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Week 2 Sterpath
BSN205 Lesson 1-16
| Question | Answer |
|---|---|
| Which skills from Paul’s Critical Thinking Theory do nurses use when caring for patients? | Analyze data, Develop a plan of care, Evaluate the patient care plan |
| Match the theorists’ names with the name of the theory or model they developed. | Lewin-Rational Thought Theory, Paul-Social Learning Theory, Erickson - Change Theory, Rosenstock-Critical-Thinking Theory |
| According to Maslow’s Hierarchy of Needs Theory, which patient needs must be met first? | Physiologic needs |
| Which theory predicts general health behaviors of an individual? | Health Belief Model |
| As Tara prepares discharge education for Mr. Duncan, which topic addresses his lowest level of needs according to Maslow’s hierarchy? | Nutrition education |
| Middle-range theories have which characteristics? | Focus on a specific condition or population, Narrow focus with a limited number of variables, Can be tested through direct application |
| The metaparadigm for nursing focuses on which concepts? | Person, Environment, Health, Nursing |
| Which describes the concept of a nursing discipline? | Specific field of study or learning |
| Match the nursing theorist with the theory or conceptual framework they created. | Martha Rogers -Adaptation Model, Rosemarie Rizzo Parse - General Systems Framework, Hildegard Peplau - Science of Unitary Human Beings Model, Betty Neuman - Human Becoming Theory |
| Match the theorist’s name with her concept or conceptual framework. | Humane and holistic care for patients -Virginia Henderson, Adaption to the environment allows for healing-Florence Nightingale |
| Match the theorist’s name with her concept or conceptual framework. | A self-care deficit exists when patients cannot meet their own needs. - Dorothea Orem Clinical caring processes include sensitivity and mindfulness.-Jean Watson |
| Who stated that the imbalance between the patient and environment decreased the patient's capacity for health? | Florence Nightingale |
| Which nursing theory is the nurse exhibiting when teaching the diabetic patient the correct procedure for blood glucose monitoring? | Dorothea Orem |
| The nurse reflects which theory when helping the patient become as independent as possible before discharge from the hospital? | Virginia Henderson |
| Which overlapping phases are concepts included in Hildegard Peplau’s Theory of Interpersonal Relations? | orientation, resolution, and working |
| The nurse and patient worked together to facilitate communication when the patient was unable to communicate verbally. Whose theory did the nurse exhibit when caring for this patient? | Imogene King |
| The nurse implemented strict infection control procedures for an immunocompromised patient. Whose theory did the nurse exhibit when caring for this patient? | Florence Nightingale |
| The nurse facilitated extended visiting hours and offered additional support to the family of a dying patient. Whose theory did the nurse exhibit when caring for this family? | Jean Watson |
| The nurse explained the need for, and advantage of, receiving pain medication before ambulating to a patient who is first day post-operative from abdominal surgery. Whose theory did the nurse exhibit with this patient? | Virginia Henderson - Humane and Holistic Care for Patients Theory focused to help patients become independent |
| The nurse is teaching a recently diagnosed diabetic patient to administer insulin injections. Whose theory was the nurse demonstrating? | Dorothea Orem - Self-Care Theory focusing on guiding, teaching and supporting to promote the pt's abilities. |
| The nurse is implementing concepts from which theory when facilitating a group discussion that involves problem-solving and interpersonal processes? | Hildegard Peplau |
| The nurse recognizes that the patient seems disinterested when discussing needed dietary changes. Based on Lewin’s Change Theory, which stage does the patient’s disinterest represent? | Unfreezing |
| A patient who is physically stable and healing is withdrawn and refusing treatment following an auto accident in which he suffered an amputated limb. Which theory would be beneficial if applied to this patient’s care? | Rosenstsock - Health Belief Model - focused on possible reasons pt may not comply with recommendations. |
| Which of Paul’s critical thinking skills will the nurse use when developing a care plan for a newly admitted patient? | Experience, Reasoning, Observation |
| According to Maslow’s Hierarchy of Needs, a patient who is unable to show affection toward his wife or accept her reassurances must have which needs met before love and belonging needs can be addressed? | Physiological needs, safety and security |
| Based on Lewin’s change theory, when a new mother accepts responsibility for the care of her infant and reports comfort with her role, which change step occurred? | Refreezing |
| Steps of the nursing process serve which purpose? | Enable organization of patient care, Ensure comprehensive patient care, Facilitate evaluation of patient care |
| Place the five steps of the nursing process in the correct order. | Assessment Diagnosis Planning Implementation Evaluation |
| Information received from the patient’s family members, friends, or other nurses is what type of data? | Secondary, Subjective |
| What type of patient assessment takes into account factors such as the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health? | Holistic |
| What determines if an assessment is primary or secondary? | Data source |
| Match the category with its corresponding data source. | Obtained directly from patient - Primary Obtained from other healthcare professionals, medical records, test results - Secondary Direct quotes describing patient feelings - Subjective Blood pressure reading and weight - Objective |
| The nursing __________ identifies an actual or potential problem or response to a problem. | Diagnosis |
| Why must nursing diagnoses include up-to-date diagnostic labels as determined by NANDA International? | Standardized language facilitates care recognized by all health care team members. |
| When a patient reports feeling anxious, what is the subjective data called? | Symptom |
| Match the type of nursing diagnoses to the correct example of that diagnosis. | Actual: Objective Skin red with open lesion Risk Patient unsteady when walking Health-promotion Patient voices readiness to learn Actual: Subjective “My head hurts” |
| What type of patient-centered care respects the input of family members and other members of the health care team? | Collaborative |
| Match type of outcome or goal with its correct definition or example. | Within 1 week, the patient will stand with support to brush teeth. Short-term goal Within 3 months, the patient will stand unsupported for 20 minutes. Long-term goal |
