NUR EXAM 2: REVIEW QUESTIONS | STUDY
GUIDE | QUESTIONS AND ANSWERS |
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,15 - A family presents to the emergency room with a 4-year- Redness and blisters forming on both legs
old child who is crying and reporting that the skin on the legs
are itching and hurting. The parent explains that they were out Crying and trying to scratch legs due to itching
walking in the woods when the child went running off the path
and into some tall weeds. Which finding(s)s should the nurse
prioritize in this assessment? Select all that apply.
Redness and blisters forming on both legs
Crying and trying to scratch legs due to itching
4-year-old at 85 percentile of growth and development
Stating "My legs feel like they are burning"
Respirations 18 breath/min and regular
LP 8 - Anxiety related to situational crisis and stress (related Problem-Focused Diagnosis Example
factors such as loss of employment) as evidenced by
restlessness, insomnia, anguish and anorexia (defining
characteristics).
- comes from data analysis & interpretation - come from Criteria for Nursing Dx
assessment
- any significant data that raises "red flag" - cues
- RN looking for actual or potential nursing problem diagnosis
- While determining what is going on with the patient, you
need to have strong interpersonal and communication skills.
Gain their trust so they can tell you "their story".
- There are no related factors (etiological factors), since we Risk Nursing Dx: They are more likely to develop this problem. Doesn't currently have it,
are identifying a vulnerability in a patient for a potential but is at a higher risk than others.
problem; the problem is not yet present. Therefore, we
identify the risk factors that predispose the individual to a
potential problem.
,Risk for infection as evidenced by inadequate vaccination and Risk Diagnosis Example
immunosuppression (risk factors).
1) Problem—identifies what is unhealthy about patient Formulating a nursing Dx
2) Etiology—identifies factors maintaining the unhealthy state
3) Defining characteristics—identify the subjective and
objective data that signal the existence of a problem
Purpose of identifying the problem in a nursing Dx Suggests the pt outcomes (expectations for change)
Purpose of identifying the etiology in a nursing Dx Suggests the appropriate nursing measures
*Fears of falling in the tub & obesity --> as evidence by (AEB)
13 - While working as part of an interdisciplinary group Clarity
developing a client's plan of care, a nurse asks the question,
"Can you give me an example?" The nurse is demonstrating
which standard for judging thinking?
Precision
Clarity
Relevance
Accuracy
, 13 - The nurse is caring for an obese client who needs to be Reflecting on prior experience and best practice, the nurse includes assistance with
turned every 2 hours. Which action by this nurse is an example turning in the client's plan of care.
of reflection-for-action?
Reflecting on prior experience and best practice, the nurse
includes assistance with turning in the client's plan of care.
The nurse decides to turn the client every 4 hours because
everyone is too busy to help.
After turning the client alone, the nurse realizes that the nurse
should have insisted on having help.
During the first attempt to turn the client, the nurse realizes
the need for assistance and calls the front desk for help
13 - Which is a characteristic of person-centered care? It is a framework for providing care.
It is a framework for providing care.
It involves general care for all clients.
It can be used in hospital settings.
It is independent of other disciplines.
GUIDE | QUESTIONS AND ANSWERS |
NURSING EXAM PREP| 100% VERIFIED | A+
GUARANTEE
Updated Questions and Answers | 100% Verified Exam Prep
,15 - A family presents to the emergency room with a 4-year- Redness and blisters forming on both legs
old child who is crying and reporting that the skin on the legs
are itching and hurting. The parent explains that they were out Crying and trying to scratch legs due to itching
walking in the woods when the child went running off the path
and into some tall weeds. Which finding(s)s should the nurse
prioritize in this assessment? Select all that apply.
Redness and blisters forming on both legs
Crying and trying to scratch legs due to itching
4-year-old at 85 percentile of growth and development
Stating "My legs feel like they are burning"
Respirations 18 breath/min and regular
LP 8 - Anxiety related to situational crisis and stress (related Problem-Focused Diagnosis Example
factors such as loss of employment) as evidenced by
restlessness, insomnia, anguish and anorexia (defining
characteristics).
- comes from data analysis & interpretation - come from Criteria for Nursing Dx
assessment
- any significant data that raises "red flag" - cues
- RN looking for actual or potential nursing problem diagnosis
- While determining what is going on with the patient, you
need to have strong interpersonal and communication skills.
Gain their trust so they can tell you "their story".
- There are no related factors (etiological factors), since we Risk Nursing Dx: They are more likely to develop this problem. Doesn't currently have it,
are identifying a vulnerability in a patient for a potential but is at a higher risk than others.
problem; the problem is not yet present. Therefore, we
identify the risk factors that predispose the individual to a
potential problem.
,Risk for infection as evidenced by inadequate vaccination and Risk Diagnosis Example
immunosuppression (risk factors).
1) Problem—identifies what is unhealthy about patient Formulating a nursing Dx
2) Etiology—identifies factors maintaining the unhealthy state
3) Defining characteristics—identify the subjective and
objective data that signal the existence of a problem
Purpose of identifying the problem in a nursing Dx Suggests the pt outcomes (expectations for change)
Purpose of identifying the etiology in a nursing Dx Suggests the appropriate nursing measures
*Fears of falling in the tub & obesity --> as evidence by (AEB)
13 - While working as part of an interdisciplinary group Clarity
developing a client's plan of care, a nurse asks the question,
"Can you give me an example?" The nurse is demonstrating
which standard for judging thinking?
Precision
Clarity
Relevance
Accuracy
, 13 - The nurse is caring for an obese client who needs to be Reflecting on prior experience and best practice, the nurse includes assistance with
turned every 2 hours. Which action by this nurse is an example turning in the client's plan of care.
of reflection-for-action?
Reflecting on prior experience and best practice, the nurse
includes assistance with turning in the client's plan of care.
The nurse decides to turn the client every 4 hours because
everyone is too busy to help.
After turning the client alone, the nurse realizes that the nurse
should have insisted on having help.
During the first attempt to turn the client, the nurse realizes
the need for assistance and calls the front desk for help
13 - Which is a characteristic of person-centered care? It is a framework for providing care.
It is a framework for providing care.
It involves general care for all clients.
It can be used in hospital settings.
It is independent of other disciplines.
