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Fundaments Midterm
Midtern U1-7
| Question | Answer |
|---|---|
| Assessment | The nurse’s observations differ from the client history, so she asks more questions to validate the data. |
| Diagnosis | The nurse compares the client height and weight to standard growth charts. |
| Planning | The nurse establishes effective airway clearance is of higher priority than knowledge deficit of diabetic diet. |
| Implementation | Prior to providing established care, the nurse reassesses the client’s status. |
| Evaluation | The nurse determines the client goals have been met and terminates nursing care. |
| Subjective data | “My headache pain comes and goes and is localized at the back of my head.” |
| Closed-ended question | Used when the nurse wishes to control the interview but may limit the depth of the client’s response. |
| Open-ended question | Used by the nurse to discover the client’s understanding, feelings, and knowledge but may take more time. |
| Objective data | Vital signs, assessment findings |
| Independent function | The nurse turns the client every 2 hours and assesses his skin. |
| Dependent function | The nurse administers medication to the client for pain relief. |
| Defining characteristics | Ambulation with walker, client statement of pain, 5 pound weight loss, statements of loneliness. |
| Cognitive Skills | The nurse interprets objective and subjective data as the client being in respiratory distress. |
| Interpersonal Skills | The nurse establishes rapport with the client whose culture is different from the nurse’s. |
| Psychomotor Skills | The nurse appropriately and safely inserts an indwelling (Foley) catheter. |
| Delegation | The nurse makes sure the new CNA understands how to collect the urine specimen before assigning the task. |
| During an interview, the nurse asks Mr. Jones if he has noticed any change in his activity tolerance. This is an example of which interview technique? | Problem seeking. |
| Mr. Davis tells the nurse he has noticed an increase in indigestion. The nurse asks him if the indigestion is associated with meals or a reclining position and what, if anything relieves the indigestion. This is an example of which interview technique? | Problem solving. |
| When a nurse collects data about a client’s past and present level of health, which phase of the interview process is taking place? | Working phase. |
| Sources of data in a nursing assessment include | Conducting a physical examination, Reviewing the results of laboratory and diagnostic tests and Collecting nursing health history, NOT Developing a list of health problems. |
| The nurse observes a client’s abdomen appears distended and she measures the abdomen with a tape measure. This action is called: | Data collecting. |
| During the working phase of an interview, the nurse does all of the | Implements the four techniques of interviewing as needed, implements communication strategies effectively, and poses questions that will obtain information to develop a data base. NOT Informs the client of his/her role in the interview. |
| The nursing health history is primarily used for: | Data collection. |
| In most circumstances, the best source of information for nursing assessment of the adult client is: | Client |
| Identify four methods of data collection the nurse uses to establish a data base. | Interview, nursing history, physical assessment, results of labs and/or diagnostic tests |
| A client is admitted with pain in the right shoulder. What specific information should the nurse obtain concerning the symptom? | Nature of onset (sudden or gradual), duration (always present or intermittent), location of pain, intensity of pain, quality of pain, pain worse, precipitate the pain, actions that relieve pain, vital signs, assoc w/ symptoms, ADLs, other health hx |
| Why is it important to explore lifestyle patterns and habits such as the use of alcohol, nonprescription/herbal or prescription medications, caffeine and tobacco? | Provides data on lifestyle and habits, information on disease risk, and opportunity for education |
| Why is it important to assess the client’s patterns of sleep, physical activity, and nutrition? | Obtain a holistic perspective of the client, Provide care/plan interventions for all areas of need, These factors and others affect overall health and Provide opportunities to educate client |
| The process of listening to sounds produced by the body. | Auscultation |
| Use of the hands and sense of touch to gather data. | Palpation |
| Observation of responses, behaviors, and physical appearance. | Inspection |
| Tapping the body’s surface to produce vibration and sound. | Percussion |
| Comparing assessed data with another source to establish accuracy is the process of | data validation |
| Grouping related data to form a picture of the client’s health needs is the process of | data clustering |
| List three ways to validate information obtained during a nursing history. | Consult another source or resources, physical exam, results of lab and diagnostic tests, compare subjective and objective data |
| List five sources of data for nursing assessment. | Client, family members/significant others, health team members, health/medical records, nursing/health/medical literature |
| The guidelines for writing an appropriate nursing diagnosis include all of the following: | State the dx terms of a prob, not a need, Use NANDA term to describe the client’s response, Use statements that assist in planning independent nursing interventions NOT Use medical terminology to describe the probably cause of the client’s response. |
| The essential components of a nursing diagnosis are: | Problem, etiology, and signs and symptoms. |
| A documented nursing diagnosis that could lead to a malpractice lawsuit against the nurse and the hospital is: | Impaired skin integrity related to improper positioning. |
| The presence of one sign or symptom is adequate support for a nursing diagnostic label. | F |
| It is acceptable to use the medical diagnosis as the etiology for the nursing diagnosis. | F |
| List three advantages of nursing diagnoses. | communication is enhanced, common language, increase quality of care |
| Mrs. French is a 45-year-old mother if two who is 50 pounds overweight. She has a smoking history of two packs per day for 20 years. She is to have a hysterectomy tomorrow. Which nursing diagnosis should appear on Mrs. French’s nursing care plan? | Risk for ineffective airway clearance related to obesity and smoking. |
| Mr. Margauz, a 52 yo exec, is admitted. He denies chest pain or sob. His pulse + BP are OK. He appears tense, does not want the nurse to leave the bedside. He states that he is very nervous. At this moment, which nursing diagnosis is most appropriate? | Anxiety related to intensive care unit admission. |
| If a nurse were to record a client’s nursing diagnosis as risk for malnutrition, it would be incorrect because it is: | Stated as a medical diagnosis. |
| If a nurse were to record a client’s nursing diagnosis as encourage client to verbalize fear, it would be incorrect because it is: | Stated as a nursing intervention. |
| Mr. Starr has the following signs and symptoms: Chronic productive cough with mucous, States he has smoked three packs of cigarettes a day for 15 years, PO2 reading of 90% | Impaired gas exchange related to smoking as manifested by chronic productive cough with mucous, history of smoking, and decreased PO2. |
| Bob O’Brien has the following signs and symptoms: States has had no appetite for 2 weeks, you have recorded a 10 pound weight loss. He weighs 15 pounds less than his recommended weight | Alteration in nutrition: less than body requirements related to loss of appetite as manifested by a 10 pound weight loss and weight that is 15 pounds less than the recommended weight. |
| Lilly Johns has the following signs and symptoms: She is unable to move either leg. She has limited passive range of motion in lower extremities. | Impaired physical mobility related to inability to move lower extremities as manifested by inability to move both lower legs and limited passive ROM in lower extremities |
| Mr. B following ss: He is blind. He states he falls and bumps himself. He gets confused when he is away from the familiarity of his home. He has a large bruise over his right forehead which he says he got when he bumped into an open cabinet door. | Risk for injury related to blindness and environmental hazards. |
| Alterations in bowel elimination related to cancer | not ok |
| Risk for malnutrition | not ok |
| Risk for pneumonia | not ok |
| Need for increased fluid related to thirst | not ok |
| Ineffective coping related to sensory bombardment | ok |
| Risk for fluid volume deficit related to fever and sore throat | ok |
| Lung cancer related to metastasis | not ok |
| Risk for situational low self-esteem related to mastectomy | not ok |
| Anxiety related to unknown etiology | ok |
| Infection related to burns | not ok |
| Impaired verbal communication related to sensory impairment | ok |
| Sudden Infant Death Syndrome related to low birth weight | not ok |
| Risk for self-directed violence related to inability to vent anger | ok |
| For each of the nursing diagnostic statements: Impaired urinary elimination related to Foley catheter | not ok |
| Mr. R is confined to bed-casts on legs. He is angry/stated does not want to talk to anyone. He has fight with girlfriend. You suspect diagnosis of Ineffective Individual Coping related to confinement to bed or possibly problems with significant others. | Risk for ineffective coping related to problems with his girlfriend and possibly related to confinement to bed. |
| Mr. Cappelli has a temperature of 1010 F. He sleeps a lot and has a poor appetite. He drinks approximately 2000 mL a day if you offer frequent fluids and encourage him to drink. You recognize that fever is a contributing factor for Fluid Volume Deficit. | Risk for fluid volume deficit related to insufficient fluid intake and fever. |
| Mr. R had his gb removed under general. His RN assessment form documented smoked a pack of cig-20 y. He has no prod cough at present, but you recognize his smoking and recent general anesthesia are contributing factors for Ineffective Airway Clearance. | Risk for ineffective airway clearance related to history of smoking and recent general anesthesia. |
| Mrs. J 6 wks after a surg. States well phys, but emotionally, not herself. She angry easily/cries. Nursing assessment adm to hosp 4 hysterectomy 6 wk ago, concern bout rectomies on sexual funct. I suspect she may have the diagnosis of Sexual Dysfunction. | Risk for sexual dysfunction related to perception of recent hysterectomy and/or spousal relationship. |
| List 4 activities involved in the planning process. | Prioritize problems and diagnosis, formulate client goals and desired outcomes, Select nursing interventions, Document nursing interventions, and Formulate nursing care plan, delegation |
| According to Mrs. Marks, her husband has very little time for their son. Based on the information provided, prioritized Mrs. Marks’ formulated nursing diagnoses as high (1), intermediate (2), or low (3). | Compromised family coping: related to mentally retarded adolescent son. |
| Under what circumstance would the nurse or nursing team independently develop client-centered goals? | If the client is unable to participate in goal setting. |