| Match type of outcome or goal with its correct definition or example. | Classification of patient outcomes evaluating the effects of interventions. Nursing Outcomes Classification (NOC) Classification of interventions that nurses perform on behalf of patients. Nursing Interventions Classification (NIC) |
| What is the most important aspect of a patient-centered care plan? | Matching the patient’s goals and relevant current status |
| The nurse establishes the ____ of unlicensed health care team members as a crucial balance between collaboration and overlapping responsibilities. | Scope of practice |
| What is the primary purpose for documenting nursing interventions? | Facilitate communication |
| Nursing care can be categorized as direct or indirect, depending on the nursing ___________. | Interventions |
| What types of care plans are used in implementation? | Standing orders that describe specific actions to be taken by a nurse. General protocols that apply to patients with similar clinical needs. Care pathways that combine several areas of health care expertise. |
| A nurse is creating a care plan and wants to put direct care items before indirect care items. Which of these is in the correct order? | Help the patient ambulate, and then order occupational therapy to come. |
| What is the fifth step of the nursing process that includes a decision point on whether to discontinue, continue, or revise the plan of care? | Evaluation |
| What questions should the nurse ask when evaluating the effectiveness of nursing interventions? | Did the patient meet the goals established during the planning phase?, Should the plan of care be discontinued?, Does the care plan need to be modified in response to patient changes? |
| The evaluation phase loops back to which earlier phases of the nursing process when considering new data? | Assessment Diagnosis Planning |
| What does the evaluation phase include? | Patient's achievement of short- and long-term goals. |
| A nurse is ready to set goals for a patient who is recovering from a hip replacement. The nurse sets goals for the first three days and for the first three weeks. What part of the nursing process is this? | Planning |
| What word does the nurse use to describe the five steps? | Process |
| A nurse is admitting a new patient who has heart failure and pitting edema. At each step of the nursing process, what is likely to happen? | Information from other steps will be used to complete the plan of care |
| A nurse is caring for a patient at risk for appendicitis. When considering the assessment, why should the nurse use the five-step nursing process? | To systematically identify actual or potential patient problems |
| A nurse is caring for a patient who is cyanotic and has edema. The nurse is making a list of the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health. What stage of the nursing process is this? | Assessment |
| A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night. When assessing the patient’s pain level, is the nurse assessing subjective or objective data? | Subjective date, because only the patient can experience the pain |
| A nurse is caring for a patient who just had a colostomy. What type of nursing diagnosis (actual, risk, or health-promotion) should the nurse select when developing the plan of care? | Risk, since the patient is at risk for infection at the site of the surgical incision |
| A nurse is caring for a patient with a UTI. The nurse’s selection of two nursing diagnoses includes acute pain and impaired urinary function. What evidence would lead the nurse to diagnose acute pain? | Low back aching Burning upon urination |
| A nurse is caring for a patient with decubitus ulcers who is dehydrated and suffering from malnutrition. In the evaluation stage, what evidence about the decubitus ulcers should initiate the nurse to change the nursing care plan? | New decubitus ulcers have formed |
| The nurse is receiving a report on a patient recovering from a myocardial infarction with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other interdisciplinary professionals may be consulted for collaboration of this patient? | Respiratory therapist, cardiologist, and pulmonologist |
| A nurse is caring for a patient with a UTI. Which of these interventions address the patient’s short-term goals? | Applying a heating pad to the low back or abdomen Refraining from sexual intercourse |
| A nurse determines the patient’s goal of decreased reflux by sleeping on a pillow wedge was not totally met. How does the plan need to be revised? | Add a step to avoid eating after 7 p.m. |
| A nurse is evaluating the care plan for a pregnant patient. What is the main reason the nurse would ask the patient about support systems and eating habits? | Ensure individualized care |
| A patient has a painful jaw that clicks during chewing. The nurse developed a care plan and taught the patient how to use a bite guard. What step of the nursing process did the nurse exhibit by teaching use of the bite guard? | Implementation |
| A patient with diabetes reports to the clinic for diabetes education. The nurse learns that the patient’s wife prepares the family meals. Why is it important to include the patient’s wife in the teaching? | The wife can learn how to follow his new diet too |
| When does care planning begin? | When patient and nurse first interact |
| The office nurse contacts a patient before surgery and informs the patient about what he can expect. What is the nurse performing? | Preadmission planning |
| What is the order of Maslow’s Hierarchy of Needs from highest priority to lowest priority? | Physiologic needs Safety and security Love and belonging Self-esteem Self-actualization |
| When planning care, which need is the highest priority? | Physiologic |
| When creating the care plan for the patient, what does the nurse analyze to prioritize the patient needs? | Nursing diagnoses |
| What is an example of a long-term goal for the patient? | Achieve wound healing in 3 weeks. A goal achievable in 3 weeks is a long-term goal. |
| Within what timeframe is a short-term goal achieved? | One week |
| What is the patient more likely to do when the nurse collaborates with the patient to set goals? | Be aware of priority needs Accept realistic goals Be more successful in achieving goals Comply with interventions and behavior changes |
| What makes a goal useful and effective? | Realistic Patient-centered Measurable Time-limited |
| Why is outcome identification important to the achievement of patient goals? | Indicates goal attainment. |
| Which statement about interventions, as they relate to the planning step of nursing process, is true? | Interventions are activities that assist the patient in achieving goals. |
