Fundamentals Ch.17

question

What bone-related changes should a nurse expect to see in a client with chronic renal failure? (only 1) Calcification Demineralization Increased bone density Bone marrow hyperplasia
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Demineralization (A client with chronic renal failure cannot make sufficient amounts of active vitamin D. As a result, these clients are at risk of demineralization of the bone due to impaired calcium absorption in the intestine. )
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What is the benefit of a conceptual care map (CCM) to a nursing student? The CCM can be used as a taxonomy for nursing outcomes. The CCM is a combination of a concept map and a care plan. The patient data can be organized in a head-to-toe approach. The assessment area can contain data according to body systems. The CCM can help identify nursing diagnoses, goals, and interventions.
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The CCM is a combination of a concept map and a care plan. The patient data can be organized in a head-to-toe approach. The assessment area can contain data according to body systems. The CCM can help identify nursing diagnoses, goals, and interventions.
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What points should the nurse keep in mind when formulating the nursing diagnosis? . Accurately selecting the diagnoses Properly making medical diagnoses Identifying defining characteristics of the diagnosis Identifying related factors pertinent to the diagnosis Selecting interventions suited for treating the diagnosed condition
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Accurately selecting the diagnoses Identifying defining characteristics of the diagnosis Identifying related factors pertinent to the diagnosis Selecting interventions suited for treating the diagnosed condition
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The nurse is caring for a patient who has been admitted to the hospital with pneumonia. Which assessment findings of the patient can the nurse group together to formulate a data cluster? Dysuria Wheezing in left lung bases Respiration 20 breaths/minute Weakness of the entire body Shortness of breath with ambulation
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Wheezing in left lung bases Respiration 20 breaths/minute Shortness of breath with ambulation
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A nurse is teaching nursing students about nursing diagnoses. What does the nurse consider as a nursing diagnosis? Nausea Pneumonia Acute pain Osteoarthritis Diabetes mellitus
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Nausea Acute pain
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The nurse is preparing a nursing care plan. Which actions would most likely prevent errors in interpretation when making a nursing diagnosis? Accurate interpretation of cues Using reliable cues Failure to consider conflicting cues Using an insufficient number of cues Consider cultural influences or developmental stage
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Accurate interpretation of cues Using reliable cues Consider cultural influences or developmental stage
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A febrile client diagnosed with pancreatitis complains of pain in the abdomen. Following an initial interview and the assessment, the nurse prepares a nursing care plan. Which diagnoses are actual nursing diagnoses? Acute pain Ineffective thermoregulation Risk of imbalanced fluid volume Risk of imbalanced nutrition Readiness for enhanced family coping
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Acute pain Ineffective thermoregulation
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The nurse is identifying the related factors by studying a patient’s assessment data. According to the North American Nursing Diagnosis Association International (NANDA I) diagnoses, under which categories should the nurse classify the related factors? . Situational Maturational Psychological Treatment-related Pathophysiological
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Situational Maturational Treatment-related Pathophysiological (According to NANDA I diagnoses, related factors come in four categories: situational, maturational, treatment-related, and pathophysiological. A related factor is identified from the patient’s assessment data. The related factor is associated with a patient’s actual response to the health problem.)
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According to the NANDA International, what are the categories of sources of error that may occur in the nursing diagnostic process? Implementing Collecting Clustering Evaluating Interpreting
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Collecting Clustering Interpreting
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After assessing a patient with urinary incontinence, the health care provider confirms that the patient is at risk for a life-threatening condition that causes severe elevation of blood pressure and pulse rate as well as diaphoresis. Which type of urinary incontinence does this patient have? (only 1) Transient incontinence Stress urinary incontinence Reflex urinary incontinence Urgency urinary incontinence
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reflex urinary incontinence (Autonomic dysreflexia is a life-threatening condition that causes severe elevation of the blood pressure and pulse rate as well as diaphoresis. Patients with reflex urinary incontinence are at an increased risk for this condition.)
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The nurse is caring for a patient with a temperature of 39.5° C (103.1° C). Which nursing interventions should be implemented to manage the patient’s condition? Keeping bed linens dry Covering the patient with blankets Ambulating the patient every 2 hours Providing measures to stimulate appetite Providing the patient with 8 to 10 glasses of fluids daily
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Keeping bed linens dry Providing measures to stimulate appetite Providing the patient with 8 to 10 glasses of fluids daily
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What should the nurse include when writing an actual nursing diagnosis? (ONLY 1) Diagnosis label and risk factors Diagnosis label and related factors Diagnosis label and defining characteristics Diagnosis label, related factors, and defining characteristics
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Diagnosis label, related factors, and defining characteristics
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On what should the nurse focus when formulating a nursing diagnosis? (only 1) Disease Complication Physiological event Potential response to a health problem
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Potential response to a health problem
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The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the E in a three-part nursing diagnostic statement using the PES format? Severe pain Natural swelling Related to incisional trauma Wincing, guarding, restricted turning and positioning
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Related to incisional trauma (The PES format stands for: problem (P), etiology or related factor (E), and symptoms or defining characteristics (S).)
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A patient has a pH value of 7.25. Which possible pathological and physiological changes may occur in this patient? Enzyme dysfunction Pruritis Anemia Impaired hemoglobin function Death
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Enzyme dysfunction Impaired hemoglobin function Death
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A patient who has a stage III pressure ulcer develops a body temperature of 103° F. While changing the wound dressing, the nurse finds purulent discharge with an odor coming from the wound. What will the nurse suspect is occurring in the patient? (only 1) Bruising Infection Internal bleeding Blanchable erythema
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infection
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Following an initial assessment of a patient, the nurse is formulating nursing diagnoses. Which guidelines should the nurse follow to reduce errors in the diagnostic statement? Identify medical diagnoses. Identify clinical signs and symptoms. Identify a treatable etiology or risk factor. Identify the problem caused by the treatment, not the treatment itself. Identify the patient’s response to the equipment rather than the equipment itself.
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Identify a treatable etiology or risk factor. Identify the problem caused by the treatment, not the treatment itself. Identify the patient’s response to the equipment rather than the equipment itself.
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Which errors may occur when the nurse makes the nursing diagnosis prior to grouping all data? (only 1) Errors in data clustering Errors in data collection Errors in the diagnostic statement Errors in interpretation and analysis of data
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Errors in data clustering
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A nurse is caring for a client who is terminally ill. The nurse finds that the client experiences chronic pain, imbalanced nutrition, fatigue, and hopelessness. In this situation, which nursing diagnosis does the nurse identify as most important to address? (only 1) Fatigue Chronic pain Hopelessness Imbalanced nutrition
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chronic pain
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Following an assessment, the nurse is formulating a nursing diagnosis using the PES format. What does the “P” in the acronym PES stand for? (only 1) Period Problem Prevention Predication
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problem
