Test Bank - Chapter 11: Assessing - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice 10th Edition

Test Bank - Chapter 11: Assessing - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice 10th Edition.Question 1 Type: MCSA The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process? 1. Deliver care to a client in an organized way. 2. Implement a plan that is close to the medical model. 3. Identify client needs and deliver care to meet those needs. 4. Make sure that standardized care is available to clients. Correct Answer: 3 Rationale 1: Delivery of organized care is not part of the nursing process, although each phase is interrelated. Rationale 2: The nursing process is not part of the medical model, as nurses treat the clients response to the disease or problem. Rationale 3: The purpose of the nursing process is to identify a clients health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. Rationale 4: The nursing process is individualized for each clients care plan. It is not about standardizing care. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the phases of the nursing process. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 155 Question 2 Type: MCSA While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working? Test Bank - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice 10th 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Correct Answer: 1 Rationale 1: Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment. Rationale 2: Diagnosis is identifying the clients response to the problem. Implementation is what the nurse does to help the client reach a goal, and then the goal is evaluated. Rationale 3: Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment. Rationale 4: The goal of the intervention is evaluated, but that is not what is being described in thisscenario. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify the four major activities associated with the assessing phase. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 159 Question 3 Type: MCSA During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document? 1. Restlessness 2. Leave me alone 3. Not talkative Test Bank - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice 10th 4. Pale and diaphoretic Correct Answer: 2 Rationale 1: Restlessness is observable so it is not subjective data. Rationale 2: Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the clients sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations. Rationale 3: Not being talkative is observable so it is not subjective data. Rationale 4: Paleness with diaphoresis is observable so this is not subjective data. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 160 Question 4 Type: MCSA Family of a client demonstrating confusion state that this is not the clients usual behavior. How should the nurse document this data? 1. Inference 2. Subjective data 3. Objective data 4. Secondary subjective data Correct Answer: 3 Rationale 1: Inference is making a judgment, and that is not what is described in the question. Rationale 2: The information provided by the spouse is not subjective because it is an observation by someone familiar with the clients usual behavior. Rationale 3: Information supplied by family members, significant others, or other health professionals are Test Bank - Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice 10th considered subjective if it is not based on fact. Because this information is factual, in that the spouse is able to provide the nurse with information about the clients routine behavior and patterns, this is objective data. Rationale 4: The information provided by the spouse is not subjective because it is an observation by someone familiar with the clients usual behavior. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Differentiate objective and subjective data and primary and secondary data. MNL Learning Outcome: 1.4.1. Analyze the role of assessment in the establishment of the nursing process. Page Number: 160 Question 5 Type: MCSA The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the clients pain. Which phase of the nursing process is this nurse implementing? 1. Assessment 2. Diagnosis 3. Implementation 4. Evaluation Correct Answer: