(Answer: ) B Show
The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessing (Answer: ) D Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess. Option C may be warranted but is secondary to altered tissue perfusion) A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time? A. Impaired gas exchange related to increased blood flow (Answer: ) D A nurse is revising a client's care plan. During which step of the nursing process does such a revision take place? A. Assessment (Answer: ) D Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime (Answer: ) C (Rationale- Making appropriate referrals is a valid part of planning the client's care. The nurse normally does not provide sex counseling. While providing time for privacy and providing support for the spouse is important, it is not as important as referring the client to a sex counselor/appropriate professional) A nurse is assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to: A. Encourage the client to ask questions about personal sexuality (Answer: ) A (Rationale - According to Maslow, elimination is a first-level or physiological need. Security and safety are second-level needs, and belonging is a third-level need.) Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need? A. Elimination (Answer: ) A (Rationale- Risk for aspiration takes priority because general anesthesia may impair gag and swallow reflexes. The other options, although important, are secondary to this.) A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Risk for aspiration R/T anesthesia (Answer: ) A (Rationale- The first priority is to evaluate airway patency. Pain management and splinting are important for client comfort, but come after an airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.) A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to: A. Assess the client's airway (Answer: ) C (Rationale- The first thing a nurse should do to differentiate is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.) When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of a patient? A. Reassess the patient (Answer: ) B (Rationale- This is the primary purpose of a nursing admission assessment.) The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to: A. Diagnose if the patient is at risk for falls. (Answer: ) D (Rationale- A nursing diagnosis is a statement about a patient's actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis.) The guidelines for writing an appropriate nursing diagnosis include all of the following except: A. State the diagnosis in terms of a problem, not a need (Answer: ) D (Rationale- A, B, & C are incorrect. These are not independent nursing interventions because they require a physician's order.) Independent nursing interventions commonly used for immobilized patients include all of the following except: A. Active or passive ROM exercises, body repositioning, and ADLs as tolerated (Answer: ) A (Rationale- Independent nursing interventions for a patient with pressure ulcers commonly include changing positions. B, C, & D all require a physician's order. Additionally, a drying agent, answer B would be contraindicated because the wound needs moisture to heal.) Independent nursing interventions commonly used for patients with pressure ulcers include: A. changing the patient's position regularly to minimize pressure (Answer: ) C (Rationale- The appropriate diagnosis for a patient with excessively dry skin is impaired skin integrity - actual not potential. R/T dehydration is appropriate because the patient complained of thirst.) While the nurse is providing a patient personal hygiene, she observes that his skin is excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate nursing diagnosis would be:
A. Potential for impaired skin integrity R/T altered gland function (Answer: ) D (Rationale- Preventative measures, such as these, will prevent the skin from cracking, which would make the client more prone to infection. The other 3 answers are options, however NOT the best choice for this particular situation.) The most important nursing intervention to correct skin dryness is: A. avoid bathing until the condition is remedied and notify physician (Answer: ) A Which of the following is an appropriately written nursing diagnosis?
(Answer: ) C Accountability is a critical aspect of nursing care. An example of accountability is demonstrated by: (Answer: ) B
The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse she wants to have her hair shampooed. How would the nurse prioritize this client need? (Answer: ) D Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The most appropriate of the
following intervention statements is: (Answer: ) D A nurse who specializes in care of clients with ostomies shows a client's significant other how to assist with the manipulation of ostomy equipment. The nurse demonstrating the technique to the client is using what type of nursing skill? (Answer: ) C During an interview, the nurse needs to obtain specific information about the signs and symptoms of a health problem. To obtain these data most
efficiently, the nurse should use: (Answer: ) D Which of the following is classified as subjective data? (Answer: ) D The nurse uses a variety of skills in the application of the nursing process. An example of a cognitive nursing skill is: (Answer: ) A Which of
the following is an appropriate etiology for a nursing diagnosis? (Answer: ) C Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The intervention statement "Nurse will apply warm, wet soaks to the client's leg while the client is awake" lacks which of the following components? (Answer: ) C Of the following statements, which one is an example of an
appropriately written nursing diagnosis? (Answer: ) A The nurse notes a narcotic is
to be administered per epidural cath. The nurse, however, does not know how to perform this procedure. Which aspects of the implementation process should be followed? A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment A. Assessment The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL. When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards A. Compare this reading against defined Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help A. Admitting not knowing how to do a procedure and requesting help Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking. The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior D. Target time Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The performance criterion is "from bed to chair." The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4). When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage Rationale: Diluting the medication in a beverage may make the medication more palatable. Using critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking for the assistance of the nurse manager. Suggesting an alternative method of taking the medication (provided that there are no contraindications to diluting the medication) should improve the likelihood of the client taking the medication. Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously C. Ask for the rationale behind the new policy Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior. Option 1 also places a client's safety at risk. The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure A. Assess the client to be sure ambulation with assistance is an appropriate care measure Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status. The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reexamine the nursing orders Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome. In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction C. Include the client and family when setting goals and formulating the plan of care Rationale: In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care for clients; instead they plan care with clients and families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take, but they will have less overall effectiveness if the client and family are not part of the plan. Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication C. The nurse who ask the client how much lunch he or she ate Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implemention phase. Option 4 represents the planning phase. The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet C. Risk for impaired skin integrity related to malnutrition Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions. The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91% Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague. Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale C. Client will state pain is less than or
