Nursing The Nursing Process PrepU Unit – Flashcards
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A nurse is formulating the nursing diagnosis of a client who has developed rashes on her skin as a result of an allergy. The nursing facility where the nurse is working requires a three-part statement including the etiology. Which is the most appropriate etiology?
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"Adverse allergic reaction"
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The clinical instructor is teaching the students the differences between a medical diagnosis and a nursing diagnosis. Which of the following statements is true regarding the nursing diagnosis?
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This type of diagnosis focuses on the patient
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A nurse is planning discharge to home for a patient who has been prescribed Coumadin for atrial fibrillation. What is the most important nursing goal of care at the time of discharge for a client receiving anticoagulation therapy?
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Patient education
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A client has turned up at a healthcare facility complaining of a chicken bone lodged in his throat. The client is coughing regularly and drooling but it is experiencing any pain, except when swallowing, and the client is at the risk of gagging. Which is an example of a correct diagnostic statement?
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Risk of choking R/T foreign object in throat AEB drooling and constant coughing
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A 60-year-old woman comes to the clinic because she had a persistent fever of 101.5 degrees F for the past 3 days. Her heart rate is 90 bpm, and her blood pressure is 150/90. She reports shortness of breath on ambulation. Oxygen saturation is 88% on room air. Lung sounds are decreased in the lower left base, and she is breathing 32 bpm. Which assessment findings have the highest priority?
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Oxygen saturation is 88%
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A nurse has conducted the admission interview of a client and assisted in physical examination. Which point should the nurse keep in mind during data analysis?
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Use critical thinking skills to identify the relevancy of the information obtained
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Which of the following statements is true of the nursing process?
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Scientific problem solving can occur within the nursing process
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A nurse is about to conduct a health interview of a 26-year-old client who has just been admitted to the healthcare facility for a stomach infection. Which point should the nurse keep in mind when conducting the client's health interview?
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Plan for the interview in advance
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Which intervention should the nurse perform to analyze a client's response in order to evaluate the nursing care plan?
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Analyze if client's care goals were met
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The nurse develops long-term and short-term objectives for a patient admitted with asthma. Which of the following is an example of a long-term objective?
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Patient returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack
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Two nurses have disagreed about the role in intuition in nursing practice, with one nurse characterizing it as "hocus-pocus" and the other nurse advocating it as a superior problem-solving strategy. Which of the following statements best conveys the role of intuition in nurses' problem solving?
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Intuition can be a clinically useful adjunct to logical problem solving.
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During which phase of the nursing process does the nurse start to put the patient's care plan into action?
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Implementation phase
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Which of the following statements best describes the relationship between nursing diagnosis and medical diagnosis?
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The nursing diagnosis is based on patient response to the medical diagnosis
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Of the following information collected during a nursing assessment, which are subjective data?
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nausea, abdominal pain
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A patient with atrial fibrillation is placed on anticoagulant therapy. Which of the following suggestions are most important to include in the discharge teaching plan?
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Report any bleeding immediately to the physician.
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A nurse is writing a care plan for a client with asthma. An expected outcome is a measurable client behavior showing the client has benefited from the care. From the following options, choose the most appropriate characteristic that describes an expected outcome that the nurse must respect.
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patient-centered outcome
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On admission, a physician diagnoses a patient with rheumatoid arthritis. The nurse uses assessments to make the nursing diagnosis of Chronic Pain. What is the nursing diagnosing?
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The response of the patient to the illness.
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A student is reviewing a patient's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis?
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appendicits
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A nurse is caring for a client in a healthcare facility. The nurse observes that the client appears uncomfortable and does not move from his bed too often. In this case, which observation should the nurse document in a very informative and objective way?
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Client having trouble moving
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Which of the following is a correct guideline to follow when composing a nursing diagnosis statement?
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Place signs and symptoms after the etiology and link them by the phrase "as evidenced by."
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The nurse ascertains that a patient is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this patient. What is the nurse's next step in correcting the problem?
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Making changes in the plan of care based upon assessment data
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A nurse who works in shifts, is caring for a client in a healthcare facility. Which nursing intervention should the nurse perform so that the next healthcare provider who replaces her can act with purpose and understanding?
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Communicate and document client care for the healthcare provider
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The nurse obtains information regarding health problems from a newly admitted client and documents them systematically. Which step of the scientific problem-solving method is comparable to this situation?
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Gathering problem-related information
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Which of the following group of terms best defines assessing in the nursing process?
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collection and analysis of patient data
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Which of the following entries would be an example of appropriate documentation?
