VN 137 Care Plans ST. GD. MIDTERM – Flashcards

The nurse who uses the nursing process will: a. help reduce the obvious signs of discomfort b. help the patient adhere to the physician's treatment protocol c. approach the patient's disorder in a step-by-step method d. make all significant nursing care decisions involving patient care

A nurse will arrive at a nursing diagnosis through the nursing process step of: a. planning b. evaluation c. research d. assessment

In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is to: a. collect data of health status b. select a nursing diagnosis c. organize data to help the RN to evaluate patient progress d. prioritize nursing diagnosis for more effective care

The nurse completing morning assessments on a patient who is sitting up in bed is told by the patient, "I'm having trouble breathing---I can't seem to get enough air." The best nursing response is to: a. notify the doctor as soon as he or she comes in later in the morning. b. finish the vital signs for the assigned patients, and then notify the charge nurse. c. reassure the patient, if his blood pressure and pulse are normal. d. notify the charge nurse immediately of the patient's statement.

The order in which the nursing process is approached is: a. planning, assessment, implementation, nursing diagnosis, evaluation b. nursing diagnosis, evaluation, assessment, implementation, planning c. assessment, nursing diagnosis, planning implementation, evaluation d. evaluation, nursing diagnosis, planning, implementation, assessment

Once the nursing plan has been initiated, the nursing care plan will: a. stay in place until all nursing goals have been met. b. change as the patient's condition changes. c. remain on the patient record to show progress d. be given to the patient for final approval

A student nurse can begin to develop critical thinking skills by means of: a. working with a more experienced nurse. b. questioning every statement made by instructors to be sure of its correctness c. memorizing class notes for tests and studying all night for big tests. d. listening attentively and focusing on the speaker's words and meaning.

When a nurse prioritizes the patient care, consideration is given to: a. completing assessments before mid-shift b. considering situations that may result in an alteration of health. c. assuming all health care activities for a group of patients d. identifying who can assist with the aspect of care

When the nurse checks to see whether a patient has had relief 45 minutes after administering pain medication, the nurse is performing a(n): a. nursing diagnosis b. implementation c. assessment d. evaluation

The activity that is implementation in nursing care is: a. checking the assigned patient's blood pressure, pulse, and respiration b. changing the patient's surgical dressing c. asking the patient to demonstrate how to give himself medication after teaching him d. discussing the patient with other team members to establish a care plan

The effect of using a scientific problem-solving approach in nursing care will cause decision making to be: a. slowed down considerably by the multiple steps b. rigid and non-patient oriented c. improved nursing care outcomes d. unrelated to the nursing outcomes

An emergency room nurse will give first priority to the patient with the most critical need, which is the patient who: a. is bleeding from a chin laceration b. complains of a productive cough c. has a fever of 102* F d. complains of severe chest pain

When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _________ data. a. objective b. medical c. subjective d. adjunct

The major goal of the admission interview (usually performed by the RN) is to: a. establish rapport b. help the patient understand the objectives of care c. identify the patient's major complaints d. initiate nursing care plan forms

An example of a structured format for gathering data that aids in forming a database is: a. North American Nursing Diagnosis Association-International (NANDA-I) b. Maslow's theory c. following the information in the history and physical d. Gordon's 11 health patterens

During the assessment phase of the nursing process, the nurse: a. develops a care plan to meet the patient's nursing needs. b. begins to formulate plans for providing nursing interventions c. establishes a nursing diagnosis for the nursing care plan d. gathers, organizes, and documents data in a logical database

After the admission assessment is completed, on subsequent shifts or days, the nurse: a. does not assess the patient again unless the condition changes. b. refers only to the admission assessment during the hospitalization c. performs a complete physical examination every day d. assess the patient briefly in the first hour of the shift

A nursing diagnosis consists of: a. the physician's medical diagnosis listed as the nursing diagnosis b. diagnostic labels formulated by the North American Nursing Diagnosis Association---International (NANDA-I) c. the patient's explanation of his or her "Chief complaint" or "current complaint d. the results of the nursing assessment without consideration of doctor's order

An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating think, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she "Can't breathe." Based on this information, an appropriately worded nursing diagnosis for this patient is: a. Airway Clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath b. Pneumonia, cough, and shortness of breath related to chronic lung disease c. difficulty breathing not relieved by oxygen and evidenced by shortness of breath. d. cough and shortness of breath caused by pneumonia, chronic lung disease, advanced age, and exhaustion.

If a patient has several nursing diagnoses, the nurse will first: a. consult with the doctor regarding which diagnosis is most important b. devise nursing interventions for the most quickly solved problems c. prioritize the nursing problems according to Maslow's hierarchy of needs. d. review the patient's medical prescriptions and other drugs being taken.

The nursing diagnoses that has the highest priority is: a. Mobility, impaired physical, related to muscular weakness as evidenced by the inability to walk without assistance b. communication, impaired verbal, related to neuromuscular weakness as evidenced by facial weakness and inability to speak c. Imbalanced nutrition: less than body requirements, related to difficulty swallowing and inadequate food intake as evidenced by weight loss of 10 pounds d. Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.

A nursing care plan consists of: a. nursing orders for individualized interventions to assist the patient to meet expected outcomes. b. orders for diagnostic and therapeutic procedures such as laboratory tests or radiographs c. the physician's history and physical examination, as well as medical diagnosis d. laboratory and radiograph reports, pathology reports, and the medication record.

The nurse takes into consideration that the difference between a sign and a symptom is that a sign is: a. subjective data b. unreliable because it depends on translation c. can be verified by examination d. something a patient reports that is verified by a relative

The nurse clarifies that nursing orders are also called: a. goals b. qualifiers c. interventions d. measurement criteria

The nurse designs the goals for the patients in long-term facilities to be: a. conditional b. open ended c. based on behavioral norms d. long-term

Standardized Nursing Care Plans can: a. be documented without alteration b. have items altered or deleted c. become part of the record without documentation d. help the family understand the concept of nursing care plans

A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is: a. Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung. b. Airway clearance, ineffective, related to right lower lobe pneumonia as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung c. RIght lower lobe pneumonia, related to airway clearance, ineffective, as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung d. Expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung related to right lower lobe pneumonia as evidenced by airway clearance.

The nurse is aware that one of the time-flexible tasks to be accomplished would be: a. administering daily insulin 30 minutes before breakfast b. taking the patient's vital signs once a day c. weighing the patient before breakfast d. monitoring a critical patient's vital signs every 15 minutes.

Prior to the nurse implementing a nursing procedure for a patient, the nurse should initially: a. question the rational for the procedure b. perform a physical assessment of the patient c. check the agency manual for the procedure d. mentally review the procedure.

Preparing a patient for a diagnostic test, and telling the patient what to expect during and after the test, is considered: a. an independent nursing action b. the doctor's responsibility c. a dependent nursing action that requires the doctor's authorization d. an interdependent nursing action.

The nurse explains that a multidisciplinary step-by-step approach to patient care is: a. documented in the nursing care plan in the patient's chart b. not used often since managed care became part of health care c. referred to as a clinical pathway and is used instead of a nursing care plan d. more expensive than the traditional separation of health care services

The nurse documents interventions periodically during the shift in nurses' notes primarily to: a. validate the number of non-licensed personnel who interact with the patient b. indicate that the nursing care plan has been implemented c. briefly summarize activities during the shift d. confirm that the nursing diagnosis in the care plan are appropriate

The nurse compares actual nursing outcomes to the expected nursing outcomes in order to: a. prepare the patient to be discharged from the facility b. determine if the patient's health problems have been treated. c. calculate charges for nursing services during the patient's hospital stay d. determine if progress is made or to determine if revisions are needed.

The general rule is that the initial care plan for a patient is: a. developed by an RN in an acute care setting b. used as the basis of care throughout a hospital stay without alteration c. completed on the day of admission d. developed by the physician and incorporated into the nursing care.

The nurse is aware that the nursing audit is a valuable process used to: a. determine whether a particular patient received the care indicated int he nursing care plan b. evaluate whether nursing care for a group of patients meets the standards of care in that facility c. determine the cost of nursing care in the hospital in order to set rates for daily care d. identify careless or negligent nursing care to protect the facility from lawsuits

The nurse evaluates that the patient has met the outcome of feeding himself independently. The nurse should: a. inactivate the nursing diagnosis from the care plan b. notify the physician that the patient can now feed himself c. document the ability to self-feed and mark the nursing diagnosis as resolved d. inform the RN to document the self-feeding and to cancel the nursing diagnosis

An example of an appropriately worded nursing goal or outcome for the nursing diagnosis of Risk For Falls related to weakness would be: a. nurse will assist the patient to the bathroom every 2 hrs. b. patient will be free of injury from falls c. patient will call for assistance when ambulating for the next week d. nurse will keep room well lit 24 hrs a day

Nurses design interventions that are appropriate for a patient that are: a. based on the physician's orders and the medical diagnosis c. used to evaluate whether the nursing care plan should be revised d. based on cost-effectiveness and staff availbility

Before performing a catheterization, the inexperienced nurse should: a. close the door or curtains to provide the patient with privacy b. provide necessary teaching and explanation of the procedure to the patient c. observe rules of standard precautions to protect herself from exposure to blood or body fluids d. review the agency's procedure manual for the accepted way of performing the procedure

During morning care in a skilled nursing facility, the student nurse notices that a patient who is at risk for impaired skin integrity has developed a small open area on his sacrum. To best address this situation, the student would first: a. position the patient to lie on his side, document it, and inform the head nurse. b. position the patient on his side and encourage him to massage around the area c. report to the physician so the the nursing care plan can be revised d. tell the nursing assistant to change the patient's position every 2 hrs.

A review of a patient's nursing care plan before beginning care allows the nurse to: a. make revisions in the plan as indicated by the shift report b. use critical thinking skills to organize care for the patient c. begin nursing interventions without needing an initial assessment d. skip the shift report and begin with the initial assessment

The nurse giving a patient a back massage is performing a intervention considered to be a(n)__________ nursing action. a. dependent b. independent c. interdependent d. semi-dependent

The nurse administering a medication to a patient is performing an intervention that is a(n)________ nursing action. a. independent b. interdependent c. semi-dependent d. dependent

The nurse caring for a group of patients would show cultural sensitivity to assign an older male nursing assistant to the care of a: a. 45-yr-old white male with uncontrolled diabetes b. 50-yr-old Hispanic man with a broken leg c. 55-yr-old Japanese man with irritable bowel syndrome d. 60-yr-old Muslim woman with pneumonia

In assigning tasks to the nursing assistant, the nurse could appropriately select: a. range-of-motion exercises to lower limbs b. sterile dressing change on a leg wound c. postoperative teaching to a post-hysterectomy patient d. witnessing of the signature on an operative permit

The nurse is assessing a patient who just returned from a bowel resection 1 hr ago. The nurse notes a dressing of the suture line that is wet with sero-sanguineous drainage. The nurse should initially: a. perform a sterile dressing change b. document and report the wet dressing to the charge nurse c. reinforce the wet dressing and document d. place a towel on the bed and turn the patient to the operated side