression?
a. Skills confidence can be shared most effectively by nurses through wearing distinctive clothing.
b. Clothing choices by a hospitalized patient rarely reflects his or her economic resources.
c. Make-up use by a patient is unnecessary for any reason during hospitalization.
d. Nondramatic make-up use and minimal accessorizing by nurses demonstrates professionalism.
D
Which defense mechanism is being exhibited when a 27-year-old patient insists on having a parent present during routine care?
a. Denial
b. Regression
c. Repression
d. Displacement
B
______ of a conversation dramatically influences the receptivity of the receiver.
Timing
_______ is a common nonverbal sign of pain. Sharing an observation encourages the patient to elaborate on nonverbal communication. Asking the patient whether something is lost indicates that the nurse has not attended to the nonverbal cues of the patient. It is important to do an assessment of the patient before initiating any interventions.
Grimacing
_______ is the most effective way to avoid misinterpretation of a message. It helps ensure that the message sent is perceived by the receiver in a way that is consistent with the intention of the sender.
Feedback
_________ is the more accurate mode of conveying feelings.
Nonverbal communication
The nurse receives change of shift report on the five assigned patients and reviews prescriptions, treatments, and medications scheduled for the shift. Based on analysis of this information, the nurse chooses which patient to assess first. Which process of critical thinking best describes the nurse’s action?
a. Problem solving
b. Decision making
c. Judgment
d. Reasoning
b
In approaching a new clinical situation, the nurse uses which question to facilitate precision in critical thinking?
a. “What do I know about this situation?”
b. “What additional details do I need to gather?”
c. “Does the clinical presentation correlate with the diagnosis?”
d. “Are the treatments appropriate for the diagnosis?”
b
Which question would be most appropriate for the nurse to ask while evaluating the relevance of patient data?
a. Do these findings make sense?
b. How can this information be verified?
c. What are the most significant factors in the problem?
d. What is the relationship of this information to other data?
c
The nurse is assigned to develop a plan of care for a patient with a medical diagnosis that is unknown to the nurse. Guided by critical thinking, which action should the nurse take first?
a. Ask the patient to describe the chief complaint
b. Request that another nurse be assigned to this patient
c. Review data about the medical diagnosis and routine management
d. Complete a physical assessment of the patient
c
The nurse obtains a lower-than-normal (88% on room air) pulse oximetry reading on a patient. Which actions by the nurse result from accurately employing the critical-thinking skill of analysis in the nursing process? (Select all that apply. )
a. Assessing the patient for symptoms of hypoxia
b. Providing oxygen according to standing orders
c. Elevating the head of the bed, if not contraindicated
d. Allowing the patient to be alone to rest more comfortably
e. Discussing adaptations needed for daily activities with the patient
a, b, c
Which of the following actions reflects inductive reasoning?
a. Using subjective and objective data to confirm a diagnosis
b. Assessing for specific clinical presentations based on a disease process
c. Correlating elevated blood pressure to pathophysiology
d. Validating an automatic blood pressure cuff reading with a manual measurement
a
The nurse is completing an assessment on a patient with sudden onset of abdominal pain. During the assessment, the nurse considers similar presentations and the underlying pathophysiology related to the patient’s clinical manifestations. Which critical-thinking skill should the nurse use first to determine the cause of the patient’s abdominal pain?
a. Evaluation
b. Interpretation
c. Reflection
d. Inference
b
The nurse can facilitate critical thinking through the use of which interpersonal skills? (Select all that apply.)
a. Teamwork
b. Intuition
c. Judgment
d. Conflict management
e. Advocacy
f. Reasoning
a, d, e
In providing care to a patient admitted to rule out human immunodeficiency virus (HIV) infection, wearing gloves during which activity may be an indication of bias?
a. Collecting the patient’s medical history
b. Administering IV medications
c. Performing oral care
d. Completing a bed bath
a
During the assessment of a patient admitted for a total hip replacement, the nurse asks the patient to explain prior hospital experiences and, more specifically, any operative experiences. These questions reflect the nurse’s use of which intellectual standard of critical thinking?
a. Clarity
b. Logic
c. Precision
d. Significance
a
is used when the nurse is faced with a situation that requires analysis and a solution.
Problem Solving
is used in the decision-making process but does not result in the actual decision.
Judgement
is logical thinking that may be used in decision making but, again, is not the actual result.
Reasoning
relates to providing sufficient detail to lead to an exact understanding of the situation.
Precision
is effective in establishing the relevance of data.
Determining Relationship
_____ of information is related to accuracy, making “sense” relates to logic, and significance more closely relates to depth.
