Exam II: "Nursing Process" (Fundamentals of Nursing/NURS9108, NWACC) – Flashcards
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Q: Which of the following examples are steps of nursing assessment? (Select all that apply) 1. Collection of information from patient's family members 2. Recognition that further observations are needed to clarify information. 3. Comparison of data with another source to determine data accuracy. 4. Complete documentation of observational information. 5. Determining which medications to administer based on a patient's assessment data. (Question 1 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: 1, 2, 3. (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? a. Value-belief pattern b. Cognitive-perceptual pattern c. Coping--stress-tolerance pattern d. Health perception-health management pattern (Question 2 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: (d.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply) 1. An observation of how a patient turns and moves in bed. 2. The unit policy and procedure manual. 3. The care recommendations of a physical therapist. 4. The results of a diagnostic x-ray film. 5. Your experiences in caring for other patients with similar problems. (Question 3 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: 1, 3, 4. (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: The nurse observes a patient walking down the hall with a shuffling gate. When the patient returns to bed, the nurse checks the strength of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: a. Cue b. Reflection c. Clinical inference 4. Probing (Question 4 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: (c.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? a. Review of systems approach. b. Use of a structured database format. c. Back channeling. d. A problem-oriented approach. (Question 5 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: (d.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: The nurse asks a patient, "describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep?" This series of questions would likely occur during which phase of a patient-centered interview? a. Orientation b. Working phase c. Data validation d. Termination (Question 6 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: (b.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)**
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Q: A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2kg (300lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? a. "I can tell that your eating habits have lead to your diabetes. Is that right?" b. "It's been difficult for people to find jobs. Is that why you work part time?" c. "You nave four children; do you have any concerns about going home and caring for them?" d. "I wish patients understood how overeating affects their health." (Question 7 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: (c.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? a. Probing b. Open-ended c. Problem-oriented d. Confirmation (Question 8 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: (b.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)**
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Q: A nurse gathers the following assessment data. Which of the following cues together form(s) a pattern suggesting a problem? (select all that apply) 1. The skin around the wound is tender to touch. 2. Fluid intake for 8 hours is 800mL. 3. Patient has a heart rate of 78 bpm and regular. 4. Patient has drainage from surgical wound. 5. Body temperature is 38.3 degrees C (101 degrees F) 6. Patient states, "I am worried that I won't be able to return to work when I planned." (Question 9 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: 1, 4, 5. (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)**
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Q: A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: a. Patient's level of function. b. Patient's willingness to perform self-care. c. Patient's level of consciousness. d. Patient's health management values. (Question 10 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: (a.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is beginning a shift do to validate the previous nurse's assessment findings when she conducts rounds on the patient? (Select all that apply) 1. The nurse asks the patient to rate his pain on a scale of 0 to 10. 2. The nurse asks the patient what caused his fall. 3. The nurse asks the patient if he has had pain in his back in the past. 4. The nurse assesses the patient's lower-limb strength. 5. The nurse asks the patient what pain medication is most effective in managing his pain. (Question 11 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: 1, 4. (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)**
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Q: A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? a. Health perception- health management pattern b. Value-belief pattern c. Cognitive-perceptual pattern d. Self-perception-- self-concept pattern (Question 12 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 223])
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A: (d.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: A nurse is conduction a patient-centered inteview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor- correct?" (Question 13 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 224])
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A: 2- 4- 1- 5- 3. (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? a. So you've had headaches periodically in the last week and sometimes they make you feel nauseated- correct? b. Have you taken anything for your headaches? c. Tell me what makes your headaches begin. d. Uh huh, tell me more. (Question 14 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 224])
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A: (c.) (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)
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Q: The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (select all that apply) 1. Listen attentively to the patient's story. 2. Use gestures that reinforce your questions or comments. 3. Stand back away from the bedside. 4. Maintain direct eye contact. 5. Ask questions quickly to reduce the patient's fatigue. (Question 15 taken from P/P Ch. 16: Nursing Assessment "Review Questions" [pg. 224])
