FNP: FINAL EXAM PRACTICE QUESTIONS WITH 100% CORRECT ANSWERS 2024 UPDATED LATEST GRADED 10, Exams of Nursing

Download FNP: FINAL EXAM PRACTICE QUESTIONS WITH 100% CORRECT ANSWERS 2024 UPDATED LATEST GRADED 10 and more Exams Nursing in PDF only on Docsity! FNP: FINAL EXAM PRACTICE QUESTIONS WITH 100% CORRECT ANSWERS 2024 UPDATED LATEST GRADED 100% PASS. ____ 1. What is the most influential factor that has shaped the nursing profession? 1) Physicians need for handmaidens 2) Societal need for healthcare outside the home 3) Military demand for nurses in the field 4) Germ theory influence on sanitation - Solution3 ____ 2. Which of the following is an example of an illness prevention activity? Select all that apply. 1) Encouraging the use of a food diary 2) Joining a cancer support group 3) Administering immunization for HPV 4) Teaching a diabetic patient about his diet - Solution3 - food diary- health promotion activity ____ 3. Which of the following contributions of Florence Nightingale had an immediate impact on improving patients health? 1) Providing a clean environment 2) Improving nursing education 3) Changing the delivery of care in hospitals 4) Establishing nursing as a distinct profession - Solution1 ____ 4. All of the following are aspects of the full-spectrum nursing role. Which one is essential for the nurse to do in order to successfully carry out all the others? 1) Thinking and reasoning about the clients care 2) Providing hands-on client care 3) Carrying out physician orders 4) Delegating to assistive personnel - Solution1 ____ 5. Which statement pertaining to Benners practice model for clinical competence is true? 1) Progression through the stages is constant, with most nurses reaching the proficient stage. 2) Progression through the stages involves continual development of thinking and technical skills. 3) The nurse must have experience in many areas before being considered an expert. 4) The nurses progress through the stages is determined by years of experience and skills. - Solution2 Movement through the stages is not constant. Benners model is based on integration of knowledge, technical skill, and intuition in the development of clinical wisdom. The model does not mention experience in many areas. The model does not mention years of experience. ____ 6. Which of the following best explains why it is difficult for the profession to develop a definition of nursing? 1) There are too many different and conflicting images of nurses. 2) not be likely to increase the number of informed people recruited into nursing. A definition of nursing would do little to improve the nurses role satisfaction. Although a definition of nursing might contribute to fighting stereotypes of nursing, other, more powerful influences (e.g., media portrayals) exist to counteract it. ___ 11. Which of the following provides evidence-based support for the contribution that advanced practice nurses (APNs) make within healthcare? 1) Reduced usage of diagnostics using advanced technology 2) Decreased number of unnecessary visits to the emergency department 3) Improved patient compliance with prescribed treatments 4) Increased usage of complementary alternative therapies - SolutionANS: 3 Studies demonstrate that APNs have improved patient outcomes over those of physicians, including increased patient understanding and cooperation with treatments and decreased need for hospitalizations. No well-known, scientific studies support APNs effect on the use of advanced technology. No well-known, scientific studies support APNs effect on the frequency of emergency department visits. No well-known, scientific studies support APNs effect on the use of alternative therapies. ____ 12. Which of the following is an example of what traditional medicine and complementary and alternative medicine therapies have in common? 1) Both can produce adverse effects in some patients. 2) Both use prescription medications. 3) Both are usually reimbursed by insurance programs. 4) Both are regulated by the FDA. - SolutionANS: 1 Both traditional and complementary therapies can produce adverse effects in some patients. Many medications are derived from herbs, but the alternative treatments usually use the herbs, not prescription medication. Insurance programs do not necessarily reimburse alternative treatments, because many are not supported by sound scientific research methodology. Alternative medications are not regulated by the FDA. ____ 13. Of the following, the biggest disadvantage of having nursing assistive personnel (NAP) help nurses is that the nurse 1) Must know what aspects of care can legally and safely be delegated to the NAP 2) May rely too heavily on information gathered by the NAP when making patient care decisions 3) Is removed from many components of direct patient care that have been delegated to the NAP 4) Still maintains responsibility for the patient care given by the NAP - SolutionANS: 2 All of the options may be disadvantages to using NAPs, but making decisions based on anothers information is the greatest drawback because of the potential for negatively affecting patient care. Treatment decisions based on incorrect information may cause harm to the patient. ____ 14. An older adult has type 1 diabetes. He can perform self-care activities but needs help with shopping and meal preparation as well as with blood glucose monitoring and insulin administration. Which type of healthcare facility would be most appropriate for him? 1) Acute care facility 2) Ambulatory care facility 3) Extended care facility 4) Assisted living facility - SolutionANS: 4 Assisted living facilities are intended for those who are able to perform self- care activities but who require assistance with meals, housekeeping, or medications. Acute care facilities focus on preventing illnesses and treating acute problems. These facilities include physicians offices, clinics, and diagnostic centers. Ambulatory care facilities provide outpatient care. Clients live at home or in nonhospital settings and come to the site for care. Ambulatory care facilities include private health and medical offices, clinics, surgery centers, and outpatient therapy centers. Extended care facilities typically provide long-term care, rehabilitation, wound care, and ongoing monitoring of patient conditions. ____ 15. The nurse in the intensive care unit is providing care for only one patient, who was admitted in septic shock. Based on this information, which care delivery model can you infer that this nurse is following? 1) Functional 2) Primary 3) Case method 4) Team - SolutionANS: 3 The nurse is following the case method model of nursing care. In this model, one nurse cares for one patient during a single shift. When the functional nursing model is employed, care is compartmentalized, and each task is assigned to a staff member with the appropriate knowledge and skills. In primary nursing, one nurse plans the care for a group of patients round-the-clock. The primary nurse assesses the patient and develops the plan of care. When he or she is working, he or she provides care for those patients that he or she is responsible for. In his or her absence, the associate nurses deliver care. Although the nurse in this case could possibly be a primary nurse, there are not enough data to confidently infer that. If the team nursing approach is utilized, a licensed nurse (RN or LVN) is paired with a nursing assistant. The pair is then assigned to a group of patients. ____ 16. Which healthcare worker should the nurse consult to counsel a patient about financial and family stressors affecting healthcare? 1) Social worker 2) Occupational therapist 3) Physicians assistant 4) Outpatient hernia repair - SolutionANS: 2 Primary care services focus on health promotion and disease prevention; administering childhood immunizations is one such service. Providing wound care and drug rehabilitation are examples of tertiary care services. Outpatient hernia repair surgery is an example of a secondary care service. ____ 21. Which of the following nursing activities represent direct care? Choose all that apply. 1) Bathing a patient 2) Administering a medication 3) Documenting an assessment 4) Making work assignments for the shift - SolutionANS: 1,2 Direct care involves personal interaction between the nurse and clients (e.g., giving medications, dressing a wound, or teaching a client about medicines or care). Nurses deliver indirect care when they work on behalf of an individual, group, family, or community to improve their health status (e.g., restocking the code blue cart [an emergency cart], ordering unit supplies, or arranging unit staffing). ____ 22. An 80-year-old patient fell and fractured her hip and is in the hospital. Before the fall, she lived at home with her husband and managed their activities of daily living very well. The goal is for the patient to recover from the injury and return to her home. The hospital is ready to discharge her because she has exceeded the recommended length of stay in a hospital. However, she cannot walk or care for herself yet, and she will require lengthy physical therapy and further monitoring of her medications and her physical and mental status. To which type of facility should she be transferred? 1) Nursing home 2) Rehabilitation center 3) Outpatient therapy center 4) None of these; she should receive home healthcare - SolutionANS: 2 A skilled nursing facility primarily provides skilled nursing care for patients who can be expected to improve with treatment. For example, a patient who no longer needs hospitalization may transfer to a skilled nursing facility to get skilled care until she is able to return home. A nursing home provides custodial care for people, like this patient, who cannot live on their own but who are not sick enough to require hospitalization. It provides a room, custodial care, and opportunity for recreation. This patient cannot ambulate or perform activities of daily living, so outpatient therapy and home care would not be appropriate. ____ 1. Which of the following are examples of a health-promotion activity? Select all that apply. 