equal to a 3 on a 0-10 pain scale within 24 hours Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal. The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? A. Administer the medication as ordered by the prescriber B. Call the prescriber to discuss the order and the nurse's concern Rationale: Client safety is of the utmost importance when implementing any nursing intervention. If the nurse feels that an order is unsafe or inappropriate for a client, the nurse must act as a client advocate and collaborate with the appropriate healthcare team member to determine the rationale for the order and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate and unsafe. Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit A. Taking vital signs of clients on the nursing unit Rationale: Part of the professional nurse's role is to delegate responsibility for activities while maintaining accountability. The nurse must match the needs of the client with the skills and knowledge of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope of practice for a UAP. In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? A. Vital signs are stable D. Client voided 250 mL of urine 2 hours after the urinary catheter removal Rationale: A change-of-shift report should include significant changes (good or bad) in a client's condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift report. Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A.
Diagnosis D. Evaluation Rationale: Evaluating is the process of comparing client responses to the outcome goals to determine whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating the nursing interventions. During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction A. Introduction Rationale: Asking about the weather initiates the social or introductory phase of the interview and allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport with the client at the beginning of the interview. In the body the client responds to the nurse's questions. During the closing the nurse or the client terminates the interview. The nurse is most likely to collect timely, specific information by asking which of the following questions? A. "Would you describe what you are feeling?" A. "Would you describe what you are feeling?" Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client's current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client's pain. A better approach to collect specific information might be, "Describe any pain you are having." The nurse should avoid asking the client which of the following leading questions during a client interview? A. "What medication do you take at home?" B. "You are really excited about the plastic surgery, aren't you?" Rationale: A leading question directs the client's answer. The phrasing of the question indicates an expected answer. The client may be influenced by the nurse's expectations and may give inaccurate responses. This process can result in an error in diagnostic reasoning. The nurse needs to validate which of the following statements pertaining to an assigned client? A. The client has a hard, raised, red lesion on his right hand. C. The client reported an infected tow Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client's toe to validate the statement. Which of the following items of subjective client data would be documented in the medical record by the nurse? A. Client's face is pale D. Client feel nauseated Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm. A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client D. Nurse rapidly reset priorities for client care based on a change in the client's condition Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process. The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an Abdominal assessment Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment. The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following? A. Incomplete data A. Incomplete data Rationale: To collect data accurately, the client must actively participate. Incomplete data can lead to inappropriate nursing diagnosis and planning. The other options are not relevant to the question as presented. The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply. A. Hopelessness A. Hopelessness Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5). Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B. Anxiety Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement. Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal
bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed. The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? A. Nursing diagnosis/problem list D. Long-term goals Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings. Which of these is a correctly stated outcome goal written by the nurse? A. The client will walk 2 miles daily by March 19 A. The client will walk 2 miles daily by March 19 Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19). The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention. While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly D. Observe client's skin color and take another set of vital signs Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions. After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods? A. Return demonstration A. Return demonstration Rationale: Interpersonal skills are the sum of the activities the nurse uses when communicating with others. Technical/psychomotor skills are "hands-on" skills, which are often procedures and are evaluated by return demonstration. Cognitive skills are the intellectual skills of analysis and problem-solving and are evaluated by tests. The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note? A. Client appears to be depressed, possibly suicidal D. Client states, "I'm tired of being sick. I wish I could end it all." Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal. The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team? A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a "Date Resolved" column. Using Liquid PaperTM is not a legal way to amend client records. Outcome goals that have been met and nursing diagnoses that have been resolved should be documented on the care plan. A progress note should also be written, but a single note may not be read by all health team members. The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should: A. Formulate post-discharge nursing diagnoses B. Draw conclusion about resolution of current client problems Rationale: Terminal evaluation is done to determine the client's condition at the time of discharge. This evaluation is best reflected in option 2 because it focuses on which goals were achieved and which were not. Ongoing evaluation is done while or immediately after implementing a nursing intervention. Intermittent evaluation is performed at specified intervals, such as twice a week. Items related to care post-discharge (options 2, 3, and 4) should be done on admission to the LTC facility.
