Nursing answers test 2 – Flashcards
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A patient who is legally blind says to the nurse "I once was able to see a little bit but now I cant see anything" What should the nurse encourage the patient to do while hospitalized? a)wear dark tinted eyeglasses b) keep a light on in the room at all times c)close the window blinds during the day d) call for assistance when getting out of bed
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d) call for assistance when getting out of bed
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Which action should the nurse include in the plan of care that is a common hygiene need of all older adults? a) remove the bottom dentures first b) assist with daily bathing c)apply a skin moisturizer d) use deodorant soap
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c) apply skin moisturizer
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What is the cause of pressure ulcers? a) pressure b) desquamation 3) skin breakdown d) cellular necrosis
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a) pressure
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A physicians order reads "up ad lib". What does this mean in terms of patient activity? a) may walk twice a day b)may be up as desired c) may only get up to use the bathroom d) must remain on bed rest
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b)may be up as desired
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A nurse has developed a plan of care with nursing interventions designed to meet specific patient outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? A) Continue to follow written plan of care B) Make recommendation for revising the plan of care C) Ask another healthcare professional to design a plan of care D0State "goalwill be met at a later date.
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B) Make recommendation for revising the plan of care
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What is the primary purpose of and incident report? A)Means of identifying risks B) basis for staff evaluation C) basis for disciplinary action D) format for audiotaped report
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A) Means for identifying risks
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What is the priority nursing diagnosis for a client experiencing a migraine headache? A) Acute pain related to biological and chemical factors B) Anxiety related to change in or threat to health status C)Hoplessness related to deteriorating physiological condition D) Risk for injury related to side effects of medical therapy
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A) Acute pain related to biological and chemical factors
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You are providing nursing care for a 24 year old female patient admitted to the unit with a diagnosis for cystis. Which intervention should you delegate to the nursing assistant? A) teaching the patient how to secure a clean catch urine sample b) assessing the patients urine color, order, and sentiment c) reviewing the nursing care plan and adding nursing interventions d) providing the patient with a clean catch urine sample container
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D) providing the patient with a clean catch urine sample container
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When a client is being prepared for a colonoscopy procedure which task is most suitable to delegate to the nursing assistant. A) explaining the need for a clear liquid diet 1-3 days before the procedure b) Reinforcing the nothing by mouth rule 8 hours before procedure c)administering laxitives 1-3 days before procedure d)administering a enema the night before the procdure
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b) reinforcing the nothing by mouth rule 8 hours before the procedure
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What is the purpose of evaluation in the nursing process? A) to direct future nursing interventions B) to formulate a database of nursing diagnosis C) to complete an intitial plan of care D) to transfer medical orders to the plan of care
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A) to direct future nursing interventions
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A nurse is evaluating the outcomes of a plan of care to teach an obese patient about the calorie content of food, What type of outcome is this? A)psychomotor b)affective c)physiologic d) cognitive
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d) cognitive
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A nurse has developed a plan of care for the nursing diagnosis risk for lonlieness for a recently widowed man. WHen evaluating the plan, the man tells the nurse new information about his active social life. What would the nurse do next? A) continue with the plan B) delete the nursing diagnosis C) tell the patient he is lonely D) adjust the time criteria
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B) delete the nursing diagnosis
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A nurse forget to raise the railings of the bed of a patient who is confused after taking pain medications. The patient attempts to get out of bed and suffers a minor fall. The nurse asks the college who witnessed the fall not to mention it to anyone because the patient only had minor bruises. What would the appropriate action of the college? A) no further steps need to be taken since the patient was not seriously injured B) the college should inform the nurse that a full report of the incident needs to be made C) the college should monitor the patient closely for any adverse affects of the fall D) the college should report the incident of the peer review of the incident
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B) the college should inform the nurse that a full report of the incident needs to be made
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Alice jones a registered nurse is documenting assesments at the beginning of her shift. How should she sign the entry? A) alice j, RN B) A.jones, RN C) ALice jones D) A j RN
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B) A.Jones RN
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What is the purpose of evaluation in the nursing process? A) to direct future nursing interventions B) to formulate a database of nursing diagnosis C) to complete an initial plan of care D) to transfer medical orders to plan of care
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A) to direct future nursing interventions
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A nurse is developing outcomes for a specific problem statement. WHat is one of the most important considerations the nurse should have? A) That the written outcomes are designed to meet certain goals B) to encourage the patient and family to be involved C) to discouarage additions by other healthcare providers D) why the nurse believes the outcome is important
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B) to encourage the patient and family to be involved
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What part of the nursing diagnosis statement suggests the nursing intervention to be included in the plan of care? A) Problem statement B) defining characteristics C) etiology of the problem D) outcomes criteria
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C) etiology of the problem
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A patient who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. WHy would the nurse review the plan of care? A) to implement evidence-based practice B) To ensure the order follows hospital policy C) to be sure interventions are individualized D) to be sure the intervention is safe
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D) to be sure the intervention is safe
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A student is ambulating a patient for the first time after surgery. What would the student do to anticipate and plan for an unexcpected outcome? A) Take the patients vital signs after ambulating B) Ask the patients wife to assist with ambulation C) Delay ambulation until the following shift D) Ask another student to help with the ambulation
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D) Ask another student to help with ambulation
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A nurse delegates a specific intervention to a UAP. What implications does this have to the nurse A) The UAP is responsible and accountable for hisor her own actions B) nurses do not have authority to delegate interventions C) The nurse transfers responsibility but is accountable for the outcome D) The UAP can function in an independent role for all interventions
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C) The nurse transfers responsibility but is accountable for the outcome
