Nursing Exam 1 Davis Plus Questions with complete solutions

Which of the following are responsibilities of each state's board of nursing? Select All That Apply 1) Determining the salaries of nurses working in the state 2) Approving nursing education programs 3) Establishing criteria that allow a person to be licensed as a registered nurse 4) Hiring instructors for schools of nursing in the state 5) Developing rules and regulations for guidance to nurses 6) Enforcing the rules that govern nursing 2) Approving nursing education programs 3) Establishing criteria that allow a person to be licensed as a registered nurse 5) Developing rules and regulations for guidance to nurses 6) Enforcing the rules that govern nursing A friend recently graduated from high school and is planning to start a program to become a registered nurse, which will include 2 years of nursing classes plus many liberal arts and science classes. Whoch of the following educational routes is your friend taking to become a nurse? 1) Diploma program 2) Associate degree program 3) Baccalaureate degree program 4) Master's entry program 2) Associate degree program Previous Pause Next Rewind 10 seconds Move forward 10 seconds Unmute 0:01 / 0:15 Full screen Brainpower Read More Which of the following trends in the United States is most likely to increase the demand for nurses and other healthcare professionals? 1) Increased access to health and medical information among healthcare consumers 2) Growing proportion of older adults 3) Collective bargaining 4) The women's movement 2) Growing proportion of older adults You work as a labor and delivery nurse in the birthing center of a large hospital. Your hospital follows a model of care in which during a single shift, you are assigned to provide all aspects of care for just one patient. This is an example of which model for nursing care? 1) Case method 2) Functional nursing 3) Team nursing 4) Primary nursing 1) Case method You are currently a registered nurse but would like to become an advanced practical nurse. In particular, you would like to work with patients with cardiovascular disease in the coronary care unit of a hospital. Which advanced practice nursing certification should you pursue? 1) Nurse practitioner 2) Certified registered nurse anesthetist 3) Clinical nurse specialist 4) Certified nurse midwife 3) Clinical nurse specialist In your career as a nurse, you have provided primary, secondary, and tertiary care to a wide variety of patients. Which of the following is an example of primary care? 1) Administering pneumonia immunizations to older adults in a community clinic 2) Administering an antibiotic to a child with strep throat in an ambulatory care center 3) Caring for a patient who is learning to walk again after a traumatic injury in a rehabilitation center 4) Providing in-home hospice care for a patient who is dying of brain cancer 1) Administering pneumonia immunizations to older adults in a community clinic You have received unexpected blood test results for a patient and would like to confirm that there were no errors in the processing of the specimen. Which of the following healthcare professionals should you contact to address this concern? 1) Nursing assistant 2) Physical therapist 3) Physician's assistant 4) Laboratory technologist 4) Laboratory technologist Which of the following is a recommendation for healthcare reform that the American Nurses Association (ANA) published in 2008? 1) Provide universal access to essential healthcare services for all citizens and residents 2) Privatize the entire healthcare system 3) Shift the priority from health promotion to illness care 4) Established a three-payer system for financing healthcare 1) Provide universal access to essential healthcare services for all citizens and residents You are providing care for a 20-year-old who is currently unemployed, has no health insurance, and is struggling financially. Which of the following would it be most appropriate to provide information on? 1) Medicare 2) Medicaid 3) CHIP 4) Individual private insurance 2) Medicaid The following each describes one of five of the stages in Benner's model of the process by which a nurse acquires clinical skills and judgement: novice, advanced beginner, competence, proficient, expert. Put the descriptions in the correct order according to the their corresponding stages. - Can handle patient load and prioritize situations - Can recognize problems in the absence of classic signs and symptoms - Has a more sophisticated use of rules; recognition of abnormal findings but not of significance - Is task oriented and focuses on "learning the rules" - Can see the "big picture," coordinate services, and forecast needs 1) Has a more sophisticated use of rules; recognition of abnormal findings but not the significance 2) Can recognize problems in the absence of classic signs and symptoms 3) Can handle patient load and prioritize situations 4) Is task oriented and focuses on "learning the rules" 5) Can see the "big picture," coordinate services, and forecast needs In the hospital where you work as a registered nurse, nursing tasks are specialized. You are responsible for performing ordered treatments, such as giving injections, taking blood draws, and taking vital signs. A licensed practical nurse distributes medications to patients. A nursing assistant gives bed baths and makes the beds. This is an example of which model of nursing care? 1) Case method 2) Functional nursing 3) Team nursing 4) Primary nursing 2) Functional nursing Which of the following were acknowledged by the American Nurses Association (ANA) in 2010 as key characteristics of registered nursing? Select All That Apply 1) Nursing practice is the same for every nurse 2) Nurses coordinate care by establishing partnerships 3) Care is central to the practice of the registered nurse 4) Registered nurses use a corporate process to plan and provide care to their healthcare consumers 5) A strong link exists between the work environment and the nurse's ability to achieve optimal outcomes 6) The profitability of the healthcare facility is central to the practice of the registered nurse 2) Nurses coordinate care by establishing partnerships 3) Care is central to the practice of the registered nurse 5) A strong link exists between the work environment and the nurse's ability to achieve optimal outcomes Your uncle, who is 56, recently has a heart attack and was in the hospital for emergency coronary bypass surgery. After his stay in the hospital, he was moved to a facility for inpatient, multidisciplinary care for 6 weeks to help him recover and regain function. In which type of care facility was your uncle most likely treated? 