| What is the purpose of interventions as they relate to the nursing process? | Assist the patient in achieving goals and improving health. |
| How does the nurse ensure individualization of the selected interventions? | Evaluates patient assessment findings. Consults other professionals involved in the patient’s care. Ensures interventions align with patient acceptance. Considers the related factors identified in the nursing diagnosis. |
| Which part of the nursing care plan would contain the statement, “Patient will display complete healing of surgical area within 3 weeks”? | Measurable goal |
| What are the components of the nursing care plan? | Nursing diagnosis Measurable goal Interventions Evaluation |
| Which statement about the nursing care plan is true? | It summarizes patient’s condition, goals, and planned interventions. |
| Which information would the nurse expect to find on a conceptual care map (CCM)? | Nursing plan of care Medical history Provider orders Medications |
| What does the planning step of the nursing process involve? | Prioritizing nursing diagnoses Developing patient-centered goals Creating a personalized plan of care |
| The patient is being scheduled for knee surgery. When does the nurse expect the care planning process to begin? | When the patient is contacted by the office nurse to schedule surgery. |
| List the nursing diagnoses in priority from highest to lowest according to Maslow’s theory. | Ineffective Airway Clearance (physiological needs), then Risk for Falls (safety and security), Risk for Loneliness (love and belonging) and Readiness for Enhanced Knowledge (self-actualization). |
| The patient is admitted after an automobile accident and now has paraplegia. Following Maslow’s Hierarchy of Needs, which nursing diagnosis has the highest priority? | Impaired urinary elimination. |
| Prioritize each need as life-threatening, clinically urgent, or routine. | Life---Ineffective airway clearance Clinically urgent---Impaired tissue integrity Routine---Disturbed sleep pattern |
| A patient is admitted to the hospital with pneumonia. He has diabetes and a partial thickness pressure ulcer on his sacrum. He hasn’t had a bowel movement in 3 days. Which nursing diagnosis should be the highest priority? | Impaired gas exchange. |
| What is the order of the planning step components within the nursing process? | Prioritize nursing diagnoses->establish goals and outcomes->select interventions->create a plan of care. |
| Match the nursing diagnosis with the level of need it reflects. | Readiness for Enhanced Knowledge Self-actualizationDisturbed Body Image Self-esteemRisk for Falls Safety and securityDecreased Cardiac Output Physiological needs |
| The nurse is identifying a goal related to weight loss for an obese patient. In order for the patient to be successful with the goal, what should the nurse do? | Ask the patient what he would like to achieve. |
| The patient needs to lose 60 pounds. The nurse thinks a goal should be that the patient will exercise for 30 minutes a day 4 times per week. The patient wants the goal to be that she will exercise for 15 minutes per day 2 times a week. What should the nur | Consider the patient's social and cultural factors that might be influencing her priorities. |
| Match the component of the nursing care plan with the related information. | Heart rate (HR) 34 beats per minute Key assessment dataDecreased Cardiac Output related to altered HR, as evidenced by bradycardia Nursing diagnosisHR return to between 60-90 in 48 hours; monitor cardiac rhythm continuously Measurable goal and interven |
| What is an example of a long-term goal for the patient? | Achieve wound healing in 3 weeks. |
| The immobile patient has a goal of maintaining tissue integrity. Why does the nurse consult the Nursing Outcomes Classification (NOC) when evaluating the achievement of the goal? | To determine the level of goal achievement. |
| Why would the nurse use a conceptual care map (CCM) to develop a plan of care? | Provides a quick, yet comprehensive, overview of the patient's status and plan |
| A nurse is discussing short-term goals with a patient in the rehab unit. Why is it important for the nurse to include the patient in the goal-setting phase? | Provides motivation for the patient to achieve goals. |
| Which step of the nursing process does a nurse use when finding blood pressure of 180/75, a heart rate of 90, and a patient complaint of chest pain? | Assessment |
| Which best describes the diagnosis step of the nursing process? | The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers. |
| Which term describes the nurse prioritizing the diagnoses and identifying goals that are realistic, measurable, and patient-focused with specific outcomes? | Planning |
| Which actions demonstrate a nurse utilizing critical thinking when her patient complains of increased pain at the surgical site? | The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient. The nurse assesses vital signs and checks to see wh |
| A patient reports that his pain level is now 6 out of 10. The patient’s goal for a pain level of 3-4 out of 10 is not met. Which step of the nursing process does this statement reflect? | Evaluation |
| A nurse educator is reviewing the steps of the nursing process with the class. While reviewing a case study, the educator asks the students to determine which part of the process a nurse uses when establishing short- and long-term goals with the patient. | Planning |
| A nurse is preparing a presentation to the unit on ANA, the organization that identified the five steps of the nursing process. What does ANA stand for? | American Nurses Association |
| What is the primary purpose of the nursing diagnosis? | Communicating patient needs |
| A patient comes to the emergency department complaining of fever and diarrhea. What should the nurse ask the patient first? | What is the severity and duration of your fever and diarrhea?" |
| Stella Jones, RN, reassesses a patient one hour after giving morphine for the patient’s pain. The patient states that she is still in horrible pain, eliciting a response of 8 out of 10. What would be the most appropriate intervention? | Give additional breakthrough pain medication. |
| Who first pioneered the term “nursing process?” | Lydia Hall |
| The five steps that make up the nursing process allow it to be: | Dynamic |
| What does the term “dynamic nature” of the nursing process refer to? | Change over time in response to the patient’s needs |
| What is a part of the assessment process? | Data collection |
| What analytical questions are asked at each step in the nursing process? | -"Is the data collection thorough and accurate?" -"Have all underlying factors been addressed in the care plan?" -"Could interventions impact the patient negatively?" |