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What is the characteristic feature of a medical diagnosis? (only 1) It initiates treatments to prevent complications. It identifies physical and psychological illnesses. It considers the patient’s attitudes and strengths. It makes judgments based on the actual condition.
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It identifies physical and psychological illnesses.
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An elderly client who has dementia is suffering from cognitive deficit. What type of urinary incontinence is this client likely to suffer? (only 1) Stress incontinence Functional incontinence Low risk of incontinence Urge incontinence
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urge incontinence (Elderly clients with cognitive deficits like dementia may have overactive bladder (OAB).These clients are at the risk of developing urge incontinence due to involuntary bladder contraction. Stress incontinence is common among elderly women with weakened pelvic musculature. Functional incontinence due to urinary infection is common among younger women with urinary infections. Incontinence risk is not lowered in clients with dementia; it is increased. )
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Which should the nurse do first after discovering an electrical fire in a patient’s room? (only 1) Activate the fire alarm. Confine the fire by closing all doors and windows. Remove all patients in immediate danger. Extinguish the fire by using the nearest fire extinguisher.
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Remove all patients in immediate danger.
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A nurse is assessing clients on the unit. What activities would the nurse perform during the diagnosis phase of the nursing process? Teach the client about preventive measures. Review information collected about the client. Find cues and patterns in the client’s data. Make conclusions related to health problems. Implement the care necessary for the client.
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Review information collected about the client. Find cues and patterns in the client’s data. Make conclusions related to health problems.
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The nurse is teaching a group of students about the application of nursing diagnosis to care planning. Which statements indicate effective learning? “Nursing diagnoses direct the planning process and the selection of nursing interventions.” “Nursing diagnoses are a universal means for communication between professional nurses and the public.” “A nursing diagnosis would lead the primary health care provider to prescribe a low-carbohydrate diet and medication to a patient with diabetes.” “Nursing diagnoses help the primary health care provider determine appropriate nursing interventions and specific outcomes.” “Nursing diagnosis of damaged skin directs a nurse to apply a support surface to a patient’s bed and initiate a turning schedule.”
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“Nursing diagnoses direct the planning process and the selection of nursing interventions.” “Nursing diagnosis of damaged skin directs a nurse to apply a support surface to a patient’s bed and initiate a turning schedule.”
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A patient diagnosed with pancreatitis complains of pain in the abdomen. Following an initial interview and the assessment, the nurse prepares a nursing care plan. Which guidelines should the nurse follow to reduce errors in the diagnostic statement? Identify medical diagnoses. Identify clinical signs and symptoms. Identify treatable etiology or risk factors. Identify the problems caused by the treatment. Identify the patient’s response.
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Identify treatable etiology or risk factors. Identify the problems caused by the treatment. Identify the patient’s response.
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A nurse is teaching nursing students about medical diagnosis. Which statements by the students indicate effective learning? . “Acute pain is a medical diagnosis.” “Osteoarthritis is a medical diagnosis.” “Medical diagnoses are based on the results of diagnostic tests.” “A primary healthcare provider is licensed to describe medical diagnoses.” “A medical diagnosis includes the clinical judgment about an individual and his family.”
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“Osteoarthritis is a medical diagnosis.” “Medical diagnoses are based on the results of diagnostic tests.” “A primary healthcare provider is licensed to describe medical diagnoses.”
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A nurse is designing a care plan for a client who is experiencing dyspnea. Which components of the assessment data can be part of the risk nursing diagnosis for this client? Cyanosis The family history of the client Impaired gaseous exchange in the lungs Reduced oxygen saturation of the blood The diet that the client should take in this disorder
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Cyanosis Impaired gaseous exchange in the lungs Reduced oxygen saturation of the blood
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While assessing the eyelids of a patient, the nurse suspects the patient has nystagmus. Which finding may have led the nurse to this suspicion? (only 1) Lid margins that are turned out Redness in the conjunctivae Abnormal drooping of the lid over the pupil Involuntary and rhythmical oscillations of the eyes
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Involuntary and rhythmical oscillations of the eyes
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While assessing the eyelids of a patient, the nurse suspects the patient has nystagmus. Which finding may have led the nurse to this suspicion? (only 1) Lid margins that are turned out Redness in the conjunctivae Abnormal drooping of the lid over the pupil Involuntary and rhythmical oscillations of the eyes
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Involuntary and rhythmical oscillations of the eyes
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Which diagnostic error in labeling may lead to an error in nursing diagnosis? Failure to seek guidance when the nurse has doubts Premature or early closure of clustering Selection of wrong diagnostic label Failure to consider conflicting cues Validation of nursing diagnosis with client
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Failure to seek guidance when the nurse has doubts Premature or early closure of clustering Selection of wrong diagnostic label Failure to consider conflicting cues
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A client is suffering from a malignancy in which the malignant cells secrete chemicals similar to parathyroid hormone. What does the nurse interpret about the client’s condition? (only 1) The client may have hyperkalemia. The client may have hypernatremia. The client may have hypercalcemia. The client may have hypermagnesemia.
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The client may have hypercalcemia.
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Which action by the nurse demonstrates the use of evidence-based practice to formulate an accurate nursing diagnosis of patient problems? (only 1) Collecting all objective and subjective patient data Analyzing patient data using personal experiences Clustering all objective patient data for an analysis Using multiple diagnosis labels in the diagnosis
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Collecting all objective and subjective patient data
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Advanced practice registered nurses generally: (only 1) Function independently. Function as unit directors. Work in acute care settings. Work in the university setting.
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Function independently.
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Which patient is most likely to exhibit symptoms such as dysuria, urgency, frequency, and nocturia? (only 1) A patient with kidney failure A patient receiving diuretic therapy A patient with a urinary tract infection A patient with uncontrolled diabetes mellitus
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A patient with a urinary tract infection
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Which is an actual nursing diagnosis? (only 1) Risk for acute confusion Impaired social interaction Readiness for enhanced nutrition Readiness for enhanced family coping
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Impaired social interaction
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A client with abdominal pain is admitted to the hospital. Which stages of client care are included in the nursing process? Assessment Nursing diagnosis Rehabilitation Intervention Pathological reports and screening
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Assessment Nursing diagnosis Intervention
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The nurses set up flu vaccine clinics in local churches and senior citizen centers. This activity is an example of which level of prevention? (only 1) Primary care Secondary care Tertiary care Restorative care
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primary care
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Nurses at a community hospital are in an education program to learn how to use a new pressure-relieving device for clients at risk for pressure ulcers. This is which type of education? (only 1) Continuing education Graduate education In-service education Professional Registered Nurse Education
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In-service education
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A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed? (only 1) Planning Evaluation Assessment Implementation
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Implementation
