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FCCA > Head to Toe Assessment (Module 3) > Flashcards

Head to Toe Assessment (Module 3) Flashcards

1
Q

What is the deliberate systemic problem solving approach for meeting a person’s health care needs by nurses?

A

Nursing process

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2
Q

What are characteristics of nursing dx?

A

A. Clinical judgement in response to actual or potential health problems
B.Developed by NANDA-I
C. Formed by recognizing patterns or data clusters

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3
Q

Which components are necessary for a nursing diagnosis statement? Select all that apply

A

A. Nursing dx identified and approved by NANDA-I
B. Defining characteristics (as evidenced by)
C. Related to factor (etiology)

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4
Q

Which component of the nursing dx statement identifies the physiologic or psychological factor that contributes to the patient problem?

A

Etiiology

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5
Q

Subjective and objective data contribute to which part of the nursing dx statement?

A

Nursing Dx

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6
Q

Which nursing dx statement is correctly stated?

A

Ineffective airway clearance r/t retained secretions as evidenced by abnormal lung sounds

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7
Q

What are the characteristics of patient outcomes? Select all that apply

A

A. Patient centered
B. Realistic
C. Directly observable and measurable
D. Used to evaluate the patient’s progress in resolving the problem

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8
Q

Which patient outcome statement is correctly stated?

A

Patient will have clear lung sounds in bilateral upper and lower lobes

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9
Q

What are the characteristics of nursing interventions? Select all that apply

A

A. Patient focused
B. Outcome directed
C. Consistent with standards of care

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10
Q

Which nursing intervention is correctly written?

A

The nurse will assist the patient with deep breathing and coughing for 3 repetitions

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11
Q

What nursing process action is the most essential for the RN to take after the interventions are completed?

A

Evaluate the effectiveness of the intervention in achieving the outcome

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12
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*What are 2 immediate, priority nursing dx that apply to Mrs. Feinstein’s current clinical condition? Select all that apply

A

A. Impaired gas exchange

B. Acute Pain

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13
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*Using Maslow’s Hierarchy of basic human needs, what is the priority nursing dx for Mrs. Feinstein?

A

Impaired gas exchange

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14
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*Mrs. Feinstein has a nursing dx of Impaired gas exchange. What is the “related to” factor for this nursing dx?

A

Imbalanced between oxygen supply and demand

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15
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*What is the evidence to support the nursing dx of impaired gas exchange for Mrs. Feinstein?

A

Impaired gas exchange r/t to imbalance between oxygen supply and demand as evidenced by: oxygen saturation of 90% on supplemental oxygen

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16
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*What is the outcome for this nursing dx statement?

A

Impaired gas exchange r/t imbalanced between oxygen supply and demand as evidenced by oxygen saturation of 90% on supplemental oxygen.
*Achieve an oxygen saturation greater than 95%

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17
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*What are the nursing interventions that would move Mrs. Feinstein’s toward the stated outcome? Select all that apply

A

Impaired gas exchange r/t imbalances between oxygen supply and demand as evidenced by oxygen saturation of 94% with supplemental oxygen.
Outcome: The patient will achieve oxygen saturation greater than95%
*Titrate oxygen as prescribed
*Reposition patient as needed in upright position

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18
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*What is the related factor (r/t) for the nursing dx of acute pain for Mrs. Feinstein?

A

Acute pain r/t tissue trauma

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19
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*What is the defining characteristic (as evidenced by) that supports and completes the nursing dx statement for Mrs. Feinstein?

A

Acute pain r/t tissue trauma as evidenced by: Patient rating pain a 5 on 0-10 verbal pain scale

20
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*What is the outcome statement for the following nursing dx statement for Mrs. Feinstein?

A

Acute pain r/t tissue trauma as evidenced by: Patient rating pain a 5 on 0-10 verbal pain scale
*The patient will: Have a pain level of or less on 0-10 verbal scale

21
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
What are the nursing interventions that would move Mrs. Feinstein toward the stated outcome? Select all that apply

A
  • Acute pain r/t tissue trauma as evidenced by: Patient rating pain a 5 on 0-10 verbal pain scale
  • The patient will: Have a pain level of or less on 0-10 verbal scale
  • Encourage patient to use PCA pump
  • Have patient perform guided imagery
22
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*Mrs. Feinstein rates her pain from a 7 to 5 on the 0 to 10 verbal pain scale after the RN provided pharmacological and non-pharmacological methods to decrease pain. Mrs. Feinstein states “Oh I really hurt alot.” What actions should the RN take before notifying the physician/provider? Select all the apply

A

A. Assess patency of the intravenous site
B. Obtain vital signs
C. Assess pain location, quality, aggravating and alleviating actions
D. Review the patient control analgesia usage hx

23
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*Which of the following nursing dx also apply to Mrs. Feinstein’s current clinical condition? Select all that apply

A

A. Impaired mobility
B. Risk for falls
C. Ineffective breathing pattern
D. Activity intolerance

24
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.
*What would be the related to (r/t) statement for the nursing dx for Mrs. Feinstein?

