NR 226 Exam 1 - Review Questions/Answers well elaborated.
NR 226 Exam 1 - Review Questions/Answers well elaborated. NR 226 Exam 1 - Review Questions While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of: A. Inference. B. Diagnostic reasoning. C. Competency. D. Problem solving. *ANS- D. Problem solving -This is an example of problem solving. The nurse collects information and tries options until she is able to find a solution to the slowed infusion rate. The focus is on solving the problem with the patient's IV and not on solving the patient's health problem; thus this is not the diagnostic reasoning process. The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of: A. Diagnostic reasoning. B. Competency. C. Inference. D. Problem solving. *ANS- A. Diagnostic reasoning -In this example the nurse collects information about the patient, sees patterns in the data collected, and makes a nursing diagnosis. This is an example of the diagnostic process. A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show? (Select all that apply.) A. Experience B. Ethical C. Analyticity D. Self-confidence E. Risk taking *ANS- C & D. -Among critical thinking concepts, the nurse shows analyticity (analyzing information, gathering additional findings, and sensing a problem), and self-confidence (calling the physician, which shows trust in his own reasoning). The nurse's experience would have influenced the familiarity of patient symptoms, but in this text experience is considered a component of the critical thinking model and not a concept. Acting ethically is a critical thinking standard. .A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients? (Select all that apply.) A. Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction. B. Think about past experience with patients who develop postoperative complications. C. Decide which activities can be combined for patients B and C. D. Carefully gather any assessment information and identify patient problems. *ANS- A & C -Considering how to involve patients in decisions and how to combine nursing activities to be more organized and allow for resolving more than one problem at a time are examples of clinical decision making for groups of patients. Thinking about past experience with patients is an example of reflection, an approach to strengthen critical thinking skills. Gathering assessment information is part of the process of diagnostic reasoning, which should be applied to each patient. The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard? A. Deep B. Relevant C. Consistent D. Significant *ANS- C. Consistent -Use of the same pain scale for assessing pain acuity is an example of being consistent. During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in which of the following actions? A. "I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax." B. "I see that you're uncomfortable. I'll call your doctor to decide the next step." C. "Show me exactly where your pain is and rate it for me on a scale of 0 to 10." D. "Is anything else bothering you? Other than the pain, is there any other reason you might not want to do the exercises?" *ANS- A. "I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax." -The nurse reviews the position of requiring exercises to restore function and decides to try a different approach to proceed, which is an example of integrity. In calling the doctor for the next step, the nurse does not reinforce the importance of exercises, which is likely the standard of care for this type of patient. In asking the location and strength of the pain the nurse is interpreting further to determine if any other physical problems are developing. In attempting to learn if any other underlying problems exist, the nurse is showing curiosity. The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't make me feel better; you don't know what it's like to lose a child." Which of the following examples of journal entries might best help the nurse reflect and think about this clinical experience? (Select all that apply.) A. Data entry of time of day, who was present, and condition of the child B. Description of the efforts to restore the child's blood pressure, what was used, and questions about the child's response C. The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death D. A description of what the nurse said to the mother, the mother's response, and how the nurse might approach the situation differently in the future *ANS- B, C, & D -The nurse can reflect on the effects of the treatment and what was difficult or confusing about the outcome. The nurse reviews the meaning of the experience to help improve understanding of personal comfort and competence in dealing with death and how to respond in the future. The nurse reflects on the communication approach used with the mother to consider if it was appropriate. A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is: A. Commitment. B. Scientific method. C. Basic critical thinking. D. Complex critical thinking. *ANS- C. Basic critical thinking -This is an example of basic critical thinking, in which the nurse trusts that experts have the right answers for how to insert the Foley catheter and thus goes to the procedure manual. Thinking is concrete and based on a set of rules or principles. A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of: A. Planning. B. Evaluation. C. Intervention. D. Diagnosis. *ANS- B. Evaluation -The patient's baseline for wound drainage was 40 mL, representing the initial assessment of the patient's wound condition. In this example the nurse is evaluating to determine if there is a change in the amount of drainage, which indicates the progress of wound healing. In which of the following examples is the nurse not applying critical thinking skills in practice? A. The nurse considers personnel experience in performing intravenous (IV) line insertion and ways to improve performance. B. The nurse uses a fall risk inventory scale to determine a patient's fall risk. C. The nurse observes a change in a patient's behavior and considers which problem is likely developing. D. The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care. *ANS- D. The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care. -The nurse is explaining how to provide care on the basis of knowledge. Considering personal experience is self-regulation through reflection. Determining a patient's fall risk is evaluation, using a criteria-based