A helping relationship develops through ongoing, purposeful interaction between a nurse and a patient. Nurse–patient relationships focus on: (Select all that Apply) -demonstrating empathy. -developing a plan of care. -building trust. When planning care for adolescents, the nurse should Give information privately to adolescents about how they can manage the specific problems that they identify Measurable goals are: (Select all that Apply)
- concrete Documentation is a vital nursing role since the patient’s health record: should be completed accurately and in a timely manner. The five rights of delegation include: right task, right circumstance, right person, right direction, and right supervision During the evaluation phase of the nursing process, the nurse realizes that the patient’s short-term goals have not been met. The nurse should: revise or adapt the plan of care. The nurse knows that standardized care plans may be available and need to be individualized for each patient. Which goal is written correctly for the nursing diagnosis of activity intolerance related to imbalance between oxygen supply and demand? Patient will ambulate 100 feet with no shortness of breath on third day after treatment. The final phase of the nursing process is evaluation, which focuses on the patient responses to interventions and outcomes The nurse is caring for a patient with lung disease.
The patient tells the nurse that the most important thing to do during the shift is to walk down to the nurses’ station and back without having shortness of breath. The patient’s request is an example of which nursing theory? Swanson’s Theory of Caring A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the pericardium. Which diagnosis
written on the plan indicates a need for further instruction on using the nursing process? The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of cocaine. Which nursing diagnosis indicates an understanding of a correct nursing diagnostic statement? (Select all that Apply) -Chronic confusion related to
excessive stimulation of nervous system as evidenced by impaired socialization The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as The framework that nurses used to provide care The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process The nursing student is observing a staff nurse demonstrating a subcutaneous injection during a skills competency fair. The student tells the nurse that nursing textbooks indicate that aspirating for blood is not necessary. The nurse replies, “I prefer to check for blood, just in case. This is the way I learned to give shots and it works for me.” The nurse’s response is most likely related to: The wound care nurse is assessing a non-healing leg wound on a patient recently admitted for uncontrolled diabetes. The nurse organizes the data using Gordon’s Functional Health Pattern of nutrition and metabolism. As the health care community explores the concept of health literacy, many organizations recognize that improvements are dependent on developing operational definitions During patient teaching led by the nurse with goals established through cooperation of the nurse and patient, the patient asks questions as needed and the nurse answers. This is known as: both formal and informal teaching The nurse is preparing a teaching plan and is applying evidence-based practice. To promote involvement, the nurse must ensure that the patient understands relevant information. According to the Healthy People 2020 initiative, health information and the associated access issues have become more complicated. There are many considerations when determining whether an individual has proficient health literacy. The patient should be able to: (Select all that Apply) - read and identify credible health
information. In determining patient goals, the nurse should allow patients to identify what is most important to them The nurse must provide patient education to a patient who has just been told by the patient that he has stage III lung cancer. The patient is complaining of chest and bone discomfort. Before providing the needed education, the nurse should: (Select all that Apply) -perhaps wait until later in the day.
Ongoing evaluation of patient education occurs by each member of the health care team who provides teaching. The nurse is to teach an 84-year-old Spanish-speaking patient newly diagnosed with diabetes how to self-administer insulin. The patient has hearing and visual impairments. In order to be effective as a teacher, the nurse should: (Select all that Apply) - determine readiness to learn. Which situation poses the greatest challenge to the nurse working with a child and family? Emergency hospitalization The nurse observes a confused patient pacing back and forth in the dining room. The patient yells, “The doctor is going to make us all drink poison!” The most appropriate intervention at this time would be to quietly ask the patient to explain the statement Touch is the intentional physical contact between two or more people. It
occurs so often in patient care situations that it has been deemed to be an essential and universal component of nursing care. Task-oriented touch occurs when the nurse (Select all that apply) - gives the patient an injection to treat discomfort. North American Nursing Diagnosis Association International (NANDA-I) is an organization focusing on revising nursing diagnosis taxonomy and evaluates nursing research to validate the diagnostic labels. The NANDA-I taxonomy and new nursing diagnoses are published every: The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of cocaine. Which nursing diagnosis indicates an
understanding of a nursing diagnostic statement? (select all that apply) -Ineffective breathing pattern related to drug effect on the respiratory center A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug may cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing diagnosis should the nurse use to address this concern? When creating a nursing diagnosis, the related factor: is the underlying etiology of the patient’s situation The nurse is admitting a patient with severe dehydration. Assessment data reveal a decreased blood pressure, an increased pulse rate, and a low circulating blood volume. The student observes that the patient is confused and restless. Which patient information would the nurse consider as a contributing factor when choosing the nursing diagnostic label? Blood pressure, pulse rate, blood volume, mental status, dehydration The charge nurse is discussing a patient’s care plan during a team meeting. The team determines that the patient has not met the goal of “ambulating to the nurse’s station twice a day” and decides to revise the plan. Which of the following characteristics of the nursing process most represents this decision? The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The essential step that was added in 1991 is: The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process? The nurse makes the following entry on the patient’s care plan: “Goal not met. Patient refuses to walk and states, ‘I’m afraid of falling.’” The nurse should: modify the care plan in response to the patient’s condition and wishes. A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. The nurse asks the manager if there is a document written by the physician for this type of reaction. The nurse is referring to a: The nurse writes a short-term goal for a patient scheduled for surgery in the morning. The goal that contains all of the necessary elements is: The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery. Professional