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A patient tells a nurse, “My urine output is lower even after increasing my fluid intake.” What does the nurse suspect is the reason behind the patient’s condition? (only 1) Urinary tract infection Inflammation of the prostate gland Uncontrolled diabetes mellitus Increased production of antidiuretic hormone
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Increased production of antidiuretic hormone
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The nurse is preparing a diagnostic statement for a patient who has diabetes. What is the most appropriate step the nurse should take in this scenario? (only 1) The nurse should identify the nursing intervention, not the patient problem. The nurse should identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. The nurse should identify the medical diagnosis rather than the patient’s response when creating the statement. The nurse should identify the treatment or the study itself, rather a problem caused by the treatment or diagnostic study.
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The nurse should identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom.
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Which steps are essential for decision making in a diagnostic process? Data clustering Risk nursing diagnosis Formulating the diagnosis Identifying patient health problems Health promotion nursing diagnosis
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Data clustering Formulating the diagnosis Identifying patient health problems
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A nurse is teaching a group of nursing students about the usage of NANDA-I terminologies in the medical record entry. Which statements by the student indicates the need for further education? ” NANDA-I diagnoses have a broad literature base.” “NANDA-I classifications are most comprehensive.” “NANDA-I diagnoses do not comprise evidence-based diagnoses.” “NANDA-I diagnoses emphasize precise documentation of health problems.” “NANDA-I diagnoses are refined by the primary health care provider on a regular basis.”
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“NANDA-I diagnoses do not comprise evidence-based diagnoses.” “NANDA-I diagnoses are refined by the primary health care provider on a regular basis.” (NANDA-I diagnoses have a broad literature base, and many are evidence-based. NANDA-I diagnoses are continually refined by the professional nurses, not primary health care providers. NANDA-I diagnoses have a broad literature base for the nurse’s reference. NANDA-I classifications are considered one of the most comprehensive of all the nursing classifications. NANDA-I diagnoses emphasize providing accurate documentation of health problems.)
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What could be the effect of an incorrect nursing diagnosis? (only 1) It could affect the quality of client care. It would get corrected automatically in the system. It could affect the client’s cost of treatment. It could produce a psychological disorder in the client.
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It could affect the quality of client care.
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Nurses on a nursing unit are discussing the processes that led up to a near-miss error on the clinical unit. They are outlining strategies that will prevent this in the future. This is an example of nurses working on what issue in the health care system? Client safety Evidence-based practice Client satisfaction Maintenance of competency
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Client safety
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The nurse is caring for a football player hospitalized for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient’s voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. Which data cluster helps the nurse determine anxiety is present? Verbal expression of worry Fidgety hands and legs A quiver in the patient’s voice while talking Impending ankle surgery Hospitalization
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Verbal expression of worry Fidgety hands and legs A quiver in the patient’s voice while talking
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A patient complains of pain when swallowing solid food. The nurse asks the patient if he or she has a history of substance abuse that has caused this pain. What kind of diagnostic error does the nurse make in this scenario? (only 1) Errors in data collection Errors in data clustering Errors in the diagnostic statement Errors in interpretation and analysis of data
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Errors in data collection
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A nurse reviews data gathered regarding a client’s pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: (only 1) Data collection. Data clustering. Data interpretation. Making a diagnostic statement.
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Data interpretation.
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What is the purpose of risk nursing diagnoses? (only 1) To identify potential problems of the patient To identify past diseases that the patient had To identify healthy behaviors in the patient To identify the current needs of the patient
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To identify potential problems of the patient
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Inaccurate data collection is a source of error in diagnosis. What factors can cause errors in data collection? . Missing data Inaccurate data Disorganization Lack of knowledge or skill Premature or early closure of clustering
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Missing data Inaccurate data Disorganization Lack of knowledge or skill
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A parent calls the pediatrician’s office frantic about the bottle of cleaner that her 2-year-old son drank. Which of the following is the most important instruction the nurse gives to this parent? Give the child milk. Give the child syrup of ipecac. Call the Poison Control Center. Take the child to the emergency department.
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Call the Poison Control Center.
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The nurse clusters all the assessment data of a patient before identifying the nursing diagnosis. What information does a cluster of data contain? (only 1) Only similar etiologies Only objective data Only subjective data Only one body system
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Only similar etiologies
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While performing a general examination of a client, the nurse finds that the client is positive for Chvostek’s sign, Trousseau’s sign, and has tetany. Which electrolyte disturbance is responsible for this clinical presentation? (only 1) Hypokalemia Hyponatremia Hypocalcemia Hypermagnesemia
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Hypocalcemia (Positive Chvostek’s sign, Trousseau’s sign, and presence of tetany indicate hypocalcemia. Low levels of calcium may affect the excitability of the nerve and muscle cells, causing cramps and abnormal muscle movements. )
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A group of nursing students are being taught about the different types of nursing diagnosis. Which ones are examples of health promotion nursing diagnoses? Readiness for enhanced family coping Acute pain Wandering Readiness for enhanced nutrition Stress urinary incontinence
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Readiness for enhanced family coping Readiness for enhanced nutrition
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The nurse formulates a nursing diagnostic statement for a patient with severe pain due to a femur fracture as evidenced by grimacing. What should the nurse include in the “defining characteristics” segment of the nursing diagnosis? (only 1) Severe pain Related to Grimacing Femur fracture
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Grimacing
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In the diagnosis statement “Impaired physical mobility related to incisional pain, evidenced by restricted turning and positioning,” which component represents the “etiology or related factor” of the PES format? (only 1) Incisional pain Impaired physical mobility Evidenced by restricted turning Evidenced by restricted positioning
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Incisional pain
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A nurse is reviewing a client’s list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: (only 1) Identifying the clinical sign instead of an etiology. Identifying a diagnosis based on prejudicial judgment. Identifying the diagnostic study rather than a problem caused by the diagnostic study. Identifying the medical diagnosis instead of the client’s response to the diagnosis.
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Identifying the medical diagnosis instead of the client’s response to the diagnosis.
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For a diagnosis of impaired skin integrity, what could be the possible related factors? (or for pressure ulcers) Age extremes Fluid retention Maturational crisis Impaired sensation Physical immobilization
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Age extremes Fluid retention Impaired sensation Physical immobilization
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The nurse uses nursing diagnoses while providing care for patients. What is the purpose of nursing diagnoses? Contains the medical treatment plan for the patient Assists in the communication of the patients’ needs Maintains a record of relevant patient assessments Promotes professional accountability and autonomy Communicates the health conditions being treated
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Assists in the communication of the patients’ needs Promotes professional accountability and autonomy Communicates the health conditions being treated
question