| Which statement illustrates the collaborative characteristic of the nursing process? | Nurses may incorporate actions by the patient or family to address patient goals. |
| Which subcategory of planning is recognized by professionals and educators as part of the traditional five-step nursing process? | Outcome identification |
| Which option exemplifies a short-term goal the nurse may identify during the planning step of the nursing process? | Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication. |
| The nurse is developing a plan of care for a patient with pulmonary embolism. During which step of the nursing process is the nursing diagnosis formulated? | Second |
| When formulating a nursing diagnosis, which component would the nurse analyze to identify patient problems and select appropriate nursing diagnoses? | Assessment data |
| In which way does the nursing diagnosis provide an effective means of communicating the patient’s status? | By consolidating a great volume of information into a concise statement. |
| Use of properly formulated nursing diagnoses promotes which outcome? | Accountability in nursing, Independent nursing practice, Patient care standardization, and Effective communication |
| During which process is a patient’s illness identified in order to provide appropriate medical care? | Medical diagnosis |
| Which statement comparing medical diagnosis and nursing diagnosis is true? | The purpose of nursing diagnosis is to clearly identify problems so appropriate nursing care can be provided. The purpose of medical diagnosis is to identify illness so medical treatment can be provided. |
| NANDA identified which goal initially during the development process? | Implement nursing diagnostic categories. |
| NANDA is known for its pioneering work in which aspect of nursing? | Nursing language and classification. |
| Which group of people make up NANDA? | Nurses from all nursing areas |
| NANDA-I members meet every two years. Which initiative is the focus of this meeting? | Taxonomy revision and Evaluation of nursing research |
| The patient fell and fractured his hip. He also has diabetes, heart failure, and osteoporosis. Which aspect of the patient’s history would a nursing diagnosis focus on? | Sudden onset of pain |
| Why does the nurse focus on airway status when developing a nursing diagnosis for a patient with asthma? | To identify the patient's response to illness |
| Which outcomes are the result of using nursing diagnoses? | Promotes accountability in nursing care, Supports independence in nursing practice, and Establishes standardization of patient care |
| In which way is the ICNP® taxonomy different from the NANDA-I taxonomy? | The ICNP® taxonomy includes different catalogs of nursing diagnoses, outcomes, and interventions. |
| In which way is the ICNP® taxonomy valuable to the nursing profession? | Documentation of the validity of nursing practice is a result of its use. |
| Which statements made by a nursing student would indicate an understanding of the benefits of using the ICNP® nursing taxonomy in practice? | ICNP® nursing diagnoses can be applied in the acute care setting as well as in other health care related settings, Use of the ICNP® taxonomy gives nursing a voice within the comprehensive health information system, The standardized terminology makes the I |
| Where are NANDA-I nursing diagnostic labels selected from? | NANDA-I approved list The nurse selects an appropriate nursing diagnostic label from the NANDA-I list of approved nursing diagnostic statements. |
| Which characteristic exemplifies nursing as a profession? | Autonomy in decision-making |
| When the nurse collaborates with the dietary department to provide a kosher meal for a patient, which professional criterion does this action support? | Diversity |
| A nurse taking continuing education classes is an example of which professional nursing criteria? | Licensure |
| Which is the most important group a nurse can join to gain support and foster growth within the profession? | Professional organization |
| Which term describes nurses who engage in selfless acts? | Altruistic |
| Which is the best document for the nurse to consult when making decisions about nursing practice or conduct? | Code of ethics |
| Which entity publishes and updates the Standards of Nursing Practice? | American Nurses Association |
| Which is the best document for the nurse to consult to ensure delivery of quality patient care? | ANA Standards of Nursing Practice |
| Which process is involved in the nurse’s socialization into the profession of nursing? | Learning the theory necessary for the nursing role |
| Which option is available to nurses who want to expand their practice, but do not desire to return to formal education? | Become certified in current practice area. |
| Which statement differentiates APRNs from RNs? | They are approved to practice in expanded roles. |
| Who can update a patient’s plan of care, but cannot initiate that plan of care? | LPN/LVN |
| A patient is considering a new health care provider. What is the difference between a FNP and a CNS? | Serve as primary care providers. |
| A nurse who holds a PhD can engage in which role? | Educator, Researcher, Scholar |
| What is a benefit for new nurses who join professional organizations as part of the socialization process? | Access to current resources |
| Which early nursing leader made significant contributions to the field of epidemiology? | Florence Nightingale |
| Regardless of how it is defined, nursing is described as which kind of profession? | holistic |
| Which organization’s definition of nursing includes the autonomous role of nurses? | International Council of Nurses |
| Which statement by a student demonstrates accurate understanding of a “competent” nurse, according to Benner’s Novice to Expert Model? | A nurse who uses more analytical thinking |
| According to Benner’s Novice to Expert Model, a nurse who sees situations holistically and perceives deviations from normal is at which level of clinical nursing practice? | proficient |
| Which entity regulates prescriptive authority for advanced practice nurses (APRNs)? | State boards of Nursing |
| Prior to discharge, the nurse reviews prescribed medication side effects and discusses conditions with the patient that should be reported to the health care provider. Which nursing role do these actions represent? | educator |
| The nurse works with the physical therapist and the family to allow a child who is confined to a wheelchair to eat lunch outside. What nursing role does this action represent? | collaborator |
| The charge nurse is authorized to make changes in the number of staff members who work that shift, based on the number and acuity of patients on the unit. Within which nursing role is the charge nurse functioning? | manager |