Verification
______ involves assessing a situation and determining what should be done based on an appropriate rationale.
Analysis
_________ uses specific facts or details to make conclusions and generalizations (i.e., going from specific to general).
Inductive Reasoning
________ involves generating facts or details from a major theory, generalization, or premise (i.e., from general to specific).
Deductive Reasoning
Nurses use________ to understand and explain the meaning of data.
interpretation
________ such as teamwork, conflict management, and advocacy engage others in the process of critical thinking.
interpersonal skills
The nurse facilitates the use of the intellectual standard of critical thinking of significance by posing which question to determine the patient’s understanding of his or her new diagnosis of type 1 diabetes mellitus on his or her lifestyle?
a. “What information do I need to provide to teach the patient?”
b. “Do you understand how to administer your insulin?”
c. “What are the signs of low blood glucose?”
d. “How will this diagnosis impact your career?”
D
In providing care to a newly admitted patient, the nurse’s inferences are more accurate if based upon which of the following?
a. Objective data
b. Assumptions
c. Intuition
d. Experience
A
During the postoperative assessment on a patient, the nurse has a “hunch” that the patient has a postoperative complication based upon
a. intuition.
b. interpretation.
c. information processing.
d. inference.
A
In using intuition to address a clinical problem, the expert nurse bases his or her approach upon which of the following?
a. Judgment
b. Data collection
c. Experiential knowledge
d. Logical deduction
C
A new graduate nurse explains a new approach in the positioning of patients with chronic low back pain. The nurse preceptor responds, “That is not the way we do it here.” The preceptor’s response illustrates which error in critical thinking?
a. Lack of information
b. Erroneous assumptions
c. Illogical thinking
d. Bias
C
The nurse uses a case study presentation to present an educational offering to the staff on the unit. This strategy improves the staff nurses’ critical thinking through which of the following?
a. Reviewing the literature
b. Practicing application of knowledge
c. Discussing with colleagues
d. Role playing
B
In preparing to administer medications to a patient, the nurse notes a medication that she has never administered. If the nurse administers the medication without researching the medication, this represents which error in critical thinking?
a. Lack of information
b. Illogical thinking
c. Close-mindedness
d. Erroneous assumptions
A
The nurse uses critical thinking to interpret data. Which of the following data sources are objective? (Select all that apply.)
a. Patient interview
b. Laboratory values
c. Body language
d. X-ray results
e. Vital signs
f. Breath sounds
b, d, e, f
In preparing for a certification examination, the nurse chooses to develop a concept map to help understand the content. This strategy is based upon which characteristics of concept maps? (Select all that apply.)
a. Facilitates note taking
b. Requires thinking aloud
c. Fosters making correlations between concepts
d. Validates content with an expert
e. Organizes visual data
A, C, E
______ focuses on how important the information (diagnosis of diabetes mellitus) is to the issue being addressed.
Significance
________ is based upon observable data that can usually be replicated by another provider, it is the more valid basis for inferences.
objective data
_______ is often characterized by hasty generalizations and assumptions that do not consider the evidence.
Illogical thinking
______ is observable data that is assessed through vision, hearing, smell, and touch.
Objective Data
_______includes patient history and nonverbal data such as body language, facial expressions, etc.
Subjective Data
_______ are a method to organize and visualize data in order to identify relationships and solve problems. _______ can be used for note taking, mapping nursing care plans, and preparing for exams
Concept Maps
What term best describes the nature of the nursing process?
a. Static
b. Linear
c. Dynamic
d. Predictable
C
A disoriented patient is admitted to the hospital accompanied by his spouse. From whom should the nurse collect subjective data on this patient?
a. An experienced nurse on the unit
b. The patient’s medical record
c. The patient’s wife
d. His physician
C
Prior to identifying accurate nursing diagnoses, what action must be taken by the nurse?
a. Reading the patient’s history
b. Setting realistic, measurable goals
c. Comparing evidence-based practices
d. Clustering related patient data
D
A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse’s first action?
a. Tell the child that if she stops crying, her parents can be with her.
b. Check to see what pain medication is ordered for the child.
c. Notify the surgeon of the child’s postoperative condition.
d. Assess the child to determine why she is crying.
D
Which statement is a correctly written example of an actual nursing diagnosis?
a. Impaired memory related to patient complaint of becoming confused with the time change
b. Risk for injury related to stumbling when walking as evidenced by patient report of occasional difficulty playing basketball
c. Activity intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea on exertion and significant drop of oxygen saturation from 98% to 88% with activity
d. Ineffective health maintenance as evidenced by inability to complete activities of daily living related to lack of familial support system
C
Which long-term goal is written correctly?
a. Patient will remain afebrile throughout hospitalization.
b. Patient will return to professional sports activities within 6 months.
c. Nurse will prevent bone infection through antibiotic therapy for 3 weeks.
d. Patient will demonstrate accurate use of crutches without assistance before discharge from emergency room.