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What is the focus of a diagnostic statement? A) the patient problem B) the potential complication C) the nursing diagnosis D) the medical diagnosis
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B) the nursing diagnosis
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Which of the following nursing diagnosis is an example of a wellness diagnosis? A) Acute pain B) risk for infection C) readiness for enchanced parenting D) possible chronic low self-esteem
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C) Readiness for enhanced parenting
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A nurse admits a patient to the hospitals short-stay unit and completes a health history and physical assessment. Using these data, the nurse develops a_________ plan of care based on __________ planning? A) intermitten, focused B) comprehensive, initial C)Single-use, ongoing D) standard, emergency
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B) comprehensive, initial
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The nursing diagnosis impaired gas exchange, prioritized by maslows hierarchy of basic human needs, is appropriate for what levels of needs? A) physiologic B) safety C) love and belonging D) self-actualization
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A) physiologic
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IN which of the following patinets has the order of priorities for nursing diagnosis changed. Select all that apply A) A patient in a long term care facility who had a stroke B) a patient who is recovering from a broken leg c) a patient who insists on using the bathroom instead of a bedpan D) a patient who appears confused after taking pain medication E)A pregnant patient whose contractions are progressing as anticipated
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A, C, D
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Which of the following examples of patient data needs to be validated? Select all that apply A) a patient has trouble reading an informed consent, but states he does need glasses B) An elderly patient explains that the black and blue markson his arms and legs are due to a fall C) a nurse examining a patient with a respiratory infection documents fever and chills D) A patient in a nursing home states that she is unable to eat the food being served E) a pregnant patient is experiencing contractions that are 2 minutes apart
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A, B
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In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process? A) to collect information about subjective and objective data B)to correlate nursing and medical diagnostic criteria C)to identify etiologies of health problems D) to evaluate mutually developed excpected outcomes
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C) to identify etiologies of health problems
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A nurse develops a plan of care to meet the needs of a patient who has had a large loss of blood after a snowmobile crash. The interventions include administering and monitoring the patients physiologic response to intravenous fluids and blood. WHat has the nurse focused care on. A) a medical diagnosis B) a nursing diagnosis C) a collarorative problem D) a goal for care
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C) a collaborative problem
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What is the most critical element of documentation of teaching? A) a summary of the teaching plan B) the implementation of the teaching plan C) the patient need for learning D) evidence that learning has occured
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D) evidence that learning has occured
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A nurse is assisting with lunch at a nursing home. Suddenly on of the residents begins to choke and is unable to breath. The nurse assesses the residents abilityto breathe and then begins CPR? Why did the nurse asses respiratory status? A) to identify a life-threatening problem B) to establish a database for medical care C) to practice respiratory assessment skills D) to facilitate the residents ability to breath
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A) to identify a life-threatening problems
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Of the following data, what type would be collected during a physical assessment? A) Color, moisture, and tempeture of the skin B) type, amount and duration of pain C) foods eaten that cause nausea D) specific allergies resulting in itching
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A) color, moisture, and tempeture of the skin
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Which of the following questions or statements would be appropriate in eliciting for information when conducting a health history interview? A) WHy didn't you go to the the doctor when you began to have this pain B) Are you feeling better now than you did during the night C) Tell me more about what caused your pain d) If I were you, I would not wait to get medical help next time
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C0 tell me more about what caused your pain
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Which of the following questions or statements would be innapropriate termination of the health history interview A) well I cant think of anything else to ask you right now B) can you think of anything else you would like to tell me C) perhaps we could talk again sometime, goodbye D) I wish you would have remembered more about your illness
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B) can you think of anything else you would like to tell me
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Which of the following is a characteristic of helping relationship? A) it occurs spontanuosly B) it is similar to a social relationship C) it is an unequal sharing of communication D) it is based on the needs of the nurse
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C) it is an unequal sharing of communication
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A diabetes nurse educater is teaching a patient newly diagnosed with diabetes about his disease process, diet, excersiz, and medications. What is the goal of this teaching A) to help the patient to develop self-care abilities B) t ensure the patient will return for follow up care C) to facilitate complete recovery from the disease D) to implement teaching and counsiling
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A) to help the patient to develop self-care abilities
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what patient characteristic is important to asses when using the health-belief model as the framework for teaching A) developmental level B) source of information C) motivation to learn D) family support
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C) motivation to learn
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A nurse is writing learning outcomes for a patient recovering from severe burns. Which of the following verbs would be good choices to use when preparing outcomes related to learning how to change dressings. Select all that apply A) assembles B) demonstrates C) gives example D) identifies E) chooses
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A, B
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A nurse asks a patient to tell her the side effects of a medication. What learning domain is the nurse evaluating? A) Affective B) cognitive C) Psychomotor D)emotional
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B) cognitive
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The family of a patient in a burn unit asks the nurse for information. The nurse sits with family and discusse their concerns. What type of communication is this A) intrapersonal B)interpersonal C)organized D) focused
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B) interpersonal
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A student caring for a unconscious patient know that communication is important even if the patient does not reply. Which of the nonverbal actions would show caring A) making constant eye contact B) Wavaing to the patient when entering C) sign frequently D) touch the patient
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D) touch the patient
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Why is communication important to the assessing type of the nursing process A) the major focus of assessing is to gather information B) assessing is primarily based off of physical assesments C) assessing is involved in nonverbal ques D) written imformation is rarely used in assesment
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A)