| A charge nurse in the intensive care unit (ICU) is trying to motivate other staff members to obtain certifications. Which nursing role does this action represent? | leader |
| A mother is concerned she won’t be able to ask questions of her child’s health care provider before she leaves for work. The nurse assures the mother the questions will be asked and recorded in writing at the child’s bedside. Which role is the nurse demon | advocate |
| When the nurse recognizes a problem and collects data to sufficiently support the need for policy updates, what role is the nurse demonstrating? | advocate, researcher, change agent |
| The nurse implements several pain relieving interventions, teaches relaxation techniques, re-evaluates the patient’s pain throughout the shift, and revises the plan of care as needed. Which nursing roles do these actions demonstrate? | educator, care provider |
| Nurses become involved in evidence-based practice (EBP) when they do what? | Apply research findings to their practice |
| Which nursing action describes the nurse’s role of advocate? | accepting pt's advanced directive for limited life sustaining treatment |
| The nurse enters the patient’s room and says, “Hi, my name is Barbara. I am your nurse. Let’s discuss why you have been admitted to the hospital.” What phase of the patient interview is taking place in this situation? | Orientation |
| A nurse is performing an interview and asks the patient about allergies and medications. These questions occur during which phase of the patient interview? | Working |
| At the end of the interview, the nurse lets the patient know the interview is complete and the doctor will be in shortly. Before leaving the room, the nurse asks the patient if there are any questions. Which phase of the patient interview is represented b | Termination |
| Which assessment should be performed during the patient’s initial visit to a new health care provider? | Comprehensive |
| A nurse enters a patient room to assess the patient’s blood pressure, temperature, pulse, and pain. What type of assessment is being performed? | Focused |
| Which assessments are completed first during an emergency? | Airway Breathing Circulation |
| During which type of assessment would the nurse be most likely to assess skin turgor and capillary refill to determine the patient's clinical status? | Shift |
| What information should be included in a health history? | Patient's social history Reason for seeking medical care Patient demographic information Medications the patient is currently taking |
| Which action is appropriate when attempting to build trust and rapport with a patient during the assessment process? | Ensuring patient comfort and privacy |
| What information is obtained during a patient interview? | Current health concerns Medical and surgical history Culture, ethnicity, and spiritual views |
| Which type of physical assessment is usually governed and directed by the policies of the health care facility? | Shift |
| Laboratory and other diagnostic tests are obtained during a patient office visit. These tests are associated with which type of patient assessment? | Comprehensive |
| During which phase of the interview is the patient given an opportunity to ask questions and add any additional information that may have been forgotten? | Termination |
| In addition to patient statements, what should the nurse be very attentive to during the interview? | Non-verbal cues |
| The nurse is about to conduct a focused assessment at the beginning of the work shift. Which assessments will be performed? | Peripheral pulses Skin Turgor Urinary output Wounds |
| When nurses make determinations about patients needing emergent, urgent or non-urgent care, which type of assessment are they using? | Triage |
| A nurse makes preliminary observations about a patient. What is the term for this action? | General survey |
| Which information is obtained from the patient’s chart, medical records, and diagnostic testing? | Secondary information |
| What type of data includes the patient’s medical history, feelings, and management of health and health concerns in the past? | Primary data |
| What type of data includes verbal descriptions of symptoms or feelings? | Subjective |
| How should subjective data be documented in the patient’s medical record? | Within quotation marks |
| As perceived by an examiner, which is an objective finding such as a fever, a rash, or the whisper heard over the chest in pleural effusion? | Sign (objective finding by examiner) |
| Which type of symptom is intrinsically associated with a disease? | Primary |
| What type of symptoms is a consequence of illness and disease? | Secondary |
| In most cases, what type of data is best to obtain first? | Primary |
| During the nurse’s assessment, the patient reports feelings of dizziness and nausea. What type of data is the patient providing? | Subjective |
| Checking the patient’s previous hemoglobin and hematocrit levels is an example of collecting what type of data? | Objective |
| Which model focuses on the physical condition rather than the holistic view of a patient? | Medical Body Systems |
| In which model does the physical examination end with the lower extremities? | Head-to-toe |
| Nutrition and metabolism is a component of which model of data organization? | Gordon's functional health patterns |
| What policy determines the manner in which medical data is collected and organized? | Health care facility |
| Which model takes a holistic view of the patient and may reveal patterns that might not be easily seen otherwise? | Gordon's functional health patterns |
| What is the focus of the body systems model? | Physical examination |
| Which are important components of the head-to-toe model? | Vital signs Subjective and Objective patient information |
| Which is a documentable component of Gordon’s functional health patterns model? | Cognition |
| An aging patient is admitted to the hospital under the guardianship of his daughter, who does not agree with his belief in alternative medicine. When the patient’s daughter leaves the room, he consults the nurse for advice. Using the values clarification | help the patient make an informed decision about the next step |
| A nurse in the emergency department is helping with a blood transfusion for a gunshot victim with the same blood type as herself, and hopes the blood she is transfusing is from her own donation. When she discovers that the injury occurred when the patient | values conflict |
| A nurse in the children’s ward is caring for a boy with impetigo who is experiencing some discomfort. In a private moment with the father, the nurse is shocked to learn that the reason they did not give the boy antibiotics was that they did not want to ki | values |