screening scale. Observing a change in the patient's behavior and considering likely developments is inference, in which the nurse looks for a relationship in findings. A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? A. Value-belief pattern B. Cognitive-perceptual pattern C. Coping-stress-tolerance pattern D. Health perception-health management pattern *ANS- D. Health perception-health management pattern -The nurse is attempting to learn about the patient's self-report of health practices, clinic appointments, and exercise plan designed to improve his health. The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? A. Setting the stage B. Gathering information about the patient's chief concerns C. Collecting the assessment D. Termination *ANS- C. Collecting the assessment -The nurse is focusing on the patient's nutritional status and asking specific questions to assess his diet history. What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply.) A. Active listening B. Open-ended questioning C. Closed-ended questioning D. Problem-oriented questioning *ANS- C & D -The nurse's technique is to ask a closed-ended question using a problem oriented approach. The patient gives a specific answer to broaden the nurse's knowledge about the character of his pain. What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.) A. Active listening B. Back channeling C. Validating D. Use of open-ended questions E. Use of closed-ended questions *ANS- A, B, & D -Active listening allows the patient to speak and shows the nurse's respect for what he or she has to say. Back channeling reinforces interest in what the patient has to say and shows the nurse's desire to hear the full story. Using open-ended questions encourages the patient to tell his or her story and actively describe his or her health status. Validation simply confirms accuracy of data collected. Closed-ended questions do not encourage storytelling. A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply.) A. The skin around the wound is tender to touch. B. Fluid intake for 8 hours is 800 mL. C. Patient has a heart rate of 78 and regular. D. Patient has drainage from surgical wound. E. Body temperature is 101° F (38.3° C). F. Patient asks, "I'm worried that I won't return to work when I planned." *ANS- A, D, & E -These form a pattern of a problem with wound healing. Fluid intake of 800 mL in 8 hours and having a heart rate of 78 are normal findings. The patient indicating some worry about not returning to work when planned may suggest a problem, but more cues are needed to see a pattern that would allow the nurse to clearly identify the problem. The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? A. The nurse is making an accurate clinical inference. B. The nurse has gathered cues to identify a potential problem area. C. The nurse has allowed stereotyping to influence her assessment. D. The nurse wants to validate her information with the other nurse. *ANS- C. The nurse has allowed stereotyping to influence her assessment -The nurse is applying a stereotype about patients with back pain. An accurate clinical inference would not include the nurse's opinion. The cues suggest that the patient has acute pain, which the nurse is rejecting. Validation would involve having another nurse also assess the patient for pain. A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment? A. Agenda setting B. Problem-focused C. Objective D. Use of a structured database format *ANS- B. Problem-focused -The nurse saw the inflammation and gathered additional information to determine if a problem existed with the IV site. The data were not all objective; the patient's report of tenderness is subjective. Setting an agenda is an interview technique. The nurse was not using a structured format for her assessment. Which of the following are examples of data validation? (Select all that apply.) A. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. B. The nurse asks the patient if he is having pain and then asks the patient to rate the severity. C. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content. D. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement. E. The nurse asks the patient to describe a symptom by saying, "Go on." *ANS- A & D -Validation involves comparing data with another source. By asking the patient about pain and then having it rated the nurse collects two assessment findings. The nurse asking an open-ended question about the patient's understanding of the booklet is not data validation. Telling the patient to "go on" is back channeling. A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? A. So you've had an upset stomach and began vomiting—correct? B. Have you taken anything for your stomach? C. Is anything else bothering you? D. Have you taken any medication for your vomiting? *ANS- C. Is anything else bothering you? -A probing question encourages a full description without trying to control the direction of the patient's story. It requires further open-ended statements. Confirming an upset stomach and vomiting is an example of summarizing findings. The questions about medications taken are examples of closed-ended questions that control the patient's response and do not ensure a full objective view from the patient. The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is which of the following? A. An objective finding B. A clinical inference C. A validation D. A concomitant symptom *ANS- D. A concomitant symptom -A concomitant symptom is a symptom that occurs along with a primary symptom. The finding is subjective based on patient self-report. There is no clinical inference since the nurse is not trying to find the meaning of the findings. The patient is reporting nausea, but there is no validation or confirmation with another source. During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply.) A. Family report B. Chest x-ray film C. Physical examination with auscultation of the lungs D. Medical record summary of x-ray film findings *ANS- C & D -The family cannot provide information to reveal that the cough is a lung problem. A chest x-ray film is not a nursing assessment; if a previous chest x-ray film had been performed, the nurse could review that report to confirm a lung problem. A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply.) A. A problem-focused approach B. A structured comprehensive approach C. Using multiple visits to gather a complete database