B
What phrase best describes the essence of critical thinking?
a. Understanding without conscious reasoning
b. Providing care based on nursing experience
c. Consulting with a primary care provider
d. Seeking solutions to problems
D
Which body is responsible for defining and disseminating information on nursing diagnoses?
a. North American Nursing Diagnosis Association International
b. International and American Nurses Association
c. Individual State Boards of Nursing
d. The Joint Commission
A
The statement “ongoing collection of data” best describes which phase of the nursing process?
a. Planning
b. Evaluation
c. Assessment
d. Implementation
C
Which statement illustrates the most measurable outcome indicator?
a. Demonstrates dressing change
b. Shares innermost thoughts
c. Understands instructions
d. Shows personal remorse
A
A nurse admits a patient to the cardiac care unit following the placement of a cardiac stent. Which step of the nursing process does the nurse do first?
a. Planning
b. Assessment
c. Evaluation
d. Implementation
B
What should be the focus of all nursing interventions?
a. Early hospital discharge for patients
b. Providing patient-centered care
c. Reduction of health care spending
d. Delegating appropriate nursing care
B
Which action should the nurse take 30 minutes after administering oral pain medication to a patient?
a. Evaluate the effectiveness of the administered pain medication.
b. Teach progressive relaxation strategies to relieve muscle tension.
c. Assess the patient’s coping skills to reduce expressed anxiety.
d. Encourage the patient to read or watch TV to provide pain distraction.
A
The ______ is dynamic, changing over time in response to patients’ individual needs. The dynamic, responsive nature of the ______ allows it to be used effectively with patients in any setting and at every level of care, from the intensive care unit to outpatient wellness clinics.
nursing process
________ are established and revised biannually by NANDA International, Inc. (NANDA-I), a professional nursing organization that provides standardized language to identify patient problems and plan customized care.
nursing diagnosis
________ focuses on the patient and the patient’s response to nursing interventions and goal or outcome attainment. During the ______ step of the nursing process, nurses use critical thinking to determine whether a patient’s short- and long-term goals were met and desired outcomes were achieved.
Evaluation
What is the purpose of the nursing process?
a. Providing patient-centered care
b. Identifying members of the health care team
c. Organizing the ways nurses think about patient care
d. Facilitating communication among members of the health care team
C
The ______ is the methodology used to “think like a nurse.”
nursing process
What is the purpose of the nursing process?
a. Providing patient-centered care
b. Identifying members of the health care team
c. Organizing the ways nurses think about patient care
d. Facilitating communication among members of the health care team
C
A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first?
a. Family history of diabetes
b. Medications the patient is taking
c. Operations the patient has had in the past
d. Severity and duration of the nausea and vomiting
D
An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient?
a. Family member
b. Physician
c. Another nurse
d. Patient
D
What is the primary purpose of the nursing diagnosis?
a. Resolving patient confusion
b. Communicating patient needs
c. Meeting accreditation requirements
d. Articulating the nursing scope of practice
B
On what premise is a nursing diagnosis identified for a patient?
a. First impressions
b. Nursing intuition
c. Clustered data
d. Medical diagnoses
C
Which statement is an appropriately written short-term goal?
a. Patient will walk to the bathroom independently without falling within 2 days after surgery.
b. Nurse will watch patient demonstrate proper insulin injection technique each morning.
c. Patient’s spouse will express satisfaction with patient’s progress before discharge.
d. Patient’s incision will be well approximated each time it is assessed by the nurse.
A
What should be the primary focus for nursing interventions?
a. Patient needs
b. Nurse concerns
c. Physician priorities
d. Patient’s family requests
A
Which nursing action is critical before delegating interventions to another member of the health care team?
a. Locate all members of the health care team.
b. Notify the physician of potential complications.
c. Know the scope of practice for the other team member.
d. Call a meeting of the health care team to determine the needs of the patient.
C
A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first?
a. Identify reasons the patient is unable to sleep.
b. Request medication to help the patient sleep.
c. Tell the patient that sleep will come with relaxation.
d. Notify the physician that the patient is restless and anxious.