| Well-formulated, client-centered goals should: | Meet immediate client needs, Include preventative health care, Include rehabilitative needs. |
| The following statement appears on the nursing care plan for an immunosuppressed client: the client will remain free from infection throughout hospitalization. This statement is an example of a (an): | Short-term goal. |
| The following statement appears on a nursing care plan for a client who experienced a stroke with complete left-sided paralysis: client will perform self-care activities independently by discharge. This statement is an example of: | Long-term goal. |
| An example of an independent nursing intervention is: | Turning a client every 2 hours to prevent skin breakdown. |
| An example of a dependent nursing intervention is: | Giving an enema to a client before x-ray studies. |
| An example of a collaborative nursing intervention is: | Following admission protocol during an initial client interview. Assessing a client for side effects of medication. |
| Dependent interventions should automatically be implemented as prescribed. | F |
| A scientific rationale is: | The reason, based on supporting literature, a specific nursing action should be taken. |
| A(n) xxxxx us a thorough investigation designated to identify, examine, or verify the performance of certain aspects if nursing care, using established professional standards. | concurrent nursing audit. |
| The evaluation process compares client responses to a nursing action with the client’s progress toward achievement of xxx and xxx. | goals and desired outcomes |
| The evaluation criteria to measure the effectiveness of nursing actions are based on the goals/desired outcomes developed in the planning process. | T |
| Each component of the nursing process is the continuously evaluated. | T |
| Once a nursing care plan has been developed, it rarely needs modifications | F |
| Evaluation determines the extent to which the health care goals have been met. | T |
| Falls | Prevention includes keeping beds in the lowest position and placing overbed tables within the client’s reach. |
| Choking | Prevention includes assessment of the client’s gag and swallow reflexes. |
| Poisoning | Prevention includes performing the six rights of medication administration. |
| Fires | Prevention includes using grounded electrical plugs. |
| Bioterrorism | Prevention includes strictly adhering to infection control policies and procedures. |
| Burns | Prevention includes monitoring the temperature of the aqua-K pad. |
| Infants | Nursing education includes the correct use of childhood safety seats. |
| Toddlers | Nursing education includes storing household chemicals in a locked cupboard. |
| School-age | Nursing education includes wearing helmets when rollerblading. |
| Adolescents | Nursing education includes not using alcohol when operating a motor vehicle. |
| Middle-age adults | Nursing education includes following occupational safety requirements. |
| Elders | Nursing education includes removing throw rugs. |
| Delirium | Jerry’s confusion was sudden and worse and night. He believes the shadow of the window drapes is a woman in his room. |
| Dementia | Marian’s confusion has come on gradually over the last few years. Lately she can’t remember to turn off the stove. |
| Sensory stimulation | The nurse includes playing a tape recording of family messages, massage, and aroma therapy into the care of the unconscious client. |
| Sensory deficit | The nurse recognizes this may be occurring in a client who turns her head toward the speaker. |
| Hearing deficit | The nurse faces the client, removes her chewing gum, and makes sure the room is well lit when providing care to a client affected with this condition. |
| Visual deficit | The nurse adapts her care by announcing her entrance and exit, and explaining the procedure before touching a client affected with this condition. |
| Sensory deprivation | The nurse recognizes this condition so she provides a change in environment by wheeling the client to the sun porch. |
| Sensory overload | The nurse recognizes this condition so she places a “visitors check at desk” sign on the client’s door. |
| Olfactory deficit | The nurse instructs the client in the importance of a smoke detector when working with a client affected with this condition. |
| Tactile deficit | The nurse encourages the diabetic client to check his feet daily when providing discharge instruction to a client affected with this condition. |
| The importance of safety from a nursing perspective | awareness needed for prevention |
| Factors affecting safety | age and environment, lifestyle, mobility and health status, sensory perceptual alterations, cognitive awareness, emotional state, ability to communicate, safety, environmental factors |
| Safety hazards throughout the lifespan | Fegus, newborn, toddler, preschooler, adolescents and older adults. |
| Aspects of a nursing safety assessment | 3. noting pertinent indicatorsi n the nursing hx and physical exam. Using specifically dveloped risk assessment tooks and evluating hoem environment. |
| Home safety appraisal | flooring carpets, showers, smoker alarms, fire escapes, pools |
| Nursing safety interventions | Risk for injury, Risk for poisoning, suffocation, trauma, latex allergy response, contamination and risk for contaninmation |
| Causes of falls and falls prevention | leading cause of injury. Poor vision, congnitive dysfunction, imapired gait/balance, orthostatic hypotension, urinary frequency, weakness from disease |
| Why use restraints? | behavior management and acute medical/surgical care standards. |
| Behavior Management restraints | nurse may apply restrains but the primary care provider must see client within 1 hr for evaluation. A written restraint order for an adult, following evaluation is only valid for 4 hrs. If restrained and secluded, must be visual/audio monitoring. |
| Medical surgical restraints | permits up to 12 hours for obtaining the primary care provider written order. All orders renewed daily. |
| Components of the sensory experience | visual, auditory, olfactory, tactile or gustatory |
| Components of the sensory process | Visceral organs control senses with skin, muscles and joints. General senses include: touch, pressure, proprioception (awareness of movement), temperature and pain. |
| Visual impairment, symptoms, risks, nurse’s role | safety and orientation in home, self care |
| Gustatory impairment, symptoms, risks, nurse’s role | taste issues, don't use salt in excess |
| Hearing impairment, symptoms, risks, nurse’s role | safety alarms |
| Olfactory impairment, symptoms, risks, nurse’s role | dangers of cleaning with chemicals, gas leaks, food poisoning. |
| Tactile impairment, symptoms, risks, nurse’s role | hot temps (burns), pressure ulcers |
| Dementia | a global impairment of cognitive function |
| Alzheimer’s disease | a disease that involves progressive dementia, memory loss, and inability to care for self |
| Care of the unconscious patient | speak to client |
| Nursing diagnoses appropriate for cognitive and sensory impairment | distrubed sensory perception, acute confusion, chronic confusion, impaired memory |
| Sensory reception | process of receiving stimuli or data |
| Sensory perception | conscious organization and translation of data into meaningful information |
| Kinesthetic | awareness of the position and movement of bodily parts |
| Stereognosis | ability to perceive the form of an object by using the sense of touch. |
| Visceral | pertaining to the internal organs of the body |
| Presbyopia | lose the ability to focus on close objects |
| Cataracts | an eye disease that involves the clouding or opacification of the natural lens of the eye |
| Glaucoma | associated with increased pressure within the eye, damages optic nerve |
| Macular degeneration | medical condition usually of older adults which results in a loss of vision in the center of the visual field (the macula) because of damage to the retina. |
| Cognition | the process of thought. |
| The nurse has investigated safety hazards and recognizes that which one of the following statements is accurate regarding safety needs? | Annual inspections of heating systems, chimneys, and appliances should be done in private homes. Carbon monoxide detectors are available but should not be used as a replacement for proper use and maintenance of fuel-burning appliances. |
| On entering the client’s room, the nurse sees a fire burning in the trash can next to the bed. The nurse removes the client and calls in the fire. The next action of the nurse is to: | The next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment. |
| Which one of the following statements by the parent of a child indicates that further teaching by the nurse is required? “Now that my child is 2 years old, I can let her sit in the front seat of the car with me.” | Further teaching is req. Children weighing less 80 # than 8 years age/weight-appropriate car seat that has been installed according to manufacturers directions. In cars with a passenger air bag, children younger than 12 should be in the back seat. |
| A 75 year old client, hospitalized with a stroke, becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate nursing measure? | The bed alarm is the least restrictive device and allows the client to feel independent and alerts the nurse and staff when the client needs assistance. |
| A mother of a young child enters the kitchen and finds the child on the floor. A bottle of cleanser is next to the child, and particles of the substance are around the child’s mouth. The parent’s first action should be to: | The first action is to assess for airway patency, breathing, and circulation. |
| A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of “Risk for injury related to decreased vision”. Based on this assessment, the client will benefit the most from: | Orienting the client to the position of furniture in the room and stairways is the best intervention to help prevent falls for the client with decreased vision. |
| A 79-year-old resident in a long-term care facility is known to “wander at night” and has fallen in the past. Which of the following is the most appropriate nursing intervention? | Alternatives to restraints should be attempted first. (A physician’s order is required for restraints to be applied). The most appropriate intervention is to check on the client frequently. |
| The workmen cause an electrical fire when installing a new piece of equipment in the intensive care unit. A client is in the next room. The first action the nurse should take is to: | If there is a fire, the nurse should move the client away from the fire. |
| Sensory Perception | Involves the conscious organization and translation of the data or stimuli into meaningful information. |
| 4 parts of sensory experience | stimulus, receptor, impulse conduction and perception |
| Stimuls | agent/acts that stimulates a nerve receptor |
| Receptor | a nerve cell acts as a receptor by converting the stimulus to a nerve impulse |
| Impulse conduction | the impulse travels along the nerve pathway directly to the spinal cord/brain |
| Perception | awareness of stimuli and interpretation of stimuli takes place in the brain, where specialized brain cells interpret the nature and quality of the sensory experience |
| Delirium | sudden onset, temporary and worse at night |
Created by:
mstcnurse