D. Focusing on the functional health pattern of role-relationship *ANS- A & C -The nurse should use a focused approach initially to determine the patient's respiratory status. However, to gather an admission assessment, multiple visits are needed because of the patient's age and level of physical distress. A structured comprehensive approach is not appropriate for this acute situation. Eventually the nurse will want to assess the patient's role-relationship health pattern because of his wife's death. But it is not appropriate at this time. A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.) A. Maintain a neutral facial expression B. Lean forward when interacting with the patient C. Acknowledge the patient's answers through head nodding D. Limit direct eye contact *ANS- B & C -Leaning forward shows that the nurse is aware and attending to what the patient is saying. The use of head nodding regulates the interaction and makes it easier for the patient to know the nurse's responses to his comments. A neutral expression does not express warmth or immediacy, which is needed to establish a positive relationship. Good eye contact communicates the nurse's interest in what the patient has to say. Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A. Anxiety related to fear of dying B. Fatigue related to chronic emphysema C. Need for mouth care related to inflamed mucosa D. Risk for infection *ANS- A & D -The diagnosis "Anxiety related to fear of dying" is stated correctly, with the related factor being the patient's response to a health problem. Risk for infection is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Fatigue related to chronic emphysema is incorrect since chronic emphysema is a medical diagnosis. Need for mouth care related to inflamed mucosa is not a NANDA-I-approved nursing diagnosis. A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement. *ANS- C. Data interpretation -In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor. The nursing diagnosis readiness for enhanced communication is an example of a(n): A. Risk nursing diagnosis. B. Actual nursing diagnosis. C. Health promotion nursing diagnosis D. Wellness nursing diagnosis. *ANS- C. Health promotion nursing diagnosis -A patient's readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient's motivation and desire to strengthen his health. In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.) A. The nurse who listens to lung sounds after a patient reports "difficulty breathing" B. The nurse who considers conflicting cues in deciding which diagnostic label to choose C. The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema D. The nurse who identifies a diagnosis on the basis of a single defining characteristic *ANS- C & D -When the nurse assesses edema without knowing how to assess the severity, the nurse fails to validate her assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to validate her findings. In identifying a diagnosis on the basis of a single defining characteristic, the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. By listening to lung sounds after the patient reports "difficulty breathing" the nurse validates findings to make an accurate diagnosis. The nurse interprets cue clusters to make an accurate diagnosis when considering conflicting cues to make a diagnosis. A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: A. Identifying the clinical sign instead of an etiology. B. Identifying a diagnosis based on prejudicial judgment. C. Identifying the diagnostic study rather than a problem caused by the diagnostic study. D. Identifying the medical diagnosis instead of the patient's response to the diagnosis. *ANS- D. Identifying the medical diagnosis instead of the patient's response to the diagnosis -In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement. Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.) A. Acute pain related to lumbar disk repair B. Sleep deprivation related to difficulty falling asleep C. Constipation related to inadequate intake of liquids D. Potential nausea related to nasogastric tube insertion *ANS- A, B & D -Acute pain related to lumbar disk repair uses a medical diagnosis as a related factor. Sleep deprivation related to difficulty falling asleep uses a clinical sign rather than a treatable etiology such as "excess noise in environment." Potential nausea related to nasogastric tube insertion uses a diagnostic study as the etiology. None of the etiologies can be managed or treated by nursing intervention. Which of the following are examples of collaborative problems? (Select all that apply.) A. Nausea B. Hemorrhage C. Wound infection D. Fear *ANS- B & C -Hemorrhage and wound infection are collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient's status. Nausea and fear are both NANDA-I approved nursing diagnoses. Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: A. Need for improved bowel function related to change in diet. B. Patient needs improved bowel function related to alteration in elimination. C. Constipation related to inadequate fluid intake. D. Constipation related to hard infrequent stools. *ANS- C. Constipation related to inadequate fluid intake -Constipation related to inadequate fluid intake is an accurate NANDA-I approved nursing diagnosis with an appropriate etiology. Need for improved bowel function related to change in diet is a goal with an etiologic factor. Patient needs improved bowel function related to alteration in elimination is a goal with a diagnostic statement. Constipation related to hard infrequent stools is a nursing diagnostic label with a clinical sign. The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? A. Risk for aspiration B. Acute confusion C. Readiness for enhanced coping D. Sedentary lifestyle *ANS- A. Risk for aspiration -A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem. A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.) A. The family comes to visit the patient. B. The patient expresses concern about pain control. ***********TBC
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Chamberlain College Of Nursng
- Course
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NR 226 (NR226)
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- July 28, 2022
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- nr 226 exam 1
- nr 226 exam 1 review
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nr 226 exam 1 review questions