A
What action should the nurse take regarding a patient’s plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery?
a. Consult the surgeon to see if the clinical pathway is being followed.
b. Discontinue the plan of care, because the patient has met the established goal.
c. Monitor patient urine output to evaluate the need for the current plan of care.
d. Notify the patient that the goal has been attained and no further intervention is needed.
C
In an _______, the nurse initially focuses on the patient’s chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.
emergent situation
The nurse collects ______ directly from patients who are alert and oriented. Family members and other members of the health care team may provide ______ on patients.
primary data
secondary data
_______ emerge from groupings of clustered data collected during the assessment phase of the nursing process.
Nursing Diagnosis
are to be patient-focused, realistic, and measurable.
Goals
_______needs are always the primary focus of nursing interventions. Nursing concerns, physician priorities, and family requests can provide additional guidance in the development of a patient-centered plan of care.
Patient
Which piece of assessment data may be accurately obtained during the observation phase?
a. Pulse irregularity
b. Slow capillary refill
c. Elevated temperature
d. Presence of body odor
d
Patients from which generation would be most comfortable with the nurse using electronic resources for health screening?
a. Baby boomers
b. Generation X
c. Millennials
d. Veterans
c
Which type of question would be best for the nurse to use when trying to determine the extent of a patient’s knowledge concerning a disease process?
a. Open ended
b. Direct
c. Close ended
d. Focused
a
Which statement by the nurse best describes health history assessment?
a. “The first patient interview is the best source of all essential health history data.”
b. “When health history data is updated, patient information collected earlier is no longer useful.”
c. “Collection of health history information is ongoing and methodical throughout patient interaction.”
d. “Gathering health history data is best accomplished in a random, relaxed fashion as topics arise.”
c
Which statement illustrates appropriate documentation following palpation?
a. Abdomen soft, non-tender without distention
b. Density noted over kidney margins bilaterally
c. Reddened area 3 inches in diameter noted on left thigh
d. Heart sounds distant over the mitral and tricuspid valves
a
What type of assessment is most appropriate for a patient newly admitted to the hospital for intermittent loss of vision in the left eye?
a. Emergency
b. Complete
c. Focused
d. Triage
b
Which statement is the best example of subjective, secondary data?
a. Unlicensed assistive personnel reports patient’s blood pressure is 138/84
b. Patient complains of extreme fatigue and dizziness when walking in the room
c. Nurse states that the patient’s chest x-ray has a shadow in the left upper lobe
d. Spouse reports patient has been vomiting intermittently for the last 48 hours
d
A patient is admitted to the nursing unit with numbness and tingling in the right hand, pain in the cervical spine, and occasional loss of consciousness. Into which functional health pattern would the nurse organize this data?
a. Self-perception and self-concept
b. Coping and stress tolerance
c. Cognition and perception
d. Activity and exercise
C
Which information gathered during assessment is considered to be subjective data?
a. The client’s urine is dark and foul-smelling.
b. The patient’s 24-hour urine output is 1800 mL.
c. The patient indicates pain and burning are present when urinating.
d. The patient is taking an antibiotic for a urinary tract infection.
c
The most important source in data collection is/are
a. nursing literature.
b. the patient.
c. medical records.
d. family members.
b
Which action(s) should the nurse take during the termination phase of the patient interview? (Select all that apply.)
a. Express appreciation for the patient’s participation.
b. Review key assessment findings that were noted.
c. Validate information covered with the patient.
d. Allow the patient to add additional insights.
a, b, c, d
The nurse uses the senses of sight, hearing, and smell during the _______ phase of assessment. The presence of body odor is the only patient data listed that can be accurately assessed during this phase. Pulse irregularity, slow capillary refill, and elevated temperature all require vital sign assessment or palpation.
observation
The best source of information about the patient is the ______, not the family, the medical record, or nursing literature.
patient
During the ______ phase, interaction should be drawn to a logical conclusion and information should be reviewed, clarified, and verified prior to initiating care. Appreciation for the patient’s participation should be acknowledged and the patient should be encouraged to add any additional information or thoughts that come to mind prior to ending the interaction.
termination
Which action by a patient marks the beginning of the physical assessment process?
a. Redressing after a physical examination
b. Breathing normally during auscultation
c. Greeting the nurse in the examination room
d. Sharing work environment information
c
Which factors should be taken into consideration by the nurse before and during a patient interview? (Select all that apply.)
a. Distance between the chairs in which the nurse and patient are sitting
b. Traditional treatments typically used by the patient to treat disease
c. Gender preference for primary care providers
d. Physical condition of the patient
e. Music preference of the patient
a, b, c, d
Which action by the nurse is most appropriate during the orientation phase of the patient interview?