| A nurse is assessing an eight-year-old girl in the hospital for tonic-clonic seizures. In speaking with the parents through the couple’s ten-year-old son who is interpreting for them, the nurse is not sure that they understand the provider’s orders for th | culture |
| A nurse is caring for a woman in her 20s recovering from a mastectomy after cancer was detected. The woman’s twin sister is visiting and they are discussing whether the twin should get regular mammograms. The patient says that her early mammogram saved he | Personal values |
| Michael grew up in a family where all the women were homemakers and nursed their sick children back to health using natural remedies, while all the men went to work all day long. Which of the following was most likely one of Michael’s first-order beliefs? | all medicines are made of natural ingredients |
| A nurse working in a pain management clinic is having a conversation with an older adult patient with bone cancer, who emigrated from Japan 60 years ago, and his 40-year-old son. The son asks why his father, who is obviously in great pain from his conditi | Values clarification |
| A nurse is working with a female patient who has a distended abdomen and has not been able to urinate for 24 hours. After catheterizing the woman, a large amount of clear urine collects in the urine bag. The patient asks for her 32-ounce cup to be filled | Asking relevant questions |
| A nurse in a skilled nursing facility is meeting her patient for the first time, a woman who is 92 years old and a retired nurse herself. The older woman says she has a Do Not Resuscitate order in her chart, and wishes to have “DNR” written on her chart b | ethical |
| Which statements are ones nursing students should learn about the relationship between beliefs and values? | It is important for nurses to have strong professional values to guide their practice that are consistent with society's expectations of a trusted professional; it is essential for nursing students to develop and continue adhering to critical professional |
| A nurse who is speaking to nursing students explains the importance of respecting patients’ own personal values. She tells the students that personal values include the life principles that are most important to people and shape the way they think. Beside | actions |
| A nurse is going over suggested dietary items for a patient who has just been diagnosed with oxalate kidney stones. The patient is anxious to eliminate the painful condition from persisting, but the diet appears to be restrictive of some of his favorite f | involving the patient in establishing goals |
| The patient recently diagnosed with iron-deficiency anemia reveals that he has trouble swallowing pills and cannot take his iron supplements. He is also a vegetarian and cannot consume red meat, which is a good source of iron. What should the nurse do to | Include the patient in determining what intervention should be implemented |
| A patient diagnosed with end-stage renal disease is undergoing dialysis. The nurse asks the patient about the patient’s values and beliefs regarding end-of-life care and death. The patient’s beliefs are a perception of what is ______. | right, true and real |
| A nurse is teaching a class of new nursing students about the scientific method. The class determines that _______ __________ in the early 1900s changed the approach of nursing from superstition to evidence-based practice. | onducting research |
| A nurse is teaching a new class of nursing students about the different orders of belief. She asks them to explain the types of belief. Which answers by the students are correct? | higher order beliefs are derived from combination of first-order beliefs and logic; a zero-order belief is a foundational belief such as knowing "I am a person different from you."; a first-order belief can be developed into adulthood based on knowledge a |
| A nurse in an assisted living facility is training a group of nursing students about the older adult population. She explains that sometimes as people live together in a group after living only with family for their whole lives, conflicts can arise. Some | prejudice |
| A nurse is meeting with a family whose father is being admitted to the hospital for infection due to radiation for the treatment of stage IV lung cancer. The nurse uses the values clarification process. What application of the values clarification process | end of life care |
| A nurse is helping a woman who is six months postoperative for a C-section, and experiencing belly pain and lumpiness below the skin. The nurse palpates the abdomen, and suspects that the lumpiness is due to postoperative adhesions of the peritoneal cover | The nurse wanted to use the choosing, prizing, actions framework to involve the patient in her own treatment |
| The nurse is caring for a patient diagnosed with diabetes who does not believe in taking medication for the condition. The patient refuses to take insulin even though the medication will help decrease the symptoms of diabetes in the patient. In order to p | actively involve the patient |
| Which quality is most helpful in a nurse interacting with patients with different backgrounds? | self-awareness |
| The foundation or the basis of an individual’s belief system based on direct experience is what order of belief system? | First-order |
| Through what means is the purpose of nursing fulfilled, according to Travelbee’s theory? | human-to-human relationships |
| Which are components of the interaction process in Travelbee’s Theory of Caring? | empathy, sympathy, and original encounter |
| A nurse is working with a 38-year-old Lebanese patient in the hospital recovering after surgery. The patient explains that it is Muslim tradition to visit the sick, and she needs everyone around to help her recover. The nurse closes the curtain to allow p | The nurse is accommodating the health care practices of the patient’s cultural practices by allowing family but closing the curtain to provide nursing care. |
| What should be the focus of compassionate nursing care, according to Travelbee? | human relationships |
| Which are nursing theories of care? | Leininger's Cultural Care Theory; Swanson's Middle Range Theory of Caring; Watson's Theory of Human Caring |
| When choosing a life-long career, what motivates people to choose nursing? | Desire to help others |
| Which statement is true regarding codependency? | codependency may lead to controlling behavior |
| Which behaviors are demonstrated by a caring nurse? | Actively listening to the patient Establishing trust through lines of open communication |
| What is an example of an important caring behavior in nursing? | administering shots |
