Practice Exam Flashcards
Which statement best describes the relationship between implementation and assessment?
a. ) Data obtained during assessment helps the nurse to plan the individualized care provided during the implementation phase
b. ) Implementation of care does not depend on assessment
c. ) Implementation and assessment can be performed simultaneously
d. ) The physician does assessment, but implementation is a nursing diagnosis
a.) Data obtained during assessment helps the nurse to plan the individualized care provided during the implementation phase
Care must be tailored to meet the individual patient’s unique needs. Assessment is necessary before the implementation phase can begin.
The nurse notes that a client’s urine appears dark and concentrated, and has a strong odor. Based on this assessment, what step of the nursing process should be performed next?
a. ) Planning
b. ) Evaluating
c. ) Diagnosing
d. ) Assessment
c.) Diagnosing
Using assessment data, the nurse will then establish one or more diagnoses for the client. The nurse first must identify potential causes of the abnormal assessment finding. Interventions must be carried out before the evaluating phase can take place. Planning cannot take place until diagnoses have been established.
A client tells the nurse, “These pills don’t look like the ones I usually take.” The best response by the nurse would be:
a. ) “Go ahead and take it. It’s the generic variety.”
b. ) “Take the pills that you recognize and leave the rest.”
c. ) “I’ll take these back and recheck your medications.”
d. ) “For now, just take the ones you recognize.”
c.) “I’ll take these back and recheck your medications.”
Always double check meds, the patients often know their meds well and can tell you if something is out of the norm
A medication order reads, “Restoril 15mg hs prn”. The nurse gives the medication:
a. ) Before meals at the nurse’s discretion
b. ) After meals at the patient’s request
c. ) At bedtime as needed
d. ) Immediately as ordered
c.) At bedtime as needed
Consider the following nursing diagnosis: Chronic Pain related to pain from stiff joints. What is the error in this diagnosis?
a. ) It should have been written as a one-part nursing diagnosis
b. ) It includes a medical diagnosis
c. ) It is judgmental
d. ) It says the same thing twice
d.) It says the same thing twice
A properly written nursing diagnosis needs to have each component stated correctly. The etiology must not restate the diagnostic label. Answer 1 is not a wellness or syndrome diagnosis. In Answer 2, there is no medical diagnosis in the nursing diagnosis. This is a nonjudgmental statement.
What is the problem with the following outcome goal: “Client will state that pain is less than or equal to 2 on a 0 to 10 pain scale.”
a. ) It does not have a condition or measure
b. ) There is no time frame stated
c. ) Client behavior is missing
d. ) None, the goal is correctly written
b.) There is no time frame stated
There is no time frame by which the goal achievement can be measured. For example, the time frame may be stated as “by 48 hours after surgery”.
Which of the following is a correctly written nursing diagnosis that the nurse should add to the client’s care plan?
a. ) Altered Nutrition: Less than Body Requirements
b. ) Pneumonia related to infectious process
c. ) Impaired Physical Mobility related to weakness in lower extremities
d. ) Acute Pain related to pain from abdominal incision
c.) Impaired Physical Mobility related to weakness in lower extremities
A two-part nursing diagnosis requires the diagnostic label (problem statement) and etiology (probable cause).
Answer 1 is a diagnostic label only, and does not include etiology. Answer 2 is a medical diagnosis, not a nursing diagnosis. Answer 4 restates the diagnosis.
A patient with acute pain has a physician’s order for meperidine (Demerol) 50 mg IM every 3-4 hrs prn for pain. The patient asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should take which of the following actions?
Nurse should assess aspects of pain before implementing any pain relief measures
Which of the following is a benefit of the evaluation process?
a. ) It promotes modifications and improvements in care
b. ) It enhances accurate diagnosis of the client’s needs
c. ) It facilitates the selection of realistic, client-centered outcomes
d. ) It facilitates collaboration between members of the health care team
a.) It promotes modifications and improvements in care
A process of ongoing evaluation permits optimization of care delivered to the client. Assessment enhances accurate diagnosis. Accurate assessment, not evaluation, facilitates the selection of client-centered outcomes. Facilitating collaboration between members of the health care team is not a direct benefit of evaluation.
Suppose a desired outcome statement is poorly written. What effect, if any, will it have on client care?
a. ) None, because the nurse can rewrite the outcome
b. ) The diagnoses will have to be rewritten
c. ) Additional assessment may be necessary
d. ) The planned interventions may be incorrect
d.) The planned interventions may be incorrect
Poorly written outcome statements affect the planned interventions. The interventions cannot be properly planned or implemented with poorly written goals. The nurse will have already begun implementing the care plan that will have been improperly planned
A client has a nursing diagnosis of Bathing/Hygiene Self-Care Deficit related to left-sided weakness manifested by inability to get in and out of the bathroom, inability to wash hands or face, and fatigue. An appropriate goal for this client would be that the client:
a. ) Demonstrate a greater interest in self-care and bathing by 9/1/07
b. ) Demonstrate a greater interest in self-care and bathing by 9/1/07
c. ) Have a nursing assistant bathe the client once daily
d. ) Attend occupational therapy once daily to focus on left arm movement
b.) Demonstrate a greater interest in self-care and bathing by 9/1/07
Goals are written in terms of client responses, not nurse activities. Goals must be realistic and compatible with therapies (if prescribed). The goals should flow from the nursing diagnoses and be measurable. Answer 1 is not measurable; therefore, it is not appropriate. Have a nursing assistant bathe the client once daily is what the nurse will do; it is not stated in client terms. Answer 4 is a client activity, but it does not have a measurable outcome for the nurse to evaluate.
After administering pain medication to a patient, it is MOST important for the nurse to take which of the following actions?
a. ) Do not disturb the patient
b. ) Keep the environment cool and quiet
c. ) Provide diversionary activities at short intervals
d. ) Determine whether the medication is effective
d.) Determine whether the medication is effective
Imperative that patient e assessed for the therapeutic physiological and psychological effects responses to pain med
The clinic nurse interviews a middle-aged adult who comes to the clinic complaining of difficulty sleeping and ongoing fatigue. The nurse learns the client works as a security guard and frequently works nights. Which of the following is the BEST initial response by the nurse?
a. ) “Tell me about your usual sleeping habits.”
b. ) “You probably sleep when you can during your night tour.”
c. ) “This is normal for your age group.”
d. ) “Working the night shift is known to disrupt sleep patterns”
a.) “Tell me about your usual sleeping habits.”