nursing requires a commitment to lifelong learning because: (select all that apply) - treatment modalities and technology continue to advance. The nurse is preparing to begin a physical examination for a patient with open
lesions on the lower extremities. Which should the nurse evaluate during the physical assessment? (select all that apply) - blood results Patient-centered care requires the nurse to: (select all that apply) - understand patient
preferences After the patient’s data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. The framework that provides the most holistic view of the patient’s condition is: After the patient’s data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. The framework that provides the most holistic view of the patient’s condition is: During the health history interview, the patient tells the nurse, “Just walking to the mailbox and back makes my calves ache. Is this normal?” Which of the following frameworks would the nurse most likely choose to document this data? Which situation poses the greatest challenge to the nurse working with a child and family? Emergency hospitalization The nurse is caring for a patient scheduled for a partial mastectomy resulting from advanced cancer. The patient tells the nurse, “I’m sure when the surgeon operates on me, he will not find any cancer in my breast. It looks just fine.” The patient is using which defense mechanism to cope with the medical diagnosis? What should the nurse keep in mind when planning to communicate with a child who has autism? The child may exhibit monotone speech and echolalia. The nurse is admitting a patient with a foul smelling leg wound. Which behavior by the nurse indicates an understanding of appropriate body language? Gentle touching of the patient’s shoulder The nurse is assisting a co-worker who is preparing to change a deep wound dressing on a patient’s abdomen. Several of the patient’s out-of-town friends are at the bedside watching a football game. Which action is most appropriate for the nurse to consider prior to the dressing change? Ask the friends to leave the room. The nursing student has been assigned to help feed patients at lunch time. Which of these nursing interventions would be most effective when assisting a blind patient to eat a meal? Describe the food arrangement using the numbers on a clock. The nurse is performing an abdominal assessment on a postoperative surgical patient. The nurse notes that the dressing needs to be changed twice a day and discusses when the patient would like to have it done. The nurse then plans to change the dressing at that time. In which phase of the nurse–patient helping relationship would this process occur? The nurse is caring for a patient with lung disease. The patient tells the nurse that the most important thing to do during the shift is to walk down to the nurses’ station and back without having shortness of breath. The patient’s request is an example of which nursing theory? Swanson’s Theory of Caring Touch is the intentional physical contact between two or more people. It occurs so often in patient care situations that it has been deemed to be an essential and universal component of nursing care. Task-oriented touch occurs when the nurse: (select all that apply) -gives the patient an injection to treat discomfort. The student nurse is planning care for a patient who believes that Western medicine is effective but not always accurate. Nursing theory would best explain the patient’s health practices? Which action observed by a nurse manager may be indicative of codependency behavior? A staff nurse orders extra desserts for a patient diagnosed with morbid obesity. The nurse is observed sitting at the bedside of a patient discussing the nursing care plan for the shift. Which theory or model most accurately reflects this nurse–patient relationship? Swanson’s Theory of Caring Which action observed by a nurse manager may be indicative of codependency behavior? A staff nurse orders extra desserts for a patient diagnosed with morbid obesity. A vital aspect of providing effective and appropriate nursing care is being able to actively listen to a patient. This requires the nurse to: practice and develop this skill over many years. The nurse on a busy medical–surgical floor contacts a social worker requesting a home care referral prior to a patient’s discharge. This action is best illustrated by which of Swanson’s Five Caring Processes? When developing a nursing practice, it is important for the nurse to: be exposed to negative as well as positive role models. When developing a nursing practice, it is important for the nurse to: be exposed to negative as well as positive role models. Professional nursing requires a commitment to lifelong learning because: -treatment modalities and technology continue to advance. The nurse has received advanced orders for a patient that she is expecting to be admitted from the emergency room (ER). The patient’s name is Mr. Herman Goldstein. Trying to get ahead on her task, the nurse changes the patient’s diet from “Regular” to “Kosher.” When the patient reaches the unit, the nurse discovers that the patient is Catholic even though his father is Jewish. The nurse is guilty of giving in to: patient has been instructed in self-administration of insulin injections. The nurse observes the patient attempting to recap the needle and realizes that further teaching is needed. The nurse is applying which critical-thinking skill of the nursing process? To develop critical thinking, the nurse needs to develop a critical-thinking character that includes: developing honesty and confidence. A patient, frequently admitted to the hospital for chronic back pain, asks the medication nurse for additional pain medication. The nurse has seen patients like this before, and “knows” that the only reason that these people come to the hospital is to get their pain medication. The nurse is demonstrating: The nurse is preparing to administer an anticoagulant when the patient says, “Why do I have these bruises on my arms?” The nurse reviews the patient’s blood tests and notes an abnormal bleeding time. Based on the findings, the nurse decides to hold the medication and notifies the health care provider. This action, by the nurse, is an example of: The nurse has been practicing for several years and has become the unofficial leader, with newer nurses going to her for advice about patient care. They are amazed at how much the older nurse “thinks like a nurse.” In order to “think like a nurse,” the nurse must: (select all that apply) -be able to apply knowledge in making clinical decisions. |
Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply)
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