1) Ambulatory care center 2) Nursing home 3) Rehabilitation center 4) Assisted living facility 3) Rehabilitation center You are interested in joining a nursing organization that has as one of its primary goals the improvement of working conditions for nurses throughout the world. Which of the following organizations would be best for you to join? 1) American Nurses Association 2) National League for Nursing 3) International Council of Nursing 4) Sigma Theta Tau International 3) International Council of Nursing Which of the following are factors that has a strong influence on the evolution of professional nursing? Select All That Apply 1) Buddhism 2) Societal beliefs 3) Architecture 4) Christianity 5) The marketplace 6) The military 2) Social beliefs 4) Christianity 6) The military You perform a blood draw on a patient and afterward the patient says, "Nobody has ever done such a good job finding my vein and taking a blood sample. You really now what you're doing." What type of knowledge is the patient referring to in this situation? 1) Theoretical knowledge 2) Practical knowledge 3) Self-knowledge 4) Ethical knowledge 2) Practical knowledge What are the two components of "doing" in the full-spectrum nursing concepts? 1) Critical thinking and theoretical knowledge 2) Practical knowledge and the nursing process 3) Self-knowledge and ethical knowledge 4) Patient data and patient preferences and context 2) Practical knowledge and the nursing process Which of the following are examples of critical-thinking attitudes? Select All That Apply 1) Independent thinking 2) Intellectual curiosity 3) Intellectual empathy 4) Intellectual pride 5) Intellectual safety 6) Intellectual perseverance 1) Independent thinking 2) Intellectual curiosity 3) Intellectual empathy 6) Intellectual perseverance While caring for a 6-year-old boy who is adjusting to being in the hospital for the first time, you suggest to his father that he bring in the boy's special blanket and favorite stuffed animal to help ease the transition. Which component of caring are you demonstrating by this action? 1) Knowing 2) Being with 3) Doing for 4) Enabling 4) Enabling You are working with a patient who is in severe pain following a traumatic accident. The patient's religious beliefs prevent her from taking any kind of medication for pain. After experimenting with several different nonpharmacological methods of pain management, you discover that a combination of distractions works: the patient views a television program while receiving a shoulder massage, which is reasonably effective in providing her with relief from pain. Which of the following types of complex thinking is this best an example of? 1) Clinical reasoning 2) Diagnostic reasoning 3) Decision making 4) Problem-solving 4) Problem-solving What are the two components of "caring" in the full-spectrum nursing concepts? 1) Critical thinking and theoretical knowledge 2) Practical knowledge and the nursing process 3) Self-knowledge and ethical knowledge 4) Patient data and patient preferences and context 3) Self-knowledge and ethical knowledge Which of the following are examples of critical-thinking skills? Select All That Apply 1) Subjectively gathering information about a problem or issue 2) Recognizing the need for more information 3) Assuming the credibility and usefulness of sources of information 4) Recognizing gaps in one's knowledge 5) Speaking carefully 6) Separating relevant from irrelevant data 2) Recognizing the need for more information 4) Recognizing gaps in one's knowledge 6) Separating relevant from irrelevant data A hospital administrator calls and asks you to prioritize treatment of a patient who is related to the administrator. This request bothers you, and you decide to report it to your supervisor. Which type of nursing knowledge are you acting on in this situation? 1) Theoretical knowledge 2) Practical knowledge 3) Self-knowledge 4) Ethical knowledge 4) Ethical knowledge After assessing a client, you determine that the client has the following problem: imbalanced nutrition: less that body requirements. At which phase in the nursing process are you? 1) Assessment 2) Diagnosis 3) Planning 4) Implementation 2) Diagnosis Which of the following are components of the definition of critical thinking? Select All That Apply 1) Reasoned thinking 2) Openness to alternatives 3) Adherence to established guidelines 4) Ability to reflect 5) Loyalty to traditional approaches 6) Desire to seek the truth 1) Reasoned thinking 2) Openness to alternatives 4) Ability to reflect 6) Desire to seek the truth You are in the process of assessing a patient who is of another race and religion than yours. As you perform the assessment, you begin to wonder what factors—including the patient's race and religion—may be influencing your behavior in this situation. Which thinking process in the critical-thinking model are you demonstrating? 1) Contextual awareness 2) Inquiry 3) Considering alternatives 4) Reflecting skeptically and deciding what to do 1) Contextual awareness In the course of a day, you encounter many different types of patients. Which of the following patients would most require you to use the most complex critical thinking skills in your care of him or her? 1) An 18-year-old football player who has broken his leg 2) A 60-year-old school teacher who has strep throat 3) A 45-year-old attorney who has developed high blood pressure 4) An 80-year-old woman with diabetes who has broken her hip 4) An 80-year-old woman with diabetes who has broken her hip You have just finished a physical examination of an 8-year-old girl and discovered bruises on her body in places that make you suspect that she has been physically abused. Before you investigate that line of reasoning, however, you stop and think about all the other likely ways that a child her age could obtain bruises in those locations. Which thinking process in the critical-thinking model are you demonstrating? 