a. Always position patients in a comfortable reclined position to ensure their comfort during questioning.
b. Ask which name a patient prefers to be called during care to show respect and build trust.
c. Quickly conduct a review of systems to determine the need for a complete or focused assessment.
d. Begin with questions about intimacy and sexuality to address sensitive issues first.
b
Which activity by the nurse best demonstrates part of the working phase of a patient interview?
a. Summarizing previously discussed key topics
b. Including selected family members in care planning
c. Transferring care responsibilities to the home health nurse
d. Verifying the name by which a patient prefers to be addressed
b
Which entry in a patient’s electronic health record best indicates the need for a nurse to gather secondary rather than primary subjective data?
a. Complaining of chest pain
b. Apical pulse 110
c. Comatose
d. Difficulty swallowing
c
Which line of questioning by the nurse best represents an appropriate approach to the review of systems aspect of the assessment process?
a. “What do you do for a living? Can you describe your work environment?”
b. “Is there a family history of heart disease, cancer, high blood pressure, or stroke?”
c. “When was your last annual physical? What immunizations did you receive at that time?”
d. “Do you have any chest tightness, shortness of breath, or difficulty breathing while exercising?”
d
Which cue by a patient can be validated by laboratory and diagnostic test results?
a. Deeply sighing with fatigue
b. Bilateral crackles in the lungs
c. Oxygen saturation of 98% on room air
d. 2+ pitting edema of the ankles and feet
a
A patient discusses his job stress and family relationships with the nurse during his health history interview. In which organizational framework is this type of data likely to be recorded most extensively?
a. Body systems model
b. Physical assessment model
c. Head-to-toe assessment model
d. Functional health patterns model
d
When initiating a physical examination, which action should the nurse take first?
a. Review of the patient’s prior medical records
b. Gather admission health history forms
c. Assess the patient’s vital signs
d. Perform light and deep palpation for fluid
c
If the nurse discovers that a patient’s right elbow is swollen and painful during a physical examination, which action should the nurse take next?
a. Apply ice to decrease swelling and reduce pain
b. Percuss the area to determine the presence of fluid
c. Perform passive range of motion to promote flexibility
d. Inspect the patient’s left elbow to compare its appearance
d
begins at the moment the patient first interacts with the nurse.
assessment
Redressing takes place at the end of the physical examination.
redressing
Breathing during auscultation is part of the ________ assessment, and sharing health history and demographic information takes place during the patient interview.
respiratory
A ________ takes place during the working phase of the nurse-patient interview, just before initiation of the physical assessment.
review of systems
Summarizing key topics covered in the interview and transferring care responsibilities take place in the ________.
termination phase
During a _______, the patient is asked questions about each body system to determine the level of functioning. Asking about work-related information, family history, and immunizations is accomplished during the collection of health history data before initiating the _________.
review of systems
A ____ is a behavioral hint of a potential disease process or concern.
cue
Job stress and family relationships data will only be recorded extensively when using the _______. The________ is holistic in its approach.
Functional health patterns model
Assessment of the patient’s vital signs begins the physical examination aspect of the _______ process. This provides the nurse with baseline information about cardiac and respiratory function, pain level, and temperature.
assessment
A major aspect of assessment is checking for _______. If an abnormality is observed on one side of a patient’s body, the next step in the assessment is to compare that area with the other side.
symmetry
The hospice nurse believes the nursing diagnosis chronic sorrow is significant in the recovery process of patients recently experiencing a loss. What is required to support the addition of new nursing diagnoses to the NANDA-I taxonomy?
a. Clinical research and data collection
b. Changes in patient status and life experience
c. Anecdotal nursing experiences
d. Patient requests
a
The nurse has just received a postoperative patient to the floor postureteral stone manipulation. Choose the priority nursing diagnosis.
a. Risk for urinary retention r/t general anesthesia and trauma to ureter
b. Pain, acute r/t recent surgical procedure and verbalization of pain of 4 on scale 0-10
c. Risk for bleeding r/t surgical site injury
d. Comfort, impaired r/t inability to urinate and verbalization “I am beginning to feel full”
A
The relationship of the medical diagnosis to the nursing diagnosis is
a. the medical diagnosis is embedded within the nursing diagnostic statement.
b. nursing diagnoses are driven by/derived from the medical diagnosis.
c. the medical diagnosis is not relevant to the nursing diagnosis.
d. the medical and nursing diagnoses should complement each other.
