NURS 202 – Quiz 3 – Flashcards

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question
A nurse is completing a plan of care for a patient. The statement "patient will be able to walk 10 feet, twice a day without shortness of breath" is which part of the nursing process?
answer
Plan
question
The nurse is taking information for the patient's database. The patient is not very talkative, is pale, diaphoretic, and restless in the bed. The patient tells the nurse to just "leave me alone." Which of the following statements is subjective data?
answer
"Leave me alone"
question
During an initial interview, the patient makes this statement: "I don't understand why I have to have surgery, I'm not really that sick or in pain right now." The nurse's BEST response is:
answer
"What kind of questions do you have about your surgery?"
question
A child is admitted to the hospital for treatment of erratic glucose levels secondary to diabetes mellitus. Which of the following nursing diagnoses will the nurse focus on as a priority?
answer
Altered nutrition, less than body requirements, related to inability to maintain glucose level
question
A nurse works in an acute psychiatric setting and sees patients as they are admitted for inpatient psychiatric care. Many of the patients exhibit paranoid behavior. The most important skill the nurse can utilize for these patient's is which of the following?
answer
Interpersonal skill
question
The nurse has formulated the following nursing diagnosis: Activity Intolerance, related to weakness and debilitation, manifested by reports of fatigue after any physical activity. What is the defining characteristic of this label?
answer
Reports of fatigue
question
The nurse is assigned to collect an admission history on a recently admitted patient to the medicine unit. No family is present. The nurse notes the patient is confused and not able to contribute to the conversation. The nurse documents this as which of the following?
answer
Objective data
question
The nurse is performing a dressing change for a patient according to the nursing care plan. He notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process?
answer
Assessment
question
A patient is diagnosed with pneumonia and has been hospitalized for 24hours. A priority nursing diagnosis for this patient is which of the following?
answer
Ineffective airway clearance, related to increased secretions
question
When implementing a care plan, the nurse involves the patient who is ready for discharge in the planning. One of the goals is that the patient will have improved mobility. Which of the following might be an appropriate desired outcome statement for this goal?
answer
The patient will ambulate without a walker by 6 weeks
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