1) Helping a client develop a plan for a low-fat, low-cholesterol diet 2) Disinfecting an abraded knee after a child falls off a bicycle 3) Administering a tetanus vaccination after an injury from a car accident 4) Distributing educational brochures about the benefits of exercise - SolutionANS: 1, 4 Health promotion includes strategies that promote positive lifestyle changes. Disinfecting an abraded knee is a treatment/intervention for an injury. Administering a vaccination is a disease-prevention and treatment activity. Direct care provider - SolutionTeaching the client about a scheduled test client advocate - SolutionDiscussing with the physician the clients reasons for not wanting the recommended surgery. Manager - SolutionPlanning the units staffing schedule client agent - SolutionParticipating on a committee to develop a program to teach schoolchildren proper handwashing 1st-century AD - SolutionFirst hospital 15th to 19th century - SolutionDisassociation of nursing from religious orders 1854 - SolutionFlorence Nightingale cared for the soldiers of the Crimean War 1861 - SolutionEstablishment of the Army Nursing Service 1873 - SolutionFirst formal nursing education in United States 1893 - SolutionStart of public health nursing with the founding of the Henry Street Settlement American Nurses Association (ANA) - SolutionProfessional organization that represents all registered nurses. Developed Code for Nurses and the Standards of Clinical Nursing Practice National Student Nurses Association (NSNA) - SolutionStudent-run and student-funded organization for student nurses. Responsible for publishing the journal, Image National League for Nursing (NLN) - Solutionadvances excellence in nursing education to prepare nurses to meet the needs of a diverse population in a changing health care environment International Council of Nursing (ICN) - SolutionProfessional organization that represents nurses in countries around the world. Represents nursing and promotes nursing leadership worldwide Sigma Theta Tau International (STTI) - SolutionNational honor society for nursing; goal of this organization is to foster nursing scholarship, leadership and research. Medicaid - SolutionA federal and state assistance program that pays for health care services for people who cannot afford them. The muscle strength of a woman weighing 132 pounds who is able to lift 72 pounds would be recorded as 0.55. The nurse explains this to the client as the 1) Ratio of weight lifted divided by body weight 2) Measure of weight pushed divided by BMI 3) Ability of a muscle to perform repeated movements 4) Ability to move a joint through its range of motion - SolutionANS: 3 Muscle strength measures the amount of weight a muscle (or group of muscles) can move at one time. This is recorded as a ratio of weight pushed (or lifted) divided by body weight. A woman weighing 132 pounds who is able to lift 72 pounds has a ratio of 72 divided by 132, or 0.55. Which is one of the greatest concerns with heavy and chronic use of alcohol in teens and young adults? 1) Liver damage 2) Unintentional death 3) Tobacco use 4) Obesity - SolutionANS: 2 Heavy and chronic use of alcohol and use of illicit drugs increase the risk of disease and injuries and intentional death (suicide and homicide). Although alcohol as a depressant slows metabolism, chronic alcohol use is more likely associated with poor nutrition, which may or may not lead to obesity. Chronic alcohol use causes damage to liver cells over time in the later years. Alcohol intake is often associated with tobacco and recreational drug use; however, the risk of unintentional injury, such as car accident, suicide, or violence, is more concerning than smoking. A 55-year-old man suffered a myocardial infarction (heart attack) 3 months ago. During his hospitalization, he had stents inserted in two sites in the coronary arteries. He was also placed on a cholesterol-lowering agent and two antihypertensives. What type of care is he receiving? 1) Primary prevention 2) Secondary prevention 3) Tertiary prevention 4) Health promotion - SolutionANS: 3 Primary prevention activities are designed to prevent or slow the onset of disease. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are examples of primary-level interventions. Secondary prevention activities detect illness so it can be treated in the early stages. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. The patient has an established disease and is receiving care to stop the disease from progressing. Health screening activities are designed to: 1) Detect disease at an early stage. 2) Determine treatment options. 3) Assess lifestyle habits. 4) Identify healthcare beliefs. - SolutionANS: 1 Health screening activities are designed to detect disease at an early stage so that treatment can begin before there is an opportunity for disease to spread or become debilitating. Which individuals should receive annual lipid screening? 1) All overweight children 2) All adults 20 years and older 3) Persons with total cholesterol greater than 150 mg/dL 4) Persons with HDL less than 40 mg/dL - SolutionANS: 1 The American Academy of Pediatrics takes a targeted approach, recommending that overweight children receive cholesterol screening, regardless of family history or other risk factors for cardiovascular disease. The American Heart Association recommends that all adults age 20 years or older have a fasting lipid panel at least once every 5 years. If total cholesterol is 200 mg/dL or greateror HDL is less than 40 mg/dLfrequent monitoring is required. A mother of three young children is newly diagnosed with breast cancer. She is intensely committed to fighting the cancer. She believes she can control her cancer to some degree with a positive attitude and feelings of inner strength. Which of the following traits is she demonstrating that is linked to health and healing? 1) Invincibility 2) Hardiness 3) Baseline strength 4) Vulnerability - SolutionANS: 2 Research has also demonstrated that in the face of difficult life events, some people develop hardiness rather than vulnerability. Hardiness is a quality in which an individual experiences high levels of stress yet does not fall ill. There are three general characteristics of the hardy person: control (belief in the ability to control the experience), commitment (feeling deeply involved in the activity producing stress), and challenge (the ability to view the change as a challenge to grow). These traits are associated with a strong resistance to negative feelings that occur under adverse circumstances. The World Health Organizations definition of health includes which of the following? Choose all that apply. 1) Absence of disease 2) Physical well-being 3) Mental well-being 4) Identifying a persons locus of control helps the nurse determine how to approach a client about health promotion. People who feel powerless about preventing illness are least likely to engage in health promotion activities. People who respond to direction from respected authorities often prefer a health promotion program that is supervised by a health provider. Clients who feel in charge of their own health are the easiest to motivate toward positive change. Health promotion programs assist a person to advance toward optimal health. Which of the following activities might such programs include? Choose all that apply. 1) Disseminating information 2) Changing lifestyle and behavior 3) Prescribing medications to treat underlying disorders 4) Environmental control programs - SolutionANS: 1, 2, 4 Health promotion programs may be categorized into four types: disseminating information, programs for changing lifestyle and behavior, environmental control programs, and wellness appraisal and health risk assessment programs. Prescribing medications to treat underlying disorders is an activity that fosters health focused at an individual level rather than at a group program level. Which of the following actions demonstrate how nurses promote health? 1) Role modeling 2) Educating patients and families 3) Counseling 4) Providing support - SolutionANS: 1, 2, 3, 4 Nurses promote health by acting as role models, counseling, providing health education, and providing and facilitating support. A middle-aged woman performs breast self-examination monthly. This intervention is considered to be ____________________ prevention. - Solutionsecondary Secondary prevention activities detect illness so that it can be treated in the early stages. Health activities such as mammograms, testicular examinations, regular physical examinations, blood pressure and diabetes screenings, and tuberculosis skin tests are examples of secondary interventions. Primary prevention activities are designed to prevent or slow the onset of disease and promote health. Activities such as eating healthy foods, exercising, wearing sunscreen, obeying seat-belt laws, and getting immunizations are examples of primary-level interventions. Tertiary prevention focuses on stopping the disease from progressing and returning the individual to the pre-illness phase. ____________________ refers to nursing actions performed to help clients to achieve an optimal state of health. - SolutionANS: Health promotion What is the name of the nursing theorist who defines health as having three elements: a high level of overall physical, mental, and social functioning; a general adaptive-maintenance level of daily functioning; and the absence of illness (or the presence of efforts that lead to its absence)? ____________________ - SolutionANS: Jean Watson In an effort to promote health, the home health nurse opens the clients bedroom windows to let in fresh air and sunlight, washes her hands often, and teaches the patient and family about the importance of hygiene and cleanliness. This most closely illustrates the ideas of which of the following people? 1) Jean Watson 2) Jurgen Moltmann 3) Florence Nightingale 4) Robert Louis Stevenson - SolutionANS: 3 Florence Nightingale believed that health was prevention of disease through the use of fresh air, pure water, efficient drainage, cleanliness, and light. Jean Watson believes that health has three elements: a high level of overall physical, mental, and social functioning; a general adaptive- maintenance level of daily functioning; and the absence of illness (or the presence of efforts that lead to its absence). Jurgen Moltmann believes that true health is the strength to live, the strength to suffer, and the strength to die. He also stated that health is not a condition of the body; it is the power of the soul to cope with the varying condition of that body. Robert Louis Stevenson wrote that health is not a matter of holding good cards; it is playing a poor hand well. Which of the following is known to be a healthy strategy for coping with stress? 1) Performing meaningful work 2) Consuming simple carbohydrates 3) Drinking three glasses of red wine each day 4) Weight training - SolutionANS: 1 Many individuals find that meaningful work is a healthy way to cope with stressors. Consuming simple carbohydrates is not a healthy way to cope with stress. Drinking more than one glass of red wine each day is considered unhealthy. Weight training has been shown to increase bone density and reduce the risk of osteoporosis and heart disease but not necessarily to reduce stress. Which family would most likely be helpful in encouraging the client to experience a high level of wellness? A family who 1) Controls feelings to avoid conflict 2) Teaches negotiation skills and independence 3) Encourages risk taking and adventure 4) Views themselves as helpless victims - SolutionANS: 2 Families who promote independence and teach good negotiation skills enable family members to experience a high level of wellness by thinking for themselves. In contrast, families who tend to squelch personal feelings Which one of the following important nursing actions is a hospitalized patient likely to experience on an emotional level and remember long after this hospitalization has ended? 