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"I am so down today, and I just don't have any energy"
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A 58 year old woman presents to the local emergency department with symptoms of nausea, vomiting, and diarrhea. She has a history of bipolar disorder and has been taking lithium for about 2 years. What independent nursing action would the nurse expect to perform to detect a potential cause of the patient's presenting symptoms?
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Measure and monitor vital signs
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The nurse has measured from the tip of the patient's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which of the following components of the nursing process has the nurse demonstrated?
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planning: implementation
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What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?
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NANDA International (NANDA-I)
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A home health nurse review the nursing care with the patient and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?
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planning
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A client starts shaking his fist and yelling profanities at the nursing staff. How should the nurse document the behaviors?
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Client is shaking fist, and using loud tones and profanity when talking to nursing staff.
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A client arrives at community health center complaining of abdominal pain. The nurse is required to assess the client. Which is the most appropriate nursing intervention that the nurse should perform after the data have been collected and analyzed?
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Notify the primary healthcare provider of assessment data
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The nursing process is based upon the process of problem solving. What type of problem solving is the nurse using if she attempts to obtain a blood pressure on the patient's right arm, the left arm, the left leg, and then finally the right leg where a blood pressure is finally obtained?
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Trial-and-error problem solving
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When documenting subjective data, the nurse should do which of the following?
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Use the patient's own words placed in quotation marks.
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Which of the following activities is the clearest example of the evaluation step in the nursing process?
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Checking the patient's blood pressure 30 minutes after administering captopril
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A nurse applies the wrong topical medication to a client. What should the nurse include in the documentation of the medication error? Check all that apply
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Actual medication applied Who was notified Any action taken to minimize harm to the client
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Which of the following best summarizes the evaluating step of the nursing process?
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The nurse and patient measure achievement of planned outcomes of care.
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A nurse is caring for a client with a lung disorder. Which nursing actions achieve the primary goal of nursing? Select all that apply
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Communicating with the client Encouraging the client's healthy habits Assisting the client in activities of daily living
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The nurse completes a health history and physical assessment on a patient who has been admitted to the hospital for surger. What is the purpose of this initial assessment?
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to collect information to identify problems and strengths
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How should a nurse best document the assessment findings that have caused her to suspect a patient is depressed following his below-the-knee amputation?
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"Patient states, "I don't see the point in trying anymore."
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Which of the following is an example of an independent nursing action?
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Offering the patient an evening bath
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During orientation to a hospital, the nurse is instructed to check a box on a flow sheet for normal assessment findings and provide detailed information on abnormal findings. The nurse recognizes this as what type of documentation?
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charting by exception
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Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their patients?
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"Assessment data about the patient should be collected continuously."
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Based on an established plan of care, a nurse turns a patient every 2 hours. What part of the nursing process is the nurse using?
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implementing
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A nurse if formulating the care plan for a client. Which nursing orders should the nurse include in the nursing plan to help bring about the desired outcome in the client? Select all that apply
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Educating the client about his or her condition Making referrals to support groups for the client Making further assessments on the client's condition
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A nurse is caring for a patient admitted with dehydration after completing a triathlon in a hot, dry climate. The nurse identifies an appropriate nursing diagnosis for this patient as "Deficient fluid volume related to insufficient fluid intake as evidenced by blood pressure 84/46, heart rate 145, concentrated urine, and patient stating that he drank 200 mL of water during the 4-hour even." Identify the problem statement in this nursing diagnosis
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Deficient fluid volume
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An experienced obstetrical nurse is collecting data on a patient in labor. What is the best approach for the development of nursing diagnoses for this patient?
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Develop nursing diagnoses from clusters of significant data
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Legally speaking, how would the nurse demonstrate that care was responsible and appropriate?
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documenting the nursing actions in the patient's records
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A nurse administers a medication for pain but forgets to document it in the patient's medical record. Legally, what does this mean?
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In the eyes of the law, if it is not documented, it was not done
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The orderly progression of steps of the nursing process is:
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assessment, diagnosis, planning, implementation, evaluation
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A 60 year old man presents to the emergency department with reports of chest pain. Which of the following is an example of objective data?
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EKG CPK Chest x-ray
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In developing a plan of care for a client, the nurse recognizes that it is essential to complete which of the following steps? Select all that apply
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Nursing Diagnosis Nursing assessment Planning
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Which of the following are verbs that are helpful in writing measurable outcomes? Select all that apply
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describe visualize list
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Based on the following order, what action by the nurse is appropriate? Ciprofloxin (ciloxan) 2 Gtt to both eyes q 4hr while awake
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Administer two drops of medication in each eye every 4 hours while awake.
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The nurse administered acetaminophen 650 mg to a patient complaining of a headache after reviewing the medication orders of the patient's chart. This is an example of which type of nursing intervention?