| In today’s technical world of nursing, what is considered the most valuable method of nonverbal communication? | Caring touch |
| A nurse is teaching a group of nursing students about the importance of caring touch. What task-oriented behaviors exhibited by the nursing students would show that the lesson on touch was effective? | giving bath, starting IV, suctioning NG tube |
| When is a nurse touching the patient perceived as being intrusive or hostile by the patient? | when pt is under influence of drugs/alcohol and when pt is victim of abuse |
| A nurse is teaching a group of students about behaviors of being a caring nurse. The nurse distinguishes between caring and codependency in a nurse. Which of these is a characteristic of a caring nurse? | Patient advocate |
| A nurse is teaching an orientation class for new nurses. In discussing the difference between caring and codependency, which behavior would the nurse most likely identify as an example of a destructive behavior that can facilitate codependency? | gambling |
| A 55-year-old female Muslim patient is on the surgical floor on the second postoperative day. According to Leininger’s Cultural Care Theory, which nursing actions would be appropriate for this patient? | lowering height of bed and offering pt prayer mat |
| A 48-year-old, obese female of Middle Eastern origin is admitted with a diagnosis of type 2 diabetes. The health care provider recommends an oral antidiabetic medication, but the patient insists on trying some of her herbal supplements first. After the nu | preserving cultural practice |
| In Watson’s Theory of Human Caring, what is suggested to promote healing and wholeness? | Conscious intention to care |
| According to Watson’s Theory of Caring, what does the term “transpersonal” mean? | to go beyond one's own ego |
| Which type of factors was Watson’s Theory of Caring originally built on? | carative |
| What are the types of NANDA-I nursing diagnoses? | Actual Risk Health promotion |
| What is the appropriate NANDA-I nursing diagnostic label for each type of nursing diagnosis? | Ineffective coping- actual Risk for impaired skin/tissue integrity- risk Readiness for enhanced self-care- health promotion |
| The nurse is identifying which type of NANDA-I nursing diagnosis to use for a clinical situation and has determined there is an identifiable patient response to a current life process. Which type of NANDA-I nursing diagnostic label should the nurse select | actual |
| The nurse is identifying which type of NANDA-I nursing diagnosis to use for a clinical situation and has determined the patient is vulnerable to developing an infection in a wound that is currently not infected. Which type of NANDA-I nursing diagnostic la | Risk |
| The nurse is identifying which type of NANDA-I nursing diagnosis to use for a clinical situation and has determined the patient has expressed a desire to learn more about his newly diagnosed diabetes. Which type of NANDA-I nursing diagnostic label should | Health promotion |
| The patient has chronic obstructive pulmonary disease. What is an appropriate NANDA-I risk nursing diagnostic label? | Risk for infection |
| The patient just had a total knee arthroplasty. What is an appropriate NANDA-I health-promotion nursing diagnostic label? | readiness for enhanced knowledge |
| The nurse is writing a NANDA-I actual nursing diagnosis. What component of the nursing diagnosis follows the diagnostic label? | Related factors |
| The nurse is writing a NANDA-I actual nursing diagnosis. What component of the nursing diagnosis follows related factors? | defining characteristics |
| The nurse is writing a NANDA-I risk nursing diagnosis. What component of the nursing diagnosis follows the diagnostic label? | risk factors |
| The nurse is writing a NANDA-I health-promotion nursing diagnosis. What component of the nursing diagnosis follows the diagnostic label? | defining characteristics |
| The patient has the nursing diagnosis Readiness for Enhanced Knowledge. Which type of NANDA-I nursing diagnosis is this? | health-promotion |
| The patient has a NANDA-I actual nursing diagnosis of Ineffective Airway Clearance related to retained secretions, as evidenced by unproductive cough and tenacious secretions. Which part of the NANDA-I nursing diagnosis is the related factor? | retained secretions |
| The patient has a NANDA-I nursing diagnosis of Ineffective Airway Clearance related to retained secretions, as evidenced by unproductive cough and tenacious secretions. Which part of the NANDA-I nursing diagnosis is the diagnostic label? | ineffective airway clearance |
| Which example represents a NANDA-I health-promotion nursing diagnosis statement? | Readiness for Enhanced Nutrition, as evidenced by verbalized willingness to adhere to ADA diet. |
| Which dimensions are included in the NLNAC’s definition of clinical judgment? | Diagnostic dimenstion, Ethical dimension, Therapeutic dimension |
| Which term is used by the NLNAC to describe the manifestation of critical thinking in nursing? | Clinical judgment |
| Which are correct statements about critical thinking? | There is no single best definition of critical thinking, formal and informal logic is essential to critical thinking |
| What is the definition of problem solving? | A systematic, analytic approach to finding a solution to a problem |
| Which statement describes clinical reasoning? | Using critical thinking to develop solutions to problems |
| Which process, based on its definition, describes the nursing process? | Problem-solving |
| Which critical thinking intellectual standard would the nurse illustrate by asking a patient to be more specific when complaining about “just not feeling right”? | Precision |
| Which critical thinking intellectual standard is demonstrated by a nurse who says to a patient, “This is what I heard you say. Am I correct about your meaning?” | Clarity |
| Asking the question, “Is there another way to approach this problem?” aligns with which intellectual standard for critical thinking? | Breadth |
| Which information about deductive reasoning is correct? | Generates facts from a major theory, Proceeds from the general to the specific |
| Which data obtained during a health assessment would require validation? | Complaint of red pin point underarm rash |
| Upon what do expert nurses base their intuition? | Experiential knowledge |
| Which statements describe the application of critical thinking to the nursing process? | Analyzing patient data Using baseline knowledge Considering alternative actions |
| Which critical thinking skill did the nurse use when verifying the latest revision date prior to using a website’s patient education brochure? | Evaluation |