1) Administering her medications according to schedule 2) Allowing flexible visitation by her family and friends 3) Explaining treatment options in terms she can understand 4) Providing a healing presence by listening and being attentive - SolutionANS: 4 The nurse can contribute meaningfully to the patients hospitalization by providing a healing presence. The nurse can do this by listening to the patient and being attentive. Administering medications according to schedule, allowing flexible visitation, and explaining treatment options are important contributions that the nurse can make, but they will not be most meaningful to the patient. Patients may be impressed, even amazed, by the healthcare technology used to diagnose and treat their illnesses. However, often what they remember, perhaps through the rest of their lives, is the people who connected with them in a personal way. Which statement best describes the health/illness continuum? 1) Health is the absence of disease; illness is the presence of disease. 2) Health and illness are along a continuum that cannot be divided. 3) Health is remission of disease; illness is exacerbation of disease. 4) Health is not having illness; illness is not having health. - SolutionANS: 2 The health/illness continuum is best described as a graduated spectrum that cannot be divided. Which of the following helps the body release growth hormone (growth hormone assists in tissue regeneration, synthesis of bone, and formation of red blood cells)? 1) A healthy diet 2) Physical activity 3) Restful sleep 4) Comfortable room temperature - SolutionANS: 3 During sleep, our bodies release the majority of our growth hormone, which assists in tissue regeneration, synthesis of bone, and formation of red blood cells. Consuming healthy foods helps prevent disease. Physical activity reduces the risk of chronic disease and promotes longevity. Keeping the body at a comfortable temperature helps maintain health but not release of growth hormone. A client has been hospitalized for 6 weeks. All of the following interventions are good ones, but which intervention is specifically focused on helping the patient cope with the emotional responses to prolonged hospitalization? 1) Providing skin care every shift to prevent skin breakdown 2) Encouraging the patient to get up in a chair to eat meals 3) Assisting the patient to ambulate in the hallway for several minutes each day 4) Designating a corner of the patients room to display personal mementos - SolutionANS: 4 The patients environment can help nourish wellness. Helping the patient designate a corner of the room to display personal mementos can be healing and help the patient cope with the prolonged hospitalization. The other interventions might be helpful to the patient but are not as helpful in specifically dealing with hospitalization as is designating a portion of the room that is uniquely hers. Which of the following is particularly valuable in helping a patient with a terminal illness maintain a sense of self? 1) Family relationships 2) Spirituality 3) Nutrition 4) Sleep and rest - SolutionANS: 2 When a patient is faced with a terminal illness, spirituality can help the patient maintain his sense of self. Family relationships can provide a loving, supportive source of comfort and reassurance but can sometimes cause the patient pain and a feeling of loneliness when faced with a terminal illness. Nutrition, sleep, and rest are healing but usually not as helpful to a patient with terminal illness as is spirituality. A client with a history of schizophrenia is diagnosed with a urinary tract infection. What is probably the most significant barrier this patient faces? 1) Chronic urinary incontinence 2) Stigma associated with mental illness 3) Risk for recurring infections 4) Auditory hallucinations (hearing things) - SolutionANS: 2 Mental illness is associated with a stigma that is usually a barrier, and even considered a debilitating handicap. Chronic urinary incontinence is not commonly associated with urinary tract infection, and nothing in the scenario suggests that the patient is incontinent. The patient is at risk for recurring urinary tract infections, but this is not considered a debilitating handicap. Auditory hallucinations are associated with schizophrenia but have not been described as the most debilitating handicap. A 76-year-old patient is admitted with an acute myocardial infarction (heart attack). The doctor tells the patient that an angioplasty is necessary. The patient agrees and signs the informed consent. This patient is experiencing which stage of illness behavior? 1) Sick-role behavior 2) Seeking professional care 3) Experiencing symptoms encourage this trait. Awareness of your own level of hardiness will help you understand your response to stress, but hardiness does not necessarily make you a better nurse. When preparing a room to receive a newly admitted patient, which of the following should the nursing assistive personnel (NAP) do? 1) Mop the floor with an approved disinfecting solution. 2) Fold the top bed linens back to open the bed. 3) Hook up the suction machine and check to see that it is working. 4) Position the bed in its lowest position. - SolutionANS: 2 The NAP should create an open bed. The housekeeping department is almost always responsible for cleaning the room between patients. The nurse is responsible for hooking up and checking special equipment such as suction. The nurse would need to tell the NAP whether the patient is to be admitted ambulatory, by wheelchair, or by stretcher to know whether to position the bed high or low. When transferring a patient from a hospital to a long-term care facility, which of the following is most helpful in facilitating the patients planning and emotional adjustment? 1) Notify the patient and family as much in advance of the transfer as possible. 2) Send a complete copy of the patients medical records to the new facility. 3) Carefully coordinate the transfer with the long-term facility to keep it smooth. 4) Help arrange for transportation and accompany the patient to the transport vehicle. - SolutionANS: 1 Notifying the patient and family well in advance of the transfer allows them time to adjust emotionally and to make any necessary plans. A copy of the records is usually sent, and the nurse does coordinate the transfer with the receiving facility; however, that does very little to assist with the patients emotional status or planning. Someone from the hospital may accompany the patient to the car; or if the transfer is by ambulance, perhaps not. Either way, that will not help the patient and family to do the necessary planning for the transfer. A 36-year-old mother of three small children has had nausea, vomiting, and extreme fatigue for the past 2 days. She calls her mother and tells her she is ill and asks if her mother can care for the children. Which stage of illness behavior is she experiencing? Choose all that apply. 1) Sick-role behavior 2) Dependence on others 3) Seeking professional care 4) Experiencing symptoms - SolutionANS: 1 The 36-year-old mother is assuming sick-role behavior because she is identifying herself as ill. She is also in the stage of experiencing symptoms; she is experiencing symptoms and realizes that illness is starting, even though she has not yet entered the stages of dependence and seeking professional care. By telling her mother of the illness, she is relieved of her normal dutiescaring for her children. Dependence on others occurs when the client accepts a diagnosis and treatment from the healthcare provider. Seeking professional care occurs after the sick-role behavior stage. During this stage, the client makes the decision that she is ill and that professional healthcare is needed. North American healthcare culture typically reflects which culture? 1) Asian 2) European American 3) Latino 4) African American - SolutionANS: 2 Although the demographics are changing in this recent decade with increasing Hispanic and Asian inhabitants, North American healthcare culture typically reflects the dominant (European American) culture because most healthcare providers belong to that culture. A 26-year-old man of Mexican heritage is admitted for observation after sustaining injuries in a motor vehicle accident. When assessing this patient, the nurse must consider that he may possess which view of pain? 1) A belief in taboos against narcotic use to relieve pain 2) Expectation of immediate treatment for relief of pain 3) Endurance of pain longer and report it less frequently than some patients do 4) Use of herbal teas, heat application, and prayers to manage his pain - SolutionANS: 3 In general, patients of Mexican heritage may endure pain longer and report it less frequently than some. Patients of Japanese heritage may have taboos against narcotic use to relieve pain. Patients of Puerto Rican heritage may use herbal teas, heat application, and prayers to manage pain. Remember that all of these are archetypes and are not necessarily true for all members of a cultural group. The nurse is caring for a 42-year-old Chinese American patient who underwent emergency coronary artery bypass graft surgery. He is self- employed and has no health insurance. Each day members of his family spend hours at his bedside. Which is the most important factor for the nurse to focus on when planning the patients discharge? 1) Ethnic background 2) Family support 3) Employment status 4) Healthcare coverage - SolutionANS: 2 The nurse should focus on the patients strengths and resources for health restoration and self-care. In this case, that is the patients family. His family can be a great support for him when he is discharged (e.g., preparing I know I need to lose weight; Ill have to begin an exercise program right away. 2) If I change my diet and begin exercising, maybe I can control my blood pressure without medications. 3) I know I need to give up foods that contain a lot of salt, but with teenagers in the house it is very difficult. 