The nurse is assessing patients on the unit. What activities would the nurse perform during the diagnostic phase of the nursing process? Teach the patient about preventative measures. Review information collected about the patient. Find cues and patterns in the patient’s data. Make conclusions related to health problems. Implement the care necessary for the patient.
answer

Review information collected about the patient. Find cues and patterns in the patient’s data. Make conclusions related to health problems.
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Which conditions might the nurse identify as causes of polyuria? Urethritis Diuretic therapy Kidney dysfunction Urinary tract infection Uncontrolled diabetes mellitus
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Diuretic therapy Uncontrolled diabetes mellitus
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In the following examples, which nurses are making nursing diagnostic errors? A nurse listens to lungs for first time and is not sure if abnormal lung sounds are present. After reviewing objective data, a nurse selects a diagnosis of fear before asking client to discuss her feelings. A nurse uses an incorrect diagnostic label. A nurse considers a client’s cultural background when reviewing cues. A nurse prepares to complete decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern.
answer

A nurse listens to lungs for first time and is not sure if abnormal lung sounds are present. After reviewing objective data, a nurse selects a diagnosis of fear before asking client to discuss her feelings. A nurse uses an incorrect diagnostic label. A nurse prepares to complete decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern.
question

The nurse has identified three nursing diagnoses for a patient who is having anxiety and hopelessness as a result of a loss. Which general approach does the nurse take to prioritize the nursing diagnoses? Use family members and physician orders as primary resources for prioritizing actions. Address the nursing diagnosis that most affects the medical diagnosis. Ask the patient to identify the most distressing symptom and first address that diagnosis. Use nursing knowledge to address the problem that is the underlying cause of other diagnoses. Focus first on the diagnosis that will be easiest to address.
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Ask the patient to identify the most distressing symptom and first address that diagnosis. Use nursing knowledge to address the problem that is the underlying cause of other diagnoses.
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What does the nurse mention while writing the health-promotion nursing diagnosis? (only 1) Diagnosis label and risk factors Diagnosis label and related factors Diagnosis label and defining characteristics Diagnosis label, related factors, and defining characteristics
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Diagnosis label and defining characteristics
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Which errors may occur when the nurse makes the nursing diagnosis prior to grouping all data? (only 1) Errors in data clustering Errors in data collection Errors in the diagnostic statement Errors in interpretation and analysis of data
answer