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Dependent intervention
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When planning for discharge planning of a client, which steps should a nurse take? Select all that apply
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Note resolved problems on the care plan Suggest revisions for unmet goals by the client Set new goals after achieving previous goals
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Which of the following actions are included in the planning process when a nurse is caring for an elderly client with AIDS?
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Identify measurable goals or outcomes
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After collecting data from a patient with respiratory distress, the nurse prioritizes the patient interventions to provide oxygen to the patient first. This is an example of the following models for organizing data?
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Hierarchy of human needs
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A nurse is preparing the nursing care plan of a client who had been admitted 5 hours before. Which point should the nurse keep in mind when writing a nursing care plan?
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Write the nursing care plan after the nursing care conference.
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A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase "Disturbed Self-Esteem identify?
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The health state or problem of the patient
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Which of the following steps does the nurse take to evaluate the needs of the newly diagnosed client with diabetes?
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Analyze the client's responses to treatment
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A nurse is caring for a patient who is sweating, pale, and short of breath. Respirations are 38 bpm, and oxygen saturation is 93%. Which assessment finding is most significant?
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Client reports shortness of breath with respirations of 38 bpm
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A nurse asks a multidisciplinary team to collaborate to develop the most appropriate plan of care to meet the needs of an adolescent with a severe head injury. Which of the skills essential to nursing practice is the nurse using?
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interpersonal skills
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A patient who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill?
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Starting a new large-gauge intravenous site on the patient and priming the infusion tubing
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A patient comes to the emergency department complaining of severe chest pain. The nurse asks the patient questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?
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assessing
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Before providing a client with a prescribed medication the nurse assesses the client's heart rate and blood pressure. This reassessment is an example of which characteristic of the nursing process?
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Continuous
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The nurse's morning assessment of an elderly patient has revealed some anomalies. The nurse should document the patient's abnormal heart rate as which of the following?
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"115 beats per minute"
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When caring for a client, the nurse observes a strange smell emanating from the client's breath. The nurse immediately informs the primary healthcare provider. The healthcare provider's diagnosis reveals metabolic acidosis. The nurse has helped in the diagnosis of metabolic acidosis by using which sense of observation?
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Olfactory observation
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In the planning the care of a patient who has been diagnosed with asthma, the nurse has written the following outcome: "Patient will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2011." Why is this outcome inadequate?
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The chosen verb is not observable or measurable
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A nurse is formulating the care plan for a client. Which nursing orders should the nurse include in the nursing plan to help bring about the desired outcome in the client? Select all that apply
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Educating the client about his or her condition Making referrals to support groups for the client Making further assessments on the client's condition
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A patient's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the patient's surgery will have a significant impact on her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this patient?
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Upon her admission to the hosptial
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Which of the following is a purpose of evaluation in the nursing process?
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to direct future nursing interventions
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A nurse interviews a pregnant teenager and documents her answers on the patient record. At the same time, the nurse responds to the patient's concerns and makes a referral for counseling and maternity care. This scenario is an example of which of the descriptors of the nursing process?
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dynamic
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A client is being discharged from the hospital with a rolling walker. When planning this client's discharge, which of the following is important to include in the evaluation process prior to the client's discharge home?
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Physical therapy consult
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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?
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to encourage the patient and family to be involved
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A 55 year old woman presents to the emergency department with reports of shortness of breath. The nurse obtains the patient's vital signs. Heart rate is 130 beats per minute; blood pressure is 100/60. Lung sounds are scattered coarse rales with wheezing. The nurse notes that the patient is using accessory muscles to breathe. The respiratory rate is 38 breathes per minute, and oxygen saturation is 90%. Breath sounds are also decreased in the middle lobe on the right side. Based on this information, which intervention should the nurse include first in the patient's plan of care?
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Apply supplemental humidified oxygen at the prescribed rate via nasal cannula
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Based on the following order, what action by the nurse is appropriate? Promethazine (Phenergan) 25.0mg PO qd prn
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Clarify the order with the physician
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A nurse has completed the nursing history for a patient admitted to the unit with reports of chest pain. What is the next step in the nursing process that the nurse should take?
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Begin the physical assessment.
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After completing assessment, a nurse uses the data collected to identify appropriate diagnoses for a patient. What are the nursing diagnoses used for?
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selecting nursing interventions to meet expected outcomes
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At the end of the shift, the nurse documents that the patient has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?
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Objective
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Which of the following data regarding a patient with a diagnosis of colon cancer are subjective? Select all that apply
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The patient's chemotherapy causes him nausea and loss of appetite The patient has been experiencing fatigue in recent weeks