4) I will reduce the amount of calories, salt, and fat that I eat; I certainly do not want to have a stroke. - SolutionANS: 3 Knowing an action is needed but giving reasons for not beginning it just now shows a focus on the present. The patient knows that he should reduce his sodium intake, but his present situation is preventing him from doing so. Therefore, he is disregarding the impact consuming sodium might have on his future. The other responses are future oriented because they indicate that the patient is planning lifestyle changes that will affect his future. A patient of Japanese heritage avoids asking for narcotics for pain relief. The nurse writes a nursing diagnosis of Pain related to reluctance to take medication secondary to cultural beliefs. If the cultural archetype is true for this particular patient, this probably means that the patient views pain as 1) A punishment for immoral behavior 2) A part of life 3) Best treated with herbal teas and prayer 4) A virtue and a matter of family honor - SolutionANS: 4 Patients of Japanese heritage may view pain as a virtue and a matter of family honor. They may be more accepting of pain medications if the nurse reassures them that pain control enhances healing. Patients of Mexican heritage may view pain as punishment for immoral behavior. Those of Navajo Indian heritage commonly view pain as a part of life, whereas those of Puerto Rican heritage may feel that pain is best treated with herbal teas and prayer. Keep in mind that these are all archetypes and do not necessarily apply to all members of a cultural group. . The nurse is developing a plan of care for a patient of Aleut descent who sustained a hip fracture. Which intervention by the nurse recognizes the patients indigenous healthcare system and should be included in the plan of care? 1) Asking the family to bring in medals and amulets 2) Scheduling a visit from the shaman 3) Providing the patient with her favorite herbal tea 4) Requesting that the physician consult the patients acupuncturist - SolutionANS: 2 For the patient of Aleut descent, contacting the shaman and scheduling a visit with the patient might be helpful in recovery. Patients of Hispanic descent might benefit from herbal tea and medals and amulets brought in by the family. However, it is important to check with the physician before administering any herbal preparations that might interfere with prescribed medications. Asians and Pacific Islanders might benefit from a visit by the acupuncturist. A client incorporates alternative healthcare into her regular health practices. For which alternative therapy should the patient visit a formally trained practitioner? 1) Use of herbs and roots 2) Application of oils and poultices 3) Burning of dried plants 4) Acupuncture - SolutionANS: 4 Acupuncture requires a formally trained practitioner. Use of herbs and roots, the application of oils and poultices, and the burning of dried plants do not require formally trained practitioners. Patients should be advised to inform their traditional primary healthcare provider when using various herbal remedies, as they can interfere with other prescribed medication and cause untoward side effects. An elderly patient tells the charge nurse that she wants another nurse to take care of her. When the charge nurse questions the patient, she states I dont want a man taking care of me. Which cultural barrier is this patient exhibiting? 1) Ethnocentrism 2) Racism 3) Sexism 4) Chauvinism - SolutionANS: 3 This patient is exhibiting sexism; she is objecting to the nurse merely because of his sex. Although we tend to think of sexism in a negative light, this woman may merely be reflecting a cultural attitude. The patient is in no position to actually discriminate against the nurse, in terms of employment, and so on. Therefore, her preferences should be respected. Ethnocentrism occurs when a person is positively biased toward their own culture. Racism is a form of prejudice and discrimination based on race. Chauvinism occurs when a person assumes that he is superior. A patient who had surgery 8 hours ago has not voided. The nurse notifies the physician for an order to insert an indwelling urinary catheter. Which of the following statements should the nurse use to describe the procedure to the patient? 1) I need to put a Foley in you because you havent voided since your surgical procedure. 2) I need to insert a tube into your bladder to drain the urine because you havent urinated since surgery. 3) I need to catheterize you because you havent urinated since having your surgery. 4) I need to place a catheter in your bladder because you havent voided since surgery. - SolutionANS: 2 static but change over time at different rates, depending on current events, other significant people, and social influences. Culture is all encompassing and affects everything its members think and do; it is not limited to food and holidays. Although those are visible manifestations of a culture, dietary practices and cultural calendars are not the essence of true and meaningful culture. The nurse is caring for a patient of Japanese heritage who refuses pain medication despite the nurses explaining its importance in the healing process. Which intervention(s) by the nurse is/are appropriate for this patient? Select all that apply. 1) Assess the patients pain levels at less frequent intervals. 2) Document in the patients record that the patient does not want to take opioids. 3) Utilize nonpharmacological measures to help control the patients pain. 4) Notify the primary care provider of the patients noncompliance. - SolutionANS: 2, 3 Patients of Japanese heritage commonly avoid opioid use; however, they sometimes reconsider after healthcare personnel explain that they improve the healing process. When the patient continues to refuse pain medications despite explanation, the nurse should respect the patients wishes and utilize nonpharmacological measures to control pain. The nurse should document that the patient wishes to avoid opioid use in the nurses notes. The nurse should continue to assess pain levels in this patient at the same frequency as before. She should recognize and respect his cultural beliefs and not label him as noncompliant. Note that the same intervention would be appropriate for any patient in this situation, not just a Japanese patient. Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking 1) Requires reasoned thought 2) Asks the questions why? or how? 3) Is a hierarchical process 4) Demands specialized thinking skills - SolutionANS: 1 The definitions listed in the text as well as definitions in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor hierarchical. That means that the steps involved in critical thinking are not necessarily sequential, where mastery of one step is necessary to proceed to the next. Critical thinking is a purposeful, dynamic, analytic process that contributes to reasoned decisions and sound contextual judgments. A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to 1) Consider all the possible advantages and disadvantages 2) Maintain an open mind about the proposed change 3) Apply the nursing process to the situation 4) Make a decision based on past experience with documentation - SolutionANS: 2 A critical attitude enables the person to think fairly and keep an open mind. The nurse has just been assigned to the clinical care of a newly admitted patient. To know how to best care for the patient, the nurse uses the nursing process. Which step would the nurse probably do first? 1) Assessment 2) Diagnosis 3) Plan outcomes 4) Plan interventions - SolutionANS: 1 Assessment is the first step of the nursing process. The nursing diagnosis is derived from the data gathered during assessment, outcomes from the diagnosis, and interventions from the outcomes. Which of the following is an example of theoretical knowledge? 1) A nurse uses sterile technique to catheterize a patient. 2) Room air has an oxygen concentration of 21%. 3) Glucose monitoring machines should be calibrated daily. 4) An irregular apical heart rate should be compared with the radial pulse. - SolutionANS: 2 Theoretical knowledge consists of research findings, facts, principles, and theories. The oxygen concentration of room air is a scientific fact. The others are examples of practical knowledgewhat to do and how to do it. Which of the following is an example of practical knowledge? (Assume all are true.) 1) The tricuspid valve is between the right atrium and ventricle of the heart. 2) The pancreas does not produce enough insulin in type 1 diabetes. 3) When assessing the abdomen, you should auscultate before palpating. 4) Research shows pain medication given intravenously acts faster than by other routes. - SolutionANS: 3 Practical knowledge is knowing what to do and how to do it, such as how to do an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), fact (type 1 diabetes), and research (IV pain medication). Which of the following is an example of self-knowledge? The nurse thinks, I know that I 1) Should take the clients apical pulse for 1 minute before giving digoxin 2) Should follow the clients wishes even though it is not what I would want 3) Have religious beliefs that may make it difficult to take care of some clients Critical thinking and the nursing process are ways of thinking that can be used in problem solving (although critical thinking can be used beyond problem-solving applications). Neither method of thinking is linear. The nursing process has specific steps; critical thinking does not. A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now 1) Analyze the assessment data 2) Consult standards of care 3) Decide which interventions are appropriate 4) Ask the clients perceptions of her health problem - SolutionANS: 1 The basis of the nursing diagnosis is the assessment data. Standards of care are referred to when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment. The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patients position every 2 hours. In the evaluation phase of the nursing process, which of the following would the nurse do first? 1) Determine whether she has gathered enough assessment data. 2) Judge whether the interventions achieved the stated outcomes. 3) Follow up to verify that care for the nursing diagnosis was given. 4) Decide whether the nursing diagnosis was accurate for the patients condition. - SolutionANS: 2 The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the nursing process steps and revising the care plan. In caring for a patient with comorbidities, the nurse draws upon her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. These activities are best described as 1) Full-spectrum nursing 2) Critical thinking 3) Nursing process 4) Nursing knowledge - SolutionANS: 1 Full-spectrum nursing (1) involves the use of critical thinking, nursing knowledge, nursing process, and patient situation. Although the other answers are important for planning and delivering nursing care, they do not reflect all the nurse has demonstrated. The nurse is preparing to admit a patient from the emergency department. The transferring nurse reports that the patient is obese. The nurse has been overweight at one time and works very hard now to maintain a healthy weight. She immediately thinks, I know I tend to feel negatively about obese people; I figure if I can stop eating, they should be able to. I must remember how very difficult that is and be very careful not to be judgmental of this patient. This best illustrates 1) Theoretical knowledge 2) Self-knowledge 3) Using reliable resources 4) Use of the nursing process - SolutionANS: 2 Self-knowledge is self-understandingawareness of ones beliefs, values, biases, and so on. That best describes the nurses awareness that her bias can affect her patient care. Theoretical knowledge consists of information, facts, principles, and theories in nursing and related disciplines; it consists of research findings and rationally constructed explanations of phenomena. Using reliable resources is a critical thinking skill. The nursing process is a problem-solving process consisting of the steps of assessing, diagnosing, planning outcomes, planning interventions, implementing, and evaluating. The nurse has not yet met this patient, so she could not have begun the nursing process. Which aspects of healthcare are affected by a clients culture? Select all that apply. 