Errors in data clustering
question

The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the S in a three-part nursing diagnostic statement using the PES format? (only 1) Severe pain Natural swelling Related to incisional trauma Wincing, guarding, restricted turning and positioning
answer

Wincing, guarding, restricted turning and positioning
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A client diagnosed with pancreatitis complains of pain in the abdomen. The client has vomited three times, and has a temperature of 101 degrees Fahrenheit. Following an initial interview and assessment, the nurse prepares a nursing care plan. The nurse formulates a diagnosis of acute pain. What could be the related factor for this diagnostic label? (only 1) Inflammation of the pancreas Fever Distention of the abdomen Vomiting
answer

Inflammation of the pancreas
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A registered nurse is teaching a student nurse about characteristic features of immigrant populations. Which statement can the nurse include in the teaching plan? “The immigrant population’s access to the health care is not limited.” “The immigrant population may practice nontraditional healing methods.” “The immigrant population has lower rates of hypertension and diabetes mellitus.” “The immigrant population will not experience physical and psychological stressors.”
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“The immigrant population may practice nontraditional healing methods.”
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Review the following nursing diagnoses and identify the diagnoses that are stated correctly. Anxiety related to fear of dying Fatigue related to chronic emphysema Need for mouth care related to inflamed mucosa Risk for infection Risk for spiritual distress related to sadness
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Anxiety related to fear of dying Risk for infection
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Which factor increases the risk of wound infection? (only 1) Absence of necrotic tissue Absence of foreign body in the wound Reduced local tissue defenses Adequate blood supply
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Reduced local tissue defenses
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What is a health promotion diagnosis, according to the North American Nursing Diagnosis Association International (NANDA)? (only 1) It describes a person’s readiness to enhance specific health behaviors for well-being. It describes human responses to health conditions that may develop in a vulnerable individual. It describes human responses to health conditions that exist in an individual or community. It is associated with a potential response to the health problem and can change by using specific nursing interventions.
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It describes a person’s readiness to enhance specific health behaviors for well-being.
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Which roles and responsibilities should every nurse be expected to fill? Caregiver Autonomy and accountability Patient advocate Health promotion Lobbyist
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Caregiver Autonomy and accountability Patient advocate Health promotion
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The nurse is caring for a football player scheduled for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient’s voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. What interventions should the nurse implement to reduce anxiety in the patient? Explain the recovery process to the patient. Provide detailed instructions about the surgery. Consult with a psychologist regarding the patient’s behavior. Teach postoperative care to the patient and his caregiver. Encourage health-promotion activities such as exercise and routine social activities.
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Explain the recovery process to the patient. Provide detailed instructions about the surgery. Teach postoperative care to the patient and his caregiver.
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A student nurse is gathering information from an elderly patient. Which of the student nurse’s actions indicates the need for further teaching? (only 1) Maintaining good eye contact with the patient Giving more time for the patient to answer questions Sitting straight in the chair while talking with the patient Nodding his or her head in response to the patient’s words
answer

Sitting straight in the chair while talking with the patient
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A patient with uncontrolled diabetes mellitus has developed diabetic ketoacidosis. Which is the most likely complication that this patient may experience? Hypokalemia Hyperkalemia Hypocalcemia Reduced serum osmolality
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Hyperkalemia (Acidosis is associated with the shift of potassium from the cells into the extracellular space. )
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A patient complains of hearing loss. The nurse performs a Rinne test and suspects that the patient has conduction loss. What may be the cause of the patient’s condition? Deterioration of the cochlea Swelling of the auditory canal Tears in the tympanic membrane Thickening of the tympanic membrane Impairment in the hearing region of the brain
answer

Swelling of the auditory canal Tears in the tympanic membrane
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A nurse is caring for a client who is admitted to the hospital with a diagnosis of left-sided heart failure. The client has been on CPAP for the last two days. The nurse notices that the client has gained weight, and has distended neck veins and pedal edema. The nurse immediately notifies the health care provider. What does this finding indicate? (only 1) Pulmonary edema Right-sided heart failure Deep vein thrombosis Pulmonary embolism
answer

Right-sided heart failure
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Which factor does the nurse consider while formulating an actual nursing diagnosis for a patient? (only 1) The existing problems of the patient The possibility of potential complications The need for positive change in the patient The need for change in the patient’s family
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The existing problems of the patient
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Which of the following is an example of the nurse participating in primary care activities? (only 1) Providing prenatal teaching on nutrition to a pregnant woman during the first trimester Working with clients in a cardiac rehabilitation program Assessing a client at an emergent care facility Providing home wound care to a client
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Providing prenatal teaching on nutrition to a pregnant woman during the first trimester
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Which of the following nursing roles may have prescriptive authority in their practice? Critical care nurse Nurse practitioner Certified clinical nurse specialist Charge nurse Orthopedic nurse
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Nurse practitioner Certified clinical nurse specialist
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What is an effective way of communicating patient status between nurses? (only 1) Formulate appropriate nursing diagnoses. Group pertinent patient-related data. Use nurse’s notes during the assessment. Chat with other health care professionals.
answer