1) Contextual awareness 2) Inquiry 3) Considering alternatives 4) Reflecting skeptically and deciding what to do 3) Considering alternatives Place the following six phases of the nursing process in correct order. - Evaluation - Planning outcomes - Implementation - Assessment - Planning Interventions - Diagnosis 1) Assessment 2) Diagnosis 3) Planning Outcomes 4) Planning Interventions 5) Implementation 6) Evaluation Which of the following is an example of a nurse who is using critical thinking? 1) Following the hospital's new policy to require a photo ID for all visitors to the birthing center 2) Questioning a medication order from a physician that doubles the patient's dosage when the patient exhibited no changes in a recent office visit 3) Recording the patient's vital signs once an hour, per the physician's request 4) Calculating the proper dosage of a child's oral medication based on established height/weight charts 2) Questioning a medication order from a physician that doubles the patient's dosage when the patient exhibited no changed in a recent office visit You are conducting an initial assessment of a new client. The client does not have time today for a comprehensive assessment, so you will be doing that at the client's next visit. Which of the following types of data should you collect as part of this assessment? Select All That Apply 1) Status of a healing laceration 2) Emotional status 3) Phone number 4) Blood pressure 5) Marital status 6) Occupation 3) Phone number 5) Marital status 6) Occupation A patient is in the examination room waiting to be assessed. You are the registered nurse assigned to assess the patient. You also have a nurse aide assisting you. Which aspects of the patient's assessment would be appropriate for you to delegate to the nurse aide? 1) Take the patient's temperature 2) Weigh the patient 3) Validate the data collected 4) Measure the patient's height 5) Conduct the patient interview 6) Complete the physical assessment 1) Take the patient's temperature 2) Weigh the patient 4) Measure the patient's height As you perform a detailed assessment of a 10-year-old client, the client asks, "Why are you taking so long to check me out?" What is your most appropriate response to this patient? 1) "I have to figure out what's wrong with you." 2) "I have to get enough information so that I can help you." 3) "I have to decide what kind of treatment to give you." 4) "I have to help you feel better." 2) I have to get enough information so that I can help you." During a physical examination, you gather much data on a client. Which of the following are data findings that you should validate? Select All That Apply. 1) A report of a height of 6 feet, 6 inches in a client who appears very tall 2) A blood pressure reading of 80/60 mm Hg in a client with hypertension who is not on medication 3) A heart rate of 40 beats/min in a moderately active 45-year-old 4) A denial of illicit drug use in conjunction with the observation of needle track marks on the client's arm 5) An oral temperature of 98.2*F 6) A total cholesterol score of 245 2) A blood pressure reading of 8-/60 mm Hg in a client with hypertension who is not on medication 3) A heart rate of 40 beats/min in a moderately active 45-year-old 4) A denial of illicit drug use in conjunction with the observation of needle track marks on the client's arm As you perform an assessment of a client, which of the following actions are required by The Joint Commission? Select All That Apply 1) Record findings of the assessment in writing or on a computer tablet 2) Delegate taking the patient's biometric measures to a nurse aide 3) Include evaluation of the client's physical, psychological, and social status in the assessment 4) Follow agency policy regarding when the client is to be reassessed 5) Assess the client for possible physical abuse 6) Assess the client for pain 1) Record findings of the assessment in writing or on a computer tablet 3) Include evaluation of the client's physical, psychological, and social status in the assessment 4) Follow agency policy regarding when the client is to be reassessed 6) Assess the client for pain Which phase of the nursing process uses the data gathered during assessment to identify the client's health problems and strengths? 1) Planning Interventions 2) Implementation 3) Diagnosis 4) Evaluation 3) Diagnosis You are assessing a child with sickle cell disease who is experiencing an acute pain crisis. You are concerned that the child's spleen may be enlarged, which is a serious complication of this disease. You don't see any signs of enlargement in the patient's abdomen but you know that the condition may still be present. You decide to examine the patient's abdomen by feel. Which of the following physical assessment techniques are you using? 1) Inspection 2) Palpation 3) Percussion 4) Auscultation 2) Palpation You are documenting the assessment data of a client. Which of the following is the most appropriate documentation? 1) Patient is angry over a long wait in the waiting room 2) Client is intoxicated 3) Child has bruises from being spanked 4) Patient has a cluster of three clear vesicles on the upper lip 4) Patient has a cluster of three clear vesicles on the upper lip As a new nurse, you are interviewing a 15-year-old client as part of a comprehensive assessment and come to the portion of the health history that relates to her sexual health. You are embarrassed to ask someone her age about her sex life and you fear what her reaction will be. Which of the following actions should you take? 1) Skip this section and assume that the client will mention any problem she has in this area 2) Ask a more experienced nurse to complete the interview 3) Ask to speak to the client's mother about this topic 4) Explain that you will keep all information confidential and then ask the necessary questions 4) Explain that you will keep all information confidential and then ask the necessary questions You are interviewing a client to obtain information about his health history. Because he appears nervous, you begin by using directive interviewing. Which of the following is an example of a question you might ask when using this type of interviewing? 