1) How the clients views healthcare 2) How the client views illness 3) How the client will pay for healthcare services 4) The types of treatments the client will accept 5) When the client will seek healthcare services 6) The environment where the healthcare services are provided 7) The ease of accessibility of healthcare services - SolutionANS: 1, 2, 4, 5 Culture affects clients view of health and healthcare. It influences how they will define illness, when they will seek healthcare, and what treatments are acceptable in their culture. How services are paid for is related to economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services. Independent thinking - SolutionQuestioning the reason for a new staffing policy Intellectual curiosity - SolutionReading the instruction manual of a new glucose monitoring machine heart rate measurements are both objective. States . . . trouble sleeping and . . . drinks coffee . . . are both subjective. States . . . frequent headaches and . . . takes aspirin . . . are both subjective. The Joint Commission requires which type of assessment to be performed on all patients? 1) Functional ability 2) Pain 3) Cultural 4) Wellness - SolutionANS: 2 The Joint Commission requires that pain and nutrition assessment be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors. Which of the following is an example of an ongoing assessment? 1) Taking the patients temperature 1 hour after giving acetaminophen (Tylenol) 2) Examining the patients mouth at the time she complains of a sore throat 3) Requesting the patient to rate intensity on a pain scale with the first perception of pain 4) Asking the patient in detail how he will return to his normal exercise activities - SolutionANS: 1 An ongoing assessment occurs when a previously identified problem is being reassessedfor example, taking an hourly temperature when a patient has a fever. Examining the mouth is a focused assessment to explore the patients complaint of sore throat. Asking for a pain rating is a focused assessment at the first complaint of pain. A detailed interview about exercise is a special needs assessment; there is no way to know if it is initial or ongoing. When should the nurse make systematic observations about a patient? 1) When the patient has specific complaints 2) With the first assessment of the shift 3) Each time the nurse gives medications to the patient 4) Each time the nurse interacts with the patient - SolutionANS: 4 The nurse should make observations about the patient each time she enters the room or interacts with the patient to gain ongoing data about the patient. Which of the following is an example of an open-ended question? 1) Have you had surgery before? 2) When was your last menstrual period? 3) What happens when you have a headache? 4) Do you have a family history of heart disease? - SolutionANS: 3 Open-ended questions such as What happens when you have a headache? are broad so as to encourage the patient to elaborate. The questions about surgery, menstrual period, and family history can all be answered with a yes, no, or short, specific answer (a date). Of the following recommended interviewing techniques, which one is the most basic? (That is, without that intervention, the others will all be less effective.) 1) Beginning with neutral topics 2) Individualizing your approach 3) Minimizing note taking 4) Using active listening - SolutionANS: 4 All are important techniques, but active listening focuses the attention on the patient and lets her know you are trying to understand her needs. The interviewer is more likely to get the patient to open up. Patients will forgive you for most errors in technique, but if they think you are not listening, that can negatively affect your relationship. Which of the following is an example of the most basic motivation in Maslows hierarchy of needs? 1) Experiencing loving relationships 2) Having adequate housing 3) Receiving education 4) Living in a crime-free neighborhood - SolutionANS: 2 The most basic needs are centered on physiological survivalshelter (housing), food, and water. All other options are for higher needs. The order from most basic to highest level is physiologic, safety and security, love and belonging, esteem, and self-actualization. Loving relationships fall under the love and belonging category. Education is a form of self- actualization. Living in a crime-free neighborhood meets the need for safety and security. What makes a nursing history different from a medical history? 1) A nursing history focuses on the patients responses to the health problem. 2) The same information is gathered; the difference is in who obtains the information. 3) A nursing history is gathered using a specific format. 4) A medical history collects more in-depth information. - SolutionANS: 1 A medical history focuses on the patients current and past medical/surgical problems. A nursing history focuses on the patients responses to and perception of the illness/injury or health problem, his coping ability, and resources and support. Nursing history formats vary depending on the patient, the agency, and the patients needs. Both nursing and medical histories typically use a specific format. A medical history does not necessarily contain more in-depth information. A nursing history can be in- A patient comes to the urgent care clinic because he stepped on a rusty nail. What type of assessment would the nurse perform? 1) Comprehensive 2) Ongoing 3) Initial focused 4) Special needs - SolutionANS: 3 An initial focused assessment is performed during a first exam for specific abnormal findings. A comprehensive assessment is holistic and is usually done upon admission to a healthcare facility. An ongoing assessment follows up after an initial database is completed or a problem is identified. A special needs assessment is performed when there are cues that more in- depth assessment is needed. A patient has left-sided weakness because of a recent stroke. Which type of special needs assessment would it be most important to perform? 1) Family 2) Functional 3) Community 4) Psychosocial - SolutionANS: 2 A functional assessment is most important because of discharge needs (e.g., self-care ability at home) and patient safety. A family and community assessment would be helpful to evaluate support systems, and a psychosocial assessment would be helpful to evaluate a patients understanding of and coping with his recent stroke. Remember that special needs assessments are lengthy and time-consuming, so they should be used only when in-depth information is needed about a topic. The nurse is interviewing a patient who has a recent onset of migraine headaches. The patient is highly anxious and cannot seem to focus on what the nurse is saying. Which of the following questions would be best for the nurse to use to begin gathering data about the headaches? 1) When did your migraines begin? 2) Tell me about your family history of migraines. 3) What are the types of things that trigger your headaches? 4) Describe what your headaches feel like. - SolutionANS: 1 For someone who is anxious, it is best to use closed questions. (When did your migraines begin?) A closed question can be answered in one or very few words and has a very specific answer. The other questions are open- ended questions. Which of the following is an example of an active listening behavior? 1) Taking frequent notes 2) Asking for more details 3) Leaning toward the patient 4) Sitting with legs crossed - SolutionANS: 3 Active listening behaviors include leaning toward the patient; facing the patient; open, relaxed posture without crossing arms or legs; and maintaining eye contact. Taking frequent notes makes it difficult to keep eye contact. Asking for more details may seem like idle curiosity. Sitting with legs crossed may indicate to the patient that you are not open to her. A nursing instructor asked his nursing students to discuss their experiences with charting assessment data. Which comment by the student indicates the need for further teaching? 1) I find it difficult to avoid using phrases like, The patient tolerated the procedure well. 2) Its confusing to have to remember which abbreviations this hospital allows. 3) I need to work on charting assessments and interventions right after they are done. 4) My patient was really quiet and didnt say much, so I charted that he acted depressed. - SolutionANS: 4 When charting data, chart only what was observed, not what it meant. Inferences should not be made about a patients behavior during data collection (he acted depressed); so that response reflects the students lack of knowledge and need for teaching. Chart specific data, not vague phrases; the student is acknowledging the importance of this. There are no universally accepted phrases, just agency-approved abbreviations; the student is acknowledging the need to use agency-approved abbreviations. The student is correct that charting should be completed as soon after data collection as possible. For which of the following purposes is a graphic flow sheet superior to other methods of recording data? 1) Easy documentation of routine vital signs 2) Seeing the patterns of a patients fever 3) Describing the symptoms accompanying a rising temperature 4) Checking to make sure vital signs were taken - SolutionANS: 2 All are benefits of the graphic flow sheet, but to easily and graphically see trends over time, the graphic flow sheet is superior to other methods of documentation. For the other options, other kinds of flow sheets would be equally effective. The most obvious reason for using a framework when assessing a patient is to 1) Prioritize assessment data 2) Organize and cluster data 3) Separate subjective and objective data 4) the client slept well? Those would be cues. If the client states, I slept well it is a cue, because it is a factthat is what the client stated. inspection - Solutiongeneral observation of the patient as a whole, progressing to specific body areas; ex. skin pink, warm and dry auscultation - Solutionnormal- lung sounds clear, bowel sounds normal etc... percussion - Solutiontapping on a surface to determine the difference in the density of the underlying structure; abdomen is tympanic palpation - Solutionabdomen is soft and nontender, no edema present community exam - SolutionDo you live near any industrial manufacturing plants? family exam - SolutionWho do you live with? functional ability exam - SolutionSince you had your stroke, have you had any problems dressing yourself? nutritional exam - SolutionWhat is your understanding of your diet? psychosocial exam - SolutionWho can you talk to when you feel sad? wellness exam - SolutionDo you perform monthly breast self-exams? spiritual exam - SolutionDo you have a religious preference? Gordons Functional Health Patterns - SolutionFormulates a model for nursing assessment and diagnosis but is not a theory NANDA Nursing Diagnosis Taxonomy II - SolutionCategorizes nursing diagnoses Taxonomy of Nursing Practice - SolutionCategorizes nursing diagnoses, client outcomes, and nursing interventions Roys Adaptation model - SolutionAssesses the clients ability to achieve balance (homeostasis) Orems Self-Care model - SolutionIdentifies deficits in activities of daily living that require nursing assistance Which of the following is an example of a problem that nurses can treat independently? 