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A: 1, 2, 4. (Answers for P/P Ch. 16: Nursing Assessment "Review Questions" found on pg. 224)**
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Q: Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply) 1. Impaired Skin Integrity related to physical immobility 2. Fatigue related to heart disease 3. Nausea related to gastric distention 4. Need for improved Oral Mucosa Integrity related to inflamed mucosa 5. Risk for Infection related to surgery (Question 2 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 237])
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A: 1, 3. (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)**
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Q: A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for "Ineffective Coping" with those for "Readiness for Enhanced Coping" and selects "Ineffective Coping" as the correct diagnosis. This is an example of a nurse avoiding an error in: (Select all that apply) 1. Data collection 2. Data clustering 3. Data interpretation 4. Making a diagnostic statement 5. Goal setting (Question 3 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
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A: 1, 3. (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)**
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Q: The nursing diagnosis "Impaired Parenting" related to a mother's developmental delay is an example of a(n): 1. Risk nursing diagnosis 2. Problem-focused nursing diagnosis 3. Health promotion nursing diagnosis 4. Wellness nursing diagnosis (Question 4 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
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A: (b.) (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)**
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Q: A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: a. Collaborative data set. b. Diagnostic label. c. Related factors. d. Data cluster. (Question 5 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
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A: (d.) (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)
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Q: In which of the following examples are nurses making diagnostic errors? (Select all that apply) 1. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data 2. The nurse who measures joint range of motion after the patient reports pain in the left elbow. 3. The nurse who considers conflicting cues in deciding which diagnostic label to choose. 4. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping. 5. The nurse who makes a diagnosis of "Ineffective Airway Clearance" related to pneumonia. (Question 6 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
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A: 1, 4, 5. (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)**
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Q: A nurse reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is "Diarrhea" related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? a. Identifying the clinical sign instead of an etiology. b. Identifying a diagnosis on the basis of prejudicial judgment. c. Identifying the diagnostic study rather than a problem caused by the diagnostic study. d. Identifying the medical diagnosis instead of the patient's response to the diagnosis. (Question 7 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
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A: (d.) (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)**
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Q: A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse conducts a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order, beginning with the first step. 1. Considers context of patient's health problem and selects a related factor. 2. Reviews assessment data, noting objective and subjective clinical information. 3. Clusters clinical cues that form a pattern. 4. Chooses diagnostic label. (Question 8 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
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A: 2- 3- 4- 1. (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)
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Q: A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of 'Deficient Fluid Volume.'" The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turger, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? a. Insufficient cluster of cues. b. Disorganization. c. Insufficient number of cues. d. Evidence that another diagnosis is more likely. (Question 9 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
answer
A: (c.) (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)
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Q: A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breast-feeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as "Ineffective Breastfeeding." Which of the following is the best "related to" factor? a. Infant crying at breast b. Infant unable to latch on to breast correctly. c. Mother's deficient knowledge. d. Lack of infant weight gain (Question 10 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
answer
A: (c.) (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)
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Q: A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (select all that apply) 1. How is your diabetic diet affecting you and your family? 2. You seem to not want to follow health guidelines. Can you explain why? 3. What worries you the most about having diabetes? 4. What do you expect from us when you do not take your insulin as instructed? 5. What do you believe will help you control your blood sugar? (Question 11 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
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A: 1, 3, 5. (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)**
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Q: A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? a. Disturbed Sleep Pattern evidenced by frequent awakening b. Disturbed Sleep Pattern related to family caregiving responsibilities c. Disturbed Sleep Pattern related to need to improve sleep habits d. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested. (Question 12 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