D
An example of implementation of evidenced practice by the nurse would be the nurse
a. initiates a new policy protocol for the removal of c-collars and bed board restraints of the emergency department patient based on empirical research results.
b. watched a news report on a new procedure for chest tube removal and implements the procedure on the patient needing chest tubes removed.
c. saw a physician perform a manipulation for vertigo related to inner ear problems and decides to utilize the manipulation for the current patient experiencing vertigo.
d. is assisting a physician with conscious sedation during a procedure and is asked to perform outside the nursing scope of practice.
A
The clustering of data is significant to the nursing diagnoses step because clustering of data will
a. show the nurse assessment is complete for this patient.
b. move the nurse toward accurate planning for the symptoms in clustered data.
c. group the data of similar problems and aid in accurate nursing diagnosis identification.
d. organize the data for clear assessment so further assessment can occur.
C
________, documenting the study findings of nurses who practice using the nursing process, is required to support the addition of new nursing diagnoses to the NANDA-I taxonomy.
Clinical research
________ are developed through comprehensive research and data collection to support the eventual confirmation of actual nursing diagnostic statements.
Nursing diagnoses
________ take into consideration a patient’s attitudes, strengths, and resources—not just the medical problems identified—which are critical for planning holistic, individualized care.
Nursing diagnoses
After collecting and reviewing all of the assessment data, the nurse looks for patterns and related data to support specific nursing diagnoses. This process is referred to as ________. ________ involves organizing patient assessment data into groupings with similar underlying causes. The nurse looks for cues among the data that support the diagnosis of a problem. ________ is not associated with assessment. Symptoms are not the only data ________. Data are _______ during diagnosis, not assessment.
clustering data or clustering or clustered
What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I?
a. Insurance documentation
b. Professional autonomy
c. Role delineation
d. Patient safety
d
Which nursing diagnosis is appropriately written? (Select all that apply.)
a. Risk for Infection related to elevated temperature and white blood count
b. Readiness for Enhanced Relationship as evidenced by mutual respect verbalized by spouses and expressed desire for improved communication
c. Noncompliance related to inability to access care as evidenced by failure to keep appointments, homebound status
d. Risk for Bleeding with the risk factor of prolonged clotting time
e. Chronic Pain related to osteoarthritis as manifested by verbalized postoperative discomfort.
b,c,d
Which phrase best represents a related factor in an actual nursing diagnosis?
a. Unsteady gait requiring the assistance of two people
b. Redness and swelling around the incision site
c. Ineffective adaptation to recent loss
d. Patient complaint of restlessness
c
Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.)
a. Thoroughly review the patient’s medical history
b. Analyze the nursing assessment data to determine whether information is complete
c. Outline an individualized plan of care to address each concern
d. Consider potential complications to which the patient is susceptible
e. Evaluate how the patient has responded to treatment
a, b, d
What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis?
a. Defining characteristics are not part of a risk diagnosis.
b. There is no cause and effect relationship established.
c. Defining characteristics are subjective in a risk diagnosis.
d. There are no nursing interventions prescribed with a risk diagnosis.
a
What is the most important action for a nurse take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy?
a. Share concerns with the nurse manager on the nursing unit
b. Offer alternative care for a patient and family members
c. Discuss how to address patient needs with physicians
d. Provide evidence-based research to support nursing care
d
What is the most significant problem that may result from improperly written nursing diagnostic statements?
a. Lack of direction for formulating patient plans of care
b. Omission of physician or primary care provider orders
c. Combining of two unrelated patient concerns
d. Increased team collaboration needs
a
Which statement best describes the relationship of medical diagnoses and nursing diagnoses?
a. Medical diagnoses are imbedded in nursing diagnoses.
b. Nursing diagnoses are derived from medical diagnoses.
c. Medical diagnoses are not relevant to nursing diagnoses.
d. Medical diagnoses may be interrelated to nursing diagnoses.
d
A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take?
a. Resume all interventions for previously identified nursing diagnoses.
b. Perform the steps of the nursing process related to the patient’s current condition.
c. Seek physician input related to updating the nursing diagnosis statements.
d. Evaluate the success of the acute care plan for management of the cardiac arrest.
b
What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.)
a. Denies any difficulty falling asleep
b. Elevated pulse rate auscultated at 140 BPM
c. Continuous foot tapping throughout intake interview
d. Demonstrates how to give insulin self-injection without hesitation
e. Patient states, “I feel nervous all the time, especially when I am alone.”
b, c, e
is the most important reason for using standardized language to communicate patient’s needs and information.
safety
is a heath-promotion nursing diagnosis and is written with two sections: the label and the defining characteristics.
Readiness for Enhanced Relationship
is a nursing diagnosis that requires a related factor and defining characteristics.