1) Hemorrhage 2) Nausea 3) Fracture 4) Infection - SolutionANS: 2 A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems. . Which of the following is an example of a cluster of related cues? 1) Complains of nausea and stomach pain after eating 2) Has a productive cough and states stools are loose 3) Has a daily bowel movement and eats a high-fiber diet 4) Respiratory rate 20 breaths/min, heart rate 85 beats/min, blood pressure 136/84 - SolutionANS: 1 A cue is an unhealthy response; a cluster of cues consists of cues related to each other. Productive cough and loose stools are abnormal findings but are not obviously or usually related to each other. Daily bowel movement and high-fiber diet are related but normal responses. The vital signs are also within normal limits. Which of the following explains why it is important to have the correct etiology for a nursing diagnosis? The etiology 1) Is the cause of the problem 2) Cannot always be observed 3) Directs nursing care 4) Is an inference - SolutionANS: 3 The etiology directs nursing interventions. If the incorrect etiology is given, the nursing care would not be appropriate for the client. The other statements are true but not a reason for the importance of the etiology being correct. How does a risk nursing diagnosis differ from a possible nursing diagnosis? 1) A risk diagnosis is based on data about the patient. 2) A possible diagnosis is based on partial (or incomplete) data. 3) Nurses collect the data to support risk diagnoses. 4) A possible diagnosis becomes an actual diagnosis when symptoms develop. - SolutionANS: 2 A possible nursing diagnosis is based on nursing knowledge, intuition, and experience and does not have enough data to support it; it is based on incomplete data. A risk diagnosis describes a problem that may develop in a vulnerable client if nursing care is not initiated to prevent it; it is made when risk factors are present in the data. Nurses collect data to support both risk and possible diagnoses; therefore, this statement does not differentiate them. A risk diagnosis becomes an actual diagnosis when symptoms develop. Which of the following describes the difference between a collaborative problem and a medical diagnosis? 1) A collaborative problem is treated by the nurse; a physician is responsible for the treatment of a medical problem. Based only on Maslows hierarchy of needs, which nursing diagnosis should have the highest priority? 1) Self-care Deficit 2) Risk for Aspiration 3) Impaired Physical Mobility 4) Disturbed Sensory Perception - SolutionANS: 2 Highest priority is given to problems that are life threatening or that could be destructive to the client. Safety is most basic in Maslows hierarchy. Even though Risk for Aspiration is not an actual problem, it poses the most immediate life-threatening risk to the client, and nursing interventions must be performed to prevent it from becoming an actual problem. Which of the following describes the most important use of nursing diagnosis? 1) Differentiates the nurses role from that of the physician 2) Identifies a body of knowledge unique to nursing 3) Helps nursing develop a more professional image 4) Describes the clients needs for nursing care - SolutionANS: 4 Benefits to nurses and nursing are that nursing diagnoses differentiate the nurses role, they identify a unique body of nursing knowledge, and some think they help nursing to develop a more professional image. However, the primary goal of nursing is to serve the good of the patient. Therefore, the most important use of a diagnosis is to specifically identify the clients needs for quality nursing care. Which of the following is a criticism of standardized nursing diagnoses developed by NANDA-I? 1) There is little research to support nursing diagnoses labels. 2) A perfect nursing diagnosis must be written for it to be useful. 3) They are not included in all states nurse practice acts. 4) Other professions do not recognize nursing diagnoses. - SolutionANS: 1 Best practice is evidence-based practice; that is, it is developed through sound, scientific research. Research is currently being conducted, but many of the diagnoses are not research based. A perfect nursing diagnosis is impossible to write, so that is not an issue. Having standardized nursing diagnoses recognized in state practice acts or by other professions has nothing to do with the value of the NANDA-I taxonomy. Which of the following most accurately describes nursing diagnoses? A nursing diagnosis 1) Supports the nurses diagnostic reasoning 2) Supports the clients medical diagnosis 3) Identifies a clients response to a health problem 4) Identifies a clients health problem - SolutionANS: 3 Nursing diagnoses are statements that nurses use to describe a clients physical, mental, emotional, spiritual, and social response to disease, injury, or other stressor. Diagnostic reasoning is used to identify the appropriate nursing diagnosis; it is not meant to support the diagnosis. A health problem is a condition that requires intervention to promote wellness or prevent illness; it is sometimes, but not always, a nursing diagnosis. Nursing diagnoses are not medical diagnoses. The diagnostic label, or patient problem, is used primarily to suggest 1) Client goals 2) Cue clusters 3) Interventions 4) Etiology - SolutionANS: 1 As a general rule, the problem suggests goals for client outcomes. The etiology suggests interventions. Cue clusters support whether the correct nursing diagnosis has been identified. Which nursing diagnosis is written in the correct format when using the NANDA-I taxonomy? 1) Bowel Obstruction related to recent abdominal surgery A.M.B. nausea, vomiting, and abdominal pain 2) Inability to Ingest Food related to imbalanced nutrition: less than body requirements A.M.B. inadequate food intake, weight less than 20% under ideal body weight 3) Impaired Skin Integrity related to physical immobility A.M.B. skin tear over sacral area 4) Caregiver Role Strain related to alienation from family and friends A.M.B 24-hour care responsibilities - SolutionANS: 3 The components of NANDA-I nursing diagnosis might include the following four parts: diagnostic label, defining characteristics, related factors, and risk factors. Impaired Skin Integrity . . . has the problem statement, etiology, and symptoms. For Bowel Obstruction . . . the problem is a medical diagnosis. The cause-and-effect order of Inability to Ingest Food . . . is incorrect; it starts with the etiology. The etiology and symptoms (A.M.B.) of Caregiver Role Strain . . . are reversed (alienation from family and friends are the symptoms that support the diagnosis). What is wrong with the format of this diagnostic statement: Possible Risk for Constipation related to irregular defecation habits A.M.B. statement that When Im busy, I cant always take the time to go to the bathroom. 1) Possible nursing diagnoses do not have signs and symptoms. 2) A nursing diagnosis is either a possible risk or a risk, not both. 3) Constipation is a medical diagnosis. 4) 1) Fatigue related to depression 2) Fatigue related to difficulty concentrating 3) Guilt related to lack of energy 4) Chronic confusion related to lack of energy - SolutionANS: 1 The diagnosis that best describes the overall health status is Fatigue. The only cue that might cause Fatigue is depression. You cannot use depression as the problem because it is a medical diagnosis, and it is not a NANDA-I label. The other cues (difficulty concentrating, inability to perform ADLs, and guilt) are symptoms of Fatigue, not etiologies. These diagnoses would lead the nurse to focus on dealing with guilt and confusion, so the source of the Fatigue would not be addressed. Which of the following nursing diagnoses is written in correct format? Assume the facts are correct in all of them. 1) Readiness for Enhanced Nutrition 2) Pain related to stating, On a scale of 1 to 5, its a 5. 3) Impaired Mobility related to pain A.M.B. hip fracture 4) Risk for Infection related to compromised immunity A.M.B. fever - SolutionANS: 1 Wellness diagnoses (e.g., Readiness for Enhanced . . .) are usually one- part statements. A pain ranking of 5 is a symptom of pain, not an etiology, so it should be preceded by A.M.B. or as manifested by. Hip fracture is a medical diagnosis that is causing an etiology of pain; therefore, it should be preceded by secondary to. Risk diagnoses do not have symptoms, so it is not correct to put anything after A.M.B. Which of the following are cues? Select all that apply. 1) Taking a brisk walk five times a week 2) Using laxatives to have a bowel movement 3) Needing more sleep than usual 4) Decreasing the amount of fat in the diet 5) Weighing less than indicated by developmental norms - SolutionANS: 2, 3, 5 Cues are a deviation from norms, such as changes in usual health behavior, indications of delayed growth and development, changes in behaviors, or nonproductive or dysfunctional behavior. Using Maslows hierarchy of needs, rank the following nursing diagnoses in order of importance, beginning with the highest-priority diagnosis. 1) Anxiety 2) Risk for infection 3) Disturbed body image 4) Sleep deprivation - SolutionANS: 4, 2, 1, 3 In Maslows hierarchy, physiologic needs and safety are the highest priority. Sleep is a basic physiologic need. Infection can threaten physical health. In this question, infection is not present; therefore, there is just a risk for it. Sleep Deprivation is an immediate problem that affects general physical, mental, and emotional health. Neither Anxiety nor Disturbed Body image is a physiologic or safety need. Anxiety is a more immediate need than Disturbed Body Image, so it probably deserves a higher ranking. Remind students that the ranking would depend on the severity of each problem, which is not known by the labels alone. Using problem urgency as your framework, rank the following nursing diagnoses as low, medium, or high priority. 