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A: (d.) (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)**
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Q: A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis "Impaired Skin Integrity." The faculty member explains that the student has made a diagnostic error for which of the following reasons? a. Incorrect clustering b. Wrong diagnostic label c. Condition is a collaborative problem d. Premature closure of clusters (Question 13 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238])
answer
A: (b.) (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)
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Q: The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply) 1. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs. 2. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves. 3. Helps nurses focus on the scope of nursing practice. 4. Creates practice guidelines for collaborative health care activities. 5. Builds and expands nursing knowledge. (Question 14 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 238/239])
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A: 1, 3, 5. (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)**
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Q: Which of the following nursing diagnoses is stated correctly? (select all that apply) 1. Fluid Volume Excess related to heart failure 2. Sleep Deprivation related to sustained noisy environment. 3. Impaired Bed Mobility related to postcardiac catheterization. 4. Ineffective Protection related to inadequate nutrition. 5. Diarrhea related to frequent, small, watery stools. (Question 15 taken from P/P Ch. 17: Nursing Diagnosis "Review Questions" [pg. 239])
answer
A: 2, 4. (Answers for P/P Ch. 17: Nursing Diagnosis "Review Questions" found on pg. 239)**
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Q: A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove her tumor and has questions about what to expect after surgery. She is observed talking with her mother and crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? a. Giving the enema on time. b. Talking with the patient about her past experiences with illness. c. Talking with the patient about her concerns and acknowledging her sense of unfairness. d. Beginning instruction on postoperative procedures. (Question 1 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 254])
answer
A: (c.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)
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Q: A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply) 1. Assess conditions of the skin before making the call 2. Rely on the nurse specialist to know the type of surgery the patient likely had. 3. Explain the patient's response emotionally to the repeated leaking of stool. 4. Describe the type of bag being used and how long it lasts before leaking. 5. Order extra colostomy bags currently being used. (Question 2 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 254])
answer
A: 1, 3, 4. (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)**
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Q: It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the beside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply) 1. Using a standardized checklist for essential information. 2. Asking the wife to briefly leave the room 3. Completing the hand-off without inviting questions. 4. Doing prework such as checking laboratory results before giving a report. 5. Including the wife in the hand-off discussion. (Question 3 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 254])
answer
A: 1, 4, 5. (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)**
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Q: A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of "Risk for Impaired Skin Integrity." Which of the following outcomes is appropriate for the patient? a. Patient will be turned every 2 hours within 24 hours. b. Patient will have normal bowel function within 72 hours. c. Patient's skin will remain intact throughout discharge. d. Erythema of skin will be mild to none within 48 hours. (Question 4 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 254])
answer
A: (d.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)**
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Q: Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnosis? (Select all that apply) 1. Numbered order of diagnosis on the basis of severity 2. Notion of urgency for nursing action 3. Symptom pattern recognition suggesting a problem 4. Mutually agreed on priorities set with patient 5. Time when a specific diagnosis was identified (Question 5 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 254])
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A: 2, 3, 4. (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)**
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Q: A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? a. Achieving wound healing of the foot ulcer. b. Enhancing patient knowledge about the effects of diabetes. c. Providing a dietitian consultation for diet retraining. d. Improving patient adherence to diabetic diet (Question 6 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 254/255])
answer
A: (b.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)
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Q: The nurse writes an expected outcome statement in measurable terms. An example is: a. Patient will have normal stool evacuation. b. Patient will have fewer bowel movements. c. Patient will take stool softener every 4 hours. d. Patient will report stool soft and formed with each defecation. (Question 7 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: (d.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)**
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Q: A patient has the nursing diagnosis of "Nausea." The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply) 1. Providing mouth care every 4 hours. 2. Maintaining intravenous (IV) infusion at 100 mL/hr 3. Administering prochlorperazine (Compazine) via rectal suppository. 4. Consulting with dietitian on initial foods to offer patient. 5. Controlling aversive odors or unpleasant visual stimulation that triggers nausea. (Question 8 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: 2, 4. (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)**