| Which statements are correct about the critical thinking skill of self-regulation? | Emphasizes reflection on reasons for one's actions Enables recognition and correction of one's errors Required for all steps of the nursing process Necessitates monitoring of self-thinking |
| What is the best method for avoiding erroneous assumptions about patients? | Asking questions to clarify information |
| Which common thinking error is most likely to hinder the development of a therapeutic nurse-patient relationship? | Closed-mindedness |
| Which statement describes a defining characteristic of illogical thinking? | Jumping to conclusions |
| Which strategies can nurses use to improve critical thinking skills? | Holding discussions with colleagues Engaging in verbalization of thoughts Conducting literature reviews |
| Which aspects of written work improve critical thinking? | Reviewing recent lectures Noting key facts while reading Rewriting study notes Identifying knowledge gaps |
| Which method ensures the competency of licensed nurses? | Specialty certification |
| Consider the goal Patient will ambulate 50 feet twice a day with assistance. Determine if the evaluation statement describes a goal that is met, partially met, or unmet. | Patient is consistently ambulating 50 feet twice daily. Goal is met.Patient ambulating 20-50 feet twice daily. Goal is partially met.Patient is on bed rest due to development of pulmonary embolus. Goal is unmet. |
| The patient has a goal of, “Skin will remain intact while in the hospital.” The nurse notices the patient has a new stage 2 pressure ulcer. What should the nurse do? | Reflect on factors that prevented the goal from being achieved. |
| Which statement about the evaluation step of the nursing process is true? | During evaluation, the nurse determines whether the patient’s goals were achieved. |
| The nurse monitors trends in patient outcomes as they relate to specific nursing interventions and notes positive changes. Procedures are changed based on the nurse’s research. What is this process called? | Quality improvement |
| The nurse evaluates the patient’s progress towards goals and determines if goals can be met. What does this include? | Patient involvement |
| The nurse evaluates the outcomes to determine if short-and long-term goals have been achieved. How is this decision made by the nurse? | Through critical thinking |
| Which notations are appropriate for the nurse to include in a patient’s chart regarding evaluation of the goal, “Patient will ambulate three times daily in the hallway before discharge without shortness of breath (SOB)?” | Goal not met; patient states he is tired Goal met; patient ambulated three times in the hallway without SOB |
| A patient sets a goal of quitting smoking within the next 30 days. After 30 days, the patient has not quit but reports that he has reduced his smoking by 50%. The goals for the next 30 days are revised. What does the nurse document in regard to goal attai | Goal partially met |
| The nurse is caring for a patient who has a goal of losing 10 pounds within the next 2 weeks. After 2 weeks, the nurse and patient determine that the goals were unmet. What factors are looked at to determine what prevented goal achievement? | A. Realistic B. Barriers C. Modifications |
| The nurse is caring for a patient in the rehab unit and preparing her for discharge. The nurse determines that the patient has unmet goals. What is the next step in the process? | The nurse decides to continue, revise, or discontinue the goal. |
| The nurse documents progress toward goals in the patient record as, “Goal unmet, patient unable to quit smoking.” What is this notation called? | Evaluation statement |
| The nurse is caring for a bedbound patient who develops a new area of skin breakdown, despite nursing interventions focused on prevention. The nurse informs the physician and updates the care plan with new interventions. How often is the care plan evaluat | Every shift |
| The nursing staff of a small emergency department implements a process to reduce wait times. What is this process called? | Quality Improvement |
| A nursing unit develops a quality improvement project aimed at decreasing patient falls. What type of guideline drives this quality improvement effort? | Evidence-based practice |
| Match the intervention category with the intervention. | Monitoring a patient's temperature and skin color for fever: Independent Administering antipyretic medication for fever as ordered by the provider: Dependent Nursing assistant providing bathing and dressing assistance to a patient. Collaborative |
| What are the highest-priority interventions? | Problem-oriented. |
| Which is an example of a collaborative nursing intervention? | Nursing assistant providing range-of-motion on the patient. |
| Which is an example of an indirect-care intervention? | Communication with providers. |
| Which are the indirect-care interventions? | -Collaboration. -Referrals. -Delegation. |
| Which are the direct-care interventions? | -Informal counseling. -ADLs. -Reassessment. |
| The nurse has assessed the patient and established a nursing diagnosis of Risk for Impaired Skin Integrity related to immobility. She has determined the interventions are to reposition the patient every two hours and maintain meticulous skin hygiene so th | Implement the interventions. |
| Why should the nurse reference Nursing Interventions Classification (NIC) when documenting interventions? | It is useful for clinical documentation. |
| The nurse performs patient care interventions according to the individualized care plan. What is the next step in the process? | Document the interventions. |
| Nurses coordinate many types of interventions when initiating a care plan. How are nursing interventions categorized? | -By purpose. -By who initiates or conducts them. -By type of patient contact. |
| The nurse is caring for a postoperative patient in the medical-surgical unit. Which interventions are considered to be independent nursing interventions? | -Use of incentive spirometer. -Hand hygiene. -Ambulating the patient. |
| The nurse is caring for a patient receiving anticoagulant therapy. Which intervention is considered to be a dependent intervention? | Holding dose due to abnormal lab value. |
| The nurse is caring for a post-operative patient. Which intervention is considered to be prevention-oriented? | -Post-operative ambulation. |
| The nurse is caring for a post-operative patient following hip repair. Which intervention is considered to be collaborative? | Ambulation with physical therapy. |
| Nurses conduct change-of-shift reports to communicate assessment findings and outstanding nursing interventions. What type of intervention is this? | Indirect-care. |
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Mrsbradley21
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