1) "How has your weight loss program been going?" 2) "When was your last physical examination?" 3) "What signs or symptoms have you experienced related to your diabetes?" 4) "How would you describe your work environment?" 2) "When was your last physical examination?" In your interview with a new client, you learn that she drinks six beers a day. In which section of the nursing health history would you record this information? 1) Biographical data 2) Chief complaint 3) Family health history 4) Social history 4) Social history You are assessing the functional abilities of a client who is in hospice care and nearing the end of life. Which of the following special needs assessments would be most appropriate to use with this client? 1) Katz Index of Activities of Daily Living (ADL) scale 2) Lawton Instrumental Activities of Daily Living (IADL) scale 3) Karnofsky Performance scale 4) Wellness assessment 3) Karnofsky Performance scale You have just completed a client assessment and need to record the data you have gathered. Which of the following guidelines should you observe as you complete this task? Select All That Apply. 1) Wait at least 24 hours before recording 2) If recording on paper, write only with pencils 3) Write the patient's own words, when possible, in quotation marks 4) Record only the most important patient words 5) Record inferences, not cues 6) Use concrete, specific information rather than vague generalities 3) Write the patient's own words, when possible, in quotation marks 4) Record only the most important patient words 6) use concrete, specific information rather than vague generalities You are preparing for an interview with a client and deciding how to incorporate directive and nondirective interviewing techniques. Which of the following is a disadvantage of directive interviewing? 1) It may cause you to miss topics important to the patient 2) It is ineffective 3) It can produce much irrelevant data 4) It is not effective for clients who are anxious 1) It may cause you to miss topics important to the patient A patient arrives at the clinic where you work complaining of pain in her temples. She describes the pain as throbbing and intense. This is an example of which type of data? 1) Primary subjective 2) Primary objective 3) Secondary subjective 4) Secondary objective 1) Primary subjective As you are weighing a client and calculating her body mass index, you begin to think that a diagnosis of "Imbalanced nutrition: more than body requirements" would be appropriate for this client. Which of the following is true of this guess? 1) It illustrates that nursing diagnosis actually begins during assessment 2) It is an example of a nurse not properly following the nursing process 3) It is an example of the nurse making a medical diagnosis, which should not be done 4) It proves that the nursing process need not be followed 1) It illustrates that nursing diagnosis actually begins during assessment. You have written your diagnostic statements for a client. Which of the following criteria should you use to judge their quality? Select All That Apply 1) In choosing a NANDA-I label, do not rely on the label definition alone 2) Include both problem and etiology, with cause and effect stated correctly 3) Be sure that the etiology restates the problem 4) Use medical diagnosis and treatments as etiological factors 5) Write the statement concisely 6) Be sure the statement is descriptive and specific 1) In choosing a NANDA-I label, do not rely on the label definition alone. 2) Include both problem and etiology, with cause and effect stated correctly. 5) Write the statement concisely. 6) Be sure the statement is descriptive and specific. You are in the process of selecting a diagnostic label for a health problem of a client. Which of the following is the first step you should take in this process? 1) Narrow your search to the class or most likely labels 2) Identify the domain that seems to fit the cue cluster 3) Consult a nursing diagnosis handbook 4) Compare definitions and defining characteristics of the diagnostic labels to your cue cluster 2) Identify the domain that seems to fit the cue cluster. You are caring for a client who complains of having hard stool and of not having had a bowel movement in 3 or 4 days. You suspect that the client has constipation. Moreover, after seeing his intake and output measures, you believe that the constipation is caused by inadequate intake of fluids and fiber-rich foods. Which of the following would be an appropriate nursing diagnosis based on these findings? 1) Hard stool and bowel movement every 3 or 4 days r/t constipation AMB inadequate intake of fluids and fiber-rich foods 2) Inadequate intake of fluids and fiber-rich foods r/t constipation AMB painful, hard tool and bowel movement every 3 or 4 days 3) Constipation r/t inadequate intake of fluids and fiber-rich foods AMB painful, hard tool and bowel movement every 3 or 4 days 4) Hard stool and bowel movement every 3 or 4 days r/t inadequate intake of fluids and fiber-rich foods AMB constipation 3) Constipation r/t inadequate intake of fluids and fiber-rich foods AMB painful, hard tool and bowel movement every 3 or 4 days Which of the following is an example of an actual nursing diagnosis? 1) Risk for infection related to surgery 2) Impaired walking related to a diabetic ulcer 3) Possible risk for imbalanced nutrition: less than body requirements 4) Readiness for enhanced nutrition 2) Impaired walking related to a diabetic ulcer While caring for a patient in the hospital, you note ulcers on the patient's feet. You recall that the patient's laboratory test results indicated a high blood glucose level. Which of the following is an appropriate nursing diagnosis that you could make in this situation? 