Noncompliance
requires at least one risk factor. Use of related factors in a risk nursing diagnosis is not the accepted NANDA-I format.
Risk for Bleeding
are broad statements that indicate the cause for the defining characteristics, which are signs or symptoms identified from collecting the patient’s data.
Related factors
_______ do not have defining characteristics; actual and health-promotion nursing diagnosis statements have defining characteristics. _________ do not establish a cause and effect, because they identify potential rather than existing problems. ________ contain related or risk factors rather than defining characteristics, subjective or otherwise. _________, like actual diagnoses, have nursing interventions to address a patient’s current or potential problem.
Risk diagnoses
consider the underlying etiology, needs, potential concerns, and patient response to a patient’s medical diagnosis, so the two types of diagnoses are interrelated.
Nursing diagnoses
Which action would the nurse undertake first when beginning to formulate a patient’s plan of care?
a. List possible treatment options
b. Identify realistic outcome indicators
c. Consult with health care team members
d. Rank patient concerns from assessment data
d
Which resource is most helpful when prioritizing identified nursing diagnoses?
a. Nursing Interventions Classification (NIC)
b. Gordon’s functional health patterns
c. Maslow’s hierarchy of needs
d. Nursing Outcomes Classification (NOC)
c
If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care?
a. Fatigue
b. Acute Pain
c. Knowledge Deficit
d. Body Image Disturbance
b
Which statement illustrates a characteristic of goals within the care planning process?
a. Goals are vague objectives communicating expectations for improvement.
b. Short-term goals need not be measurable, unlike long-term goals.
c. Goal attainment can be measured by identifying nursing interventions.
d. Long-term goals are helpful in judging a patient’s progress.
d
Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery?
a. Nurse will encourage use of sterile technique during each dressing change.
b. Patient’s white blood count will remain within normal range throughout hospitalization.
c. Patient’s visitors will be instructed in proper hand washing before direct interaction with patient.
d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.
b
If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.)
a. Expressed desire to eat
b. Report that food smells good
c. Use of relaxation techniques before meals
d. Preparation of home-cooked meals for self and family
e. Uses nutritional information on labels to guide selections
a, b, d
Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult?
a. Providing a written copy of care options to the patient and family
b. Collaborating with the patient’s social worker to determine resources
c. Listening to the patient’s concerns and beliefs about proposed treatment
d. Engaging the patient’s family, friends, or care providers in conversation
c
Which intervention can the nurse initiate independently while providing patient care? (Select all that apply.)
a. Ordering a blood transfusion
b. Auscultating lung sounds
c. Monitoring skin integrity
d. Applying heel protectors
e. Adjusting antibiotic dosages
b, c, d
The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider?
a. Elevating the head of the patient’s bed
b. Administering oxygen by nasal cannula
c. Assessing the patient’s oxygen saturation
d. Evaluating the patient’s peripheral circulation
b
Which situation indicates the greatest need for collaborative interventions provided by several health care team members?
a. Hospice referral
b. Physical assessment
c. Activities of daily living
d. Health history interview
a
Prioritizing or ranking patient needs precedes the identification of outcome indicators, consulting with team members, or consulting with interdisciplinary team members.
prioritizing
is one method of organizing assessment data.
Functional health patterns
is the most urgent nursing diagnosis to address.
acute pain
may be a result of the pain and may be alleviated if the patient’s pain level is reduced.
fatigue
________ can be treated only after the patient’s pain level is at an acceptable level. Both diagnoses require teaching, during which the patient needs to concentrate.
Body Image Disturbance and Knowledge Deficit
A person’s ability to concentrate is affected by the ________.
pain level
It is most important to _____ the patient in developing realistic, attainable, patient-centered plans of care.
involve
The nurse seeks assistance from the speech therapist on a patient’s case to determine the patient’s ability to swallow food. Which care technique is utilized here?
a. Indirect communication
b. Collaboration
c. Delegation
d. Assistive contribution
b
______ entails using expertise of health care professionals to pool resources and knowledge to provide quality care.
Collaboration
Which of the following is a direct care intervention?
a. Reviewing the most recent clinical results from the laboratory
b. Collaborating with social services regarding patient discharge plans
c. Performing patient education regarding use of an incentive spirometer
d. Obtaining medical records from a previous admission
c
______ interventions are completed directly with the patient.
direct care
Documentation is a component of which part of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
c
_______ includes performing and documenting nursing interventions.
implementation
Which of the following would be an inappropriate intervention for a patient with the nursing diagnosis of “Impaired Physical Mobility”?
a. Use pressure relieving devices on bed and chair.
b. Promote independence in performing all activities of daily living.