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Q: (Part 1 of 4) An 82-year-old patient who resides in a nursing home has the the following nursing diagnoses: "Risk for Fall," "Impaired Physical Mobility r/t pain," and "Imbalanced Nutrition: Less Than Body Requirements r/t reduced ability to feed self." The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goal: ____________ Patient will ambulate independently in 3 days. Outcomes: a. Patient expresses fewer nonverbal signs of discomfort within 24 hours. b. Patient increases caloric intake to 2500 daily. c. Patient walks 20 feet using a walker in 24 hrs. d. Patient identifies barriers to remove in the home within 1 week. (Question 9 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: (c.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)
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Q: (Part 2 of 4) An 82-year-old patient who resides in a nursing home has the the following nursing diagnoses: "Risk for Fall," "Impaired Physical Mobility r/t pain," and "Imbalanced Nutrition: Less Than Body Requirements r/t reduced ability to feed self." The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goal: ____________ Patient will be injury free for 1 month. Outcomes: a. Patient expresses fewer nonverbal signs of discomfort within 24 hours. b. Patient increases caloric intake to 2500 daily. c. Patient walks 20 feet using a walker in 24 hrs. d. Patient identifies barriers to remove in the home within 1 week. (Question 9 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: (d.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)
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Q: (Part 3 of 4) An 82-year-old patient who resides in a nursing home has the the following nursing diagnoses: "Risk for Fall," "Impaired Physical Mobility r/t pain," and "Imbalanced Nutrition: Less Than Body Requirements r/t reduced ability to feed self." The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goal: ____________ Patient will achieve 5-lb weight gain in 1 month. Outcomes: a. Patient expresses fewer nonverbal signs of discomfort within 24 hours. b. Patient increases caloric intake to 2500 daily. c. Patient walks 20 feet using a walker in 24 hrs. d. Patient identifies barriers to remove in the home within 1 week. (Question 9 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: (b.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)
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Q: (Part 4 of 4) An 82-year-old patient who resides in a nursing home has the the following nursing diagnoses: "Risk for Fall," "Impaired Physical Mobility r/t pain," and "Imbalanced Nutrition: Less Than Body Requirements r/t reduced ability to feed self." The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goal: ____________ Patient will achieve pain relief by discharge. Outcomes: a. Patient expresses fewer nonverbal signs of discomfort within 24 hours. b. Patient increases caloric intake to 2500 daily. c. Patient walks 20 feet using a walker in 24 hrs. d. Patient identifies barriers to remove in the home within 1 week. (Question 9 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: (a.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)
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Q: Which of the following factors does a nurse consider for a patient with the nursing diagnosis of "Disturbed Sleep Pattern r/t noisy home environment" in choosing an intervention for enhancing the patient's sleep? (Select all that apply) 1. The intervention should be directed at reducing noise. 2. The intervention should be one shown to be effective in promoting sleep on the basis of research. 3. The intervention should be one commonly used by the patient's sleep partner. 4. The intervention should be one acceptable to the patient. 5. The intervention should be one you used with other patient's in the past. (Question 10 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: 1, 2, 4. (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)
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Q: A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to as about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply) 1. Policy for conducting hourly rounds. 2. Staffing level. 3. Interruption by staff nurse colleague. 4. Rn's years of experience. 5. Competency of patient care technician. (Question 11 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: 1, 2, 3. (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)**
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Q: A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 1/2NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted." If the nurse's goal for Mr. Roarke was to improve activity tolerance, which outcomes were shared in the hand-off? (Select all that apply) 1. IV site not tender 2. Uses cane to walk 3. Walked to end of hall 4. No shortness of breath 5. Slept better during the night (Question 12 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: 3, 4. (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)**
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Q: A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 1/2NS." Which intervention is a dependent intervention? a. Reporting hand-off at change of shift. b. Ambulating patient down hallway. c. Sleep hygiene. d. IV fluid administration. (Question 13 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: (d.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)
question
Q: A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? a. Engage the patient in setting mutual outcomes for distance he is able to walk. b. Confirm with the patient's health care provider about ambulation goals. c. Have physical therapy assist with ambulation. d. Refer to medical record regarding nature of patient's physical problem. (Question 14 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: (a.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)
question
Q: A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? a. Reconnect the drainage tubing. b. Inspect the condition of the IV dressing. c. Obtain the next IV fluid bag from the medication room. d. Explain when the health care provider is likely to visit. (Question 15 taken from P/P Ch. 18: Planning Nursing Care "Review Questions" [pg. 255])
answer
A: (a.) (Answers for P/P Ch. 18: Planning Nursing Care "Review Questions" found on pg. 255)**