Formulate appropriate nursing diagnoses.
question

Review the following list of nursing diagnoses and identify those stated incorrectly. Acute pain related to lumbar disk repair Sleep deprivation related to difficulty falling asleep Constipation related to inadequate intake of liquids Potential nausea related to nasogastric tube insertion Activity intolerance
answer

Acute pain related to lumbar disk repair Sleep deprivation related to difficulty falling asleep Potential nausea related to nasogastric tube insertion
question

A client suffering from gastroenteritis has tachycardia, hypotension, oliguria, and dark-colored urine. The lab reports reveal increased hematocrit, elevated blood urea nitrogen, and increased specific gravity of the urine. What is the probable electrolyte disturbance in the client? (only 1) Low levels of sodium in the body Low levels of potassium in the body Decreased extracellular fluids with normal tonicity Combined hypernatremia and extracellular volume depletion
answer

Decreased extracellular fluids with normal tonicity
question

The nurse is teaching a group of nursing students about the application of a nursing diagnosis to nursing practice. Which statement made by a student indicates the need for further teaching? (only 1) “Nursing diagnosis helps with the identification of patient health problems.” “Nursing diagnosis offers an approach to ensure comprehensive nursing assessment.” “Research gives backing to nursing diagnoses that are used to identify a patient’s health care problem.” “Nursing diagnosis improves the selection of nursing interventions by nurses in certain practice settings.”
answer

“Nursing diagnosis improves the selection of nursing interventions by nurses in certain practice settings.”
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A patient reports a burning sensation and pain while passing urine. What should the nurse include in the assessment? (only 1) Ask if other family members are sick. Determine height and weight. Look for presence of blood in the urine. See if the patient has a history of hypertension
answer

Look for presence of blood in the urine.
question

A neighborhood with old homes is undergoing a lot of restoration. Lead paint was used in the buildings. The clinic is initiating a lead screening program. This activity is an example of which level of prevention? (only 1) Primary prevention Secondary prevention Tertiary prevention Disease prevention
answer

Secondary prevention
question

Which type of interpretation errors may occur with a nursing diagnosis? . Insufficient cluster of cues Inaccurate interpretation of cues Failure to consider conflicting cues Use of an insufficient number of cues Failure to validate the nursing diagnosis with the patient
answer

Inaccurate interpretation of cues Failure to consider conflicting cues Use of an insufficient number of cues
question

Which symptom may indicate hyperthyroidism? Bulging eyes Crossed eyes Inflamed eyes Blurry eyes
answer

bulging eyes
question

A group of nurses is organizing an educational session to teach the population of a particular community about the roots of cardiovascular disease and its impact on the human body. Which type of nursing diagnosis is being followed in this scenario? (only 1) Medical diagnosis Risk nursing diagnosis Problem-focused nursing diagnosis Health promotion nursing diagnosis
answer

Health promotion nursing diagnosis
question

A patient with cardiac failure is found to have excess extracellular fluid of normal tonicity. Which life-threatening complication is this patient most likely to suffer? (only 1) Coma Seizures Pulmonary edema Hypovolemic shock
answer