1) low 2) medium 3) high ____ 1. Risk for Spiritual Distress ____ 2. Decreased Cardiac Output ____ 3. Chronic Confusion - Solution1. low 2. high 3. medium Label the parts of the following nursing diagnosis statement: Activity Intolerance related to prolonged bedrest A.M.B. increased heart rate, decreased blood pressure with activity, statements of weakness, and dyspnea with exertion. 1) diagnostic label or problem 2) etiology 3) cues or defining characteristics ____ 4. Activity Intolerance ____ 5. Prolonged bedrest ____ 6. Increased heart rate, decreased blood pressure with activity, statements of weakness, dyspnea with exertion - Solution4. #1 5. #2 6. #3 For which patient would it be most important to perform a comprehensive discharge plan? 1) A teen who is a first-time mother, single, and lives with her parents 2) An older adult who has had a stroke affecting the left side of his body and lives alone 3) A middle-aged man who has had outpatient surgery on his knee and requires crutches 4) A young woman who was admitted to the hospital for observation following an accident - SolutionANS: 2 A comprehensive discharge plan should be developed for older adults and anyone who has complex needs, including self-care deficits. The other Include specific goals and nursing orders 3) Become a part of the patients comprehensive care plan 4) Usually describe ideal nursing care - SolutionANS: 1 All of the statements are true for standardized care plans, but only 1 is true of both standardized care plans and unit standards of care. Both describe care needed by patients in defined situations, although unit standards usually describe care for groups of patients (e.g., all women admitted to a labor unit), and standardized care plans are often organized around a particular or all nursing diagnoses commonly occurring with a particular medical diagnosis. Unit standards are more general and do not have goals for each patient. Unit standards are kept on file in a central place on the unit and do not become a part of the care plan. Unit standards describe minimal, not ideal, care. The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient? 1) Validate conflicting data with the patient. 2) Transcribe medical orders. 3) State the frequency for ambulation. 4) Perform a comprehensive assessment. - SolutionANS: 3 Individualizing the care plan means identifying specific problems, outcomes, and interventions and the frequency of those interventions to meet the patients needs. Validating data ensures your assessment is accurate. Transcribing orders is a part of developing and implementing the care plan but not of individualizing the plan. Performing an assessment is the beginning step to developing a care plan. Assessment helps you to know the ways in which a standardized plan needs to be individualized. Which of the following is the best example of an outcome statement? The patient will 1) Use the incentive spirometer when awake 2) Walk two times during day and evening shifts 3) Maintain oxygen saturation above 92% while performing ADLs each morning 4) Tolerate 10 sets of range-of-motion exercises with physical therapy - SolutionANS: 3 Outcome statements should have specific performance criteria and a target time; maintain oxygen saturation is the only one that meets those criteria. The incentive spirometer goal should say how many times the incentive spirometer should be used each hour as well as the volume. The walking goal should state how far the patient should walk. In the range-of-motion goal, tolerate is a vague word and is difficult to measure, and the outcome needs to specify how often. How are critical pathways and standardized nursing care plans similar? Both 1) Specify daily, or even hourly, outcomes and interventions 2) Prescribe minimal care needed to meet recommended lengths of stay 3) Describe care common to all patients with a certain condition or situation 4) Emphasize medical problems and interventions - SolutionANS: 3 Both critical pathways and standardized care plans are preplanned documents; they describe care common to all patients who have a certain condition (e.g., all patients who have a heart attack need some of the same interventions). The other statements are true of critical pathways but not of standardized nursing care plans. How is NOC different from the Omaha System? 1) NOC can be used to write health restoration outcomes. 2) NOC can be used in all specialty and practice areas. 3) NOC can be used for individuals, families, or groups. 4) NOC formulates goals based on nursing diagnoses. - SolutionANS: 2 NOC was developed for all specialty and practice areas. The Omaha System was developed for community health nursing. Both address health restoration and can be used for individuals, family, or groups (community). Both base goals on nursing diagnoses, although Omaha does not use the NANDA-I taxonomy. How are short-term goals different from long-term goals? Short-term goals 1) Can be met within a few hours or a few days 2) Are developed from the problem side of the nursing diagnosis 3) Must have target times/dates 4) Specify desired client responses to interventions - SolutionANS: 1 Short-term goals may be accomplished in hours or days; long-term goals usually are achieved over weeks, months, or even years. The other statements are true for both short-term and long-term goals. What do standardized nursing care plans and individualized care plans have in common? They both 1) Reflect critical thinking for a specific patient 2) Are preprinted to apply to needs common to a group of patients 3) Address a patients individual needs 4) Provide detailed nursing interventions - SolutionANS: 4 They both provide detailed nursing interventions, although the individualized care plan is more specific to the patients needs and reflects critical thinking, whereas standardized plans do not. It is not true of individual nursing care plans that they are preprinted and apply to a group. The essential goal/outcome is aimed at the problem response Impaired Memory. The other goals in this question address the etiology. A client arrives in the emergency department, pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that are needed. This scenario demonstrates 1) Formal planning 2) Informal planning 3) Ongoing planning 4) Initial planning - SolutionANS: 2 Informal planning is performed while doing other nursing process steps and is not written; this nurse is forming a plan in her mind. The end product of formal planning is a holistic plan of care that addresses the patients unique problems and strengths; this nurse has no time to create a holistic plan of care. Ongoing planning refers to changes made in the plan as you evaluate the patients responses to care; no care has been given at this point. Initial planning does indeed begin with the first patient contact. However, it refers to the development of the initial comprehensive plan or care; this nurse does not have enough data for a comprehensive plan, nor does she have time to make such a plan at the moment. A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Choose all that apply. 1) Developing culturally appropriate outcomes 2) Using the outcomes preprinted on the clinical pathway 3) Choosing the best outcome for the patient, regardless of the costs involved in bringing it about 4) Involving the patient and family in formulating the outcomes - SolutionANS: 1, 4 ANA standard 3 includes derives culturally appropriate expected outcomes from the diagnosis and involves the patient, family . . . in formulating expected outcomes. . . . It is acceptable for the nurse to use outcomes on a clinical pathway, but these are not individualized; ANA standard 3 says that the nurse identifies . . . outcomes for a plan individualized to the patient. . . . The standard also says that the nurse should consider associated risks, benefits, and costs. . . . Which of the following nursing interventions is an indirect-care intervention? 1) Emotional support 2) Teaching 3) Consulting 4) Physical care - SolutionANS: 3 An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocacy, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care. Which nursing intervention is considered an independent intervention? 1) Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour 2) Encouraging the postoperative client to perform coughing and deep breathing exercises 3) Explaining his diet to the client; then communicating the teaching with the dietitian 4) Administering morphine sulfate 2 mg IV to the client with postoperative pain - SolutionANS: 2 Encouraging the postoperative client to perform coughing and deep breathing exercises is an independent nursing intervention. An independent intervention is one that nurses are licensed to prescribe, perform, or delegate based on their skills and knowledge. Administering IV fluid or morphine sulfate are dependent interventions; they require an order from a physician or advanced practice nurse but are carried out by the nurse. Explaining to the client how sodium intake affects his heart failure and then communicating the teaching with the dietitian is an interdependent intervention, one that is carried out in collaboration with other healthcare team members. A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write? 1) Collaborative 2) Interdependent 3) Dependent 4) Independent - SolutionWriting an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physicians order. The nurse is licensed to prescribe, perform, or delegate the intervention based on her knowledge and skills. A collaborative or interdependent intervention is one that is carried out in collaboration with other health team members, such as providing the client with a sodium-restricted diet. A dependent intervention is prescribed by a physician or advanced practice nurse; for example, administer oxygen at 2 L/min via nasal cannula. The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not currently have any respiratory problems. The nurses teaching plan includes coughing and deep breathing exercises. Which type of nursing intervention is the nurse performing? 1) Health promotion 2) Treatment 3) Standardized plan of care for frequently occurring conditions 2) Systematically developed statement to assist practitioners and patients in making decisions 3) Systematic review of clinical evidence for an intervention 4) Set of interrelated concepts that describes or explains something - SolutionANS: 1 Critical pathways are standardized plans of care for commonly occurring health conditions (e.g., myocardial infarction) for which similar outcomes and interventions are appropriate for the majority of patients with the condition. Clinical practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure. Evidence reports are systematic reviews on clinical topics for the purpose of providing evidence for guidelines, quality improvement, quality measures, and insurance coverage decisions. A theory is a set of interrelated concepts that describe or explain something. A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? 