A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview? A. Help the client to get settled and do the interview the next morning when the client is rested C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns Rationale: To collect data accurately, the client must participate. Attending to the client's immediate personal needs before expecting the client to focus on the interview will maximize the accuracy of the data collected. Data should be collected shortly after admission. The best source of data is the client. The management of the client's anxiety is the responsibility of the nurse conducting the interview and initiating the relationship. The nurse overhears an unlicensed assistive person (UAP) who has just been accepted to nursing school say to a client, "You must be so pleased with your progress." The nurse later explains to the UAP that this is an example of what type of question? A. Close-ended question C. Leading question Rationale: A leading question is asked in a way that suggests the type of answer that is expected. This can result in inaccurate data collection. A closed-ended question generally requires only a "yes" or "no" or short factual answer. Open-ended questions encourage clients to elaborate on their thoughts and feelings. Neutral questions do not influence the client's answer. The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. A. Collect and organize client information B. Analyze
data Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase. The functional health pattern assessment data states: "Eats three meals a day and is of normal weight for height." The nurse should draw which of the following conclusions about this data? Select all that apply. A. Client has an actual health problem B. Client has a wellness diagnosis Rationale: The description indicates a healthy pattern of nutrition for the client. A wellness diagnosis might be stated as: "Potential for enhanced nutrition." An actual health problem is a client problem that is currently present. The nurse should also do a diet assessment to determine the quality of the food eaten during meals. These actions by the nurse are within the scope of independent nursing practice and are not collaborative in nature. For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse? A. Discomfort D. Fractured Wrists Rationale: The etiology or related factors of a nursing diagnostic statement define one or more probable causes of the problem and allow the nurse to individualize the client's care. In this case, the fracture is the cause of the client's feeding problem. The nurse would make which of the following inferences after performing the appropriate client assessment? A. Client is hypotensive A. Client is hypotensive Rationale: An inference is the nurse's judgment or interpretation of cues such as judging a blood pressure to be lower than normal. A cue is any piece of data information that influences a decision. Options 2, 3, and 4 are cues that could lead to inferences. The nurse would write which of the following outcome statements for a client starting an exercise program? A. Client will walk quickly three times a day D. Client will progress to walking a 20-minute mile in one month Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable. The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply. A. Client and Family A. Client and Family Rationale: Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it. The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? A.
Assessment C. Implementation Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation. A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write? A. Client understands the signs of impaired circulation C. Goal not met: Client able to name only two signs of impaired circulation Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal. What are the steps of the nursing diagnostic process?There are three phases during the diagnostic process: (1) data analysis, (2) identification of the client's health problems, health risks, and strengths, and (3) formulation of diagnostic statements.
What is a nursing sensitive client outcome?Nurse-sensitive outcomes are defined as patient outcomes that are relevant based on nurses' scope and domain of practice and that are influenced by nursing inputs and interventions.
What step in the nursing process wherein you determine the clients progress towards the attainment of expected outcomes and effectiveness of nursing care?In the five-step nursing process, the evaluation phase is the final step involving conducting evaluative measures to determine whether nursing interventions have been effective and whether the patient has met expected outcomes.
Which intervention should the nurse perform as part of the nursing diagnosis process?Rationale- The first thing a nurse should do to differentiate is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered. The nurse performs an assessment of a newly admitted patient.
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The nurse is working with a client who is being prepared for a diagnostic test this afternoon
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