1) Advanced type 2 diabetes mellitus 2) Staphylococcus infection of the feet 3) Impaired tissue integrity 4) Potential complication of type 2 diabetes mellitus: hyperglycemia 3) Impaired tissue integrity You are reflecting critically on your diagnostic reasoning after formulating a nursing diagnosis. Which of the following questions should you ask yourself to evaluate your self-knowledge? Select All That Apply. 1) Is this diagnosis based on sound knowledge? 2) What biases and stereotypes may have influenced my interpretation of the data? 3) Did I rely too much on past experiences? 4) Do I feel reasonably sure I have interpreted the data correctly? 5) Did I rely too much on the client's medical diagnosis, the setting, or what others say about the client instead of on the data? 6) Am I qualified to make this diagnosis, or should I consult with a more experienced nurse or other member of the collaborative healthcare team? 2) What biases and stereotypes may have influenced my interpretation of the data?3) Did I rely too much on past experiences? 6) Am I qualified to make this diagnosis, or should I consult with a more experienced nurse or other member of the collaborative healthcare team? Which of the following is the first step in the process of analyzing and interpreting data? 1) Cluster cues 2) Identify data gaps 3) Identify significant data 4) Identify data inconsistencies 3) Identify significant data Which of the following is the best definition of health problem? 1) Any condition that requires intervention to promote wellness or to prevent or treat disease or illness 2) A statement of client health status that nurses can identify, prevent, or treat independently 3) A description of a disease, illness, or injury developed so that appropriate medical treatment can be given 4) A complication related to a disease that a nurse monitors to detect a change in status 1) Any condition that requires intervention to promote wellness or to prevent or treat disease or illness You are preparing to write a collaborative problem diagnosis. Which of the following elements is typically left out of a collaborative problem? 1) Complication 2) Disease 3) Etiology 4) The word potential 3) Etiology Which of the following is an example of a wellness nursing diagnosis? 1) Risk for infection related to surgery 2) Impaired walking related to a diabetic ulcer 3) Possible risk for imbalanced nutrition: less than body requirements 4) Readiness for enhanced nutrition 4) Readiness for enhanced nutrition You are working with a client in the hospital who has lost 5 pounds since being admitted. You recognize that this client is probably experiencing imbalanced nutrition: less than body requirements. Which of the following are likely etiologies related to this diagnosis? Select All That Apply. 1) Excessive fear of weight gain 2) Self-induced vomiting related to self-starvation 3) Diet high in fat 4) Inability to ingest food 5) Lack of physical activity 6) Depression 1) Excessive fear of weight gain 2) Self-induced vomiting related to self-starvation 4) Inability to ingest food 6) Depression Put the following steps of the diagnostic reasoning process in the correct order. - Verify problems with the patient. - Analyze and interpret data. - Record the diagnostic statements. - Draw conclusions about the patient's health status. - Prioritize the problems. 1) Analyze and interpret data 2) Verify problems with the patient 3) Draw conclusions about the patient's health status 4) Record the diagnostic statements 5) Prioritize the problems Which of the following is an accurate statement regarding the relationship of the nursing diagnosis to outcomes and interventions? 1) The problem suggests the goals. 2) The etiology suggests the problem. 3) The goals suggest the etiology. 4) The interventions suggest the etiology. 1) The problem suggests the goals. You are preparing to prioritize the health problems that you have identified for a patient. You have decided to prioritize them based on the problems that relate to the client's most basic human needs. Which theoretical framework are you using? 1) Problem urgency 2) Future consequences 3) Patient preference 4) Maslow's hierarchy 4) Maslow's hierarchy You are creating a comprehensive care plan for a patient. Which of the following are examples of appropriate information to include in this plan? Select All That Apply. 1) Assistance the patient will require with bathing 2) Prescriptions for an antibiotic and an analgesic 3) A detailed family health history 4) A nursing diagnosis of "Impaired mobility related to fractured toe" 5) Information on the patient's insurance plan 6) Special teaching on care of an ostomy pouch 1) Assistance the patient will require with bathing 2) Prescriptions for an antibiotic and an analgesic 4) A nursing diagnosis of "Impaired mobility related to fractured toe" 6) Special teaching on care of an ostomy pouch You are caring for a patient who is experiencing significant pain following surgery. You have been administering acetaminophen by mouth for the past 24 hours but can clearly see that the patient's pain level is high. You add a note to the patient's care plan and notify the patient's provider about the pain, recommending a change in medication. Which type of planning is this? 1) Initial, formal 2) Initial, informal 3) Ongoing, formal 4) Ongoing, informal 3) Ongoing, formal Your hospital has recently implemented a new electronic health record system that includes computer-generated care plans. Which of the following are advantages of computerized planning? Select All That Apply. 1) Increases the use of intuition 2) Ensures consideration of a variety of actions 3) Prevents overlooking common and important interventions4) Increases the use of insight 5) Reduces time spent on paperwork 6) Enhances nursing expertise 2) Ensures consideration of a variety of actions 3) Prevents overlooking common and important interventions 5) Reduces time spent on paperwork You are using the standardized Nursing Outcomes Classification (NOC) vocabulary to develop patient outcomes. In NOC vocabulary, the observable behaviors and states you can use to evaluate patient status are which of the following? 1) Indicators 2) Outcomes 3) Measurement scales 4) Outcome labels 1) Indicators You are formulating a goal for a patient who is experiencing a disturbed sleep pattern related to anxiety about finances. Which of the following would be specific and concrete performance criteria for such a goal? Select All That Apply. 