1) Determine airway adequacy hourly and as needed. 2) Administer oxygen as needed. 3) Monitor arterial blood gas values. 4) Place the client in a high Fowlers position. - SolutionANS: 1 For any acute respiratory problem, prior to implementing interventions, the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventions should be listed according to priority. Airway always takes precedence, as ventilation, oxygenation, and positioning will be ineffective without a patent airway. Who is the primary decision maker when caring for healthy adult clients? 1) Physician 2) Family 3) Client 4) Nurse - SolutionANS 3 The client is the primary decision maker in the care of healthy clients. The nurse functions as a teacher and health counselor. The physician plays a role in health promotion and screening. The family may give input, but the client is the decision maker. A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the nurse do first? 1) Identify several interventions likely to achieve the desired outcomes. 2) Review the problem and etiology of the nursing diagnosis. 3) Choose the best interventions for the patient. 4) Review the goals she has written. - SolutionANS: 2 The process of choosing interventions is review the nursing diagnosis, review the desired outcomes, identify several interventions or actions, choose the best interventions for the patient, and then individualize standardized interventions to meet the patients unique needs. The nurse is using electronic care planning. He enters the patients nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions the program generates, he sees that none of them fit this patients individual needs. What should the nurse do? 1) Reject them all and type in appropriate interventions. 2) Select the interventions from the program that are most suitable. 3) Ask another nurse to assess the patient and give her recommendation. 4) Restart the computer; it is probably a program malfunction. - SolutionANS: 1 The nurse can reject all the suggested interventions if they do not address patient needs. Nearly all computer programs have a screen that allows you to type in interventions and nursing orders. It is the nurses responsibility to choose interventions: He cannot abdicate this responsibility and let the computer choose. As a professional, this nurse has already validated the data, nursing diagnosis, and goals, so he can feel reasonably certain that there is nothing wrong with the plan to that point. Although consultation with other nurses can be wise and prudent at times, the nurse caring for the patient would likely have the most familiarity with the healthcare needs and is in a better position to make sound judgments than another nurse who does not know the patient. Therefore, it might not be productive or efficient to consult another nurse or restart the computer. Which statement(s) about nursing interventions is/are true? Select all that apply. 1) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. 2) The best nursing interventions are based on tradition. 3) Nursing interventions should be individualized and culturally sensitive. 4) Standardized nursing interventions improve care for a specific client. - SolutionANS: 1, 3 Some nursing interventions and activities can be delegated to the LPN/LVN or nursing assistive personnel (NAP); however, writing nursing orders is the responsibility of the registered nurse. Nursing interventions should always be individualized and culturally sensitive. Whenever possible, nursing interventions should be based on scientific evidence, not tradition. Diagnosis - SolutionANS: 3 The implementation phase ends when you document nursing actions on the clients chart. Implementation evolves into the evaluation step when you document the clients response to your interventions. As a general rule, the steps in order are as follows: assessment diagnosis, planning outcomes, planning interventions, implementation, and evaluation. Which nursing intervention is best individualized to meet the needs of a specific client? 1) Suction the client every 2 hours per unit policy. 2) Use incentive spirometry every hour while awake per postoperative protocols. 3) Institute swallowing precautions. 4) Move client out of bed to the chair daily; client prefers to be out of bed for dinner. - SolutionANS: 4 Positioning the client in the chair for meals considers the clients desire to be out of bed for dinner, so it is obviously individualized. An intervention performed according to unit policy or protocols is not necessarily individualized. Institute swallowing precautions does not provide instructions for the specific actions needed to do that for this particular client. The primary provider prescribes an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? 1) Ask a colleague for help, because the nurse cannot safely perform the procedure alone. 2) Gather the equipment and prepare it before informing the client about the procedure. 3) Obtain an order to restrain the client before inserting the urinary catheter. 4) Inform the provider that the nurse cannot perform the procedure because the client is confused. - SolutionANS: 1 Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance. A patient underwent surgery 3 days ago for colorectal cancer. The patients critical pathway states that he should participate in a teaching session with the wound ostomy nurse to learn colostomy self-care. The patient appears depressed and refuses to look at the colostomy or even make eye contact. How should the nurse proceed? 1) Postpone the teaching session until the patient is more receptive. 2) Follow the critical pathway for patient teaching about ostomy care. 3) Administer a prescribed antidepressant and notify the physician. 4) Explain to the patient the importance of skin care around the ostomy site. - SolutionANS: 1 A depressed affect and poor eye contact likely indicate that the client is having difficulty coping with the new colostomy. At this time, the client would not be physically and psychologically ready to obtain the most benefit from teaching pertaining to ostomy care. Therefore, the nurse should postpone the teaching session for this client until the client is receptive to receiving the information. The nurse should not perform the teaching session simply because the critical pathway indicates it is appropriate. Simply administering an antidepressant does not address the clients readiness to participate in a teaching session and ultimately self- care of the ostomy. The nurse should encourage the client to verbalize his feelings. Client education is not effective unless the client is receptive to the information. Readiness to learn is important. Proceeding with teaching when the client is struggling with coping is not sensitive to the clients individual needs. Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? 1) Psychomotor 2) Interpersonal 3) Cognitive 4) Critical thinking - SolutionANS: 2 Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills. Which intervention depends almost entirely on the clients adhering to the therapy? 1) Inserting an IV catheter 2) Turning a client every 2 hours 3) Shortening a surgical drain 4) Following a low-fat, low-calorie diet - SolutionANS: 4 Instituting and adhering to a low-fat, low-calorie diet is an intervention that depends almost entirely on the clients adhering to the therapy. Client cooperation is necessary for performing the other interventions, but the interventions do not depend on the client to the same extent. The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? 1) Teaching the client that he must lose weight to control his blood sugar 2) The criterion that states a defibrillator is present on each client care area is associated with structure evaluation. Refrains from sharing computer password, washes hands before each client contact, and verifies client identification before initiating care are criteria associated with process evaluation. Which of the following is a client outcome criterion? 1) Central venous catheter site infection does not occur (90% of cases). 2) Client will sit out of bed in a chair for 20 minutes three times per day. 3) Postoperative phlebitis does not occur (95% of cases). 4) Falls will decrease by 2% between January 1 and March 30. - SolutionANS: 2 A client outcome criterion states the client health status or behaviors one wishes to effect. Client will sit out of bed . . . is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution. When should the nurse collect evaluation data for this expected outcome: Patient will maintain urine output of at least 30 mL/hour? 1) At the end of the shift 2) Every 24 hours 3) Every 4 hours 4) Every hour - SolutionANS: 4 The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patients urine output every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient. Which type of client-centered evaluation is performed at specific, scheduled times? 1) Intermittent 2) Ongoing 3) Terminal 4) Process - SolutionANS: 1 Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the clients health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation. Which of the following is the most valid criterion for determining the status of a patients anxiety at discharge? The patient 1) Has a relaxed facial expression 2) States that he feels more relaxed today 3) Shows no physiological signs of anxiety (e.g., pallor) 4) Has no further questions about home care - SolutionANS: 2 A criterion is considered valid when it measures what it is intended to measure. Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it. A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety. All of the options except what the patient states could be measuring something other than anxiety. The nurse works with the respiratory therapist to administer a patients breathing treatments. He reports the patients breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of 1) Delegation 2) Collaboration 3) Coordination of care 4) Supervision of care - SolutionANS: 2 Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain the big picture. Supervision is the process of directing, guiding, and influencing the outcome of an individuals performance of an activity or task. The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Choose all that apply. 1) 75-year-old patient newly admitted to the hospital with dehydration 2) 65-year-old patient hospitalized for a stroke, whose blood pressure is 188/90 mm Hg 3) 92-year-old patient with stable vital signs who was admitted with a urinary tract infection 4) 56-year-old patient with chronic renal failure who has vital signs within his normal range - SolutionANS: 1, 3, 4 The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered