NURS 121 Exam 1 Review – Flashcards
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The nurse is caring for a client diagnosed with cancer. When formulating the plan of care for this client, what should the nurse consider related to client goals? a) Goals should indicate whether treatment is successful. b) Goals should be attainable c) Goals may address multiple actions d) Goals should center on the client e) Goals should be measurable
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B, D, and E
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The nurse is implementing care for clients in an acute care facility. Which guidelines should the nurse use when choosing interventions for goal achievement? A) They are identified with specific laws and regulations. B) They can be performed with limited resources. C) They are interchangeable among clients for optimal applicability. D) They are consistent with clients?'? values, beliefs, and culture.
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D
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The nursing student is writing a care plan for a client who was recently cared for during a clinical rotation. What should the student nurse do when planning nursing interventions for the? client? A) Ensure relevancy to situation B) Be realistic C) Be general and brief D) Be specific and concise E) Include priorities of care
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A, B, D, and E
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The nurse is formulating a plan of care for a client who is pregnant. Which goal is appropriate for the nursing diagnosis dealing with a knowledge deficit related to? pregnancy? A) Client will attend medication management classes within four weeks. B) Client will attend prenatal classes through the course of the pregnancy. C) Nurse will facilitate learning readiness. D) Nurse will teach client about prescribed exercise regimen for pregnancy at next appointment.
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B
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The nursing student is participating in revising the plan of care for a client diagnosed with myasthenia gravis who did not meet care goals. Which will the nurse consider when revising the plan of? care? A) Did the client have access to planned? interventions? B) What nurses were assigned to the? client? C) Were the goals realistic and? attainable? D)Were the interventions that were selected? appropriate? E) Were interventions implemented as? planned?
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A, C, D, and E
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The nurse is working with an adult client who has a diagnosis of posttraumatic stress disorder? (PTSD). The client shares that he has begun exercising daily at a local? gym, and states that this lowers his daily stress level. Which type of nursing diagnosis would best capture the client?'s exercise? behavior? A) Wellness diagnosis B) Health promotion diagnosis C) Syndrome diagnosis D) Risk diagnosis
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A
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When formulating a nursing diagnosis for a client diagnosed with diabetes? mellitus, which information should be taken into consideration to mobilize health and the recovery process for this? diagnosis? A) The client joins the ADA support group. B) The client requests information on how to control blood pressure. C) The client demonstrates the ability to monitor blood glucose. D) The client tells the nurse that he adheres to his 1800 calorie ADA diet. E) The client independently administers insulin.
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A, C, D, and E
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Which evaluation statement by the nurse is appropriate and indicates a goal has been met for a client diagnosed with a stroke? ?A) 04/03/2015, 1830: Goal partially? met: Client demonstrates use of home oxygen machine. ?B) 1750: Goal? met: Client voices understanding of treatment therapy. ?C) 04/03/2015: Goal not? met: Client does not demonstrate use of incentive spirometer. ?D) 04/03/2015, 1800: Goal? met: Client demonstrates? self-injection of Lovenox prior to discharge.
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D
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Following the collection of assessment? data, what does the nurse do? next? ?(Select all that? apply.) A) Compares the data with suspected medical problems B) Clusters cues to generate tentative hypotheses C) Identifies strengths and resources D) Analyzes the data for gaps and inconsistencies E) Measures the data against standards to identify significant cues
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B, D, and E
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Which statements are true of nursing? diagnoses? ?(Select all that? apply.) A) Nursing diagnoses describe responses to a health problem. B) A nursing diagnosis is a condition that nurses are licensed to treat. C) Nursing diagnoses are flexible and change based upon client responses. D) Nursing diagnoses are uniform between clients. E) A nursing diagnosis is a judgment statement.
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A, B, C, and E
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What are the components of a nursing? diagnosis? ?(Select all that? apply.) A) Data clusters B) Variations C) Etiology D) Defining characteristics E) Diagnostic label
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C, D, and E
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What is a purpose of a? goal? A) To measure the end result of nursing action B) To evaluate the client?'s response to the plan of care C) To provide direction for nursing interventions D) To identify a time frame for an action to occur
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C
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Which are characteristics common to all? goals? ?(Select all that? apply.) A) Measure nursing interventions B) State nursing actions C) Relevant to the client D) Describe a single action E) Identified for each nursing diagnosis
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C, D, and E
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What is used as the framework for identifying nursing? interventions? A) Signs and symptoms B) Previous health history C) Etiology of the problem D) Healthcare provider?'s orders
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C
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What should be done first before implementing a nursing? intervention? A) Ensure the client?'s privacy B) Review nursing diagnoses C) Reassess the client D) Find someone to help
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C
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Which skills are used when implementing client? care? ?(Select all that? apply.) A) Interpersonal B) Psychomotor C) Cognitive D) Physical examination E) Assessment
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A, B, and C
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Gordon? Sullivan, a? 58-year-old client with acute pain and bleeding from prostate? cancer, rates his pelvic pain as an 8 on a pain rating scale from 1 to 10. He is considering surgery to remove the prostate before beginning chemotherapy and radiation. When writing a? three-part nursing diagnosis for? Gordon, what should the nurse use as the? etiology? A) Prostate Cancer B) Surgery C) Bleeding D) Acute Pain
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A
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The nurse identifies the diagnosis? "Imbalanced Nutrition: Less than Body Requirements related to poor nutrition as evidenced by low serum albumin? level" for Isabella? DeMarco, a? 65-year-old client with osteoporosis. What should the nurse identify as a goal for Ms.? DeMarco? A)The client will select healthy food choices when planning meals. B) The client will eat? 75% of all snacks in 2 days. C) The client will consume three meals a day. D) The client will increase oral intake by? 25% within a week.
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D
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The nurse is assessing Julia? McMichael, an? 82-year-old client with pneumonia. Mrs. McMichael is experiencing? dyspnea, has a pulse oximeter reading of? 90, and lung assessment reveals rales. Which nursing intervention is the most appropriate for Mrs. McMichael at this? time? A) Use a face mask for oxygen even though a request for nasal cannula was made B) Keep the head of Mrs.? McMichael's bed flat C) Empty fluid from the oxygen humidifier D) Explain that the oxygen will help Mrs. McMichael breath better
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D
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While making morning? rounds, the charge nurse observes an assistant irrigating a nasogastric tube of a client recovering from gastric surgery. What is the most appropriate action by the charge nurse at this? time? A) Ask the assistant of the location of the nurse B) Intervene and complete the irrigation of the tube for the assistant C) Discuss the issue of overdelegation with the nurse D) Ask the assistant if help is needed
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B
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The nurse manager is performing responsible actions associated with a delicate client care situation. Which actions are appropriate for the nurse manager to? complete? ?(Select all that? apply.) A) Directing nursing staff to check expiration dates before using intravenous fluids B) Ensuring paper work is completed and submitted to the security department as required C) Notifying central storage of stock items no longer needed for the care area D) Meeting with staff about the need to maintain client confidentiality E) Referring to the nurse practice act before delegating a task to a nurse
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B, C, and D
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The charge nurse observes a registered nurse delegate tasks to a nursing assistant. What did the charge nurse observe that indicates additional information about delegation is? required? ?(Select all that? apply.) A) The nurse did not have complete information about the status of delegated tasks at the? change-of-shift report. B) The assistant and nurse discussed completion of delegated tasks. C) The assistant was unable to recognize a change in a client?'s condition. D) The nurse provided direction and feedback on task progress and completion. E) The assistant asked another nurse to assist with the delegated task.
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A, C, and E
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The director evaluates a nurse? manager's time management skills as being? "outstanding." Which actions by the manager would the nursing director identify as being worthy of an outstanding? rating? ?(Select all that? apply.) A) Declined participation in a newly formed task force B) Used the software program to run a productivity report C) Cleared off the desk and focused on one project at a time D) Returned phone calls and emails before attending change of shift report E) Closed the office door when discussing performance appraisals
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A, B, C, and E
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While following up on a delegated? task, the nurse observes the task was not completed as required and agreed. Which is the priority nursing action in this? situation? A) Inquire as to why the task was not be completed as planned B) Instruct the assistant on ways to avoid similar situations in the future C) Discuss disciplinary action for the assistant with the nurse manager D) Discipline the assistant for failing to complete the agreed upon task
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A
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Which activity is required of the delegate who accepts a? task? ?(Select all that? apply.) A) Define the task B) Keep the delegator informed of progress C) Clarify how to report completion of the task D) Report concerns E) Clarify the time frame to complete the task
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B, C, D, and E
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The nurse is delegating a task to an assistant. Which factors should the nurse include when describing the task to be? completed? ?(Select all that? apply.) A) Expectation that the task is completed within 1 hour B)The need to complete the task before the client attends physical therapy C) Location of the nurse if there are any issues with completing the task D) The need to complete the task when possible E) The fact that the client?'s family is not local
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A, B, and C
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After shift? report, the registered nurse directs a nursing assistant to provide morning care to four clients. What behavior did the nurse demonstrate with the nursing? assistant? A) Dumping B) Collaborating C) Delegating D) Assigning
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A
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When caring for an older adult? client, what collaborative therapy is utilized in the management of fecal? impaction? (Select all that? apply.) A) Intake of? high-residue foods with decreased fluids B) Saline enemas C) Digital removal of the impaction D) Intake of cold? drinks, especially before the usual time of defecation E) Bowel training program
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C and E
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The nurse is caring for a group of residents in a? long-term care facility. Which? condition, if present in a? resident, would be the most likely cause of fecal? incontinence? A) Anorectal injury B) Irritable bowel syndrome C) Gastrointestinal reflux disease D) Parkinson disease
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A
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A nurse is admitting a child to the pediatric unit with altered bowel elimination. What cause can lead to encopresis that the nurse needs to explore? further? (Select all that? apply.) A) Fecal impaction B) Anger issues C) Stress D) Premature birth E) Diet
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A, B, C, and E
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The nurse is providing home care instructions for a client with fecal incontinence. What information should the nurse? include? A) Reduce fluid intake B) Maintain good skin care C) Avoid taking? bulk-forming laxatives D) Eat a? low-fiber diet
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B
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The nurse is caring for a child experiencing altered bowel elimination. What collaborative therapy could be implemented with a child who has? encopresis? (Select all that? apply.) A) Psychological treatment B) Behavioral modification C) Collaboration with school nurses and teachers D) Limit fluid intake E) Pharmacologic treatment of constipation
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A, B, C, and E
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The nurse is providing education on measures to facilitate defecation to a client who has a history of constipation. Which suggestion does the nurse include when teaching the? client? (Select all that? apply.) A) Take a laxative if a bowel movement does not occur daily B) Eat a pureed diet C) Consume up to 1000 mL of fluid per day D) Drink a glass of warm water before breakfast E) Eat? high-fiber foods
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D and E
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The nurse reviews the medical chart for a client who is experiencing urinary incontinence. The healthcare provider?'s admission assessment identifies that the incontinence is related to an overactive detrusor muscle. Based on the provider?'s ?note, which type of urinary incontinence is this client? experiencing? A) Urge B) Functional C) Stress D) Overflow
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A
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The nurse is providing care to a client with urinary incontinence who has been prescribed bladder training behavior modification. Which goal of therapy does the nurse include in the teaching session with the? client? A) To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times B) To toilet the client on a schedule that corresponds with the normal pattern C) To improve pelvic floor muscle strength by stopping the urine flow during voiding and holding for a few seconds D) To toilet the client at regular intervals? (e.g., every? 2-4 hours)
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A
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The nurse is caring for a client at risk for urinary retention. Which clinical manifestations does the nurse document during the nursing assessment to support this? diagnosis? A) Nausea and vomiting B) Hematuria C) Overflow voiding D) Cool and clammy skin
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C
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The nurse is educating the parents of a? preschool-age child about the causes of nocturnal enuresis. Which statements are appropriate for the nurse to include in the teaching session with the? parents? (Select all that? apply.) A) Many children wet the bed due to difficulties in arousal from sleep. B) ?Bed-wetting is more common in girls than boys. C) Your child may be constipated. Constipation is a known cause for? bed-wetting. D) This is caused by an overproduction of urine at night. E) Your child is just being lazy.
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A, C, and D
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The nurse is providing care to a client diagnosed with urinary retention. Which medication on the? client's medical administration record would the nurse question for this? client? A) Ibuprofen B) Acetaminophen C) Diphenhydramine hydrochloride D) Bethanechol chloride
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C
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The nurse is providing care to a client who is prescribed a complete decompression of bladder using intermittent catheterization. Which explanation about this procedure to the family is the most? appropriate? ?A) "A diagnostic urodynamic? test." ?B) "The postvoiding insertion of a catheter to determine the volume of urine retained in the? bladder." ?C) "A nonpharmachologic therapy for urinary? retention." D) ?"A diagnostic? uroflowmetry."
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C