A

Activity intolerance r/t imbalance between oxygen supply and demand

25
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.

  • From the following list, select the defining characteristics/evidence (AEB) that supports and completes the nursing diagnostic statement for Mrs. Feinstein.
  • Activity intolerance r/t imbalance between oxygen supply and demand
A

as evidenced by: verbal report of feeling weak

26
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.

  • Select the outcome statement for the following nursing dx
  • Activity intolerance r/t imbalance between oxygen supply and demand as evidenced by: verbal report of feeling weak
A

The patient will verbalize feelings of being less weak with activity

27
Q

This question is r/t developing a nursing care plan for Mrs. Feinstein.

  • Which nursing interventions would help Mrs. Feinstein achieve outcome? Select all that apply
  • Activity intolerance r/t imbalance between oxygen supply and demand as evidenced by: verbal report of feeling weak
  • Outcome: The patient will verbalize feeling less weak
A

The nurse will: Assist patient with mobility, provide rest periods during care

28
Q

The RN has identified the nursing dx activity intolerance r/t imbalanced between oxygen supply and demand as evidenced by exertional dyspnea. What is the next step in developing a plan of care?

A

?

29
Q

The RN uses clinical judgement to determine that a patient may develop a neurovascular problem following the application of a long leg cast. Which nursing dx is most appropriate for this patient?

A

Risk for ineffective peripheral tissue perfusion

30
Q

For recently admitted patients, the health care facility has standardized nursing care plans generated by the computer. Which statement reflects the most appropriate RN response to the computer generated plan of care?

A

The appropriateness of the plan of care needs to be validated

31
Q

A patient is admitted to the hospital for hallucinations, confusion to time, place, and person, and a urinary tract infection. The family states the patient has some short term memory loss and does participate in activities of daily living. What is the appropriate outcome for the nursing dx of acute confusion?

A

The patient will: Interact appropriately with others

32
Q

Which is example of a complete nursing dx statement?

A

Acute pain r/t tissue trauma as evidenced by pain rating of 6 on 0-10 scale

33
Q

A patient has a nursing dx of risk of falls related to decreased strength in lower extremities. Which nursing intervention should be most effective in fall prevention for this patient?

A

?

34
Q

The RN has identified the nursing diagnosis of fatigue for a patient with cancer. Which nursing intervention will help the patient reach the outcome of reporting adequate energy to participate in important activities?

A

?

35
Q

Which statement contains accurate nursing dx and etiology components?

A

Ineffective airway clearance related to retained secretions

36
Q

The RN chooses the nursing dx of deficient fluid volume related to diarrhea for an infant with gastroenteritis. What is an appropriate outcome?

A

?

37
Q

A routine sonogram has detected a low implantation of the placenta on a woman in her second trimester of pregnancy. What is an appropriate intervention for the nursing dx of risk for bleeding related to placenta previa?

A

Have the patient report any bleeding

38
Q

Parents voice concerns about their 18 month old child who does not reach to be picked up, fails to cuddle when held, and does not make eye contact. What is an appropriate nursing dx for this child?

A

Impaired social interaction

39
Q

Which is the most appropriate outcome statement for the nursing dx of impaired gas exchange for a patient with pneumonia receiving oxygen therapy?

A

Have an oxygen saturation of 95% or greater

40
Q

A person with a 5 year hx of diabetes mellitus, hypertension, and body mass index of 35, is now seeking weight reduction assistance. What assessments should the RN perform before developing a nursing care plan using eh nursing dx of imbalanced nutrition: more than body requirements? Select all that apply

A

A. Tolerance to physical activity
B. Cultural meaning of foods
C. Economic information
D. Previous dieting information

41
Q

A patient verbalizes frustration about receiving unwelcomed electronic communication that is threatening their personal reputation. What is an appropriate nursing dx for this patient?

A

Powerlessness

42
Q

Using Maslow’s hierarchy of human needs, which patient problem identified by the RN should have the highest priority?

A

Ineffective airway clearance

43
Q

Place the steps of the nursing process in the order the RN should take to develop a plan of care for a patient.

A
  1. Assess
  2. Dx
  3. Plan
  4. Implement
  5. Evaluate
44
Q

What is the initial step the RN performs to identify significant data on a newly admitted patient?

A

Gather and organize objective and subjective data

45
Q

Which nursing dx has the highest priority for a patient immediately post abdominal surgery?

A

Acute pain related to tissue trauma

46
Q

The RN has assigned a patient the nursing dx of acute pain related to tissue trauma as evidence by reporting pain as an 8 on the 0 to 10 verbal pain scale. The mutually identified outcome is the patient will rate their pain as a 3 or less on the 0 to 10 verbal pain scale. After interventions are performed, the patient rates their pain as a 6. What action should the RN take first?

A

Review the interventions for appropriateness and effectiveness

47
Q

The patient states the current year is 1960 and John Kennedy is the President. Which component of the nurising dx: Acute confusion would this data support?

A

?

FCCA (6 decks)

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