Pulmonary edema
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The nurse in a geriatric clinic collects the following information from an 82-year-old client and her daughter, the family caregiver. The daughter explains that the client is “always getting lost.” The client sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, “I just don’t know what to do because I worry she will fall or hurt herself.” The daughter states that, when she took her mother to the store, they became separated, and the mother couldn’t find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? Daughter’s concern of mother’s risk for injury Pacing Client getting lost easily Daughter working part time Getting up frequently
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Pacing Client getting lost easily Getting up frequently
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A patient is experiencing the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). For which electrolyte disturbance should the nurse evaluate the patient? (ONLY 1) Hypernatremia Hyponatremia Hemoconcentration Increased serum osmolality
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Hyponatremia
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Upon assessing a patient’s surgical incision on the left hip, the nurse observes reddened periwound tissue, foul drainage, and open areas between the staples. What is the likely nursing diagnosis? (only 1) Risk for infection Risk for inflammation Impaired skin integrity related to limited mobility Impaired physical mobility related to incisional pain
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Risk for infection
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A 78-year old patient complains of blurred vision. The nurse sees that abnormal growth of blood vessels behind the retina are documented in the ophthalmoscopy reports. Which condition might the nurse suspect? (only 1) Cataract Glaucoma Retinopathy Macular degeneration
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Macular degeneration
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After assessing a patient, a nurse suspects that the patient has overflow urinary incontinence. Which findings support the nurse’s conclusion? Nocturia Frequency Distended bladder on palpation Leakage of urine on the way to the bathroom Diminished or absent awareness of bladder filling and the urge to void
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Nocturia Frequency Distended bladder on palpation
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In the examples given, which nurses are making nursing diagnostic errors? The nurse who listens to lung sounds after a patient reports difficulty breathing The nurse who considers conflicting cues in deciding which diagnostic label to choose The nurse who is assessing the edema in a patient’s lower leg and is unsure how to assess the severity of edema The nurse who identifies a diagnosis based on a single defining characteristic The nurse who identifies a risk-for diagnosis related to a medical diagnosis
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The nurse who is assessing the edema in a patient’s lower leg and is unsure how to assess the severity of edema The nurse who identifies a diagnosis based on a single defining characteristic The nurse who identifies a risk-for diagnosis related to a medical diagnosis
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Which nursing activity is found in a tertiary health care environment? (only 1) Administering influenza immunizations at the senior independent living facility Providing well-baby care in the clinic run by the local community health department Admitting a patient following open heart surgery to the cardiovascular intensive care unit Working the triage desk in the emergency department
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Admitting a patient following open heart surgery to the cardiovascular intensive care unit
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Evidence-based practice is defined as: (only 1) Nursing care based on tradition. Scholarly inquiry of nursing and biomedical research literature. A problem-solving approach that integrates best current evidence with clinical practice. Quality nursing care provided in an efficient and economically sound manner.
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A problem-solving approach that integrates best current evidence with clinical practice.
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What is the most commonly reported bacterial sexually transmitted infection (STI) in the United States? (only 1) Syphilis Gonorrhea Genital herpes Chlamydia
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Chlamydia
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Which condition may cause decreased tissue oxygenation due to decreased oxygen-carrying capacity of the blood? (only 1) Obesity Anemia Pregnancy Neuromuscular disease
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Anemia
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Which skill is the most important to help the nurse to formulate a nursing diagnosis? (only 1) Clinical judgment Observation Communication Nursing experience
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Clinical judgment
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The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the P in a three-part nursing diagnostic statement using the PES format? (only 1) Severe pain Natural swelling Related to incisional trauma Wincing, guarding, restricted turning and positioning
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Severe pain
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A mother of three teenage daughters is diagnosed with a brain tumor and is scheduled to undergo major brain surgery. The client says, “My daughters are my strength. When they are with me, nothing is going to happen to me.” What nursing diagnosis can be attributed to this client? (only 1) Ineffective coping Readiness for enhanced spiritual well-being Risk for spiritual distress Spiritual distress
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Readiness for enhanced spiritual well-being
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The nurse assesses a patient and formulates a nursing diagnosis related to pain. Which patient data would support this diagnosis? (only 1) The patient has an asthma exacerbation. The patient has monthly dysmenorrhea. The patient has lower-extremity edema. The patient has an elevated body temperature.
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The patient has monthly dysmenorrhea.
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Which term describes data that appear to show some type of patterned relationship with a nursing diagnosis? (only 1) Data cluster Concept map Related factors Defining characteristic
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Related factors
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As per Yura and Walsh, what are the components of the nursing process? Planning Evaluation Assessment Implementation Nursing diagnosis
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Planning Evaluation Assessment Implementation
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What are the different types of nursing diagnoses, according to NANDA-I? . Risk diagnoses Acute diagnoses Problem-focused diagnoses Chronic diagnoses Health promotion diagnoses
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Risk diagnoses Problem-focused diagnoses Health promotion diagnoses
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A nurse is assessing the clients on the unit. The nurse identifies some collaborative problems among the clients. What are some examples of collaborative problems? Cold Nausea Paralysis Hemorrhage Wound infection
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Paralysis Hemorrhage Wound infection (Collaborative problems are actual or potential physiological complications that the nurse can monitor to detect the onset of changes in the client’s status. )
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What is the reason for heart failure after myocardial infarction (MI)? (only 1) Increased myocardial workload Increased oxygen demands of the myocardium Inability of the heart chambers to fill adequately Impairment of the contractile function of the ventricle
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Impairment of the contractile function of the ventricle (Heart failure is a physiological state in which the heart cannot pump enough blood to meet the metabolic needs of the body. )
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Following an assessment, the nurse finds that the client has impaired verbal communication. Which observations in the client’s speech and behavior would have led the nurse to this conclusion? Difficulty in sitting Inability to draw pictures Inappropriate verbalization Inability to articulate words Difficulty in comprehending
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Inappropriate verbalization Inability to articulate words Difficulty in comprehending
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A client is anxious about an operation scheduled for the next day. The nurse identifies that the client is anxious. Which interventions does the nurse use to decrease the client’s anxiety related to surgery? Provide satisfactory answers to the client’s questions. Instruct the client to perform range-of-motion exercises. Provide detailed instructions about the recovery process. Provide detailed instructions about the surgical procedure. Provide detailed instructions about discharge planning.
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Provide satisfactory answers to the client’s questions. Provide detailed instructions about the recovery process. Provide detailed instructions about the surgical procedure.
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The nurse is assessing an older patient who attempted suicide twice due to death of his life partner. He has undergone psychotherapy for depression, but the symptoms have not subsided. Which therapy would be beneficial for the patient? (only 1) Reminiscence Validation therapy Medication therapy Electroconvulsant therapy
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Electroconvulsant therapy
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While caring for a debilitated patient, a nurse learns that the patient has been unable to pass stool for several days, despite the repeated urge to defecate. The nurse suspects that the patient has a fecal impaction. Which other findings support the nurse’s suspicion? Anorexia Rectal pain Dark-colored urine Continuous oozing of liquid stool Less frequent urination than usual
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norexia Rectal pain Continuous oozing of liquid stool
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Two nurses are having a discussion at the nurses’ station. One nurse is a new graduate who added, “Client needs improved bowel function related to constipation” to a client’s care plan. The nurse’s colleague, the charge nurse says, “I think your diagnosis is possibly worded incorrectly. Let’s go over it together.” A correctly worded diagnostic statement is: (only 1) Need for improved bowel function related to change in diet. Client needs improved bowel function related to alteration in elimination. Constipation related to inadequate fluid intake. Constipation related to hard infrequent stools.
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Constipation related to inadequate fluid intake.
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A nurse is caring for a client who is admitted to the hospital with a diagnosis of left-sided heart failure. The health care provider asks the nurse to provide continuous positive airway pressure (CPAP) for this client. What could be the primary motive behind giving CPAP to this client? (only 1) To facilitate gas exchange To prevent airway collapse To reduce pulmonary edema To improve contractility of the cardiac musculature
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To prevent airway collapse (CPAP helps keep the alveoli in an inflated position, thereby preventing them from collapsing.)
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What must the nurse bear in mind while formulating the nursing diagnosis for a patient? (only 1) Use a unified language system. Document in his or her own simple terms. Write in-depth notes for accuracy. Identify and label medical illness.
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Use a unified language system.
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The nurse completed the following assessment: 63-year-old female client has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? Vital sign results Abdominal distention Age of client Change in bowel elimination pattern Abdominal pain No past history of hospitalization
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Abdominal distention Change in bowel elimination pattern Abdominal pain
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A 45-year-old single mother lives with her 10-year-old son who has Down’s syndrome. The client’s facial expressions and manners demonstrate fatigue and malaise. She has an unkempt appearance and has no interest in going out and meeting people. The client states that she feels worthless, and is overburdened with her responsibilities. What are the differential nursing diagnoses for this client? Anemia Psychosis Depression Ineffective coping Caregiver role strain
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Ineffective coping Caregiver role strain
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A neighborhood with old homes is undergoing a lot of restoration. Lead paint was used in the buildings. The clinic is initiating a lead screening program. This activity is an example of which level of prevention? (only 1) Primary prevention Secondary prevention Tertiary prevention Disease prevention
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Secondary prevention
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What is a health promotion diagnosis, according to NANDA-I? (only 1) It describes a person’s readiness to enhance specific health behaviors for well-being. It describes human responses to health conditions that may develop in a vulnerable individual. It describes human responses to health conditions that exist in an individual or community. It is associated with a potential response to the health problem and can change by using specific nursing interventions.
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It describes a person’s readiness to enhance specific health behaviors for well-being.
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A patient reports mucus in the feces. What is the most likely cause? Constipation Intestinal infection Increased peristalsis Malabsorption of fat
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Intestinal infection (Mucus will be present in the feces of patients with intestinal infection, irritation, inflammation, or injury.)
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A nurse is analyzing the laboratory results of a hospitalized client. The nurse reads the differential count of white blood cells and makes a note that the eosinophils, basophils, and monocytes are within normal limits. The neutrophilic count, which should be between 55%-70%, is increased to 90%. The lymphocytes, which should be between 20%-40%, are increased to 60%. What does the increased count indicate? Sepsis Viral infection Tuberculosis infection Chronic bacterial infection Acute suppurative infection
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Viral infection Chronic bacterial infection Acute suppurative infection
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The nurse is attending to a patient in a coronary care unit. She is revising the care plan after evaluating the patient outcomes. Which steps of the nursing processes is the nurse performing? Assessment Evaluation Implementation Planning Diagnosis
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Assessment Evaluation
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The nurse is designing a care plan for a patient admitted to the hospital with pneumonia, the patient is a smoker. The nurse is using the PES format (problem, etiology, and symptom) for formulating nursing diagnoses. Which components can the nurse include in this PES format? Cough and shortness of breath Medications that the patient must take Dyspnea or difficulty in breathing Problems caused by smoking The diet and regimen to be followed in this disease
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Cough and shortness of breath Dyspnea or difficulty in breathing Problems caused by smoking
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Which is an example of an interpreting error in nursing diagnostics? (only 1) Inaccurate data Disorganization Failure to seek guidance Inaccurate understanding of cues
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Inaccurate understanding of cues
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What is a clinical judgment that concerns motivation and desire to increase well-being and actualize human health potential? (only 1) Medical diagnosis Risk nursing diagnosis Problem-focused nursing diagnosis Health promotion nursing diagnosis
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Health promotion nursing diagnosis
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Which patient-related factors fall under health promotion nursing diagnosis? The patient follows poor hygiene measures. The patient is willing to eat nutritious foods. The patient shows decreased interaction with society. The patient is ready to increase his or her coping skills. The patient is ready to perform regular exercises.
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The patient is willing to eat nutritious foods. The patient is ready to increase his or her coping skills. The patient is ready to perform regular exercises.
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The nurse is teaching a group of nursing students about the use of standard formal nursing diagnostic statements from the North American Nursing Diagnosis Association-International (NANDA-I). Which statements by a student indicate the need for further learning? “The nursing diagnostic statements foster the development of nursing knowledge.” “The nursing diagnostic statements emphasize following traditional practice guidelines.” “The nursing diagnostic statements align the role of the nurses with other health care providers.” “The nursing diagnostic statements help the nurses focus on the scope of medical practice as a whole.” “The nursing diagnostic statements allow nurses to communicate among themselves in both written and electronic formats.”
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“The nursing diagnostic statements emphasize following traditional practice guidelines.” “The nursing diagnostic statements align the role of the nurses with other health care providers.” “The nursing diagnostic statements help the nurses focus on the scope of medical practice as a whole.”
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The nurse is assessing a patient’s data for the related factor of the nursing diagnosis. Which statements are true regarding the related factor? The related factor is within the domain of nursing practice. The related factor does not always respond to nursing interventions. In the case of a risk nursing diagnosis, the risk factor is the related factor. The related factor is not associated with the patient’s actual response to a health problem. The related factor is identified from the patient’s assessment data.
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he related factor is within the domain of nursing practice. In the case of a risk nursing diagnosis, the risk factor is the related factor. The related factor is identified from the patient’s assessment data.
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The nurse is identifying the related factors by studying a patient’s assessment data. According to NANDA-I diagnoses, under which categories should the nurse classify the related factors? Situational Maturational Psychological Treatment-related Pathophysiological
answer

Situational Maturational Treatment-related Pathophysiological

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