1) Will return to a normal sleep pattern 2) Will sleep at least 8 hours each night 3) Will fall asleep within 1 hour of going to bed 4) Will get enough sleep at night 5) Will report feeling rested in the morning 6) Will sleep more 2) Will sleep at least 8 hours each night 3) Will fall asleep within 1 hour of going to bed 5) Will report feeling rested in the morning You are preparing to discharge a client and are deciding whether you need to create a comprehensive, formal discharge plan. Which of the following client characteristics or situations would tend to necessitate a formal discharge plan? Select All That Apply. 1) Mental illness 2) Medication continued at home 3) Complicated major surgery 4) Inadequate financial resources 5) A significant other to help provide care 6) Malnutrition 1) Mental illness 3) Complicated major surgery 4) Inadequate financial resources 6) Malnutrition You have given a client the following nursing diagnosis: Ineffective Airway Clearance related to ineffective cough secondary to incisional pain. Which of the following is an example of an essential patient goal related to this diagnosis? 1) Coughs forcefully/effectively 2) Rates pain as 3 on a scale of 1 to 10 scale 3) Splints incision while coughing 4) Lungs clear to auscultation 4) Lungs clear to auscultation Below are the steps in the process for writing an individualized patient care plan. Put them in the correct order. - Transcribe medical orders to appropriate documents - Write activities of daily living and basic care needs in special sections of the Kardex, care plan, or computer - Make a working problem list - Develop individualized care plans for problems not addressed by standardized documents - Decide which problems can be managed with standardized care plans or critical pathways - Individualize the standardized plan as needed 1) Individualize the standardized plan as needed 2) Write activities of daily living and basic care needs in special sections of the Kardex, care plan, or computer 3) Make a working problem list 4) Transcribe medical orders to appropriate documents 5) Decide which problems can be managed with standardized care plans or critical pathways 6) Develop individualized care plans for problems not addressed by standardized documents You have diagnosed a patient with the following nursing diagnosis: Possible Constipation related to suspected inadequate intake of fiber and fluids. Which of the following is the appropriate patient goal to address this diagnosis? 1) Will have normal, formed bowel movement within 24 hours after receiving stool softener 2) Will have bowel function within normal limits for patient 3) There is no patient goal. 4) Reports increased intake of dietary fiber and fluids 3) There is no patient goal. You have given a client you are working with a nursing diagnosis of "Impaired Mobility related to atrophied muscles from confinement to bed." Which of the following states an appropriate long-term goal that addresses that problem? 1) Walk three steps using a walker 2) Walk down the hall and back unassisted 3) Perform exercises daily to strengthen legs 4) Client resists efforts at rehabilitating his legs 2) Walk down the hall and back unassisted In preparing a care plan for a patient, you decide to use a preprinted plan. The plan you choose groups patients according to diagnosis, describes the minimal standard of care required to meet the recommended length of stay, and specifies patient outcomes and broad interventions for each day and each hour. Which type of plan have you chosen? 1) Unit standards of care 2) Critical pathway 3) Standardized patient care plan 4) Integrated plans of care 2) Critical pathway A new nurse you are training asks why you have to write down the patient care plan. She tells you that at her last job, she didn't have to write anything down. Which of the following reasons would you tell her? Select All That Apply. 1) To ensure that care is complete 2) To help instill confidence in patients 3) To provide continuity of care 4) To promote efficient use of nursing efforts 5) To provide a guide for assessments and charting 6) To meet the requirements of accrediting agencies 1) To ensure that care is complete 3) To provide continuity of care 4) To promote efficient use of nursing efforts 5) To provide a guide for assessments and charting 6) To meet the requirements of accrediting agencies During your physical examination of a new client, you observe that she appears underweight and you make a mental note that she may require counseling related to disordered eating. Which type of planning is this? 1) Initial, formal 2) Initial, informal 3) Ongoing, formal 4) Ongoing, informal 2) Initial, informal You are formulating goals as part of creating an individualized care plan for a client. Which of the following is a goal or expected outcome, as opposed to just an outcome? 1) Constipation relieved 2) Pain level unchanged 3) Anxiety related to pending surgery 4) Allergic reaction to penicillin 1) Constipation relieved A patient is becoming discouraged because she is struggling to relearn how to brush her teeth after a stroke. You decide to have her first attempt to grasp her modified toothbrush handle and hold it up for 10 seconds. This is an example of which of the following? 1) Short-term goal 2) Long-term goal 3) Short-term outcome 4) Long-term outcome 1) Short-term goal Nursing interventions are actions based on clinical judgment and nursing knowledge that nurses perform to achieve client outcomes. Interventions are also referred to as which of the following? Select All That Apply. 