c. Reinforce safety precautions with the patient and family.
d. Perform active and passive range of motion three times daily.
b
A patient presents to the emergency room with chest pain. Which of the following is the priority nursing intervention?
a. Administer acetaminophen immediately.
b. Provide oxygen via nasal cannula as ordered by the physician.
c. Provide emotional support.
d. Prepare the patient for emergency surgery.
b
Which of the following statements most accurately reflects the nursing process?
a. Cyclical in nature and steps overlap
b. Can be delegated to increase productivity
c. Must be completed in an orderly sequence from beginning to end
d. Should follow standard structure for all patients
A
is cyclical and ever-changing as the patient condition changes.
nursing process
Which of the following is an example of collaboration?
a. The nurse receiving orders from a physician
b. The nurse and physical therapist creating an ambulation schedule for the patient
c. The nurse arranging for discharge instructions to be provided to the patient and family
d. The nurse providing the patient with a video on insulin injections
B
______ involves teamwork to accomplish a patient goal. The nurse and physical therapist creating an ambulation schedule can maximize the efforts and effects of the activity.
collaboration
Which of the following is an important component in evaluating patient outcomes and the plan of care?
a. Nursing judgment and critical thinking
b. Communication with the interdisciplinary team
c. Implementing every intervention
d. Nursing attitude
a
Which of the following are components of delegation? (Select all that apply.)
a. Assigning the correct task
b. Assigning planning in the nursing process
c. Having the LPN contact the physician for orders
d. Using correct supervision to the delegate
e. Assigning a task under the right circumstances
A, D, E
What should the nurse consider before implementation of all nursing interventions? (Select all that apply.)
a. Potential communication barriers
b. Diverse cultural practices
c. Scope of nursing practice
d. Functional status of the patient
e. Time of most recent shift change
a, b, c, d
Which intervention would be most important for the nurse to include in a patient’s care plan if the patient is unable to complete activities of daily living without becoming fatigued?
a. Instruct the patient to shower and shave simultaneously
b. Discourage the patient from bathing while hospitalized
c. Encourage the patient to rest between bathing activities
d. Ask the patient’s spouse to assist with all bathing
c
Which nursing intervention is most important to complete before giving medication to a patient?
a. Provide water to aid in the patient’s ability to swallow the medication.
b. Double-check the patient’s allergies before giving the drug.
c. Ask the patient to verify having taken the medication before.
d. Place the patient in a side-lying position to prevent aspiration.
b
Which direct-care intervention would be most effective in helping a patient cope emotionally with a new diagnosis of cancer?
a. Reassessing for changes in the patient’s physical condition
b. Teaching the patient various methods of stress reduction
c. Referring the patient for music and massage therapy
d. Encouraging the patient to explore options for care
d
What should be taken into consideration by the nurse when deciding on interventions to include in a patient’s plan of care? (Select all that apply.)
a. Patient’s treatment preferences
b. Cultural and ethnic influences
c. Professional level of expertise
d. Current evidence-based research
e. Convenience to the nursing staff
a, b, c, d
Which task may the registered nurse safely delegate to unlicensed assistive personnel without prior intervention?
a. Ambulating a patient with ataxia and new right sided paresthesia
b. Feeding a patient with cerebral palsy who recently aspirated
c. Transporting a patient to the hospital entrance for discharge
d. Administering prescribed programmed medications
c
Which action is a part of the evaluation step in the nursing process? (Select all that apply.)
a. Recognizing the need for modifications to the care plan
b. Documenting performed nursing interventions
c. Determining if nursing interventions were completed
d. Reviewing whether a patient met their short-term goal
e. Identifying realistic outcomes with patient input
a, d
Which action by the day-shift nurse provides objective data that enables the night- shift nurse to complete an evaluation of a patient’s short-term goals?
a. Encouraging the patient to share observations from the day
b. Leaving a message with the charge nurse before shift change
c. Documenting patient assessment findings in the patient’s chart
d. Checking with the pharmacist regarding possible drug interactions
c
Which notation is most appropriate for the nurse to include in a patient’s chart regarding evaluation of the goal, “Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)”?
a. Goal not met; patient states he is tired.
b. Goal not met; patient ambulated three times in room.
c. Goal met; patient ambulated three times in the hallway.
d. Goal met; patient ambulated three times in the hallway without SOB.
d
What is the primary purpose of quality improvement?
a. Recognizing the need to discipline employees violating policies
b. Preventing patient injury that may contributor to the death of others
c. Increasing institutional profits to support further scientific research
d. Enhancing current practices to improve patient outcomes and care
d