1) Goals 2) Outcomes 3) Nursing actions 4) Measures 5) Strategies 6) Activities 3) Nursing actions 4) Measures 5) Strategies 6) Activities Put the following steps in the evidence-based practice process in correct order. - Formulating an answerable question about prevention, diagnosis, prognosis (likely outcome), and interventions - Evaluating or grading the quality of the evidence obtained - "Translating" the evidence into guidelines for practice - Integrating the guidelines and evidence with clinical expertise and the patient's preferences and characteristics - Compiling and analyzing the data to prepare a structured report of the review - Conducting a systematic review of published evidence (research) to find studies that shed light on the desired topic 1) Formulating an answerable question about prevention, diagnosis, prognosis (likely outcome), and interventions 2) Evaluating or grading the quality of the evidence obtained 3) Integrating the guidelines and evidence with clinical expertise and the patient's preferences and characteristics. 4) Compiling and analyzing the data to prepare a structured report of the review 5) "Translating" the evidence into guidelines for practice 6) Conducting a systematic review of published evidence (research) to find studies that shed light on the desired topic You are reflecting critically about a nursing order you have just composed for a client. You should make sure that the order is which of the following? Select All That Apply. 1) Complete, addressing all aspects of the problem 2) Generic, able to be used for a wide variety of clients 3) Clear, specific, and precise, avoiding vague language 4) Long and complex, including the details of all procedures 5) Technically complete, including all required components 6) Prioritized, indicating which orders must be implemented immediately 1) Complete, addressing all aspects of the problem 3) Clear, specific, and precise, avoiding vague language 5) Technically complete, including all required components 6) Prioritized, indicating which orders must be implemented immediately In caring for a patient who is confined to bed in the hospital for many weeks, you are seeking interventions to help prevent decubitus ulcers, or pressure sores. You decide to conduct a systematic review of published research to find studies that shed light on this topic. This action is an example primarily of which of the following? 1) Theory 2) Critical pathway 3) Evidence-based practice 4) Protocol 3) Evidence-based practice You are preparing to perform a blood draw on a client who is seated in a phlebotomy chair. The client appears pale and confesses that he "gets squeamish" at the sight of blood. Which of the following responses best illustrates the use of the critical-thinking skill of predicting to help generate an intervention in this situation? 1) With other clients who were squeamish, I have successfully distracted them by making small talk; maybe that will work for this client. 2) Because the client is squeamish, he may faint during the blood draw, so I should have him lie down. 3) I learned in a music therapy workshop that music can help calm anxious clients; perhaps I should play some soft music. 4) This client is experiencing a vasovagal response, in which the parasympathetic nervous system is triggered by a threat in the environment. 2) Because the client is squeamish, he may faint during the blood draw, so I should have him lie down. Below are the steps for selecting the best nursing intervention for each patient. Put them in the correct order. - Identify several interventions or actions - Review the nursing diagnosis - Choose the best interventions for the patient - Review the desired patient outcomes - Individualize standardized interventions 1) Review the desired patient outcomes 2) Individualize standardized interventions 3) Identify several interventions or actions 4) Review the nursing diagnosis 5) Choose the best interventions for the patient You are providing wellness teaching to a client who frequently experiences constipation. Which of the following interventions would be most appropriate in this situation? 1) Recommend an over-the-counter laxative 2) Administer a prescribed stool softener 3) Obtain more data to confirm or rule out constipation 4) Provide the patient with a daily fluid intake guide to promote optimal health 4) Provide the patient with a daily fluid intake guide to promote optimal health You are researching standardized intervention classification systems to find spiritual care interventions to use with your clients. Which of the following are some spiritual care interventions you might consider? Select All That Apply 1) Spiritual growth facilitation 2) Religious ritual enhancement 3) Decision-making support 4) Health screening 5) Spiritual support 6) Bereavement support 1) Spiritual growth facilitation 2) Religious ritual enhancement 5) Spiritual support 6) Bereavement support You are writing up a nursing order for a client. Which of the following components should you include in it? Select All That Apply. 1) Date 2) Subject 3) Prescribed medications 4) Action verbs 5) Times and limits 6) Signature 1) Date 2) Subject 4) Action verbs 5) Times and limits 6) Signature Which of the following is an example of an interdependent intervention? 1) Assisting the client in performing leg exercises and reporting results to the physical therapist 2) Administering a prescribed antibiotic 3) Collecting a stool sample per orders 4) Encouraging the client to increase fluid intake to prevent dehydration 1) Assisting the client in performing leg exercises and reporting results to the physical therapist While caring for a patient one day, you perform many interventions, both direct care and indirect care. Which of the following is an example of an indirect-care intervention? 1) Teaching a patient how to care for an incision site 2) Administering an injection 3) Listening to the patient explain fears related to death 4) Making a referral for the patient to see a speech pathologist 4) Making a referral for the patient to see a speech pathologist You are a home health nurse and are planning interventions for a client who is recovering from a stroke. You would like to use an intervention classification system that is especially designed to meet the needs of home health nursing. Which of the following systems should you choose? 1) North American Nursing Diagnosis Association—International (NANDA-I) 2) Nursing Interventions Classification (NIC) 3) Clinical Care Classification (CCC) 4) Omaha System 3) Clinical Care Classification (CCC) You are caring for a patient for whom you have given the actual nursing diagnosis of constipation. Based on the status of this problem, which of the following interventions should take priority? 1) Encourage the patient to drink more fluids 2) Administer a prescribed stool softener 3) Obtain more data to confirm or rule out the constipation 4) Provide the patient with a daily fluid intake guide to promote optimal health 2) Administer a prescribed stool softener You are counseling a client on potential lifestyle changes to optimize her health. Which of the following is an appropriate wellness intervention for the client? 1) "The client will spend at least 15 minutes per day meditating for the next week." 2) "I will walk at least 1 mile every day at lunch time with a coworker for the next month." 3) "The client will take all prescribed medications at the right time for the next 3 months." 4) "I will perform hand exercises daily to regain strength lost following carpal tunnel surgery." 2) "I will walk at least 1 mile every day at lunch time with a coworker for the next month." Throughout your day as a nurse, you make many interventions, both independent and dependent. Which of the following is an example of an independent intervention? 1) Administering a prescribed analgesic 2) Delegating the bathing of a patient to a nurse aide 3) Drawing blood for an ordered complete blood count 4) Starting IV therapy 2) Delegating the bathing of a patient to a nurse aide You are preparing to discharge a client and have concerns about his ability to adhere to the diabetic diet that you and the nutritionist have developed for him. Which of the following are effective ways to promote cooperation with the diet? Select That All Apply. 1) Assess the client's knowledge of diabetes. 2) Ask the client what concerns he has about going on the diet. 3) Provide teaching on what foods to avoid and what foods will help keep his blood glucose level steady. 4) Talk openly and regularly about adherence. 5) Be determined to change any of the client's attitudes that contribute to resistance to the diet. 6) Help the client set ambitious, challenging goals. 1) Assess the client's knowledge of diabetes. 2) Ask the client what concerns he has about going on the diet. 3) Provide teaching on what foods to avoid and what foods will help keep his blood glucose level steady. 4) Talk openly and regularly about adherence. You are critically reflecting on variables that could have affected the results of an intervention. Which of the following should you consider? Select All The Apply. 1) Client's ability and motivation to follow directions for treatment 2) Effectiveness of the same treatment in clients in other regions 3) Availability and support from family and significant others 4) Client's family history 5) Client's lack of experience, knowledge, or ability 6) Staffing in the institution 1) Client's ability and motivation to follow directions for treatment 3) Availability and support from family and significant others 5) Client's lack of experience, knowledge, or ability 6) Staffing in the institution Which of the following are key components of the implementation phase? Select All That Apply. 1) Diagnosing 2) Data gathering 3) Doing 4) Documenting 5) Decision making 6) Delegating 3) Doing 4) Documenting 6) Delegating You are evaluating a client's collaborative problem of Potential Complication of myocardial infarction: congestive heart failure (CHF). Which of the following should be your primary goal in such evaluation? 1) Client reports no pain. 2) Client's reassessment data are within normal range. 3) Client achieves activities of daily living. 4) Client does not have another heart attack. 2) Client's reassessment data are within normal range. As you are preparing to implement your nursing plan for applying dressings to a client who has sustained third-degree burns, you decide that it would be best to include times during each intervention that you will stop and check in with the client before continuing. This action is known as which of the following? 1) Checking your knowledge and abilities 2) Preparing supplies and equipment 3) Establishing feedback points 4) Preparing the patient 3) Establishing feedback points A scale is reliable if it does which of the following? 1) Functions for many years 2) Yields consistent results time after time 3) Is accurately measuring a person's mass or weight 4) Is achieving expected or accepted levels of performance 2) Yields consistent results time after time You are preparing to delegate several tasks to a licensed vocational nurse. Which of the following "rights" of delegation should you keep in mind as you do this? Select All That Apply. 1) Right task 2) Right circumstance 3) Right dosage 4) Right person 5) Right communication 6) Right supervision 1) Right task 2) Right circumstance 4) Right person 5) Right communication 6) Right supervision You are now entering the implementation phase of the nursing process with a client. Which of the following are actions that would be appropriate to take in the implementation phase? Select All That Apply. 1) Write up a nursing order for the client. 2) Reposition a pregnant patient to her side to prevent compression of the inferior vena cava vein. 3) Develop expected outcomes related to a patient's progress with feeding himself. 4) Document a patient's anaphylactic response to a medication. 5) Delegate the application of cold compresses to the patient's forehead to a nurse aide. 6) Interview the patient to obtain a detailed health history. 2) Reposition a pregnant patient to her side to prevent compression of the inferior vena cava vein. 4) Document a patient's anaphylactic response to a medication. 5) Delegate the application of cold compresses to the patient's forehead to a nurse aide. One of your patients needs to be transported via wheelchair to radiology for a chest x-ray. You have a nurse aide perform this task. This is an example of which of the following? 1) Assigning 2) Delegating 3) Collaborating 4) Coordinating 2) Delegating Which of the following is a program designed to promote excellence in nursing? 1) Quality assurance 2) Reliability 3) Validity 4) Collaboration 1) Quality assurance See 80 more Add or remove terms